IR 05000482/1993024

Insp Rept 50-482/93-24 on 930801-0911.Violations Noted. Major Areas Inspected:Plant Status,Operational Safety Verification,Maintenance & Surveillance Observations

ML20058M766
Person / Time
Site:	Wolf Creek
Issue date:	09/29/1993
From:	Johnson W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20058M752	List: IR 05000482/1993024 ML20058M749 ML20058M761
References
50-482-93-24, NUDOCS 9310070014
Download: ML20058M766 (26)

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APPENDIX B U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Inspection Report: 50-482/93-24 License: NPF-42 Licensee: Wolf Creek Nuclear Operating Corporation P.O. Box 411 Burlington, Kansas

Facility Name: Wolf Creek Generating Station Inspection At: Coffey County, Burlington, Kansas Inspection Conducted: August 1 through September 11, 1993 Inspectors: G. A. Pick, Senior Resident Inspector J. F. Ringwald, Resident Inspector, Palo Verde W. D. Johnson, Chief, Project Section A, Division of Reactor Projects ,

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Approved: zt//)

W-~[D. Johns

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, Chief, Project Section A 9/49/93 Dhte '

Division o Reactor Projects

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Inspection Summary ,

Areas Inspected: Routine, unannounced inspection of plant status, operational safety verification, maintenance observations, surveillance observations, employee concerns program, and followup on corrective actions for violation Results:

• The inspectors identified a violation of Technical Specification 6.8. i because the procedure that specified starting a safety injection pump to fill the safety injection accumulators failed to require that a '

component cooling water pump be started. The inspectors expressed concern that operators continue te have weaknesses in maintaining

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control panel awareness. No response to the violation was required because the licensee responded promptly and implemented appropriate corrective actions (Section 2.5).

• The failure to post the response to an escalated enforcement action within 2 days, as required by 10 CFR 19.11(e), was a noncited violatio The individual responsible for posting the information required by 10 CFR immediately implemented corrective actions. After conducting a 0070014 933903 p G ADOCK 05000482 4?

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thorough root cause evaluation, the licensee implemented good, thorough corrective actions to prevent recurrence (Section 2.2).

. The licensee identified another instance of operator unawareness of control panel indications. The steam dumps were armed for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> 25 minutes without notice until the operations supervisor questioned the alarm (Section 2.4).

• Operators performed detailed control board walkdowns with excellent transfer of information during crew turnovers (Section 2.3). *

• A clearance order deficiency resulted in the collapse of a condensate ammonia supply tank. The licensee performed a strong investigation that identified several program weaknesses (Section 2.6). .

. Because the licensee failed to promptly implement effective corrective *

actions for check valve problems (refer to NRC Inspection Report 50-482/93-21), another failure of the increased frequency inservice check valve closure test occurred. The licensee promptly developed a detailed plan to address the failure (Section 2.7).

• Personnel inattention while establishing a hydrostatic test boundary resulted in contaminating 940 square feet of the radioactive waste -;

building (Section 2.8). *

• Throughout this inspection period, the licensee responded more ;

aggressively than in the past to identified problems. Additional r actions by the licensee to improve facility performance involved soliciting input from workers on areas needing improvement and addressing these areas (Section 2.9).

. Overall, qualified, knowledgeable licensee personnel performed maintenance activities well (Section 3).

• The inspectors observed a mechanic use poor radiation worker practices ,

that were subsequently addressed (Section 3.2).

• The licensee had mixed performance this period while conducting i maintenance that placed the facility in Technical Specifications !

limiting conditions for operation. During repair of a pump bearing, -

maintenance personnel waited 7 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> prior to beginning work (Section 3.2). During air conditioning unit maintenance, the licensee l implemented the repairs in accordance with a preplanned schedul ,

(Section 3.3).  ;

• The inspectors identified a work instruction weakness for documenting torque values. The licensee had used an out-of-date revision of the ,

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work instructions (Section 3.3).

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• The licensee effectively implemented actions to clear a battery monitor ,

alarm and to remove a battery cell from service. The inspectors considered the licensee actions to be conservative (Section 3.4).

• The inspectors noted that licensed operators were distracted from fully .

monitoring the control panels during performance of an inservice pump -

test (Section 4.2).

• The inspectors reviewed characteristics of the licensee's employee concerns program (Section 5). -

Summary of Inspection Findings:

• Violation 482/9324-01 was opened (Section 2.5).

• A noncited violation was identified (Section 2.2).

• Violations 482/9230-01 and 482/9230-05 were closed (Section 6).

Attachments:

• Attachment 1 - Persons Contacted and Exit Meeting -

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• Attachment 2 - Employee Concerns Program

• Attachment 3 - Items Needing Improvement Based on Employee Input

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L DETAILS

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1 PLANT STATUS The plant operated at essentially 100 percent power throughout the inspection perio >

2 OPERATIONAL SAFETY VERIFICATION (71707)

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The objectives of this inspection were to ensure that the licensee operated-the facility safely and in conformance with license and regulatory ,

requirements and that the licensee's management control systems effectively discharged the licensee's responsibilities for safe operatio i The methods used to perform this inspection included direct observation of I activities and equipment, observation of control room operations, tours of the facility, interviews and discussions with licensee personnel, independent verification of safety system status and Technical Specifications limiting conditions for operation, verification of corrective actions, and review of facility record ; I_ncreased Unidentified leakage On August 2, 1993, because of a continued increase in the reactor coolant system unidentified leakage over the previous 2 weeks, the licensee ;

established a team to review potential sources of reactor coolant system t leakage. Chemistry personnel sampled the sumps to identify the presence of radionuclides and boron. System engineering and operations personnel ,

investigated the possible sources of leakage into the auxiliary building (

sump Chemistry personnel determined that the boron concentration in the auxiliary l

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building dirty radioactive waste sump was 3 ppm and that the boron concentration in the auxiliary building clean radioactive waste sump was l 1357 ppm with several short-lived radionuclides present. The licensee stroked .

several chemical and volume control system manual valves that could contribute I to the leakage into the clean radioactive waste sump. Tightening of the'three valves aecreased the leakage into the clean radioactive waste sump from ,

0.3 gpm to 0.05 gpm. The inspectors considered the licensee actions to be j appropriat .2 Posting Violation On August 2, 1993, the licensee informed the inspectors that they had violated the notice of violation posting requirements specified in 10 CFR 19.ll(e).

