IR 05000461/1998011
| ML20237D401 | |
| Person / Time | |
|---|---|
| Site: | Clinton |
| Issue date: | 08/07/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20237D399 | List: |
| References | |
| 50-461-98-11, NUDOCS 9808260140 | |
| Download: ML20237D401 (33) | |
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U.S. NUCLEAR REGULATORY COMMISSION
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l REGIONlli l
Docket No:
50-461
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License No:
NPF-62 Report No:
50-461/98011(DRP)
Licensee:
lilinois Power Company Facility:
Clinton Power Station
Location:
Route 54 West Clinton,IL 61727 Dates:
May 27 - July 10,1998 Inspectors:
T, W. Pruett, Senior Resident inspector K. K. Stoedter, Resident inspector C. E. Brown, Resident inspector D. E. Zemel, Illinois Department of Nuclear Safety Approved by:
Thomas J. Kozak, Chief
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Reactor Projects Branch 4
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9808260140 980807
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PDR ADOCK 05000461 j
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EXECUTIVE SUMMARY Clinton Power Station NRC inspection Report 50-461/98011(DRP)
This inspection included aspects of licensee operations, engineering, maintenance, and plant support. The report covers a 6-week period of resident inspection.
Operations The inspectors concluded that while reactor operators performed comprehensive control
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room panel walkdowns during shift tumover, oncoming senior reactor operators and shift managers performed cursory reviews of the control panels and did not examine all panels during shift tumovers. This may have contributed to performance problems involving identification of degraded or nonconforming conditions by control room personnel (Section O1.1).
One violation for which enforcement discretion was exercised was identified for the failure
to implement corrective actions in response to a long-standing, nonconforming condition involving excessive shut down service water flow to the residual heat removal heat exchanger bypass. Operations personnel did not challenge engineering personnel to seek a remedy for the condition (Section 01.2).
Operations personnel demonstrated improved command and control, appropriate
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prioritization of restoration activities, and good procedure adherence following a momentary loss of the emergency reserve auxiliary transformer (ERAT). The development of just-in-time training regarding electrical transients and plant response prior to an ERAT outage was considered a positive effort towards improving operator performance (Section 01.3).
The inspectors concluded that operations personnel responded well to the loss of three of
four offsite power sources during a storm. A Notice of Unusual Event was conservatively declared and safety system restoration was appropriately prioritized and accomplished in a reasonable timeframe (Section 01.4).
One example of a degraded condition affecting the calibration of control room indications
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was identified by engineering personnel but not brought to the attention of operations personnel. Consequently, an evaluation of the generic implications of uncalibrated instrumentation on continued plant operations was not initiated until prompted by NRC inspectors (Section O2.1).
Two examples of a violation for which enforcement discretion was exercised were
identified due to the failure to implement piocedures to perform required testing on the meteorological monitoring tower and a process radiation monitor prior to retuming the equipment to an operable condition. The failure to perform required surveillance prior to retuming equipment to service is a repeat of previous, similar issues at the station (Section O2.2).
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l One violation for which enforcement discretion was exercised was identified for the failure l
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to implement procedural requirements while performing troubleshooting activities on the I
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logic for the outboard main steam isolation valves (MSIVs) and on main control room i
panet P-680 (Section O2.3).
Eight days elapsed and inspector prompting was needed to initiate a condition report to
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document the repetitive failure of the outboard MSIVs to open during a monthly i
preventive maintenance task. Additionally, operations personnel did not recognize the l
failure of the MSIVs to open as a Technical Specification mode restraint until prompted by
the inspectors (Section O2.3).
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l One violation for which enforcement discretion was exercised was identified conceming I
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the failure of reactor operators to appropriately identify and resolve unusual trends in the shut down service water, reactor recirculation, and standby gas treatment systems during j
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l the performance of control room panel walkdowns (Section O2.4).
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Operations personnel conservatively directed an inspection of the Divisions I and il
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i emergency diesel generators (EDGs) following the discovery of fastener issues during the Division lli EDG outage (Section M1.3).
I Maintenance One violation for which enforcement discretion was exercised was identified concerning
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I the failure to ensure an adequate procedure was used during testing of the high pressure
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core spray discharge isolation valve. The inspectors concluded that some procedural adequacy and adherence problems continued to occur at the facility (Section M1.2).
One violation for which enforcement discretion was exercised was identified when the
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inspectors determined that corrective actions to address 4160 Vac circuit breaker testing problems were not applied to molded case circuit breakers (MCCBs). Specific MCCB test program deficiencies included: improper test cable size, not performing a low current instantaneous trip, excessive test current pulse length, excessive instantaneous test current, improper instantaneous trip times, preconditioning of breakers, not documenting valid test attempts, and not evaluating breaker coordination issues for failed breakers. In addition, the inspectors determined that the licensee did not effectively utilize industry
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information and experience even though it was involved in the Development of standard
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l industry guidance for testing of 480 Vac MCCBs (Section M1.4).
The inspectors observed two poor electrical maintenance work practices during testing of
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480 Vac MCCBs which involved the use of excessive torque on fasteners and improper use of megger test equipment (Section M1._4).
l Enaineerina The adequacy of information provided in engineering and operability evaluations was
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mixed. Engineering personnel provided an adequate basis for continued operation of the residual heat removal B and C water jeg pump. However, engineering personnel did not initially provide an adequate basis for the automatic transfer of the Division lit electrical safety bus or adequate assurance that a piece of copper tube was not located in the lube oil system of the Division l EDG (Section E2.1).
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Report Details Summary of Plant Status The facility remained shutdown during the inspection period. On June 28,1998, the licensee declared an Unusual Event at the discretion of the shift manager after receiving reports of damage to three of four offsite power sources. Major maintenance activities which occurred l
during the inspection period involved a Division lli outage and the continuation of degraded l
voltage modifications affecting the emergency reserve auxiliary transformer (ERAT) and the I
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reserve auxiliary transformer (RAT).
l. Operations
Conduct of Operations 01.1 Control Room Observations a.
Inspection Scope (71707)
The inspectors observed control room shift tumovers and manipulations of plant components, and reviewed station logs.
b.
Observations and Findinas Shift Turnover The inspectors observed that the oncoming and off-going reactor operators (ROs)
performed a thorough review of plant status including station logs, ongoing activities, and a discussion of plant indications and parameters on control room panels. The oncoming control room supervisors performed a limited, independent walkdown (less than 5 minutes) of control room panels prior to assuming watch standing responsibilities. The oncoming shift managers performeo a cursory, independent walkdown (less than 1 minute) of control room panels prior to assuming watch standing responsibilities. The shift technical advisors did not perform a walkdown of control room panels prior to assuming watch standing responsibilities. In response to the observation, operations oncoming relief personnel commenced performing walkdowns of control room panels with the off-going crew.
Station Logs The inspectors performed frequent reviews of station logs during the inspection period.
Most log entries were thorough in that they included the start and end time of Technical Specification (TS) required surveillance tests and annotated entry and exit into TS limiting conditions for operation. However, the documentation of plant conditions in station logs was poor on two occasions. Specifically, on June 9,1998, control room operators did not document issues associated with an off-scale high indication for SX flow in the station tog
(see Section 01.2). In addition, on June 11 and 12, operations personnel did not
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document the inability to open the outboard main steam isolation valves (MSIVs)
following the reset of the Group I isolation logic on three occasions (see Section O2.3).
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Peer Checks l
The inspectors noted the increased use of peer checks during the performance of switch manipulations in the main control room. In addition, personnel filling the newly created operations field supervisor position provided periodic peer checks of valve and switch manipulations performed by non-licensed operators.
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Conclusions The inspectors concluded that, while ROs performed comprehensive control room panel
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walkdowns during shift tumover, oncoming SRos and shift mcnagers performed cursory reviews of the control panels and did not examine all pansis during shift tumovers. This may have contributed to performance problems involving identification of degraded or nonconforming conditions by control room personnel.
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01.2 Abnormal SX Flow Indication a.
Inspection Scope (71707 and 37551)
The inspectors performed a review of SX flow to components following their observation of an off-scale high flow indication in the main control room.
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Observations and Findinas l
Residual Heat Removal (RHR) System Heat Exchanger Bypass Function l
The RHR heat exchanger bypass valves (SX173A/B) were installed prior to initial fuel load to provide minimum flow protection for the SX pumps (Division I and il SX pumps required 3,200 gpm minimum flow each for pump protection). Each bypass valve is interlocked with its respective RHR heat exchanger inlet and outlet valve such that SX173A/B open if the heat exchanger inlet and outlet valves are not full open.
Control Room Observation of SX Flow On June 3,1998, operations personnel started the Division l SX pump and aligned the i
system to the RHR heat exchanger bypass in support of a Division IV nuclear system protection system outage. On June 9, the inspectors observed an off scale high SX flow rate to the RHR heat exchanger (greater than 8,000 gpm). The control room supervisor was unaware of the abnormal flow indication and requested the assistance of the ROs.
