IR 05000461/1997020
| ML20211Q494 | |
| Person / Time | |
|---|---|
| Site: | Clinton  |
| Issue date: | 10/11/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20211Q479 | List: |
| References | |
| 50-461-97-20, NUDOCS 9710220321 | |
| Download: ML20211Q494 (13) | |
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U.S. NUCLEAR REGULATORY COMMISSION REGION lll Docket Nos:
50-461
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License Nos:
NPF-62 Report No:
50461/97020 (DRP)
Licensee:
Illinois Power Company Facility:
Clinton Power Station Location:
Route 54 West Clinton, IL 61727 Dates:
July 7 - August 29,1997 Inspectors:
T. W. Pruett, Senior Resident inspector K K Stoedter, Resident inspector Approved by-Geoffrey C. Wright, Chief Reactor Projects Branch 4
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9710220321 971011 PDR ADOCK 05000461
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EXECUTIVE SUMMARY Clinton Power Station NRC Inspection Report 50-461/97020 (DRP)
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This inspection included aspects of licensee operations, engineering, and maintenance.
Maintenance One apparent violation was identified for the failure to implement corrective actions for multiple failures of safety related components. Maintenance, operations, and management did not recognize the significance of multiple safety-related component failures. The failure to take prompt and effective corrective actions demonstrated a lack of pwnership in the facility, a poor questioning attitude, and a willingness to accept substandard workmanship. (Section M1.1)
One apparent violation was identified for not controlling the use of consumable materials which -
resulted in the failure of multiple safety-related components. (Section M1.1)
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Manag6thent demonstrated poor oversight of the corrective action program in that the initiation of efforts to determine the causes for inadequate control of consumable materials were delayed until August 1997, even though deficiencies were noted in February and June 1997.
(Section M1.1)
One apparent violation was identified due to the failure to provide procedural guidance commensurate with the knowledge, skills, and abilities of personnel performing neon indicating light replacemer.t activities. The assignment ofinexperienced personnel to perform this work demonstrated poor oversight by maintenance management. (Section M1.1)
The root cause evaluation for neon indicating light failures was an improvement over past root cause analyses.-- However, the root cause analysis only addressed the specific equipment failure and did not address ineffective management oversight, the poor quality of engineering
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evaluations, and the lack of control for consumable materials.- (Section M1.1)
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Report Details 11. Maintenance i
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M1 Conduct of Maintenance M1.1 Improperty Controlled Material Results in Neon Llaht Failure and Inoperability of Safety Related Eauioment a.
Inspection Scope (37551. 62707. and 71707)
On November 6,1996, maintenance initiated Condition Report (CR) 1-96-11-114 to document the existence of different configurations for neon indicating lights / sockets within the main control room panels. In response to the CR, management decided to replace 592-neon light sockets.
Between January 1 and June 2,1997, following socket replacernent,16-neon indicating lights failed with 11 occurring after successful post maintenance testing (PMT). The failure of indicating lights was of significant concem in that shorting of the light socket could cause the control power fuse within motor operated valve control circuitry to kil.
Failure of the control power fuse interrupts power to the valve resulting in the valves inability to operate automatically during accident conditions or remotely from the main control room.
During the inspectors review, several concems were identified. The concems included:
(1) inadequate implementation of the corrective action program, (2) improper use of an uncontrolled soldering flux, and (3) procedures which did not include instructions commensurate with the knowledge, skills, and abilities of electrical maintenance (EM)
technicians.
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Observations and Findinos Failure of Neon Lichts On January 1,1997, the reactor high water level trip status light lost indication when the light fuse blew during PMT. EM used the maintenance work request (MWR) initiated w install the light sockets (D75237) to restore the control room indication. EM deter nined that the heat shrink did not properly cover the socket terminals and that extra solder and flux found at the base of the socket caused the tangs to short together. A CR was not -
initiated to document this event. EM inspected all other lights powered of 'he cem ;use and found no other deficiencies. A review to determine whether there v u any generic implications related to shorts being caused by the presence of extra flu,.snd solder was not performed.
