IR 05000482/1987031

Insp Rept 50-482/87-31 on 871031-1118.Potential Violation Noted.Major Areas Inspected:Ler Review,Physical Security Verification,Radiological Protection & Operational Safety

ML20238C135
Person / Time
Site:	Wolf Creek
Issue date:	12/16/1987
From:	Bruce Bartlett, Cummins J, Haag R, Jaudon J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20238C129	List: IR 05000482/1987031 ML20238C128
References
50-482-87-31, NUDOCS 8712300072
Download: ML20238C135 (12)

Text

.

.

.

. .

I APPENDIX

'

U. S. NUCLEAR REGULATORY COMMISSION

REGION IV

NRC Inspection Report: 50-482/87-31 Operating License: NPF-42 Docket: 50-482 Licensee: Wolf Creek Nuclear Operating Corporation (WCNOC)

P.O. Box 411 Burlington, Kansas 66839 Facility Name: Wolf Creek Generating Station (WCGS)

Inspection At: Wolf Creek Site, Coffey County, Burlington, Kansas Inspection Conducted: October 31 through November 18, 1987 l

Inspecto rs:~.. A ( u.w urto) /2!/0 7 l

[' p. nE. hCummi~ns, ( Senior Resident Inspector Date Dperations, Project Section A awr W lb ,a. - 17 -/6 - 9)

B. L. Bartlett, Resident Reactor Inspector Date Operations, Project Section A

[. C /k. - / I- /6 - S 7 R. C. Haag, Reactor Inspector, Materials & Date Quality Programs Section, Engineering Branch Approved: N /2 // . J(udon Chief, Pro,}ect Section A Datd '

8712300072 871221 PDR ADOCK 05000482 0 DCD

__-_

'

'

.

e ,

2 >

Inspection Summary Inspection Conducted October 31 through November 18, 1987 (Report 50-482/87-31)

Areas Inspected: Routine, unannounced inspection including onsite event followup, review of licensee event report, physical security verification, radiological protection, and operational safety verificatio Results: Within the five areas inspected, one potential violation was identified (failure of management controls, paragraph 2).

i

,

m_____________.__.______.__.. _

.

., .

DETAILS Persons Contacted Principal Licensee Personnel B. D. Withers, President >

• F. T. Rhodes, Vice President, Nuclear Operations

• M. Grant, Vice President,. Quality

• J. A. Bailey, Vice President, Engineering and Technical Services

• G. D. Boyer, Plant Manager 0. L. Maynard, Manager, Licensing C. M. Estes, Superintendent of Operations

• M. D. Rich, Superintendent of Maintenance

• G. Williams,. Superintendent of Regulatory, Quality, and Administrative Services W. J. Rudolph, QA Manager-WCGS

• A. A. Freitag, Manager, Nuclear Plant Engineering (NPE), WCGS

• Nichols, Plant Support Superintendent  !

• K. Peterson, Licensing G. Pendergrass, Licensing W. M. Lindsay, Supervisor, Quality Systems C. J. Hoch, QA Technologist

• B. Wood, General Counsel V. J. MacTaggart, Results Engineering Supervisor B. McKinney, Superintendent of Technical Support

• J. L. Houghton, Operations Coordinator-0perations j

• J. M. Pippin, Manager, NPE j

• H. Chernoff, Licensing Engineer  !

• C. W. Fowler, Supervisor Instrumentation and Control

• L. M. Pavelac, Compliance

• Denotes those personnel in attendance at the exit meeting held on November 27, 198 The NRC inspectors also contacted other members.of the licensee's staff l J

during the inspection period to discuss identified issue . Onsite Event Followup During this report period, the NRC inspectors performed followup on  ;

certain events that occurred during the second refueling outage that 1 l

'

began on September 28, 1987, and was originally scheduled to last 49 day The events are described in chronological order below (Events 1 through 4 l were also discussed in NRC Inspection Report 50-482/87-27 and were  ;

considered as unresolved items).