The ROs initially stated that the high flow rate indication was due to the formation of back i
pressure on the flow orifice resulting from the system configuration (RHR heat exchanger l
inlet and outlet isolation valves closed and the RHR heat exchanger bypass valve open).
The inspectors considered the ROs reasoning for the indication invalid since back pressure on the flow orifice would reduce the differential pressure and cause the flow to indicate lowerinstead of higher.
Operations personnel stated that the SX flow typically indicated high when aligned to the l
RHR heat exchanger bypass. The inspectors questioned operations personnel on the l
validity of the indication, the affect on system operation if excess flow through the RHR heat exchanger bypass resulted in reduced flow to other loads cooled by SX (emergency
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diesel generators and room coolers), and the impact that an over-ranged instrument had on the calibration of the device in response to the inspectors' concem, operations personnel contacted engineering personnel for assistance in determining the validity and effect of the abnormal flow indication.
Engineering personnel calculated a flow rate of 14,000 gpm for the Division l SX pump and estimated that the flow rate through the RHR heat exchanger bypass was 12,000 gpm. Operations personnelinitiated Procedure Deviation for Revision (PDR) 98-0347 for Procedure 3211.01, " Shutdown Service Water," to shut the RHR heat exchanger bypass valve and open the RHR heat exchanger inlet and outlet isolation valves. PDR 98-0347 was necessary to ensure operability of SX loads pending further evaluation of tne affect of excess flow through the bypass on the ability to supply cooling water to other components.
On June 10, the licensee determined that the alignment of SX to the RHR heat exchanger
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bypass was reportable to the NRC in that the condition alone could have prevented the fulfilment of a system safety function needed to mitigate the consequences of an accident. Specifically, the RHR heat exchanger bypass line was incorrectly sized such that excessive flow rates through the bypass line could result should the RHR heat exchanger be bypassed with the SX pump in operation during accident conditions. In this configuration, inadequate cooling water flows to other safety components may exist such that proper operation of the components would not be assured. The inadequate flow condition would potentially exist on the Division I and ll systems due to the similar design.
Licensee Review of Abnormal SX Flow Indication During the review, the licensee noted that the abnormal SX flow indication had been previously identified, yet unresolved, on at least four occasions. Specifically:
l Comment Control Forms were submitted by the SX system engineer on June 23,
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1994, to add a caution to Procedure 3211.01 to warn of reduced flow to cornponents when SX was aligned to fuel pool cooling while bypassing the RHR
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heat exchangers.
l Engineering Work Request (EWR) 95-00025 had been written to address the high
bypass flow concern on January 25,1995. EWR 95-00025 specified that the SX173A/B valves bypassed approximately 2,000 gpm more than the RHR heat exchanger, which could invalidate the SX flow balance under certain configurations. The originator rnied that recommended procedure changes were inadequate to control system configuration and recommended two resolutions:
(1) limit the stroke of valves SX 173A/B to limit flow, or (2) install an orifice in the RHR heat exchanger bypass line to reduce flow. EWR 95-00025 was voided by the work review board on June 22,1995, and returned to the originator for further discussion with the system engineer.
On April 3,1998, engineering personnel initiated CR 1-98-04-047 to document a
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concem that the SX system had no surveillance to simulate overall flow j
capabilities of components for a loss of offsite power (LOOP) or loss of coolant j
accident (LOCA). Additionally, engineering personnel determined that the last flow balance was performed in 1990 for a LOO.VLOCA condition and not the
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worst case LOOP condition. Recommended corrective actions included performing a flow balance test and revising applicable calculations. The
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j inspectors noted that the operability assessment for Mode 4 conditions did not include the impact of aligning SX to the RHR heat exchanger bypass.
On May 18,1998, engineering personnelinitiated contingency maintenance work
requests (MWRs) D85536 and D85537 to install orifices in the RHR heat exchanger bypass line if required to support potential adverse results of the SX flow balance.
Criterion XVI of Appendix B to 10 CFR Part 50 requires that in the case of significant t
conditions adverse to quality, measures shall assure that the cause of the condition is determined and corrective actions taken to preclude repetition. The failure to implement
corrective actions to resolve concerns regarding excessive SX flow through the RHR heat l
exchanger bypass and the effect on other loads cooled by SX is considered a violation of 10 CFR Part 50, Appendix B, Criterion XVI. However, because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions"(Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-01).
Corrective Actions At the end of the inspection period, the licensee was performing engineering calculations to assess the effect of RHR heat exchanger bypass flow on components cooled by SX.
Additionally, the following corrective actions were being implemented or planned:
(1) processing of a design change to restrict bypass flow; (2) performing an SX system flow balance; (3) improving communications between the engineering and operations departments; (4) reviewing evaluations used to clear mode restraints that have not had operability determinations; (5) reviewing EWRs to ensure items with operability impacts were not voided; (6) reviewing operating procedures for work arounds; (7) reviewing CRs from the system design and functional validation (SDFV) evaluation that were not listed as a mode restraint; and (8) reviewing the mode restraint list to ensure MWRs used to clear mode restraints were actually performed and not canceled. The inspectors determined that the completed and planned corrective actions should be adequate to resolve the concems associated with SX system flow.
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Conclusions One violation was identified for the failure to implement corrective actiors ir. response to a long-standing, nonconforming condition involving excessive SX flow to the RHR heat exchanger bypass. Operations personnel did not challenge engineering pernnnel to seek a remedy for the condition.
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01.3 Momentary Loss of ERAT Durina Thunderstorm a.
Inspection Scope (93702)
The inspectors observed operations personnel respond to a momentary loss of the ERAT.
b.
Observations and Findinas On June 16,1998, at 5:54 a.m., the 138kV supply to the ERAT was momentarily lost when two breakers on the Illinois Power distribution system tripped due to a ground fault.
Although the breakers automatically reclosed within one second, the loss of voltage condition was of a sufficient duration to cause the Division lll 4160V safety bus to transfer from the ERAT to the RAT and the loss of several systems and components. All effected systems and components were restored within 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />.
The control room supervisor demonstrated good command and control throughout the event as evidenced by the continuous assessment of plant conditions and the re-evaluation of system restoration priorities. In addition, the inspectors noted that all members of the operations crew property adhered to procedures during the event.
However, only one control room briefing was held during the approximately 70 minutes the inspectors were present in the main control room. The inspectors discussed the lack of briefings with the Director of Operations following the event and were informed that he had provided feedback on poor communications to the shift manager during the event who, in tum, prompted the control room supervisor to hold additional briefings.
The operations department developed two initiatives in response to the event.
Operations requested that engineering personnel perform a post-event review in accordance with Procedure 4041.01, " Post-trip Review." The results of this review determined that all systems and components functioned as designed (see Section E2.1).
In addition, the Director of Operations planned to develop just-in-time training to improve each operator's familiarity with electrical transients and component response. The inspectors considered the implementation of just-in-time training a positive effort in improving operator performance and preparing the department for possible transients
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which may occur during an ERAT outage scheduled for mid-July.
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Conclusions Operations personnel demonstrated good command and control, appropriate prioritization of restoration activities, and good procedure adherence following a momentary loss of the ERAT. The development of just-in-time training regarding electrical transients and plant response prior to an ERAT outage was considered a positive effort towards improving operator performance.
l 01.4 Notice of Unusual Event a.
Inspection Scope (93702)
The inspectors responded to the site following the licensee's declaration of a Unusual Event on June 29,1998.
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b.
Observations and Findinas On June 29,1998, at 5:06 p.m., Clinton Power Station experienced high wind conditions which resulted in the loss of three of four off-site power sources within 26 minutes.
Specifically, the facility lost the 138kV feed, the 345kV Latham feed, and the 345kV Rising feed. The 345 Brokaw feed remained connected to the facility via the reserve auxiliary transformer and a main power transformer back-feed lineup to the nonsafety busses. The loss of the 138kV cff-site source resulted in a transfer of the Division I and ll safety related 4160 VAC busses from the ERAT to the RAT. The transfer of the 4160 VAC busses resulted in a loss of the shutdown cooling mode of RHR, fuel pool cooling, and various ventilation systems. Because of the back-feed line-up, the reactor water cleanup system remained energized during the event and maintained core circulation. No appreciable rise in reactor coolant temperature was noted and the facilities electrical system responded as designed.
l At 7:08 p.m., the shift manager conservatively declared an Unusual Event after receiving reports of damage on the 138kV line and two of the three 345kV lines.. At 8:05 p.m.,
operations personnel restored the shut down cooling mode of RHR. On June 30, at 2:04 a.m., operations personnel restored fuel pool cooling. No appreciable rise in fuel pool temperature occurred as a result of the loss of fuel pool cooling prior to its restoration. At 8:42 p.m., an additional 345kV offsite power source was restored. At 10:20 p.m., the licensee exited from the Unusual Event due to having two reliable offsite power sources, c.