The licensee determined that personnel failed to post by July 23, 1993, the Notice of Violation response related to Escalated Enforcement Action 93-12 Procedure ADM 01-085, "10 CFR Posting Requirements," Revision 5, specified in Step 5.1.3 that any notice of violation involving a proposed imposition of

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-5-civil penalty shall be posted within 2 working days after receipt of the document and the response shall be posted within 2 working days of dispatc The licensee immediately posted the violation response and promptly investigated this incident to identify the root cause and corrective actions required. The licensee attributed the root cause to personnel error, and appropriate corrective actions were pron:ptly implemente Because of the licensee's prompt and thorough actions in response to this failure to post a civil penalty letter response, this violation of 10 CFR 19.11(e) will not be cite .3 Control Room Observations Throughout the inspection period, the inspectors observed operations crew turnovers. The inspectors noted that operators used appropriately detailed turnover sheets to communicate pertinent plant status and other relevant information. The inspectors accompanied several operators and supervising operators during their control board walkdowns. The inspectors noted that operators conducted the walkdown turnover discussions at an unhurried pace, and off-going operators demonstrated genuine interest in providing all relevant information to the oncoming crew. The inspectors concluded that operators performed the crew turnovers wel .4 Operator Inattention On August 6, 1993, as documented in Performance Improvement Request (PIR) OP 93-0858, the operations supervisor questioned operators about why the condenser steam dumps had armed. The control room operators were not aware that the steam dumps had armed. Operations management considered this occurrence to be significant after determining that the steam dumps were armed for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> 25 minutes without operators identifying the conditio The licensee attributed the root cause to reduced operator vigilance in j monitoring the control panels. The licensee considered the lack of an audible cue to be an additional factor. Corrective actions included developing a list ,

of parameters to be monitored every 30 minutes by control room operators, 7 placing PIR OP 93-0858 into operations required reading, and discussing the event at the shift supervisor / supervising operator meeting conducted on August 23, 1993. At the operations meeting, the operations manager expressed his expectations regarding operator awareness of control panel indications and equipment conditions. The operations manager discussed this event and the ,

failure to ensure component cooling water flow to a safety injection pump :

(refer to Section 2.5). j The licensee initiated Work Request (WR) 04802-93 to ensure that personnel determined the cause for the arming of the steam dumps. Instrumentation and control technicians connected a trend recorder to inputs and outputs that -

could arm the steam dumps. From the trend recorder, the instrumentation and '

control personnel found that a lead / lag card spiked high. After changing the lead / lag card, the licensee verified that no additional spiking occurre *

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i-6-i 2.5 Inadequate Safet_Y-related Pump Oil Coolin_q l l

On August 13, 1993, control room operators filled Safety Injection Accumulator D to clear a low pressure alarm using Safety Injection Pump A, in accordance with Procedure SYS EP-200, " Accumulator Safety Injection Operations," Revision 11. Prior to starting a safety injection pump, the operators dispatched a nonlicensed operator who verified that the cooling '

valves were open and that oil levels were prope i Operators started Safety Injection Pump A, filled each accumulator approximately 4 percent, and secured the pump after 6 minutes of operatio The nonlicensed operator, who remained at the pump, informed the control room that the bearing oil temperature had increased but did not exceed 105o l Subsequently, the licensee determined that control room operators failed to start a Train A component cooling water pump. Operators determined that Procedure SYS EP-200 did not specify starting the appropriate component cooling water pcmp. The operators immediately changed the procedure to ,

specify operating the appropriate component cooling water pum Senior management directed that a thorough investigation be conducted. The ,

licensee determined from review of procedures (system operating procedures, surveillances, and general operating procedures) affecting other safety systems that Procedu m STS BG-210, "CVCS Inservice Check Valve Test,"

Revision 10, failed to specify that the appropriate component cooling water pump should be operate Even though the component cooling water pumps start i automatically when a centrifugal charging pump is started, the licensee ,

changed Procedure STS BG-210 to require starting a component cooling water pump. The licensee performed an evaluation of the effects of operating Safety Injection Pump A without cooling water flow to the lubricating oil heat exchangers. The evaluation determined that the pump remained operable since ,

the temperature increased to 109of (as listed in the computer) with a temperature limit of 155 F. Review of an oil sample indicated that the oil I had not degrade The operations manager conducted a meeting with all shift supervisors to f discuss his expectations regarding plant awareness and generic aspects of this event. Also, the operations manager issued a memorandum discussing the increased accountability within the operations department. The operations !

manager informed the inspectors that he considered this a significant event l and that he expected the involved personnel to have noticed during crew turnovers and control board walkdowns that Component Cooling Water Train A was secured and that Component Cooling Water Train B provided coolin The licensee's failure to establish an adequate system operating procedure to i

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ensure proper cooling of a safety injection pump was a violation of Technical Specification 6.8.1.a (482/9324-01).

The inspectors considered the licensee review of this event to be thoroug Corrective actions included: (1) revising Procedure SYS-EP-200; (2) reviewing procedures for other safety systems; (3) revising Procedure STS-BG-210;

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(4) conducting meetings with shift supervisors; and (5) issuing a memorandum ;

on personal accountability. The inspectors were encouraged that operations management recognized that this event was a recurrence of NRC Violation 482/9316-01. The licensee satisfactorily implemented appropriate corrective actions prior to the end of the inspection period and no written response will be require ;

2.6 Condensate Ammonia Supply Tank Collapse l On August 18, 1993, as operations personnel implemented Clearance Order 93-1647-KH to isolate the low pressure nitrogen system for repair of- ,

Valve KH V0008, low pressure nitrogen to north penetration Room PCV-29 upstream isolation, nonlicensed operators found Condensate Ammonia Supply Tank B collapsed. The operators attributed the tank collapse to a vacuum pulled on the low pressure nitrogen system by the condenser after personnel closed Valve KH V0001, low pressure nitrogen supply header isolation, without isolating the condenser. Temporary Modification 91-09-AD provided a method to supply low pressure nitrogen to the condenser hotwell to reduce the dissolved oxygen levels, In response to the tank collapse, senior licensee management directed a root cause be determined to prevent future similar event t The licensee assigned a team of nuclear safety engineering personnel to determine the root cause. Surveillance Report SSR 93-011, " Collapse of the .