On January 4, Reactor Core Isolation Cooling (RCIC) Turbine Exhaust Drain Control Valve 1E51-F004 lost indication due to a blown fuse while being operated remotely from the control room. Operations initiated MWR D73383 to document the event. EM determinea that the loss ofindication to this air operated valve was due to one of the light
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sockets shorting. After replacing both light sockets, the indication functioned as required.
No other actions were taken to determine the possible generic implications.
- On January 8, the indicating lights for Main Steam Line inboard Drain Valve 1821-F016 flashed intermittently while stroking the valve during PMT. Troubleshooting performed via MWR D75202 determined that the red light socket had grounded. The light sockets were replaced but the problem continued to exist. Further troubleshooting determined that the lights failed to function property due to being incorrectly wired during replacement.
Maintenance initiated CR 1-97-01-110 to document this event. After correcting the wiring deficiencies on this containment isolation valve, maintenance closed the CR without determining if there were any generic implications related to improper wiring of the light sockets.
On April 30, two failures occurred:
In the first failure, operations discovered that the indicating lights for Safety Relief Valve 1B21-F041B were not lit due to a blown fuse. This valve also performs an automatic depressurization system (ADS) function. Operations initiated MWR D73510 to document the occurrence but a CR was not written. While the specifics of what caused the failure were not given in the body of the MWR, EM stated that the socket for the green indicating light was replaced. Since the
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indicating lights worked property following the installation of the new socket, no other actions were taken to assess potential generic implications. The failure of the indicating lights had no effect on the ADS function since the indication has separate fuses within the valve's circuitry.
Second, the indicating lights for the Division 111 Emergency Diesel Generator (EDG) Heat Exchanger Outlet Valve 1SX006C failed due to a blown control power fuse. Operations initiated CR 1-97-01-236 and MWR D73549. EM determined that the socket for the green indicating light had grounded. Further inspection determined that the barrier between the A and 8 tangs for the green light socket had been melted which created a connection between the two tangs. After the light socket had been replaced and successfully passed PMT, both the MWR and CR were closed without assessing potential generic implications. The inspectors considered this failure to be significant because the failure of this valve to open during an EDG start could result in inadequate cooling water flow.
' On May 7, operations identified that the Division I Plant Service Water to Shutdown Service Water (SX) Cross Tie Valve 1SX014A did not have control room indication.
Maintenance documented the failure on MWR D73532 but no CR was written. EM determined that the failure was caused by a short of the green light socket which resulted in a blown control power fuse. Following the repair of the light socket, no other actions were taken to assess potential generic implications. The failure of the indicating lights for this valve was considered significant because failure of the valve to full close prevents the Division i SX Pump from starting.
On May 9, two failures occurred:
First, the indicating lights for Residual Heat Removal (RHR) Heat Exchanger Outlet Valve 1E12-F003A failed due to a blown control power fuse. Maintenance
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I documented the failure in MWR D75361 and CR 1-97-05-099. Troubleshooting.
determined that both the red and green lamps were shorted. After the sockets
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retum wd.er to the reactor vessel after being cooled by the heat exchanger could have been effected.
Second, the indicating lights for Drywell Chiller Isolation Valve 1SX020A incorrectly energized when stroking the valve during PMT (red light came on when valve was shut). Oprations documented this problem in MWR D75360 and CR 1-97-05-138. Work performed under the MWR determined that the light socket had been mis-wired. After the wiring was corrected, both the MWR and CR were closed without assessing potential generic implications. The inspectors -
considered this failure to be significant since the failure of this valve to close during an event could result in cooling water being diverted from safaty related equipment.
On May 10 and 16, the indicating lights for the Low Pressure Core Spray (LPCS) Injection f:>hutoff Valve 1E21-F005 failed due to a blown control power fuse (one failure during PMT and one after). This failure caused the valve to stop in an intermediate position.