Conclusions
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The inspectors concluded that operations personnel responded well to the loss of three of i
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four offsite power sources during a storm. A Notice of Unusual Event was conservatively
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declared and safety system restoration was appropriately prioritized and accomplished in l
a reasonable timeframe.
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O2 Operational Status of Facilities and Equipment O2.1 C_alibration of Control Room Instrumentation a.
Inspection Scope (71707)
The inspectors reviewed the circumstances surrounding the emergency core cooling system (ECCS) motor current indications not being properly calibrated.
b.
Observations and Findinas During the review of the abnormal SX flow indication (see Section 01.2), the inspectors were informed by engineering personnel that CR 1-98-04-066 had been initiated during the system design and functional validation (SDFV) effort on April 3,1998, due to ECCS motor current indications not being calibrated. Specific ECCS pumps listed in the CR included SX, RHR, low pressure core spray (LPCS), and high pressure core spray (HPCS). Engineering personnelinitially determined that although the failure to maintain the instruments had a negative effect on overall system reliability, the calibration of these instruments was not considered to impact system operability or functionality.
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CR 1-98-04-066 noted that: (1) the SX system operating procedure required checking of the ammeter indication during system actuation, but did not specify a quantitative limit; l
(2) the precautions section of the RHR system operating procedure mentioned the use of the ammeter to detect blockage of the pump suction strainer; and (3) neither the LPCS l
nor HPCS system operating procedures referenced the ammeter.
l l-On June 16,1998, the inspectors reviewed CR 1-98-04-066 and noted that no action had been taken to resolve the issue and that operations personnel had not been informed of the condition by engineering personnel. Consequently, an evaluation of the generic implications of uncalibrated instrumentation on continued plant operations by on-shift operations personnel was not performed.
On June 17,1998, the inspectors discussed CR 1-98-04-066 with the operations shift manager. Following the discussion, the shift manager initiated operability determination OD 1-98-04-066 to evaluate the impact of the ECCS motor current: indications not being calibrated. Operations personnel concluded that the ammeters are one of many -
indications (annunciators, flow, computer display, or field operators) used by operators to determine if an ECCS pump is operating properly. At the end of the inspection period, the licensee was performing a review to determine the extent and generic implications of uncalibrated instrumentation in the main control room.
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Conclusions One example of a degraded condition affecting the calibration of control room indications was identified by engineering personnel but not brought to the attention of operations personnel. Consequently, an evaluation of the generic implications of uncalibrated instrumentation on continued plant operations was not initiated until prompted by NRC inspectors.
02.2 Components Declared Operable Prior to Completion of Surveillance a.
Inspection Scope (71707 and 61726)
The inspectors reviewed the sequence of events regarding retuming the meteorological monitoring tower and a process radiation monitor to an operable status prior to completing the required surveillance.
b.
Observations and Findinas Meteorological Monitoring Tower On June 18,1998, at 8:50 p.m., operations personnel declared the meteorological monitoring tower inoperable due to a lightening strike. The operating crew initiated maintenance work request (MWR) D83641 to troubleshoot and repair the meteorological monitoring tower and appropriately entered ORM Operating Requirement 2.2.8 which required the meteorological monitoring tower to be restored to an operable status within 7 days.
On June 19, maintenance personnel performed repairs on the meteorological monitoring tower and returned the MWR to the on-shift operations crew to perform a
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post-maintenance channel check. By 11:09 a.m., operations personnel had performed a channel check, retumed the meteorological monitoring tower to an operable status, and cleared the restraint against ORM 2.2.8. At 10:50 p.m. the same day, operations personnel identified that ORM Testing Requirement (TR) 4.2.8.1 had not been satisfied prior to retuming the meteorological monitoring tower to service and initiated CR 1-98-06-252. The meteorological monitoring tower was again declared inoperable and the appropriate testing was performed within 40 minutes.
The inspectors determined that poor implementation of ORM requirements and poor communications contributed to this event. Originally, operations management believed that the channel check performed by operations personnel met the intent of ORM TR 4.2.8.1, but that the required paperwork had not been completed prior to declaring the meteorological monitoring tower operable. Discussions with a shift manager the following day indicated that operations personnel failed to recognize that ORM TR 4.2.8.1 required that a channel check be performed using the. data acquisition modules for the area radiation and process radiation (AR/PR) system as described in Procedure 9911.24, "AR/PR Shiftly/ Daily Surveillance." In addition, operations personnel did not communicate with the AR/PR operator prior to returning the meteorological monitoring tower to an operable status. Due to the poor communications, one of the barriers in place to identify the need to perform Procedure 9911.24 was circumvented.
Technical Specification 5.4.1.a requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures
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recommended in Regulatory Guide (RG) 1.33, Revision 2, Appendix A, February 1978.
j RG 1.33, Revision 2, Appendix A," Typical Procedures for Pressurized and Boiling Water Reactors," Section 7, recommends procedures for radiological and meteorological f
monitoring. The failure to implement procedures for radiological and meteorological monitoring prior to returning the meteorological monitoring tower to service as required by ORM TR 4.2.8.1 is considered a violation of TS 5.4.1.a. However, because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions"(Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-02a).
Process Radiation Monitor On June 23, the operations department identified another example in which a process radiation monitor was declared operable and the restraint against ODCM requirement 3.9.2, " Radioactive Gaseous Effluent Monitoring Instrumentation," was cleared prior to reviewing the surveillance performed as part of the post-maintenance testing for potential operability impacts. The operations department initiated CR 1-98-06-275 to document the premature retum of station HVAC exhaust process radiation monitor OPR002 to an operable status.
l Technical Specification 5.5.1 requires, in part, that pmgrams and manuals for the ODCM be established, implemented, and maintained. The failure to implement procedures for process radiation monitor OPR002 prior to returning the monitor to service as required by ODCM 3.9.2 is considered a violation of TS 5.5.1 and is an additional example of retuming equipment to service prior to completing required surveillance. However,
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because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions"(Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-02b).
The examples mentioned above were considered for possible discretion under Section Vll.B.1 of the Enforcement Policy. However, these items were considered repetitive examples of the failure to meet TS requirements and corrective actions for the previous incidents should have prevented these occurrences and therefore, Section Vll.B.1 of the policy did not apply.
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Conclusions Two examples of a violation were identified due to the failure to implement procedures to perform required testing on the meteorological monitoring tower and a process radiation monitor prior to returning the equipment to an operable condition. The failure to perform required surveillance prior to returning equipment to service is a repeat of previous, similar issues at the station.
02.3 Failure to Utilize Troubleshooting Procedures a.
Inspection Scope (71707. 62707. and 37551)
The inspectors reviewed the actions taken by operations, engineering, and maintenance personnel during the performance of troubleshooting activities.
b.
Observations and Findinas Failure of the Outboard MSIVs to Open On June 11,1998, operations personnel attempted to reset the Group 1 isolation logic for the MSIVs and open the outboard MSIVs as part of a monthly preventive maintenance task on two separate occasions. During each attempt, the MSIVs failed to open. Since operations personnel believed that the MSIVs failed to open due to plant conditions, they decided that engineering support to investigate the failures, documentation of the failures in the control room logs, and the initiation of a corrective action document was not needed.
On June 12, operations personnel tried to open the outboard MSIVs a third time. Again, the MSIVs failed to open. Following the third failed attempt, operations personnel requested assistance from the engineering response team (ERT) and a member of the fix-it-now (FIN) team in determining the cause of the MSIVs failing to open. The ERT and FIN team personnel performed a system diagnostic on the logic trains for the outboard MSIVs and identified no deficiencies. When the ERT member asked the operations crew to attempt to reset the Group 1 isolation logic and open the outboard MSIVs, the valves opened. Although operations, engineering, and FIN team personnel were unable to l
explain what had caused the outboard MSIVs not to open on three previous occasions, a control room log entry was not made and a corrective action document was not generated to record the failures.
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The inspectors reviewed the troubleshooting performed by the ERT and FIN team personnel and identified that the impact of the troubleshooting was not reviewed and approved by the workmen, the work authority, and the Shift Manager / Control Room Supervisor prior to performing troubleshooting activities as required by Step 2.1.1 of Procedure 8170.06," Maintenance Troubleshooting." In addition, the results of the troubleshooting were not documented. The inspectors discussed the lack of procedure usage with the maintenance manager since this was the second example of a failure to j
follow the troubleshooting procedure identified within a 6-week period and the third i
example in the last 4 months. In response to the inspectors concems, maintenance personnel initiated a level 2 CR (1-98-06-347) and the maintenance manager held a meeting with the maintenance supervisors to review the procedural requirements and j
management expectations regarding troubleshooting. The inspectors also noted that operations personnel demonstrated poor plant ownership when they failed to ensure that i
the troubleshooting was performed in accordance with a procedure and that the scope of
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the troubleshooting was understood prior to commencing troubleshooting activities.