Condensate Ammonia Supply Tank (TAQO2B)," documented the investigation and !

findings and recommended corrective actions. The investigation team ;

determined that:  !

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• The clearance order group did not have green-lined drawings (controlled control room drawings marked in green to reflect the configuration of ,

temporary modifications) readily available. Also, the potential existed for a similar error with red-lined drawings (controlled control room drawings marked in red to reflect installed plant modifications). i

• Personnel took longer than expected to implement Clearance Order 93-1647-K ,

• An opportunity to identify the potential for the vacuum being created occurred while personnel implemented the clearance; however, the radioactive waste control room drawings were not green-lined;

• Clearance Order 93-1647-KH did not implement a proper tagout sequenc Since the clearance order was extensive, the licensee should have :

developed a temporary procedure to isolate the low pressure nitroge * Valve KH V0ll2, ammonia supply tank's check valve for low pressure nitrogen to condensate, in the low pressure nitrogen supply line to Condensate Ammonia Supply Tank B stuck ope .

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The investigation team identified five specific corrective action recommendation PIR OP 93-0907 documented the two recommendations assigned *

to operations: (1) use red-lined / green-lined drawings to develop clearance ,

orders, and (2) develop a procedure for taking the low pressure nitrogen  :

system out of service. PIR NP 93-0937 documented three recommendations assigned to system engineering: (1) evaluate Temporary Modification 91-09-AD, I

which supplied low pressure nitrogen to the condenser, (2) change the temporary modification process to eliminate those extending beyond one refuel ,

cycle, and (3) ensure red-lined / green-lined drawings are available in the  !

clearance order preparation area and in the radioactive waste control roo {

During the inspection period, the licensee began implementing several of the recommendations. By September 8, 1993, the tagging group had green-lined ,

drawings to reflect outstanding temporary modifications. Other actions ,

implemented by operations included: revising the alarm response procedure for low pressure in the low pressure nitrogen system to require isolating the  !

condenser, updating the clearance order template to reflect lessons learned, ,

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placing PIR OP 93-0907 in opera.tions required reading, and using control room '

red-lined drawings until corrective actions for upgrading the drawing process are completed. Operations management requested that the shift supervisors review all their assigned systems to assure that procedures exist for startup and shutdow In response to PIR NP 93-0937, the licensee reviewed Temporary Modification 91-09-AD and, on August 25, 1993, the licensee installed a vacuum break in the low pressure nitrogen supplied to the condenser. By i September 30, 1993, the licensee will establish milestones to address actions needed to eliminate temporary modifications extending beyond 18 months. The licensee will change the drawing control process so that changes affecting the ,

approximately 2000 essential control room drawings will be updated within

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24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of turning the modification over to plant operation .7 Essential Service Water System Check Valve Failures '

I On September 2, 1993, the inspectors determined that the increased frequency inservice test of Check Valve EF V0046, Essential Service Water A return from Air Compressor A check valve, failed. The licensee performed the test in  ;

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accordance with Procedure STS EF-210A, "ESW System Inservice Check Valve Test," Revision 4. Consequently, the inspectors observed maintenance '

activities performed in accordance with WR 04876-93 to evaluate and repair Check Valve EF V0046. The licensee had increased the test frequency from quarterly to monthly because of previous test failures. The inspectors  ;

determined that the mechanics received a prejob brief on the task, used l calibrated tools, and were familiar with the detailed instructions. The j mechanics cleaned the check valve internals and reassembled the valve. The ,

licensee successi$y retested the valve on September 3,199 l Also, on September 3, 1993, the licensee conducted a meeting to develep an action plan to eliminate the sticking check valve. The licensee increased the test frequency from monthly to weekly. In addition, the plant manager

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l, requested that personnel test Check Valve EF V0046 on September 7. Othe .

short-term corrective actions included: (1) developing an alternate method j for isolating the nonsafety from the safety portion of essential service water, and (2) replacing the old carbon steel valve internals with new internals. The licensee determined the long-term solution to be installation .

of stainless steel valve internal +

Check Valve EF V0046 failed the inservice check valve closure test performed on September 7, 1993. Consequently, the licensee installed the new carbon steel internals and successfully retested the check valve. Additionally, the licensee implemented Plant Modification Request 04738 that installed a ,

1 1/2-inch drain line to replace the 3/4-inch drain line. The larger diameter drain line allowed the licensee to better approximate design flow and differential pressure conditions across the check valve. On September 10,. .

after receipt of the staicless steel internals, the licensee replaced the internals and performed a successful retes e The inspectors observed the shop fabrication-activities performed in accordance with WR 05338-93 on the 1 1/2-inch replacement drain line. The inspectors determined that the licensee performed an effective 10 CFR 50.59 evaluation, which added Valve EF V0346, essential service water return from ;

Air Compressor A after cooler manual isolation, to the valve inservice test program. The licensee added Valve EF V0346 to the inservice test program a an alternative method to isolate the nonsafety-related pipin Either valve prevents the loss of essential service water flow returning from Air Compressor A, in the event of a downstream line break coincident with a main dam failure, to assure the 30-day supply of water from the ultimate heat sin The inspectors reviewed the calculation that demonstrated that 21/2 days of

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margin existed in the ultimate heat sink water availability before decreasing the 30-day required water supply, if the line brake without notic As discussed in NRC Inspection Report 50-482/93-21, the licensee's corrective actions following previous inservice test failures of Valve EF V0346 were ineffective. Corrective actions following the September 2 failure were more aggressiv .8 Hydrostatic Test Boundary Valve Failure ,

On August 31, 1993, during a hydrostatic test of liquid radioactive waste i piping, a test boundary valve leaked and highly contaminated water spilled out of an overpressure vent onto approximately 940 square feet of the radioactive waste building. The licensee initiated PIR MA 93-0960 since the test used nitrogen as the test medium and water should not have sprayed from the ven .