- MWR D73534 was used to investigate the cause of the failure in both cases but a CR was not written. In the first failure, EM stated that the socket connections appeared dirty and cleaned the connections as necessary. Following the cleaning, the indications -
worked property. In the second failure, the light sockets were replaced even though no apparent problems were found. Since the lights functioned property after the sockets were replaced no additional actions were taken. These failures were significant since the LPCS system may not have been able to deliver the required flow to the reactor vessel when needed.
On May 14, the indicating lights for RCIC Test Retum Valve 1E51-F059 smelled bumt.
The original MWR used to replace the light socket (D75223) was used to investigate the cause of the bumt smell but a CR was not written. Troubleshooting determined that an are had formed over the barrier between the two tangs which shorted out the light.
Again, the light socket was replaced and no further actions were taken to assess potential generic implications.
On May 21, the indicating lights for the Main Steam Line "C" Downstream Drain Valve 1821-F066C failed from a standby condition due to a blown control power fuse.
Operations documented the failure via MWR D75275 but no CR was written. Notes written by EM within the body of the MWR stated that the tangs on the red indicating light socket appeared to be soldered together. No action was taken after the socket was replaced to assess potential generic implications.
On May 28, the amber light socket for the RCIC Water Leg Pump 1E51-C003 failed during PMT due to a blown control power fuse. EM used the original MWR (D75223) to investigate the failure but a CR was not written. EM determined that an arc between the socket's terminals created a short.- No further actions were taken after EM replaced the light socket to assess potential generic implications.
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On May 29, two failures occurred. One indicating light for both the Reactor Water -
Cleanup (RT) Retum Une Outboard Isolation Valve 1G33-F039 and the RT to Condenser Outboard isolation Valve 1G33 F034 failed while being remotely operated from the main control room due to blown fuses in their respective control power circuits. Operations -
Initiated MWRs D72875 and D75372 and CRS 1-97-05-322 and 1-97-05-355 to document each failure. In each case; a short had caused the sockets to fail. After the sockets were repaired, the CRS were closed without assessing the potential generic implications. The inspectors considered the failures to be significant since the failures could have resulted
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On May 29, the inspectors questioned the assistant plant manager-maintenance to determine the cause of the multiple failures and the extent of corrective actions.
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On June 2, the EM supervisor initially informed the inspectors that only 9-neon indicating lights out of the approximately 400 tested had failed following PMT. The supervisor admitted that the rework rate for the neon light replacement was higher than the 2% site goal; however, he felt that the percentage of post PMT failures was statistically insignificant. The inspectors explained that the post PMT failures were significant because they resulted in operators being unable b operate safety related components.
Following this discussion, the EM supervisor stated that he would look further into the inspectors questions conceming any relationship between the failures.
On June 2, the other indicating light for the RT Retum Line Outboard isolation Valve 1G33-F039 failed while being remotely operated from the main control room due to a
~ blown control power fuse. MWR 75373 and CR 1-97-06-023 were written to document this failure. The socket was repsired and the CR remained open pending resolution of the neon light failure issue. This CR was also being used to track the corrective actions for the failures which occurred on May 29. The inspectors considered this failure to be significant since it could have resulted in a containment isolation valve being unable to perform its safety function.
10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures shall be established to assure that significant conditions adverse to quality are promptly identified, the cause of the condition is determined, and that corrective actions are taken to preclude repetition. The inability of individuals in operations, maintenance, and management to recognize the multiple failures of safety related components as a significant condition adverse to quality demonstrated a lack of ownership of the facility and a poor questioning attitude. The failure to identify, determine the root cause, and preclude repetitive occurrences is considered an apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI (eel 50-461/97020-01).
All but one of the CRS were closed without determining the effect the neon light indicating
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failures had en the ability of equipment to perform its safety function. In late May, control room operators informed the inspectors that they were concemed about the increased number of light failures and the lack of aggressive action by Clinton management to resolve the failures. Although operations was concemed, they also failed to take aggressive actions to address the failures. This lack of action demonstrated a willingness by the operations staff to accept substandard workmanship and degraded equipment.
Additionally, the inspectors noted that significant involvement by the NRC was required to prompt the licensee to review the multiple component failures.