Troubleshooting on Main Control Room Panel P-680 The inspectors determined that the meeting held by the maintenance manager was not fully effective since another maintenance crew was observed performing troubleshooting that was not in accordance with the troubleshooting procedure approximately 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> later. Specifically, operations personnel requested controls and instrumentation personnel to perform troubleshooting to determine the cause of a ground on main control room panel P-680 prior to the impact of the troubleshooting activity being fully reviewed and understood by the workmen, the work authority, and the Shift Manager / Control Room Supervisor. The inspectors discussed this observation with the responsible maintenance supervisor and leamed that information provided in the meeting was not communicated to the mid-shift maintenance crew, therefore, they were not aware of the expectations regarding troubleshooting.
I Technical Specification 5.4.1.a requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in RG 1.33, Revision 2, Appendix A, February 1978. RG 1.33, Revision 2, Appendix A, Section 9, recommends procedures for performing maintenance activities.
The failure to implement the provisions of the licensee's maintenance troubleshooting procedure during MSIV and main control panel troubleshooting is a violation of TS 5.4.1.a. However, because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-03). The lack of procedural adherence within the maintenance department has been the subject of several NRC 0350 Panel meetings, therefore, this issue will continue to be reviewed as part of the NRC's 0350 Panel oversight of licensee improvement initiatives.
One week after the initial failure of the outboard MSIVs to open, the inspectors questioned engineering personnel regarding the initiation of a CR to document the failure.
Engineering personnel informed the inspectors that they were working with the operations department to ensure that a CR was initiated. The inspectors prompted several
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individuals within the engineering and operations depa iment regarding the initiation of a CR. The time delay and the need for inspector prompting to ensure that a CR was initiated demonstrated poor commitment to the implementation and execution of the corrective action program by the operations and engineering departments.
Eight days following the initial MSIV failure, the Director of Operations informed the inspectors that a CR was written to document the failure. The inspectors questioned the Director on why the failure of the MSIVs to open was not considered a mode restraint since the cause of the failure was indeterminate. After further review, operations personnel agreed with the inspectors assessment, declared the outboard MSIVs (
inoperable, and entered the appropriate TS mode restraint.
c.
Conclusions l
The inspectors identified one violation for the failure-to implement procedural
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requirements while performing troubleshooting activities on the logic for the outboard MSIVs and on main control room panel P-680.
l Eight days elapsed and inspector prompting was needed to initiate a CR to document the
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repetitive failure of the outboard MSIVs to open during a monthly preventive maintenance task. Additionally, operations personnel did not recognize, the failure of the MSIVs to open as a TS mode restraint until prompted by the inspectors.
i O2.4 Monitorina of Main Control Room Indications a.
Inspection Scope (71707)
i The inspectors questioned operations personnel to determine their awareness of control l
room indications, b.
Observations and Findinos During a control room tour on June 19,1998, the inspectors questioned an on-shift RO
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regarding the indication provided for the two reactor recirculation (RR) pumps.
J Specifically, the main control room computer screen indicated that both RR pumps were
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running even though the system was tagged out of service. The RO checked the j
computer points which monitor the status of the RR pumps and determined that the
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computer points were reading correctly. -The RO then contacted a computer maintenance l
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technician who recommended rebooting the computer; however, th] indications did not
change. The RO then informed the inspectors that he would initiate an MWR for each j
RR pump indication to capture the problem within the corrective action program. On l
July 6, the inspectors were informed that the indications for both RR pumps were
incorrect due to an equipment tagout on the system.
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On June 22, the inspectors questioned an on-shift RO regarding the control room
indications for the standby gas treatw.:nt system (VG). Specifically, the inlet flow for l
VG train "A" was indicating 900 cfm even though the train was not in operation.
l Operations personnel told the inspectors that the VG inlet flow meter was reading incorrectly due to the installation of test equipment; however, this was not verified while the inspectors were present in the control room. Approximately 4 days later, the
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l inspectors questioned operations personnel to determine when the test equipment would be removed from VG "A" and learned that test equipment was not currently installed on the system. Operations personnel later determined that the incorrect inlet flow indication j
l was likely due to an out of calibration instrument. An MWR was written to perform the calibration and a caution tag was placed on the indication.
The inspectors determined that the performance of panel walkdowns to identify deficient conditions and maintain operator awareness of control room indications was not alNays effective in that operations personnel either failed to identify and/or question abnormal conditions. Technical Specification 5.4.1.a requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures l
recommended in RG 1.33, Revision 2, Appendix A, February 1978. RG 1.33, Revision 2, l
Appendix A, Section 1, recommends procedures describing the authorities and responsibilities for safe operation and shutdown. Procedure 1401.01, " Conduct of
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Operations," Steps 8.1.5.4f and 8.1.7.7d required that the control roomsupervisor and
~the ROs monitor cathode ray tubes, indicators, annunciators, and recorders in order to detect unusual or abnormal trends and initiate appropriate, timely action to correct or l
. mitigate the situation. The failure to detect unusual trends in the SX (see Section 01.2),
VG, and RR systems is considered a violation of TS 5.4.1.a. However, because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During
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Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and I
Procedures for NRC Enforcement Actions"(Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-04).
As a result of the inspectors concems, the Director of Operations held additional
meetings with the operations staff to discuss the need for improved awareness of main
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control room indications by all members of the operating crew. As a result of these
. meetings, operations personnelidentified in excess of 50 new main control room deficiencies within a 2 week period.
c.
Conclusions One violation for which enforcement discretion was exercised was identified concerning the failure of reactor operators to appropriately identify and resolve unusual trends in the-emergency service water, reactor recirculation, and standby gas treatment-systems during the performance of control room panet walkdowns.
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Miscellaneous Operations issues (92901)
08.1 fClosed) Violation 50-461/96412-01: Operators Failed to isolate Idle Loop per Procedure 3302.01, " Reactor Recirculation." This item was previously identified as 50-461/96010-02a. Operators closed the seal shutoff valve,1833-F0758 before the idle loop cooled down to below 250*F. The licensee conducted expectations training and seminars addressing this and similar human performance errors. The training emphasized procedure adherence and conservative decision making. Additionally, the licensee established an in-plant crew observation and monitoring program to provide l-critical assessments of human performance. The licensee implemented
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Procedure 1005.15, " Procedural Use and Adherence" to establish the expectations for procedure use. The inspectors reviewed the licensee's corrective actione and determined that they were acceptable.
b8.2 (Closed) Violation 50-461/96412-02: Operators Failed to Close the Control Rod Drive (CRD) Supply isolation to the Reactor Recirculation Pump per Procedure 3302.01,
" Reactor Recirculation." This item was previously identified as 50-461/96010-02b.
Operators closed CRD Supply isolation Valve 1C11 F0268 before the idle loop cooled down to below 250*F. The corrective actions for this violation were similar to those described in Section 08.1 and were also acceptable for this violation.
08.3 (Closed) Violation 50-461/96412-03: Failure to Follow Fuel Pool Cooling Procedure. This item was previously identified as 50-461/96011-03c. Operators did not close Fuel Pool Cooling Heat Exchanger inlet Valve 1FC015A(B) and Outlet Valve 1FC026A(B) as required by Procedure 3317.01, " Fuel Pool Cooling Cleanup.".The corrective actions for this violation were similar to those described in Section 08.1 and were also acceptable for this violation.
08.4 (Closed) Violation 50-461/96412-04: Failure to Follow Control Room Heating, Ventilation, and Air Conditioning (HVAC) Procedure. This item was previously identified as 50-461/96011-03b. Operators did not restore the moisture separator drain valve to the open position and the loop seal fill valve to the closed position after filling the makeup air filter moisture separator loop seal per Procedure 3402.01, " Control Room HVAC." The corrective actions for this violation were similar to those described in Section 08.1 and were also acceptable for this violation.
08.5 (Closert) Violation 50-461/96412-05: Failure to Notify Radiation Protection Department as Required per Procedure 4001.01, " Reactor Coolant System Leakage." This item was previously identified as 50-461/96010-01b. On September 5,1996, Clinton Station declared an Unusual Event due to an unidentified reactor coolant leak of greater than 5 gallons-per-minute. Operations personnel did not request assistance from radiation protection personnel to identify the location and source of the leak as required by procedures. The corrective actions for this violation were similar to those described in Section 08.1 and were also acceptable for this violation.
08.6 (Closed) Violation 50-461/96412-08: Failure of Shift Supervisor to Maintain Monitoring Role During Unusual Event. This item was previously identified as 50-461/96010-01d.