Senior licensee management directed that a thorough investigation be performe As specified in WR 04236-93, the licensee reoriented and performed a '

hydrostatic test for Valve HB V0743, waste feed to liquid radioactive waste demineralizer skid. As the field engineer increased the test pressure, he )

observed that the pressure increased smoothly up to 220 psig and then i

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-10-t fluctuated. After determining that no leaks existed on the nitrogen supply, the field engineer investigated the overpressure protection valve, Valve HB V0460, waste evaporator / secondary liquid waste evaporator feed l crossconnect header vent valve. Valve HB V0460 was located between the inner ;

and outer hydrostatic test boundary isolation valves. The licensee used i

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Valve HB V0742, waste feed header isolation, as the inner isolation valve and used Valve HF V0102, secondary liquid waste evaporator / radioactive waste evaporator crossconnect isolation, as the outer isolation valve. The licensee found Valve HB V0460 blowing air and water onto the floor from the dead leg between Valves HB V0742 and HF V0102. The licensee determined that the stop nut for Valve HB V0742 was slightly misadjuste :

The licensee determined that Valve HB V0742 would have functioned to' isolate ;

the system under normal operating pressures. The licensee calculated that the 120-foot length of 2-inch pipe between the hydrostatic test boundary valves released a maximum of 21 gallons of contaminated water. The licensee attributed the root cause to failure of the test engineer to ensure that a t drain hose was attached to the vent on the outlet of Valve HB V046 As corrective actions, the licensee immediately increased the valve stem travel for Valve HB V0742 and decontaminated the area from highly contaminated to contaminated. By the end of the inspection period, the licensee had f decontaminated the area to a clean area. The licensee clarified Procedure ADM 08-217, " Hydraulic and Pneumatic T:3 ting," Revision 2,_by assigning the test engineer the responsibility to assure all planned flow l paths are properly aligned to minimize the spread of contamination. The ;

manager of modifications discussed this event and the new program requirements with personnel who normally conduct hydrostatic test (

2.9 Management Initiatives  :

During this inspection period, senior licensee management requested that operations personnel identify the five plant material conditions that were of greatest concern to them. Also, licensee management requested that maintenance personnel identify the five greatest impediments to conducting maintenance. After the issues (listed in Attachment 3) were identified, -

managers were assigned to identify simple, effective solutions and schedule Senior management required the solutions to be implemented in addition to the regularly scheduled activities. Licensee management intended to demonstrate, ,

by action, their interest in addressing areas identified by employees as -

needing improvement. By the end of the inspection period, the emergency diesel generator room lighting had been installed. The licensee changed their policy to allow scheduled work activities to be preapproved and reviewed for

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impact on plant systems by the shift supervisor the evening before the day on which the work is scheduled. This was intended to reduce control room delay The licensee actively pursued implementation of the other areas of concer '

Licensee managers will obtain and address additional concerns as the initially identified concerns are resolve :

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The licensee established a team to identify and reduce increasing unidentified

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leakage, and the licensee effectively resolved the issue. Licensee actions, in response to a failure to post a violation response in accordance with 10 CFR 19.ll(e), resulted in a noncited violation because of the licensee's ;

prompt, thorough corrective actions. Throughout the period, the inspectors ;

observed detailed discussions among operators during crew turnover :

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Operators failed to notice that steam dumps had armed for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> 25 minutes because of operator inattention to the control panels. A violation was identified when operators failed to assure that cooling water was supplied to a safety-related pump prior to operating the pump because of an inadequate 1 procedure. The licensee attributed the root cause of the events to operator !

unawareness of control panel indications and equipment status, respectivel The licensee collapsed a condensate ammonia tank because of clearance order problems. An investigation team performed a detailed evaluation that identified several programmatic weaknesses that contributed to the event. The licensee implemented extensive corrective actions and responded appropriatel The licensee implemented detailed, thorough actions to eliminate check valve leakage. However, this corrective action to address repeated check valve failures was not prompt. The licensee determined that a personnel error resulted in contaminating portions of the radioactive waste building during a hydrostatic test. Licensee management obtained the top five plant material condition concerns of operations personnel and the top five impediments to completing work as identified by maintenance personnel. The managers provided

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resources to address the identified problem MAINTENANCE OBSERVATIONS (62703)

The inspectors reviewed this area to ascertain that the licensee conducted ;

maintenance activities on safety-related systems and components in accordance with approved procedures and Technical Specifications. Methods used in this inspection included direct observations of maintenance activities, interviews with personnel, and review of record .1 Main Steam Isolation Valve Preventive Maintenance On August 6, 1993, the inspectors observed mechanics perform work activities on Main Steam Isolation Valve A in accordance with WR 51302-93. This WR referenced Procedure MPM AB-001, " Main Steam Isolation Valve Monthly PM

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Activity." Procedure MPM AB-001 provided instructions for inspecting the valve actuators for oil and air leaks and for replenishing hydraulic fluid The inspectors noted that the mechanics initiated corrective WR 04803-93 to ensure repair of a broken air filter 0-ring, as instructed by the procedur ,

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Discussions with the craft personnel indicated that they were familiar with the maintenance activitie .

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-12-3.2 Centrifugal Charging Pump B Oil Leak Repair On August 11, 1993, the inspectors observed mechanics draining oil from Centrifugal Charging Pump B in preparation for bearing work to repair an oil leak. The inspectors noted that the WR provided minimal guidance regarding ,

the location of the oil drain plug. During the draining, as the mechanic removed a drain plug from the lube oil cooler, the mechanic noted that water <

rather than oil emanated from the opening and quickly tightened the drain plug. The mechanic subsequently drained the oil from the coole The licensee posted the centrifugal charging pump skid as a contaminated area, yet the mechanics pumped the oil through tubing into containers located outside the contaminated area. The inspectors noted that, while the mechanic obtained a sample of oil for the health physics technician to test for radioactivity, oil spilled onto the mechanic's bare hands. The inspectors questioned the mechanic, the health physics technician, and the radiation protection manager regarding this practice. All responded that historically the oil has been clean (i.e., below contamination limits). The inspectors noted that this practice could result in a future personnel contamination if contaminated water leaked 'nto the oil subsystem. Subsequently, the radiation ;

protection manager directei expectations to his supervisors to require rubber !

gloves while handling potertially contaminated oil on radiation work permit .