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l Control of Flux On June 6, mt.intenance planning determined that the soldering flux (Stock Code IPNXE30070) used to install the tangs of the neon light assemblies was conductive, corrosive, and not intended for electrical applications. Based unon this determination, EM performed as found continuity and megger tests which identified that the soldered connections for 50% of the light sockets tested were unsatisfactory.
The inspectors reviewed the licensee's program for determining the limitations for chemicals / materials and found it to be inadequate. The inspectors noted that tne determination of chemical restrictions was difficult in that the method used to determine the limitations was contained in procurement procedures not typically referenced by maintenance. For e ;mple, procedure CPS 1019.00, " Control of Chemicals," Revision 9, directed maintenance individuals to refer to the material management information system (MMIS) when determining possible chemicallimitations. MMIS information for this flux stated that it was to be used in applications previously approved by engineering per procedure NSED instruction FE-5, " Procurement / Materials Engineering (P/ME) Review of Purchase Requisitions." The approved applications were provided in NSED Review
- 40111. The inspectors determined that NSED Review #40111 was weak in that it approved this flux for " general plant use" without specifying that it should not be used on electrical components ln addition, no tneasures were established to ensure that the determinhtion of limiMlans for chemicals was appropriate.
10 CFR Part 50 Appendix B, Criterion XV, " Nonconforming Materials, Parts, or Components," 4tates that measures shall be established to control materials which do not conform to requirements in order to prevent their inadvertent use or installation. The failure to establish measures to ensure that specific limitations associated with the use of flux were identified to prevent the inadvertent use on safety related electrical components is considered an apparent vlotation of 10 CFR Part 50, Appendix B, Criterion XV (eel 50-461/97020-02).
The inspectors also identified that the definition of" general plant use" was not clearly understood by maimenance personnel due to the definition being excluded from maintenance procedures. Maintenance depertment individuals believed that items approved for ' general plant use" could be used anywhere in the plant without performing any additional review of chem!callimitations. NSED instruction FE-5,
" Procurement / Materials Engineering (P/ME) Review of Purchase Requisitions,"
Revision 8, Attachment FE-5-1, defined general plant use as those chemicals or materials which are allowed to be installed only when the use of the item in the application is verified on an approved design document. The inspectors determined that the improper use of flux would have occurred even if maintenance had understood the definition of general plant use due to the weaknesses in NSED Review #40111.
However, confusion regarding the definition of * general plant use' resulted in the control of this flux being informal and untraceable.
Conduct of Maintenance Activities Procedure CPS 1501.02, " Conduct of Maintenance " Revision 18, Step 2.2.24, lists soldering as a toolbox skill (e.g., a toolbox skillis a standard industry practice that does not normally require a job step, instructions, or an approved procedure to be in hand
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while performing the skill). The inspectors reviewed the maintenance activity records of four of the sixteen electricians that performed the neon light indicating replacement.
Three individuals had only performed one other soldering activity since joining EM in 1988,1990, and 1992 respectively. The remaining individual had performed five soldering jobs since joining EM in the early 1980's.
Not only was soldering rarely performed by tha electricians, but training provided to them significantly differed from the training provided to the controls and instrumentation (C&l)
technicians who normally perform hook and pierced tab terminal soldering tasks.
Specifically, the s I ctricians attended one training seminar which described how to perform basic rosin core soldering while C&l technicians attended nine different seminars which discussed severcl different types of soldering applications. In addition, maintenance management did not consider the impact of having less experienced electricians performing a task which required work to be performed in awkward positions.
The inspectors determined that maintenance management demonstrated poor oversight of the soldering activity in that they selected electricians that did not possess the requisite knowledge, skills, and abilities to perform the safety related task.