I 2.1 On October 10, 1987, two Duratek contract personnel were contaminate )

l in the radwaste building. Their duties included the operation of a '

I water processing system. During an attempt to clear a clogged' hose,

_____ _ ___ ____-_ ___-_-_ -__-__ ___ _____--_________ _ . - - _ _ _ _ _ _ - _ _ = _ _ _ _ - - - _ _ - - _

-,

. 4

l the workers disconnected a pressurized line. This resulted in the ejection of resin media that sprayed on the workers and the surrounding area. This event led to the following' findings and conclusions:

l Licensee personnel should have provided more oversight controls

'

for the Duratek personne The radiation work permit did not say what to do if the system had to be opened for wor A continuous air sample was not being drawn by health physics personnel as required by the radiation work permi The Duratek personnel did not have a procedure which covered the l evolution that they were performin The Duratek personnel were allowed to work excessive overtime hour Licensee management _ failed to provide an appropriate level of management oversigh .2 On October-14, 1987, personnel inside containment' reported hearing a loud noise. Personnel welding near the top,of the pressurizer reported hearing a loud rushing noise for approximately 5 seconds.

l The sheetmetal cover, placed over a hole left where one of the code l safety relief valves'had been, was blown off. Followup has shown

'

that the-rushing noise was hydrogen burning inside the pressurize The hydrogen was ignited by a welder installing a new instrument root valv This event led to the following findings and conclusions:

The workers' ignition source permit stated that the pressurizer was purged of combustibles, but a sample was not taken to verify the vessel's contents. Inspections and calculations have shown that the pressurizer was not damaged by the bur Hydrogen in the vessel was caused by an inadequate procedure for the purging of hydrogen from the reactor coolant syste The pressurizer was not sampled prior to the burn permit being issue Licensee management failed to provide an appropriate level of management oversigh .3 On October 14, 1987, the licensee declared a notification of unusual event. The cause of the unusual event was an apparent fire in the NB02 switchgear room. A few minutes into the event, it was found

- _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ - _ - -_

- _ _ - _ - - _ . . _ _ _ _ _ - -_ _ _ _ . -__ _

--

.

c ..

that the fire was actually a' worker being electrocuted. . Operations personnel verified the electrical source was de-energized and then removed the injured man. . The-man-was later pronounced dead as a result of his injurie Followup of this event has:shown that:

-

Electrical maintenance was not aware'of the actual boundaries of-the clearance orde Electrical maintenance personnel failed to verify the limits of-the clearance orde '

Shift turnover by electrical maintenance did not identify all o the energized cubicle The worker who was electrocuted did.not check the' cubicle uponL which he was working for energized-circuit Warning signs were placed on a'nother energized cubicle but not-on the cubicle in which the accident occurre The warning signs were not controlled by procedur Licensee management failed to provide an appropriate level of management oversigh '

2.4 On October 15, 1987, a number of. engineered safety actuations occurred. The actuations occurred when'the voltage degraded on safety-related buses'. Approximately.3-hours after'the.actuations, the steam generators.were found to be-filled _with lake water. .The essential service water pumps had discharged water as designed-through the auxiliary feedwater system into the steam generators an the condensate storage tank.'

Control room operators believed that manual valves to block essential service water from entering the condensate-system were shut. lThere were." operator aids" (i.e., magnetic backed indicators) on.the:

control room panels that indicated this. The manual block valves were open. The operator aids'were not' controlled by procedures and had not been removed when the valves'were ' repositioned,' licensee management put operator aids under the clearance procedure after thi even Procedures existed to de-energize Bus NB02, but they were not followed. In fact, the 200-minute limit for loading on batteries stated in System Procedure SYS NG-331, "De-energization of 480.V-(Class 1E) Bus (es),"'was violated. It was licensee management's failure to believe in and to enforce, strict procedural compliance ~

that was the root cause of this' event. 'The licensee's report on this event described their' corrective actions.'One corrective: action was-to revise Procedure ADM 01-108,." Outage' Planning."- As documented in-NRC Inspection Report 50-482/87-.32,-Procedure ADM-01-108 was revised-

..

=______--___ _

- ___ _ - _ - _ _ .

-

.