The inspectors noted that operators removed the pump from service at 5 a.m., '

that mechanics began draining the oil at 12:30 p.m., and that the leak repairs began at approximately 4 p.m. The inspectors discussed this delay with the 4 plant scheduling supervisor who acknowledged that organized efforts have only recently begun to minimize the amount of time in Technical Specifications action statements during maintenanc The inspectors concluded that the work planning was not fully consistent with

" skill of the craft" expectations, that the mechanics demonstrated poor radiation protection practices, and that work scheduling is not yet fully effective at minimizing the use of Technical Specifications action statement time for maintenance activitie After operators returned Centrifugal Charging Pump B to service, personnel noticed that the oil continued to leak but at a slower rate (20 drops per minute versus 100 drops per minute). The system engineer contacted the pump manufacturer and questioned other causes for the oil leak beyond those items repaired. The licensee had previously verified that the oil baffle and bearings were installed correctly and that the oil pressure remained within specification The vendor suggested that the bearing clearances could be slightly out of specification such that an oil leak path occurred along the shaft. The licensee initiated WR 05004-93 to measure the bearing clearance -

during the next scheduled Centrifugal Charging Pump B maintenance outag The oil that M ked from tne bearing collected in the trough at the base of the pump. The ins,,ectors questioned whether the oil represented a fire hazard. The licensee's fire protection group evaluated the quantity of oil at

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the base of the pump and determined that no fire hazard existed because the ]

amount of oil in the room fell below that specified in the fire hazards j analysis. Also, the . inspectors determined that the Mobil DTE 797 oil used for lubricating the bearings had a flash point of 410o .3 Electrical Equipment Air Conditioning Unit )

On August 25, 1993, the inspectors observed craft personnel perform the ;

maintenance activities summarized below:

• WR 51245-93, inspect, adjust, and calibrate hydrometer at SGK05A, J Class lE electrical equipment A/C unit;  :

• WR 05431-90, repair control panel door gaskets; i

• WR 06234-92, repair Valve GK V0767, Class 1E electrical equipment A/C 1 Unit SA condenser outlet isolation, packing leak; and

. WR 03539-92, repair damaged copper sensing lin l The inspectors determined from review of open WRs for SGK05A that all WRs were worked with~ the exception of two undergoing engineering evaluation and two issued for performance of the 10-year hydrostatic tests that were not due :

until February 1995. The inspectors verified that the work instructions for ;

WRs 05431-90, 06234-92, and 51245-93 provided appropriate guidance. All the work activities had appropriate quality control personnel oversigh Personnel determined that the valve stem for Valve GK V0767 was damaged and initiated WR 05105-93 to replace the valve ste As electricians implemented WR 03539-92, Step 05.01, that replaced the freon filter cartridges, the inspectors noted that the electricians used a ;

calibrated torque wrench; however, the work instructions did not require i'

documenting the torque value. The electricians informed the inspectors that Vendor Manual Drawing D-9386, "SNUPPS-Filter Dryer Assembly," specified torquing the filter housing jack bolts to 10 inch-pounds to ensure a secure fit in accordance with seismic requirements. The inspectors found that the licensee seismically qualified the filter housing because the filter housing i hold down springs failed during seismic testing. The inspectors considered l the torquing of the filter housing bolts to be a critical measurement that should be documented to ensure that seismic qualifications can be i demonstrated. The inspectors verified that the vendor manual and ,

Drawing D-9386 contained the requirement to torque the jack bolts. The j inspectors questioned the licensee about the need to document critical torque

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valves, such as those necessary to ensure seismic qualifications were maintaine The licensee reviewed past performance of filter changeouts for Air Conditioning Units SGK04A and -B, Train A and -B control room air conditioning i units, and SGK05A and -B, Train A and -B Class lE electrical equipment air l I

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_14 conditioning units. The licensee determined that, out of 15 previous filter changes, the first 3 filter changes did not document torquing the jack bolt ;

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Twelve WRs performed later specified the torque requirement, referenced the vendor manual drawing, and required quality control verification. The ,

licensee initiated PIR MA 93-0981 to identify the root cause and to assure +

corrective actions were implemented. The licensee determined that the work ,

planner had used an old revision of supplemental work instructions maintained ;

in the database. The electrical supervisor stated that personnel will- delete the out-of-date instructions to prevent future problems. Also, the licensee addressed generic problems by requiring all maintenance groups to purge all outdated supplemental work instruction t The inspectors considered the electrician's actions while performing the !

maintenance to be commendable. The electricians had an outstanding level of :

knowledge related to the maintenance requirements for changeout of the freon :

filters. The inspectors considered the practice of maintaining out-of-date supplemental work instructions on their database a weakness that could have resulted in a violation of regulatory requirements. The licensee responded well to the identified weaknes .

3.4 Station Batteries i 3. Battery Monitor Alarm  :

On August 29, 1993, Control Room Annunciator 27C alarmed to indicate a local i alarm for the NK13 125 Vdc battery. The operators dispatched a nonlicensed operator who determined that the local battery monitor had alarmed. The ,

operators determined that the battery remained operable because the battery voltage was 134 Vd The inspectors verified from review of Procedure ALR 00-027C, "NK03 Trouble," ;

Revision 4, and Procedure ALR 303-02A, "NK03 Battery Monitor Alarm,"

Revision 3, that operators had taken appropriate actions in accordance with i'

procedures. The electricians contacted the electrical maintenance engineer responsible for the batteries. The engineer specified that the battery would probably require an equalize charge. Personnel verified calibration of the battery monitor in accordance with Procedure MPE BA-004, "125/250 Volt Battery i Monitor Annual Calibration," Revision 3. The licensee identified no problems with the battery monitor calibration. The inspectors determined from i discussions with licensee personnel that the battery had a history of voltage driftin In the past, the difference in voltages had rat exceeded 1.85 Vdc; however, electricians found the present voltage difference to be 2.1 volt The battery monitor compares the overall voltage produced by the last 30 cells to that produced by the first 30 cells. The battery monitor identifies a possible dead cell by noting a voltage difference of 2.13 Vd l The licensee initiated WR 05154-93 and performed an equalizing charge on the battery in accordance with Procedure MPE E050Q-05, " Battery Equalizing :