The MWR packages which govemed the neon indicating light replacement stated that the sockets were to be installed and terminated per procedure CPS 8492.04,"Non-Routine Terminations or Splices," Revision O. Steps 8.17.2.6 and.7 instructed electricians to solder the slip-t41 terminal to the wires and te the lamp socket terminal. No other instructions and no restrictions on solder were given. The inspectors determined that the guidance given in procedure CPS 8492.04 was inadequate in that it was not commensurate with the knowledge, skills, and abilities of the electricians performing the task. Specifically, the solder being used had a rosin core which precluded the need for additional flux and the technicians did not know that the flux being applied was not intended for use on electrical components due to the conductive and corrosive nature of the material.
10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings,"
states, in part, that activities affecting quality shall be prescribed by documerited instructions and procedures appropriate to the circumstances. The failure to provide appropriate instructions and procedures regarding the soldering of neon indicating light sockets which were commensurate with the knowledge, skills, and abilities of the technicians is considered an apparent violation of 10 CFR Part 50, Appendix B, Criterion V (eel 50-461/97020-03).
Corrective Actions As part of Licensee Event Report 97-015, issued on July 9,1997, the licensee performed an assessment of the safety consequences and implications of this event. The assessment stated that the event was safety significant since it resutted in multiple safety related systems being unable to perform their safety functions if needed. The affected systems included RHR, LPCS, SX, RCIC, EDGs, high pressure core spray, reactor recirculation, main steam, and control rod drive. Of these systems, SX, RCIC, LPCS, main steam, and the Division lli EDG experienced actual failures.
In response to the event, the licensee initiated a root cause evaluation performed by the independent Analysis Group (IAG). The IAG determined that the failures occu.ved due to
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a lack of control of flux material and poor workmanship. Corrective actions included retraining EM on soldering techniques, evaluating whether the guidance provided in CPS 8492.04 was adequate to perform soldaring tasks, updating the chemical restrictions for the solder flux on the MMIS screen, planning to establish a method of trending PMT failures, placing the definition of general plant use into a maintenance procedure, and
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improving controls goveming the use of flux.
The inspectors noted that the root cause evaluation was an improvement from previous evaluations, however, it lacked information in three areas. Fiist, the IAG determined that the reason that the high number of failures was not identified earlier was due to the failure to write CRS when failures occurred. However, the root cause did not determine why operations, maintenance, and plant managemont did not recognize the significance of the component failures. The inspectors consideted this item to be significant in that substantial NRC involvement was required prior to the initiation of corrective actions.
Second, the corrective actions stated that the maintenance shops were searched for additional uncontrolled chemicals and uncontrolled flux was removed. However, other actions to ensure that additional uncontrolled materials had not been used were not taken. On August 7, the inspectors leamed that the IAG was performing a root cause evaluation on the control of consumables in response to the NRC's identification of improper control of lubricants in February 1997 (NRC Inspection Report 97003). The inspectors noted that no actions were taken to identify a root cause for the use of uncontrolled consumable material until August 1997. Even though the NRC identified a laen of consumable material controlinvolving lubricants in February 1997 and the licensee identified of a lack of consumable material controlinvolving flux in June 1997.
The inspectors determined that management demonstrated poor ove91ght of the corrective action program in that a delay of several months occurred prior to the initiation of efforts to determine the causes fer the inadequate control of consumables.
Third, while the root cause identified that the understanding of general plant use was different between maintenance and procurement, the root cause did not identify that the NSED Review for the soldering flux performed in accordance with FE 5 lackeo the appropriate information. During the licensee's review of this event, procurement engineering revised NSED Review #40111 to clearly delineate the limitations associated with the soldering flux used in the neon indicating light replacement activity. In addition, NSED documentation for other soldering fluxes was reviewed to ensure that the limitations for use were clearly specified.
All 592-light sockets had been replaced by the conclusion of the inspection period.
Maintenance planning reviewed all open and closed maintenance work peckages and determined that the flux may have been used when repairing a containment penetration for Source Range Monitor (SRM) "B" and eleven solid state trip devices (SSTDs)
associated with 480V circuit breakers. The SRM connectian and the SSTDs were repaired. A review of work packages which used other types of soldering flux determined that a flux which was corrosive in nature may have been used duriag maintenance performed on another portion of SRM *8" and on the cables / connections for several intermediate range monitors (IRMs). Due to the lack of identified problems with these components, the licensee was reasonably assured that the equipment would continue to function properly. However, MWRs were initiated to inspect, and replace as necessarv, the additional SRM cable and the IRM cables / connections by December 31,1997.