The shift supervisor failed to remain in a monitoring role and direct activities to place the unit into single loop operation. The shift supervisor proceeded with other required duties before verifying that the line assistant shift supervisor had assumed the monitoring functions. This was in violation of Procedure 1401.01," Conduct of Operations." The shift supervisor was counseled on required duties and adherence to procedures. In addition, the licensee conducted similar corrective actions for this violation as those described in Section 08.1 which were also acceptable for this violation.
l 08.7 (Closed) Violation 50-461/96412-09: Required Entry was not Made in the Shift Supervisor's Journal During an Unusual Event. This item was previously identified as 50-461/96010-01e. The shift supervisor did not make a joumal entry for abnormal suppression poollevel that exceeded TS limits. This was contrary to Procedure 1401.01,
" Conduct of Operations." The shift supervisor was counseled on required duties and
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adherence to procedures. The additional corrective actions for this violation were similar I
l to those described in Section O8.1 and were also acceptable for this violation.
08.8 (Closed) Violation 50-461/96412-11: Failure to Perform Overtime Usage Reviews. This item was previously identified as 50-461/96011-04. TS 5.2.2e," Unit Staff," requires that administrative procedures be followed by operations management to ensure that excessive hours have not been assigned or worked without an acceptable evaluation and prior approval by station management. In addition, Administrative Procedure 1001.10, j
" Control of Working Hours," required a monthly verification by operations management that proper reviews were being done and that prior approval was being obtained before assigning overtime. Some operations supervisors were not performing the monthly reviews. The licensee implemented an automatic tracking system to alert operations supervisors of requirements to perform the overtime usage reviews on a monthly and bimonthly basis. The inspectors reviewed the licensee corrective action and determined that it was acceptable.
08.9 (Closed) Violation 50-461/96412-12: Failure of RO to Remain in the At-the-Control area.
j This item was previously identified as 50-461/96011-02. The "A" RO left the at-the-control area for about 3 minutes without obtaining an appropriate relief. This was in violation of Procedure 1401.01," Conduct of Operations." The RO was counseled on required duties and adherence to procedures. The additional corrective actions for this violation were similar to those described in Section 08.1 and were also acceptable for this violation.
08.10 (Closed) Inspection Follow-up Item 50-461/97012-01: Control room monitoring. This item is administratively closed since observations of activities in the control room are frequently performed as part of the routine inspection program.
II. Maintenance M1 Conduct of Maintenance M1.1 General Comments (61726 and 62707)
Portions of the following maintenance and surveillance activities were observed or reviewed by the inspectors:
PMMDGQO36 and 38 Diesel generator air compressors 1DG03CA and 1DG03CB oil change PMMDGQO18 Diesel generator air compressor belt tension and clean air filter PMMDGM033 Inspection of diesel generator crankcase for signs of coolant leakage Procedure 8410.04 Molded case circuit breaker functional testing and j
maintenance
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Procedure 8410.06 GE 4160V power circuit breaker maintenance l
Procedure 8451.01 Preventive maintenance for motor operated valves Procedure 8451.50 MOV testing with VOTES Procedure 9051.02 HPCS valve operability test
MWR D85091/92 inspect Division I/II Diesel Generator head bolt washers See specific discussions of maintenance observations under Sections M1.2, M1.3, and M1.4 below.
M1.2 VOTES Testina of HPCS Discharae Isolation Valve a.
Inspection Scope (62707)
On May 22,1993, the inspectors observed maintenance, engineering, and operations personnel during the performance of VOTES testing on HPCS Discharge Valve 1E22-F004.
b.
Observations and Findinas Electrical maintenance personnel performed VOTES testing on HPCS Discharge Valve 1E22-F004 in accordance with Procedure 8451.50, " Motor Operated Valve Testing with VOTES." The inspectccs noted that electrical maintenance personnel had difficulty setting up the VOTES equipment due to a lack of procedural guidance. As a result, electrical maintenance personnel contacted a cognizant engineer to correctly set-up the VOTES equipment prior to performing the test.
When the equipment set-up was completed, operations personnel cycled the valve to collect as-found data. The inspectors noticed that one of two data collection traces on the VOTES computer remained flat as the valve cycled which signified that no data was j
recorded and that the as-found data was lost. During troubleshooting of the VOTES j
equipment, the engineer identified that the VOTES computer had not operated as i
expected because he had forgotten to " trick" the computer prior to peKorming testing.
Due to the number of difficulties experienced while performing the test, the inspectors questioned engineering and maintenance personnel to determine if the VOTES test could be performed as described in Procedure 8451.50. Both individuals stated that the procedure could not be performed as written; however, they did not feel as though the procedure needed to be revised prior to continuing with the test since Step 2.3 of Procedure 8451.50 stated that the method of testing described in the procedure was guidance and did not supersede the knowledge of a " qualified individual." Additionally, the electrician and engineer believed it was acceptable for the engineer to direct the activity in lieu of a workable procedure. The inspectors determined that the interpretation of what constituted a " qualified individual" was suspect in that the electrician stated he l
was not familiar with performing VOTES testing on this type of valve and the engineer stated that he had not performed a VOTES test in over two years. The failure to revise a
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known inadequate procedure due to being under the direction of a cognizant engineer demonstrated poorimplementation of the procedure adherence program.
l Technical Specification 5.4.1.a requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in RG 1.33, Revision 2, Appendix A, February 1978. RG 1.33, Revision 2, Appendix A, Section 9, recommends procedures for performing maintenance activities appropriate to the circumstance. The failure to develop and implement an adequate procedure for VOTES testing the HPCS discharge isolation valve is considered a TS 5.4.1.a violation. 'iowever, because this violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-05).
c.
Conclusions One violation for which enforcement discretion was exercised was identified concerning the failure to ensure an adequate procedure was used during testing of the HPCS discharge isolation valve. The inspectors concluded that some procedural adequacy and adherence, problems continued to occur at the facility.
M1.3 ' Problem identification and Resolution Durina EDG Outaae During the performance of the Division lli EDG outage, mechanical maintenance (
personnel identified two conditions which potentially impacted the operation of the EDG.
In the first instance, the mechanics identified that 128 washers were not placed on the cylinder head bolts. The mechanics initiated a CR and took action to re-install the washers. An inspection of the remaining two EDGs initiated by the operations department, determined that the washers had been installed on the Division I and 11 EDGs following previous maintenance activities. In the second instance, mechanical maintenance personnelidentified the presence of metal shavings in the Division lli EDG lube oil sump. The mechanics later identified that the metal shavings were caused by a mis-aligned bearing stud retaining nut which had contacted one of the crankshaft counterweights. In response to this finding, the operations department directed that the other two EDGs be examined for similar problems. The subsequent inspections identified two mis aligned nuts on the Division 11 EDG, neither of which had contacted the crankshaft. The inspectors concluded that mechanical maintenance and operations personnel performed well with respect to identifying problems and determining the extent of the condition during the Division 111 EDG outage.
M1.4 Testina of Molded Case Circuit Breakers (MCCBs)
a.
Inspection Scope (62707 and 61726)
The inspectors reviewed the licensee's test program for MCCBs. Documents reviewed by the inspectors included:
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i National Electric Manufacturers Association (NEMA) Standard Publication
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No. AB 4-1991," Guidelines for Inspection and Preventative Maintenance of Molded Case Circuit Breakers used in Commercial and Industrial Applications."
Nuclear Maintenance Applications Center (NMAC), " Breaker Maintenance," Volume 3,
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" Molded Case Circuit Breakers," September 1991.
Vendor Technical Information, Licensee Document No. K297600001 A.
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Procedure 8410.04, " Molded Case Circuit Breaker Functional Testing and j
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Maintenance," Revision 10.
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Procedure 8410.05, " Type HE Molded Case Circuit Breaker Revision Level Test."
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Licensee responses to NRC Information Notices IN 89-21;." Changes in Performance
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Characteristics of Molded Case Circuit Breakers," and IN 92-51, Supplement 1,
" Misapplication and inadequate Testing of Molded Case Circuit Breakers."
Licensee response to NRC Bulletin 88-10, "Non-conforming molded case circuit
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breakers."
NRC Information Notices IN 93-64, " Periodic Testing and Preventive Maintenance of
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Molded Case Circuit Breakers" and IN 96-24. " Pre-conditioning of Molded Case Circuit Breakers Before Surveillance Testing."
b.
Observations and Findinas The inspectors performed a comparison of the licensee's 480 Vac MCCB test program to current industry and NRC guidance and determined that the licensee had not effectively utilized industry information and experience even though a licensee representative was involved in the development of standard industry guidance for testing of 480 Vac MCCBs.
Specific deficiencies included:
Vendor technical information, NEMA AB-4, and NMAC Volume 3, specified that the
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MCCB should be connected to test equipment with copper conductors approximately, but no less than, four feet in length and of the proper size for.each breaker rating.