Procedure," Revision 4. From review of surveillance data and discussions with

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personnel, the inspectors determined that, for one set of 30 cells, 26 cells had higher than nominal voltages; and for the other set of 30 cells, 26 cells !

had lower than nominal voltages. On September 3,1993, upon removal of th t battery from the equalize charge, the voltage difference decreased below the battery monitor alarm setpoin . Inoperable Battery Cell On August 31, 1993, licensee personnel took a voltage reading for Pilot Cell 13 of Battery NK14 to identify whether the voltage had degraded from previous readings. After measuring 2.08 Vdc, licensee personnel contacted

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integrated scheduling personnel who subsequently contacted the control roo The shift supervisor entered Technical Specification 3.8.2.1. Since Pilot ,

Cell 13 remained OPERABLE, Technical Specifications Table 4.8-2, " Battery ;

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Surveillance Table," allowed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> to determine the status of the other 59 individual battery cells. The licensee determined that the other  !

59 battery cells met the limits specified in Technical Specifications Table 4.8-2; consequently, the licensee had 6 days to bring Cell 13 within limits. The licensee performed the verification for the battery in accordance with WR 05200-93 and -STS 'iT-019, "125 Vdc Class 1E Quarterly Battery :

Inspection," Revision 8. The inspectors determined that the Cell 13 voltages

i averaged 2.14 to 2.15 Vdc since Refuel VI. However, the voltage had dropped to 2.13 Vdc 1 week earlier. The licensee initiated WR 05125-93 because

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trending indicated the voltage was decreasing and might fall below the ,

Technical Specifications limit of 2.13 Vd Since the voltage had trended down, the licensee jumpered out the cell. The battery operated at approximately 134 Vdc on a floating charge. The licensee can remove up to two cells from the battery without dropping below the ,

Technical Specification 4.8.2.1.b limit of 130.2 Vdc. The work instructions :

for WR 05125-93 provided guidance to: jumper out the NK14 battery, Cell 13; ;

to discharge and charge the NK14 battery, Cell 13; and to reinstall a new :

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battery cell, if required. The licensee jumpered out NK14 battery, Cell 13, in accordance with Temporary Modification 93-045-NK. The temporary modification specified the cable to be used and documented the deviation from l the normal 60-cell configuration. The inspectors verified that i Calculation NK-EW-002 demonstrated that a loss of up to two cells for each 125 Vdc battery could occur and maintain an operable batter .5 Conclusions Generally, craft personnel performed maintenance activities well. During repair of a bearing oil leak, personnel handled potentially contaminated oil without following good radiation work practices. There were unnecessary delays in starting bearing maintenance while in a 72-hour limiting condition for operation. The inspectors verified that the oil collecting in the trough for Centrifugal Charging Pump B did not create a fire hazard. An electrical switchgear room air conditioning unit outage was performed in a strong manne All available outstanding WRs were implemented and the allowed outage time was controlled. The inspectors identified weak supplemental work instructions, i

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personnel performed the work correctly. The licensee performed battery .

trouble investigations and battery maintenance activities in a superior manne SURVEILLANCE OBSERVATIONS (61726)

The inspectors reviewed this area to ascertain whether the licensee conducts '

surveillance of safety-significant systems and components in accordance with Technical Specifications and approved procedure !

4.1 Control Room Air Intake Radiation Monitor Operational Test On August 10, 1993, the inspectors observed instrumentation and control technicians verify operation of the control room intake air radiation monitors in accordance with Procedure STS IC-255B, " Analog Channel Operational Test Control Room Air Intake Radiation Monitor GKRE04," Revision 9. The inspectors r,ated that this test satisfied Technical Specification Surveillance Requirement 4.3. The technicians used effective communication technique The inspectors verified that the technician followed the procedure and noticed the technician performed needed switch manipulation sequences not detailed in ;

the procedur i 4.2 Residual Heat Removal Pump Inservice Test On August 11, 1993, the inspectors observed operators and results engineering personnel perform the quarterly inservice test of Residual Heat Removal Pump B in accordance with Procedure STS EJ-1008, "RHR System Inservice Pump B Test,"

Revision 8. While the licensed operator manipulated plant controls to establish the appropriate component cooling water flow, the inspectors noted that intermittent alarms, plant component manipulations, and close monitoring of system parameters dominated the licensed operator's attention for a-prolonged period. The inspectors determined from discussions with the shift ,

supervisor and operations management that these component manipulations are a l normal practice during the performance of this surveillance. Also, flow l perturbations in the component cooling water system cause reactor coolant pump l thermal barrier isolations and alarms. A plant modification is planned to

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adjust the thermal barrier isolation setpoints to reduce spurious isolation The inspectors noted that the test accomplisned the Technical Specifications surveillance requirements listed in the procedure. The test personnel utilized appropriate radiation protection practice .3 Reactor Coolant Pump Undervoltage/Underfrequency Relay Checks On August 12, 1993, the inspectors observed instrument and control technicians perform reactor coolant pump relay checks in accordance with Procedure STS IC-217, "RCP Loss of Voltage and Underfrequency Trip Actuating Device Operational Test," Revision 10. The inspectors noted that this surveillance satisfied Technical Specification Surveillance

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Requirement 4.3.3.1, and noted that Procedure STS IC-217, Step 5.1.5 had a description error. The licensee acknowledged this error and revised the !

procedur P 4.4 Conclusions t

The inspectors found surveillance activities to be performed wel The

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licensee's acceptance of a significant and prolonged operator distraction during a surveillance could cause operators to overlook key indications in the

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5 EMPLOYEE CONCERNS PROGRAM (2500/028) .