, ,

but has not been implemented for.the current outage. Another licensee corrective action was to commit to writing a de-energization procedur This procedure was to be written prior to the next refueling outage. Bus NB02, however,'had to be taken down fo maintenance during the current outage. After the NRC inspectors questioned the lack of a de-energization procedure, the licensee wrote the one prior to de energizing the bu The licensee's. investigative report. states that the root cause was a lack of communication between work groups.- The NRC's' followup disagrees with this" analysis.. The NRC inspectors concluded that the root cause was a lack of adequate management oversigh .5 On November 7, 1987, performance of Surveillance Procedure STS IC-275B, Revision 1, "7300 Process and N. I. Response' Time Test (2/4 Logic) Protection Set II," actuated an interlock which de-energized both channels of source range nuclear instrument At the time fuel assemblies were being installed in the reactor vesse This fuel movement-is a " core alteration." Technical Specification 3.9.2' required these two source range nuclear instruments to remain operable during core alteration The failure to coordinate refueling activities and surveillance testing is an apparent breakdown in management control .6 On November 9, 1987, licensee. health physics personnel mistakenly released radioactive material from the.. radiologically controlled area as clean trash. The material ended up being dumped at the Coffey-County landfil The released radioactive material was surveyed around 1:30 a.m. CST on November 9, 198 At the time.the health. physics technicians got radiation readings of 200 to 400 counts 1above background but' assumed this was a naturally occurring isotope (Tungsten-187)'found in welding material. The health physics technicians retained one' piece' .-

of the material for counting on'a. gamma analyzer and released the

.

]

rest of the material for disposal. . The gamma. analyzer was i out-of-service for calibration, and the piece: retained was no analyzed until approximately e p.'m. CST;, when the health physics. .

technicians returned to work for their next shifti At-that time it'

was determined that~the material containe'd the:following isotopes:

60Co, 5800, 52Cr,:and 59Fe. .Sinceithe Coffey. County. landfill was closed, the material could not be. retrieved.until the. day shift'on November 10, 198 ,

There were 39 pieces dumped. TheElicensee retrieved all but 3' pie'ces from the dump on November!10,'1987. Licensee calculations determined:

that the total. activity of the material was.approximately 5 microcuries. This? amount.of activity did not present a hazard to the-public. In~a followup' survey of the Coffey County ~1andfill',-o November 16, 1987, licensee" personnel and NRC inspectors found two-w- . . _ . i

. . .

,

-

. . l

.. j 7  !

radioactively contaminated wiping cloths that had apparently come from WCGS. One cloth was-approximately 6 inches by 12 inches and the other was approximately 18 inches square. As a result of these events, the licensee initiated a thorough survey of the landfill l area. The licensee also stopped the release of material from the 1 radiologically controlled area, pending a review of applicabl procedures and qualifications of health physics personnel performing .

activities in this are ,

Administrative Procedure ADM 03-202, Revision 4, " Radiological Control and Unconditional Release of Tools'and Equipment," has been established and implemented by the licensee. Step 4.1.1 of ADM 03-202 states, "All items prior to leaving the RCA, will be surveyed for loose contamination and for fixed contamination . . ."

and ". . . will be-verified to have no . . . contamination." This was not done for material released on November 9, 198 This is another example of the failure of management oversight.

I 2.7 On November 13, 1987, Work Hold Agreement No. 23 was issued by the licensee to suspend all forming, fitting, rigging, and aligning of safety-related piping performed by mechanical maintenanc The stop-work order was issued as a result of problems encountered during the installation ~of Plant Modification Request, PMR-2116. The problems were failure to follow procedures and work instructions and a failure to accomplish work activities by appropriately qualified workers. Selected' events that caused issuance of Work Hold Agreement No. 23 on November 13, 1987, are discussed below: l WCNOC Work Request No. 05013-87, Erosion on Valve EF HV048 retaining ring.

! Licensee personnel failed to document that the hydrostatic test l

manifold relief valve setting had been verified for the t hydrostatic test of Spool Piece EF05-505 This problem was identified but not resolved prior to installing the spool piec On October 25, 1987, mechanical maintenance. personnel, with '

maintenance engineering concurrence, attempted to align the ,

flanges and install Spool Piece EF05-S050, by jacking the piping l 1/4-inch to align the flanges. The allowable limits specified in Bechtel Specification M-204'for cold springing piping were A quality control verification point for flange

,

exceede alignment had been bypassed by the personnel working this I procedur To correct the misalignment problem, one of the j spool piece welds had to be. cut out, the piping realigned in the f

, field, and reweldad. The repaired spool piece was [

l hydrostatically tested prior to installatio j l

1

!

l

_ _ - - _ _ _ _ _ _ _ _ _ _ _ _ - - - _ - _ -

- -_ _ _ _

_ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -

-

,

. .