The licensee incorporated NEMA AB-4 and NMAC Vol. 3 cable size tables into Procedure 8410.04; however, the. size specified in Procedure 8410.04 only noted the minimum and not a maximum acceptable size cable.
NMAC Volume 3 specified that copper conductors act as a heat sink during testing and thus must be standardized to ensure consistent test results. Smaller cable or shorter lengths can shorten the trip time. Larger cables or a heavy bus bar lengthen the trip time.- Small frame breakers are particularly susceptible to variations caused by this effect. Test cables should be connected with mounting lugs specifically designed for the MCCB being tested to avoid damaging the terminals. The inspectors observed the use of larger than acceptable wire sizes during testing and cable lengths between 30 inches and about six feet. The licensee did not record the test cable size used for each breaker and the lugs on the cables had been modified to allow attaching the heavier cables to smaller MCCBs. The inspectors determined that the
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use of improper test cables could have resulted in the inability to compare test results to the manufacturers specifications.
NEMA AB-4, NMAC Volume 3, and the manufacturer specified that initial testing of
the instantaneous trip should be at a current setting five percent below the lower tolerance limit specified for the breaker. The purpose is to verify that the MCCB is not subject to premature tripping thereby ensuring that the breaker coordination is not affected by a feeder breaker tripping before a load breaker trips. The inspectors noted that Procedures 8410.04 and 8410.05 did not require iesting of the lower instantaneous tolerance limit.
Industry and NRC guidance on instantaneous trip testing specified using a short pulse
length (five to ten cycles in duration or about 0.083 to 0.166 seconds).
Procedure 8410.04 specified using the " momentary" position of the test switch but did not direct using a short pulse. The inspectors noted pulse lengthstf up to 2 seconds during instantaneous testing before the MCCB opened on a thermal trip. The purpose of using a short pulse was to ensure that there was not any thermal-magnetic interaction due to heating the thermal trip element. Conversely, Procedure 8410.05 did specify using a short pulse and explained how to prevent the thermal interaction with the instantaneous (magnetic) trip unit. Procedure 8410.04 did not direct resetting the breaker immediately after a trip to ensure that the trip had been caused by only the instantaneous trip unit, however Procedure 8410.05 did. The inspectors noted that the test results for instantaneous trips were not reliable in that Procedure 8410.04 did not verify if an actualinstantaneous trip of the MCCB occurred.
NMAC Volume 3 and IN 93-64 both noted that mechanically exercising MCCBs
materially increased their reFability. However, the inspectors noted that the licensee did not regularly exercise MCCBs unless the MCCBs were being tested in accordance with Procedure 8410.04.
NRC Bulletin 88-10 specified a maximum allowable instantaneous trip time of
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0.1 seconds, where as Procedure 8410.04 allowed 0.15 seconds for 40 ampere or larger breakers.
During interviews with electrical maintenance and engineering personnel, the
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inspectors determined that no evaluation of breaker coordination had been performed for failed breakers. The purpose of the evaluation would have assessed the reliability of the 480 Vac distribution scheme.
NRC and industry guidance specified the sequence of testing of MCCBs chould be a
trip test of each phase at 300 percent of the thermal trip rating, followed by a verification that the breaker will not trip while pulsed at a current level below the lower instantaneous trip limit, followed by a trip test while pulsed at a current level at the upper instantaneous trip limit. Testing in this manner would require six trips and
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resets of the MCCB.
Conversely, Procedure 8410.04, Step 8.2.4.7 stated that breaker trips while adjusting the test current for instantaneous trips test are not considered attempts to test the instantaneous trip function and that test current adjustments should be made by momentarily pulsing current to the breaker. On June 18, the inspectors observed i
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maintenance personnel trip MCCB 1 AP74E13A for the suppression pool makeup system dump shutoff valve 6 times on a single phase before they were satisfied with the test current setting. On June 23, the inspectors observed electrical maintenance personnel cycle MCCB 1 AP95E-6A for the RR pump "A" oil pump subloop #2 starter at least 18 times because Procedure 8410.04 specified up to 5 trip attempts per phase if the instantaneous trip failed. The inspectors noted that the method of testing resulted in excessive cycling which preconditioned the MCCB, a condition inconsistent with NRC IN 96-24.
Procedure 8410.04 specified an initial test current of 100 - 150 percent of the MCCB l
high current rating and increasing up to 200 percent during the five attempts to pass
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the instantaneous trip time requirement. While observing MCCB testing, the
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inspectors noted at least 16 instances where a MCCB tripped while electrical j
maintenance personnel attempted to set the test current for the instantaneous trip j
test. In some cases, the instantaneous trip time.was greater.than that allowed by l
procedure, in each instance, electrical maintenance personnel did not record the data as a failed test because the test current was being " adjusted." Industry and NRC guidance
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specified using 125 percent of the high current rating on a one time pulse. The inspectors noted that electrical maintenance personnel failed to obtain accurate
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as-found data and potential test failure data by not recording the results of trips which I
I occurred when the current met the required value (greater than or equal to 100 percent of the high current rating) and the allowable time was exceeded. In addition, the licensee had not assessed the impact on the breaker for testing
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completed with current settings greater than 125 percent of the high current rating.
On June 26, the inspectors informed maintenance personnel of the testing concerns. In l
response to the observations, electrical maintenance personnel stopped MCCB testing.
However, as of June 29, management had not been notified of the observations until j
NRC inspectors questioned whether or not a CR had been initiated. On June 30, the i
licensee initiated CR 1-98-06-357 to document the inadequacies in the MCCB test procedure.
Operations personnel performed OD 1-98-06-0357 to assess the impact of the observations on operability of plantequipment. The inspectors noted that the operability determination lacked rigor in that it did not completely assess test _ cable issues, the failure to perform a low instantaneous trip.testi-or the impact of undocumented test failures. In response to the concerns raised during the review of OD 1-98-06-0357, the licensee initiated an operability evaluation to support the OD. The licensee was still developing the operability evaluation at the end of the inspection period. The licensee also initiated a revision of Procedure 8410.04 to ensure the procedure incorporated the latest industry guidance with respect to testing of MCCBs. Following the revision to Procedure 8410.04, the licensee planned to test approximately 130 previously untested MCCBs and adjust the l
test program accordingly.
l The NRC previously identified significant problems with the 4160 Vac circuit breaker l
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testing program. While extensive corrective actions were taken specific to the 4160 breaker testing program, these actions were not applied to the MCCB testing program. It j
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is reasonable to have expected the licensee to have reviewed the MCCB tcsting program in light of the significant deficiencies identified in another breaker testing program.
10 CFR Part 50, Appendix B, Criterion XVI, requires that in the case of significant conditions adverse to quality, measures shall assure that the cause of the condition is determined and corrective actions taken to preclude repetition. The failure to extend the corrective actions in response to the identification of problems with the 4160Vac circuit breaker testing program to the MCCB test program to assure 480 Vac MCCBs will perform satisfactorily in service is a violation of 10 CFR Part 50, Appendix B, Criterion XVI. However, because mis violation was based upon activities prior to the events leading to the current extended plant shutdown and satisfies the criteria in Section Vll.B.2, " Violations identified During Extended Shutdowns or Work Stoppages," of the " General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, a Notice of Violation is not being issued (NCV 50-461/98011-06).
During the performance of testing the inspectors noted two poor maintenance work practices. In the first instance, electrical maintenance personnel used excessive torque while installing test cables on the MCCBs in the test stand. Procedure 8410.04 required the use of a torque wrench and applying 55 inch-pounds when installing the same fasteners in the switchgear unit. Over torquing could reduce the strength of the fasteners. In the second instance, electrical maintenance personnel obtained megger readings on a MCCB without zeroing the instrument. Additionally, the ground lead was attached to a painted surface, instead of a bare metal surface, an action which could have masked a low resistance to ground reading due to the resistance of the painted surface.
c.
Conclusions One violation for which enforcement discretion was exercised was identified when the inspectors determined that corrective actions to address 4160 Vac circuit breaker testing problems were not applied to molded case circuit breakers. Specific MCCB test program deficiencies included: improper test cable size, not performing a low current instantaneous trip, excessive test current pulse length, excessive instantaneous test current, improper instantaneous trip times, preconditioning of breakers, not documenting valid test attempts, and not evaluating breaker coordination issues for failed breakers. In addition, the inspectors determined that the licensee did not effectively utilize industry information and experience even though it was involved in the development of standard industry guidance for testing of 480 Vac MCCBs.
M8 Miscellaneous Maintenance issues (92902)
M8.1 (Closed) Violation 50-461/97011-05: Inadequate shift turnover between maintenance personnel. The licensee's corrective actions involved issuance of a night order and discussions with maintenance personnel regarding expectations for turnover. The inspectors determined that the corrective actions were appropriate for the issue.