The inspectors reviewed the licensee employee concerns program, the Quality First Program. The inspectors interviewed the coordinator of the employee '

concerns program and reviewed procedures to collect the information required by Temporary Instruction 2500/028. The licensee's Quality First Program is administered on a part-time basis by one individual. Concerns were generally entered into the site corrective action program by initiating a PIR, which ,

ensured the concern was resolved. The coordinator monitored the process and j

provided feedback to the concerned employee. The inspectors summarized information about the program in Attachment 2. The inspector reviewed the following procedures:

Number Revision Title KGP-1211 2 Quality First Program  :

QFP-2410 1 Receipt, Investigation and Closure of Concerns QFI-241 Conducting Exit / Walk-In Interviews QFI-241 Preparation, Maintenance and Security of Quality First Files QFI 241 Investigation of Potential Section 210 Violations 6 FOLLOWUP ON CORRECTIVE ACTIONS FOR VIOLATIONS (92702) (Closed) Violation 482/9230-01: Inadeauate Work Instructions

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This item documented that craft personnel expanded the work scope of the maintenance beyond that allowed by the preventive maintenance work instructions. Also, the specified postmaintenance test failed to identify the mispositioned valve. The licensee replied that the most likely cause for the l mispositioned valve was the accuracy of the indicator dial and pointer and the ;

ccver plate wear. The licensee stated that a potential contributor included !

ambiguous work instructions that allowed for interpretatio l l

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The corrective actions included: installing more precise indicator dials and ;

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pointers, reviewing preventive maintenance work instructions to identify potential ambiguities, inspecting the internals of the affected valve during l Refuel VI, and measuring the total cumulative tolerance of the cover ,

plate / pointer to verify whether the total cumulative tolerance exceeded I degree on the pointe ,

The inspectors monitored portions of the work activities conducted on Valve EF V0058, Component Cooling Water Heat Exchanger A - Essential Service Water A return HV-59 bypass isolation, during Refuel VI. The inspectors .

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verified that new indicator dial cover plates and pointers were installed on the throttled butterfly valves. The inspectors determined that the physical locked throttle valve positions agreed with the valve positions designated in the locked valve log, Procedure ADM 02-102, " Control of Locked Components," ,

Revision 26. The inspectors independently evaluated three of the preventive !

maintenance WRs reviewed by the licensee. The inspectors determined that the i reviewed WRs contained appropriate instructions for performing the maintenance activit The inspectors reviewed the licensee's electronic postmaintenance test .

databas Personnel are not required to use the database, but it is i referenced in Procedure 08-240, " Post Maintenance Testing," Revision 2, to aid ,

personnel in assigning the proper postmaintenance test requirements. The postmaintenance test requirements for prior jobs can be identified by equipment number, WR number, or preventive maintenance activity. The inspectors reviewed specified postmaintenance test requirements for four different components. In addition, the inspectors reviewed the training provided to personnel about the database. The licensee developed the database from several sources, which included the locked valve log components, inservice test program, local leak rate tests, and Technical Specifications surveillances. After work completion and prior to filing WRs, the maintenance support group reviews WRs to identify any assigned postmaintenance test that should be added to the postmaintenance databas .2 (Closed) Violation 482/9230-05: Failure to Correctly Translate .

Vendor Information  :

i This item documented that the licensee had inappropriately translated vendor information into administrative controls. The licensee had placed an -

inaccurate operator aid that could have caused too much force to be applied to valve handwheels. The force value listed for the handwheel should have documented the force applied to the internal gears of the actuator on the valve ste !

The licensee placed Hardware Failure Analysis Request NP 92-003 into operators required reading to ensure that personnel were familiar with operation of the ;

affected butterfly valves. The licensee installed accurate operator aids to reflect the maximum rim pull values for the handwheels. The inspectors verified that selected valves in the facility had'the correct information ;

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i displayed and. verified that Hardware Failure Analysis Report NP 92-003 was placed in required readin .

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ATTACHMENT 1-l 1 PERSONS CONTACTED  !

1.1 Licensee Personnel R. S. Benedict, Manager, Quality Control N. S. Carns, President and Chief Executive Officer M. E. Dingler, Manager, Nuclear Plant Engineering Systems, Support C. W. Fowler, Manager, Maintenance and Modifications R. B. Flannigan, Manager, Nuclear Safety Engineering M. A. Gayoso, Controller W. J. Goshorn, Wolf Creek Coordinator, KEPC0 D. Jacobs, Supervisor, Mechanical Maintenance R. L. Logsdon, Manager, Chemistry 0. L. Maynard, Vice President, Plant Operations F. T. Rhodes, Vice President, Engineering C. E. Rich, Jr., Supervisor, Electrical Maintenance 3 T. L. Riley, Supervisor, Regulctory Compliance B. B. Smith, Manager, Modifications C. M. Sprout, Manager, System Engineering J. D. Weeks, Manager, Operations S. G. Wideman, Supervisor, Licensing 1.2 NRC Personnel W. D. Johnson, Region IV The above licensee personnel attended the exit meeting. In addition to the personnel listed above, the inspectors contacted other personnel during this inspection perio EXIT MEETING An exit meeting was conducted on September 15, 199 During this meeting, the inspectors reviewed the scope and findings of the report. The licensee did not identify as proprietary any information provided to, or reviewed by, the inspector The Vice President, Plant Operations stated that the delay experienced during the centrifugal charging pump maintenance (Section 3.2) did not meet his expectations. He commented that, although aggressive actions had been taken in response to several events, the next. task for the company was to take steps to prevent the problems and deficiencie .

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l ATTACHMENT 2 j EMPLOYEE CONCERNS PROGRAMS j PLANT NAME: WOLF CREEK GENERATING STATION ,

LICENSEE: WOLF CREEK NUCLEAR OPERATING CORPORATION l DOCKET 050-0482 NOTE: Please circle yes or no if applicable and add comments in the space provide PROGRAM:

Does the licensee, have an employee concerns program?