1 WCNOC Work Request No. 2828-87, Replace carbon steel flange and reducer downstream of Valve EF-V090 with a stainless steel flange and reduce When the reducer was cut out of the piping, the piping " tee" l that was left was. cut so short that the pipe had to be built up

'

with weld approximately 1 inch. Mechanical maintenance machinists in lieu.of pipefitters were used for performing this wor WCN00 Work Request No. 2827-87, Replace carbon steel flange and reducer downstream of EF V-058 with a stainless steel. flange and reduce On November 2, 1987, an air dam bag installed in the piping to maintain cleanliness was set on fire by hot slag from the cutting operation. The cutting operation was being performed in accordance with Step 5.0 of Work Request 02827-87. A quality control verification point at Step 5.0 for verifying the air dam i bag was installed, had been bypasse The failure to install temporary supports.on the piping upstream of Valve EF V-058 resulted in the piping below the valve being cut too short and at'an incorrect angl The piping had to be built back up with weld, approximately l'1/2 inche '

On three separate occasions, weld filler material different from that specified on the field. welding material requisition was ,

issued to welders. The welders accepted and used this. wrong ,

material and the wrong procedure to perform hard surfacing weld overlay on piping. Paragraph 6.2.4 of Administrative Procedure ADM 08-302,' Revision 4, " Wolf Creek Generating Station Control of Welding Filler Material" requires that each welder shall have in his possession only that type and classification of weld filler material authorized on the field welding material

!

requisition. Paragraph 7..'2.1 of Quality Control  ;

l Procedure QCI - 12.1-601 requires the quality control inspector to 1 l verify that the weld filler material is that specified on the I

weld data shee The weld data sheet for Work Request 02827-87 specified Weld Procedure WPS1-0101530 and weld material ECoCr-A i

for shielded metal arc welding.

On November 5, 1987, Field Welding Material  :

Requisition 9443 specified weld material ECoCr-A for  !

shielded metal arc welding. However, the welder was issued weld material RCoCr-A for gas tungsten arc welding. The welder accepted this wrong material and performed the welding in accordance with Weld Procedure WPS1-0101T30 for gas tungsten arc welding. The quality control inspector mistakenly. verified that i.he material issued'was the correct material. These non-compliances were documented

---

__ _ _ -

'

.

-

)i

,

l

.

9 I i

)

I several days after the weld was made by the licensee on ]

Programmatic Deficiency Reports OP 87-104 and OP 87-106, and on Quality Control Report of Procedure Violation 87-01 On November 5 and 6, 1987, Field Welding Material l Requisitions 9446 and 9448 specified weld material ECoCr-A for shielded metal arc welding. However, the welders were issued weld material RCoCr-A for gas tungsten arc weldin The welders performed the welding using weld material and a welding procedure other than what was specified on the weld data sheet. This non-compliance was later documented by the licensee on Programmatic Deficiency Report OP 87-10 On November 12, 1987, another welder, working on the same job, requested welding material for shielded metal arc-welding on Field Welding Material Requisition 9501. The ,

welder was issued weld material for gas tungsten arc welding. The welder called a maintenance welding engineer to determine which weld material and welding procedure were i correc The welder then performed the shielded metal. arc I welding using weld material ECoCr-A and welding )

Procedure WPS1-101S30 as specified on the weld data shee It was later determined that this welder was not qualified to do shielded metal' arc welding. Paragraph 6.2.1 of Procedure ADM 08-302 requires that welder; shall use only those materials they are qualified to us This j nonconformance was documented by the licensee on Work'-

Request 04968-8 ,

Field Welding Material Requisitions 9446 and 9448 were added to the same block on the weld data sheet that had- i been used to accept Field Welding Material )

Requisition 9443. By adding these field welding material requisitions to a block on the weld data sheet that had ]

already been used by quality control, the check on the weld procedure specification / material acceptance verification was defeate On November 13, 1987, the licensee turned all safety-related major modifications involving piping fabrication and welding over to the facilities and modifications group. .The facilities and modifications I group had personnel who had expertise in pipefitting of major 1 component i j

3. Review of Licensee Event Reports (LER) ]

The.NRC inspectors reviewed LERs to determine if the licensee was properly ,

addressing root causes and if corrective action was sufficient to prevent i recurring events. Several LERs in which the depth of root cause analysis i

______-_-__Q

--_ _ . _ - - _ _ _ _ _ - - - _ _

-

'

.

.