M8.2 (Closed) Unresolved item 50-461/97015-05: Adequacy of secondary containment ventilation damper testing questioned pending further NRC review. The NRC has since reviewed the issue and concluded that the testing of secondary containment with both
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inboard and outboard sets of fuel building ventilation (VF) system isolation dampers closed was acceptable. Although the VF system was required to be able to withstand a single failure of an isolation damper to close, there was no requirement to test the leak tightness of individual dampers. (This conclusion was documented in a docketed NRC memorandum dated June 18,1998, from the Acting Director, Division of Reactor Projects lil/IV, NRR, to the Director, Division of Reactor Safety, Region Ill.)
111. Enaineerina E1 Conduct of Engineering E1.1 Transportation of Anhydrous Ammonia a.
Inspection Scope f37551)
The inspectors performed a review to determine if the licensee had accounted for shipments of anhydrous ammonia within a 2.4 mile radius of the facility.
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Observations and Findinas In May 1998, the inspectors noted the shipment of 1,000 gallon anhydrous ammonia tanks by local farmers within a two mile radius of the facility and questioned the licensee to determine if use of anhydrous ammonia by local farmers had been accounted for in the facilities hazard analysis. In response to the inspectors' observation, licensing personnel stated that an evaluation did not exist which reviewed the use and shipment of anhydrous ammonia tanks near the facility.
USAR Section 2.2.3.1.3, " Toxic Chemicals," specified that the potential for hazard is low enough that transportation of ammonia in the area surrounding CPS does not need to be considered in the design of CPS. The inspectors noted that the hazard evaluation was based on truck shipments to a local storage facility 2.4 miles from the facility and did not consider shipments away from the storage facility to locations within 2.4 miles of the facility.
USAR Section 1.8, "Conformance to NRC Regulatory Guides," stated that CPS complies with RG 1.78, " Assumptions for Evaluating the Habitability of a Nuclear Power Plant Control Room During a Postulated Hazardous Chemical Release."-RG 1.78, prescribed 10 truck shipments per year as a frequency threshold for evaluating the impacts of a hazardous chemical release on control room operators. The licensee stated that they did not have documentation describing the frequency of shipments within 2.4 miles of the facility, but acknowledged that tank shipments probably exceeded the threshold of ten shipments per year. Table C-2 of RG 1.78 specified that at a distance of 0.5 - 0.7 miles, with a Type C control room (no provision for detecting hazardous chemicals), the weight of hazardous chemicals that require consideration in control room evaluations (for a toxicity limit of 50 mg/ cubic meter) is 400 pounds. The inspectors noted that the closest public road was approximately 0.5 miles from the facility, CPS did not have hazardous chemical detection capability,1,000 gallons of anhydrous ammonia exceeded
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400 pounds, and the toxicity limit for anhydrous ammonia was 70 mg/ cubic meter.
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Licensing personnel initiated CR 1-98-06-032 to evaluate the potential hazard from shipment of the anhydrous ammonia tanks within 2.4 miles of the facility. The licensee estimated that the evaluation would be completed in the fall of 1998. The review of the evaluation and implementation of corrective actions, if necessary, is considered an unresolved item (URI 50-461/98011-07).
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Conclusions The USAR did not account for the hazard associated with the use and shipment of anhydrous ammonia nearby the facility. One unresolved item was identified regarding the licensee's evaluation of anhydrous ammonia shipments within 2.4 miles of the facility.
E2 Engineering Support of Facilities and Equipment E2.1 Review of Current Operability and Enaineerina Evaluations a.
Inspection Scope (37551)
The inspectors reviewed the following engineering evaluations and operability evaluations (OEs) for thoroughness and accuracy:
OE 1-98-06-174 Evaluation of degrading labyrinth seal on RHR B and C water leg pump.
Engineering Evaluation 1 90-06-189 Review of system response to momentary loss of ERAT.
Engineering Evaluation 1-98-06-276 Evaluation of copper tubing in Division i EDG oil sump, b.
Observations and Findinas The adequacy of information provided in the evaluations listed above was mixed. The inspectors noted that the information provided in OE 1-98-06-174 was thorough and
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provided an adequate basis for continued operability of the RHR B and C water leg pump.
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' The information provided in engineering evaluation.1-98-06-189 was initially incomplete.
The inspectors identified that the engineer performing the evaluation did not consider the potential that the Division I and ll buses should have fast transferred from the ERAT to the RAT after the momentary loss of the ERAT. Because this condition was not
. evaluated, the engineer's original conclusion that the buses operated as designed was questionable. In discussions with the engineer, the inspectors learned that the engineer had not considered the possibility of a fast bus transfer because he was unaware that the equipment had this ability. The need for inspector prompting to ensure that all potential modes of operation were thoroughly evaluated was considered a weakness. After further review, the engineer determined that a fast bus transfer should not have occurred and that the Division I and 11 buses had operated as designed.
Engineering Evaluation 198-06-276 was initiated following an inspection of the Division i
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EDG 16 cylinder engine which identified a broken piece of copper tubing, and evaluated
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the potential that the tubing was present in the lube oil system for the Division i EDG 16 cylinder engine. While engineering personnel provided adequate information to determine that no copper tubing was present in the lube oil system prior to May 28,1997, operations personnel determined that Uttle information was provided to ensure that a piece of tubing had not entered the oil sump between May 1997 and June 1998. Due to the lack of information, operations personnel INtiated actions to have the oil sump l
drained and re-inspected. Although no copper tubing was found, the actions taken by the j
operations department were appropriate and conservative.
c.
Conclusions The adequacy of information provided in engineering and operability evaluations was mixed. Engineering personnel provided an adequate basis for continued operation of the RHR B and C water leg pump. However, engineering personnel did not initially provide i
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an adequate basis for the automatic transfer of the Division 111 electrical safety bus or adequate assurance that a piece of copper tube was not located in the lube oil system of
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the Division i EDG.
E8 Miscellaneous Engineering items E8.1 (Closed) Licensee Event Report 50-461/96013: Inadequate Actuator Design and Failure to Recognize Limitations of Resilient Seat Design Results in Local Leak Rate Test Failures of Feedwater Containment Iso!ation Valves. The event was documented m inspection report 50-461/96009 and resulted in violations 50-461/96412-29 and 50-461/96412-30. The inspector reviewed the LER and determined that the licensee appropriately reported the event and met reporting requirements. Additional corrective actions taken by the licensee will be evaluated during the closure of the violations.
E8.2 - (Closed) Licensee Event Report 50-461/96016: Invalid Local Leak Rate Testing of Feedwater Isolation Valves. The event was documented in inspection report 50-461/96009 and resulted in violations 50-461/96412-29 and 50-461/96412-30. The inspector reviewed the LER and determined that the licensee appropriately reported the event and met reporting requirements. The licensee's corrective actions to resolve the testing deficiencies will be evaluated during the closure of the violations.
E8.3 (Closed) Violation 50-461/96412-26; inadequate Safety Evalaation for a Control Rod Drive (CRD) Pump Test. This item was previously identified as.50-461/96011-03k. The licensee performed a test on a CRD pump that was not described in the safety analysis report. The test was to determine if the CRD pump's drop in pressure was due to leaking valves or pump degradation. Engineers and station management did not recognize that a safety evaluation needed to be performed to determine if an unreviewed safety question (USQ) existed, instead of a safety evaluation, the test was reviewed and controlled with a " coordination plan." Although the coordination plan was adequate to ensure that the
. test was performed adequately and that resources were available, the coordination plan did not require a safety evaluation. Subsequently, a safety evaluation was performed by station engineers. The engineers determined, based on the results of the safety evaluation, that a USQ did not exist. The licensee revised Procedure 1070.01,
" Coordination Plans" to ensure that safety evaluations are performed if equipment manipulation is required and an approved procedure does not exist. The inspector reviewed the licensee's corrective actions and determined that they were acceptable.
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l E8.4 (Closed) Violation 50-461/96412-27: Inadequate Safety Evaluation for Degraded Cathodic Protection System. This item was previously identified as 50-461/96011-05b.
l The inspectors identified that the cathodic protection system was degraded according to j
the system description in USAR Section 9.4.5.2. The licensee agreed in their July 9,
1997, response to the Notice of Violation, that the diesel generator fill line was not totally
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provided with cathodic protected. As part of the corrective actions for this event, engineering personnel performed a safety evaluation which determined that cathodic j
protection was not needed for the entire diesel generator fill line and the USAR was l
revised to reflect the as-built condition of the diesel generator fill line. The licensee also revised Procedure 1005.06, " Conduct of Safety Reviews" to establish a " core review group." The review group was established to ensure that plant and equipment modifications, operability evaluations, and procedure changes received the proper safety evaluation or review.
l E8.5 -(Closed) Violation 50-461/96412-28: -Inadequale Safety Evaluation for. Control Room Chiller Automatic Start. This item was previously identified as 50-461/96011-07b. A
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discrepancy existed between the as-built condition of the control room chiller automatic start function and the system description in the USAR. The USAR stated that the chiller would automatically start 20 minutes after an event. During Division i EDG loss of power / emergency core cooling system surveillance testing, the control room chiller automatically started quicker than expected at 2.5 minutes after the initiation of the test signal. The licensee determined that the chiller logic system had malfunctioned and resulted in a relay chase that initiated the automatic start prematurely. A safety evaluation was not done because the licensee was controlling the repair activities through the coordination plan process. The coordination plan procedure was inadequate in that a safety evaluation of the chiller's degraded condition was not required. The licensee revised Procedure 1070.01, " Coordination Plans" to ensure that safety evaluations are performed if equipment are degraded according to design basis or USAR. The inspector reviewed the licensee's corrective actions and determined that they were acceptable.