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^onclusions Management conservatively decided to replace 592 neon indicating lights following the licensee's noentification of different confiprations for control room panelindicating light sockets.
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One apparent violation was identified for the failure to impiement the corrective action program. The failure to recognize the significance of multiple failures of safety-related components and take prompt and effective corrective actions demonstrated a lack of ownership in the facanty, a poor questioning attitude, and a willingness to accept substandard workmanship by operations, maintenance, and management.
A second apparent violation was identified for the failure to propeny control consumable materials. Management demonstrated poor oversight of the corrective action program in that the initiation of efforts to determine causes forinadequate control of consumable materials were delayed until August 1997, even though deficiencies were noted in February and June 1997.
A third apparent violation was identified for the failure to provide procedural guidance appropriate to the circumstances which were commensurate with the knowledge, skills, and abilities of personnel performing neon indicating light replacement activities. The assignment of inexperienced electrie".ns to perform a soldering activity demonstrated poor oversight by maintenance manal,ement.
While the root cause evaluation for this event was an improvement, it did not address poor management oversight, the continued use of uncontrolled consumable materials, or the poor quality of engineering evaluations.
MB Miscellaneous Maintenance issues (92903)
MB.1 (Closed) URI 50-461/97011-10: Failure to identify and trend material condition deficiencies identified in maintenance work requests. As discussed in Section M1.1 of this report, the inspectors identified that the licensee was not effectively identifying material condition deficiencies identif;ed in MWRs and documenting them via the corrective action program. The correc tive actions for degraded safeh-related breakers will be reviewed during the closure of NRC Violation 50-461/97003-01.
V. Manaaement Meetinas X1 Exit Mocting Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection period on August 29,1997. The licen ee acknowledged the findings presented.
The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was ideritified.
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INSPECTION PROCEDURES USED IP 62707:
Maintenance Observation IP 71707:
P; ant Operations IP 92903:
Followup-Maintenance IP 37551:
Engineering Observations ITEMS OPENED, CLOSED, AND DISCUSSED Opened 50-461197020-01 eel failure to implement effective corrective actions 50-461/97020-02 eel failure to provide controls for consumable materials 50-461/97020-03 eel failure to ensure procedures are commensurate with knowledge, skills, and abilities of personnel Closed
50-461/97011-10 URI Failure to identify and trend material condition deficiencies identir:ed M maintenance work requests
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PERSONS CONTACTED Ucensee J. Cook, Senior Vice President
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W. Romberg, Assistant Vice President P. Yocum, Manager-Clinton Power Station D. Thompson, Manager-Nuclear Station Engineering Department L Wigley, Assistant Manager-Nuclear Station Engineering Department R. Phares, Manager - Nuclear Safety and Performance improvement J. Palchak, Manager - Nuciear Training and Support G. Baker, Manager-Quality Assurance J. Gruber, Director - Corrective Action
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D. Wood, Director - Plant Radiation and Chemistry B. Joyce, Assistant Plant Manager-Maintenance M. Lynn, Assistant Plant Manager-Operations J. Hale, Director - Planning & Scheduling
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LIST OF ACRONYMS ADS Automatic Depressurization System C&l Controls and Instrumentation CR Condition Report EDG Emergency Diesel Generator EM Electrica. Maintenance IAG Independent Analysis Group LPCS Low Pressure Core Spray MMIS Material Management Information System MWR Maintenance Work Request
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NRC Nuclear Regulatory Commission NSED Nuclear Station Engineering Department PDR Public Document Room PMT Post Maintenance Testing RCIC Reactor Core Isolation Cooling RHR Residual Heat Removal RT Reactor Water Cleanup SRM Source Range Monitor SSTD Solid State Trip Device SX Shutdown Service Water
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