. ,

10 was questioned were further investigate These LERs'and the inspector's concerns are listed below:

ESF actuations, particularly control room ventilation isolation signals (CRVISs), have occurred because of chlorine monitor malfunctions. Since April 1985, a total of 24 LERs which identify )

31 occurrences have been written concerning the chlorine monitor The malfunctions are divided into three main categories: Paper tape ,

(used to detect chlorine) problems, electrical problems', and spurious spikes. The licensee could not identify the common. root cause .

factors associated with these malfunctions. Previous LERs (those j written since LER 86-02) have stated that design changes to the 1 l

monitors are being considered, but no changes have yet been-l implemente l l

LER 87-37. describes plant responses to a high. voltage transmission line failure that resulted in a main turbine and reactor trip During plant recovery and restart operations, two feedwater isolation signals (FWIS) and auxiliary feedwater actuations signals (AFAS)

occurred because of an operator's failure to control and maintain steam generator water level. Corrective actions taken include

" evaluation of' potential feedwater control system design enhancements" and operater training. At least eight other LERs associated with events involving FWIS/AFAS actuations as a result of steam generator water level control have been identifie Less than 3 weeks later, operator error again resulted in a failure to control steam generator water level, resulting in a FWIS. LER 87-042 reported this event. It appears that the corrective actions of previous LER events have not been effective in correcting problems with steam generator water level contro Numerous LEb have been written against technical specifications violations caused by inadequate surveillance procedures. The LERs include 85-05, 85-80, 86-03, 86-67, 87-13, 87-29, 87-38, 87-43, and 87-44. In all cases, surveillance tests required by technical specifications were not completed because of inadequate surveillance procedures. Technical specification requirements were not added to the procedures during development or were deleted during subsequent procedure revisions. The root cause determination and corrective action for these LERs focused on the specific area of-the missing surveillance and limited improvements to the procedure change review process. However, the' licensee'did not address the possible widespread problem of existing inadequate surveillance procedures as j indicated by the number of LERs of _this typ Missed fire watch inspections have been'an ongoing problem.since initial operatio LER's.87-21, 87-16, 86-58, 86-27, 86-05, 85-68, )

85-59, 85-47, and 85-04 reported the missed inspections. The root j cause for each event was attributed to personnel error with 1 l corrective action including retraining, reprimands, modifications to l fire watch logs, .and improvements to fire door marking While the l 1 i L  !

E--_--- --- - 1

l

l' ,

'D .

'

.. ..

( annual number of missed inspections has decreased, inspections i

continue to be missed. Therefore, either the root cause  ;

determination or the' corrective' action'was not effectiv It appears that the licensee'_s program for evaluating root causes for identified problems and taking prompt and adequate corrective actions has not'been effective. This is yet another example where licensee 4 management oversight has not been adequat l l

4. Physical Security Verification The NRC inspectors verified that the facility physical security plan-(PSP)

is being followed by direct observation of licensee facilities.and security personne The NRC inspectors, by observation of randomly. selected activities, verified that search equipment was operable, that the protected area .

barriers and vital area barriers were well maintained, that access control  :

procedures were followed and that appropriate compensatory measures were  !

'

followed if require No violations or deviations were identifie . Radiological Protection By performing the following activities, the NRC inspectors verified that i radiologically related activities were controlled in accordance with the

,

licensee's procedures and regulatory requirements:

l .

. .

l

'

Reviewed documents such as active radiation work permits'and the health physics shift turnover log Observed personnel activities in the radiologically controlled area (RCA) such as:

. Use of the required dosimetry equipment

. " Frisking out" of the RCA

. Wearing of appropriate anti-contamination' clothing where required Inspected postings of radiation and contaminated areas

Discussed activities with radiation workers and health physics supervisors No violations or deviations were identifie :

_ . . _ . _ _ _ . _ . _ _ _ _ _ _ _ _ _ .

- _ - - _ .

.

..

.

. . . >

r 12 Operational Safety Verification-The NRC inspectors verified that the facility is being operated safely and in conformance with regulatory requirements by direct observation of licensee facilities, tours of the facility, interviews and discussions with licensee personnel, independent verification of safety system status and limiting conditions for operations, and reviewing facility record The NRC-inspectors, by observation of randomly selected activities and interview of personnel verified that physical security, radiation protection, and fire protection activities were controlle By observing accessible components for correct valve position and electrical breaker position, and by observing control room indication, the NRC inspectors confirmed the operability of selected portions of safety related systems. The NRC inspectors also visually inspected safety components for leakage, physical damage, and other impairments that could prevent them from performing their designed function . Exit Meeting The NRC inspectors met with licensee personnel to discuss the scope and findings of this inspection on November 27, 198 J u

I

!

- - _ _ - _ _ _ _ _ _ _ _