IV. Plant Support R8 Miscellaneous RP&C issues (92904)
R8.1 (Closed) Violation 50-461/96015-02: '. Failure to perform survey upstream of leaking resin transfer line prior to repressurizing the line. The licensee determined that this violation occurred due '.o a lack of conservative decision making by radiation protection and operations personnel. As part of the corrective actions for the extended plant shutdown, the licensee has taken significant action to improve conservative decision making by all i
plant personnel. The inspectors have reviewed these corrective actions and considered them to be appropriate for this issue.
I S1 Conduct of Security and Safeguards Activities S1.1 Liahtina Tour (71750)
I On June 17,1998, the inspectors performed a lighting tour of the protected area. No discrepancies were noted.
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F8 Miscellaneous Fire Protection Issues (92904)
F8.1
[ Closed) Violation 50-461/96015-08: Failure to take prompt corrective actions to address multiple failures of the "A" diesel driven fire pump. The licensee determined that the fire pump failures were caused by corrosion within the fuel oil tanks. In response to this violatiori, the licensee completed several activities to improve the performance of the fire
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l pumps. Activities included. sand blasting, chemically treating and coating the fuel oil tanks, changing out the fuel oil tank fill lines, and installing fuel oil filters on the inlet and outlets of each fuel oil tank. The inspectors reviewed the licensee's corrective actions for this issue and considered them appropriate.
V. Manaaement Meetinas X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection period on July 10,1998. The licensee acknowledged the findings presented. The inspectors asked the licensee whether any materials examined during the inspection period should be considered proprietary. No proprietary information was identified.
X3 Management Meeting Summary On June 23,1998, a public meeting pursuant to NRC Inspection Manual Chapter 0350 between the NRC and Illinois Power was held to discuss improvements and challenges in the areas of management leadership, conduct of operations, conduct of maintenance, l
material condition, work management and corrective actions.
On July 7,1998, Mr. Frank Miraglia, Jr., Deputy Director, Office of Nuclear Reactor Regulation, and Mr. James Caldwell, Deputy Regional Administrator, visited the Clinton site. Items discussed during the site visit included recent licensee challenges and improvements.
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PERSONS CONTACTED
Licensee W. MacFarland IV - Chief Nuclear Officer G. Hunger, Plant Manager W. Romberg, Manager - Nuclear Station Engineering Department R. Phares, Manager - Nuclear Safety and Performance improvement G. Baker, Manager-Quality Assurance J. Goldman, Manager - Work Management V. Cwietniewicz, Manager - Maintenance W. Maguire, Director-Operations J. Sipek, Director-Licensing J. Place, Director-Plant Radiation and Chemistry
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INSPECTION PROCEDURES USED IP 37551: Onsite Engineering IP 61726: Surveillance Observations IP 62707: Maintenance Observation IP 71707: ' Plant Operations IP 71750: Plant Support Observations IP 92901: Followup - Operations IP 92902: Followup'- Maintenance IP 92903: Followup - Engineering
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IP 92904: Followup - Plant Support
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lP 93702: Prompt Onsite Response to Events at Operating Power Reactors ITEMS OPENED; CLOSED, AND DISCUSSED Opened 50-461/98011-01 NCV Enforcement Discretion: Failure to take corrective actions in response to excessive SX flow through the RHR heat exchangers.
50-461/98011-02a NCV Enforcement Discretion: Failure to implement procedure for testing meteorological monitoring tower prior to retuming it to service.
50-461/96011-n?b NCV Enforcement Discretion: Failure to implement procedure for testing process radiation monitor OPR002 prior to retuming it to service.
50-461/98011-03 NCV Enforcement Discretion: Failure to implement provisions of maintenance troubleshooting procedure and have adequate
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VOTES procedure.
50-461/98011-04 NCV Enforcement Discretion: Failure to detect unusual trends in main control room and initiate timely actions to correct the deficiency.
50-461/98011-05 NCV Enforcement Discretion: Inadequate procedure for VOTES test I
50-461/98011-06 NCV Enforcement Discretion: Failure to apply corrective actions for 4100 Vac circuit breaker testing to molded case circuit breakers.
50-461/98011-07
- URI Evaluate hazards from transporting anhydrous ammonia within 2.4 miles of the site.
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l 50-461/96013 LER Inadequate actuator design and failure to recognize limitations of i
resilient seat design results in localleak rate test failures of feedwater containment isolation valves.
50-461/96016 LER Invalid localleak rate testing of feedwater isolation valves.
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50-461/96412-01 NOV Operators failed to isolate idle RR loop per the RR operating procedure.
50-461/96412-02 NOV Operators failed to close the CRD isolation to the RR pump.
50-461/96412-03 NOV Failure to follow the fuel pool cooling procedure.
50-461/96412-04 NOV Failure to follow control room HVAC procedure.
50-461/96412-05 NOV Failure to notify radiation protection department of reactor coolant i
leakage.
50-461/96412-08 NOV Failure of shift supervisor to maintain monitoring role during an event.
i 50 461/96412-09 NOV Failure to make entry into shift supervisor's joumal.
50-461/96412-11 NOV Failure to perform overtime usage reviews.
50-461/96412-12 NOV Failure of RO to remain in the at the controls area.
50-461/96412-26 NOV inadequate safety evaluation for CRD pump test.
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50-461/96412-27 NOV Inadequate safety evaluation for cathodic protection system.
j 50-461/96412-28 NOV inadequate safety evaluation for control room chiller automatic start.
50-461/96015-02 NOV Failure to perform survey upstream of leaking resin transfer line prior to pressurizing line.
j 50-461/96015-08 NOV Failure to take corrective actions to address multiple failures of "A" fire pump.
l 50-461/97011-05 NOV Inadequate turnover between maintenance personnel.
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50-461/97012-01 IFl Control room monitoring.
50-461/97015-05 URI Adequacy of secondary containment ventilation damper testing.
50-461/98011-01 NCV Enforcement Discretion: Failure to take corrective actions in response to excessive SX flow through the RHR heat exchangers.
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50-461/98011-02a NCV Enforcement Discretion: Failure to implement procedure for testing meteorological monitoring tower prior to returning it to service.
50-461/98011-02b NCV Enforcement Discretion: Failure to implement procedure for testing process radiation monitor OPR002 prior to returning it to service.
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50-461/98011-03 NCV Enforcement Discretion: Failure to implement provisions of maintenance troubleshooting procedure and have adequate VOTES procedure.
50-461/98011-04 NCV Enforcement Discretion: Failure to detect unusual trends in main control room and initiate timely actions to correct the deficiency.
50-461/98011-05 NCV Enforcement Discretion: Inadequate procedure for VOTES test l
L 50-461/98011-06 NCV Enforcement Discretion: Failure to apply corrective actions for 4160 Vac circuit breaker testing to molded case circuit breakers.
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LIST OF ACRONYMS AR/PR Area Radiation / Process Radiation v
CFM Cubic Feet per Minute j1 CR Condition Report l
CRD Control Rod Drive L
. Emergency Core Cooling Systems l
EDG Emergency Diesel Generator j
ERAT Emergency Reserve Auxiliary Transformer l
ERT Engineering Response Team EWR Engineering Work Request
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HPCS High Pressure Core Spray HVAC Heating, Ventilation, and Air Conditioning LOCA Loss of Coolant Accident LOOP Loss of Offsite Power l
LPCS Low Pressure Core Spray
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MCCB Molded Case Circuit Breaker -
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' Maintenance Work Request NOUE Nouce of Unusual Event ODCM Offsite Dose Calculation Manual OE Operability Evaluation ORM Operational Requirements Manual PDR Procedure Deviation for Revision RAT Reserve Auxiliary Transformer
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RG Regulatory Guide RHR Residual Heat Removal RO Reactor Operator RR Reactor Recirculation SDFV System Design and Functional Validation SRO Senior Reactor Operator STA
. Shift Technical Advisor SX Shut Down Service Water TR Testing Requirement TS
' Technical Specifications USAR-Updated Safety Analysis Report USQ
- Unreviewed Safety Question VF Fuel Building Ventilation VG Standby Gas Treatment j
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