(Yes prNo/ Comments)

YES. IT IS CALLED THE QUALITY FIRST PROGRAM Has NRC inspected the program? Report #

NOT IN RECENT YEARS BUT A REVIEW OF THE PROGRAM WAS PERFORMED PRIOR TO LICENSING IN 198 SCOPE: (Circle all that apply)

Is it for: Technical? (Yes, No/ Comments) YES Administrative? (Yes, No/ Comments) YES ., Personnel issues? (Yes, No/ Comments) YES THE PROGRAM ACCEPTS ALL TYPES OF CONCERNS. PERSONNEL ISSUES ARE REFERRED TO MANAGEMENT OR HUMAN RESOURCES. CORRECTIVE ,

ACTION DOCUMENTS (PERFORMANCE IMPROVEMENT REQUESTS) ARE WRITTEN FOR SAFETY ISSUE . Does it cover safety-as well as non-safety issues?

(Yes gr_No/ Comments)

YES Is it designed for: Nuclear safety? (Yes, No/ Comments)

YES, THIS IS THE PRIMARY PURPOS , Personal safety? (Yes, No/ Comments)

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-2-I YES, THESE ARE REFERRED TO THE SUPERVISOR OF INDUSTRIAL j SAFET ' Personnel issues - including union grievances?

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YES, BUT SUCH ISSUES ARE REFERRED TO HUMAN RESOURCES OR MANAGEMENT. THERE IS NO UNION REPRESENTATIO l Does the program apply to all licensee employees? '

(Y<s or_No/ Comments) YES Contractors?

(Yes .o_r_No/ Comments) YES Does the licensee require its contractors and their subs to have a similar program?

(Yes n No/ Comments) NO I Does the licensee conduct an exit interview upon terminating employees asking if they have any safety concerns?  !

(Yes g No/ Comments)

i EXITING EMPLOYEES AND CONTRACTORS ARE PROVIDED A CONCERN DISCLOSURE STATEMENT FORM. ECP PERSONNEL DO NOT CONDUCT EXIT INTERVIEW C. INDEPENDENCE: What is the title of the person in charge?  :

SENIOR PERFORMANCE ENHANCEMENT SPECIALIST Who do they report to?

DIRECTOR, PERFORMANCE ENHANCEMENT Are they independent of line management?

YES, THE DIRECTOR OF PERFORMANCE ENHANCEMENT REPORTS TO THE PRESIDENT AND CHIEF EXECUTIVE OFFICF . Does the ECP use third party consultants?

NO How is a concern about a manager or vice president followed up?

WOULD SEND IT TO CORPORATE LEGAL COUNSE D. RESOURCES: ,

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ONE, USING ABOUT 15% OF HIS TIM I What are ECP staff qualifications (technical training, interviewing training, ;

investigator training, other)?

ENGINEERING BACKGROUND, TRAINING IN ROOT CAUSE ANALYSIS l AND INVESTIGATION TECHNIQUE REFERRALS: Who has followup on concerns (ECP staff, line management, other)?

i CONCERNS ARE REFERRED TO THE EXISTING CORRECTIVE ACTION PROGRAM. THE ECP COORDINATOR MONITORS THE RESOLUTION OF THE CONCERN AND PROVIDES FEEDBACK TO THE CONCERNED INDIVIDUA CONFIDENTIALITY:

, Are the reports confidential?

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QUALITY FIRST FILES ARE CONFIDENTIAL. PERFORMANCE IMPROVEMENT REQUESTS ARE NOT CONFIDENTIAL, BUT THE CONCERN IS NOT IDENTIFIED IN THE PI . Who is the identity of the alleger made known to (senior management, ECP staff, line management, other)?

(Circle, if other explain)

TECHNICAL CONCERN - ONLY ECP STAFF PERSONNEL CONCERN - MANAGEMENT OR HUMAN RESOURCES PERSONAL SAFETY CONCERN - ONLY ECP STAFF ADMINISTRATIVE CONCERN - ONLY ECP STAFF Can employees be: Anonymous? (Yes, No/ Comments) YES Report by phone? (Yes, No/ Comments) YES - HOTLINE WITH ANSWERING MACHINE FEEDBACK: Is feedback given to the alleger upon completion of the followup?

(Yes gr_No - If so, how?)

YES, BY THE METHOD REQUESTED ON THE CONCERN DISCLOSURE FOR ,

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MANAGER Am the resolutions of anonymous concerns disseminated?

NO Are resolutions of valid concerns publicized (newsletter, bulletin board, all hands meeting, other)?

NO II. EFFECTIVENESS: How does the licensee measure the effectiveness of the progmm?

NOT DONE Are concems:

, Trended? (Yes or NolComments) YES, INFORMAL BY ECP STAFF

' Used? (Yes or No/ Comments) YES, ECP COORDINATOR DISCUSSES TRENDS AND RECURRING CONCERNS WITH MANAGE . In the last three years how many concerns were raised? _35 of the concerns raised, how may were closed? 32 What percentage were substantiated? 34 %

' How are followup techniques used to measure effectiveness (random survey, interviews, other)?

NOTHING FORMAL IS DONE IN THIS ARE . How frequently are internal audits of the ECP conducted and by whom?

NONE ARE PERFORME ADMINISTRATION / TRAINING: Is ECP prescribed by a procedure? (Yes or No/ Comments)

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-5-YES, BY A SITEWIDE PROCEDURE AND SEVERAL BIPLEMENTATION PROCEDURES FOR THE ECP STAF . How are employees, as well as contmetors, made aware of this program (training, newsletter, bulletin board, other)?

GENERAL EMPLOYEE TRAINING BULLETIN BOARDS - HOTLINE NUMBER ADDITIONAL CONIMENTS: (Including characteristics which make the program especially effective, if any.)

THE PROGRAM USES THE EXISTING CORRECTIVE ACTION PROGRAM FOR RESOLUTION OF CONCERNS. THE ECP STAFF DOES NO INVESTIGATION NAME: W. D. JOHNSON TITLE: CHIEF, PROJECT SECTION A, DIVISION OF REACTOR PROJECTS PHONE #: 817-860-8148 DATE COMPLETED: AUGUST 17,1993

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ATTACHMENT 3 Items Needing Improvement - Based on Employee Input

• Top five operator issues

• Turbine ouilding and auxiliary feedwater area sump pumps

• Water treatment and condensate demineralizer systems in poor repair

= Diesel generator room lighting

• Untimely drawing updates

• Doors

• Top five impediments to maintenance

. Timeliness of engineering and material support

. Work coordination and scheduling among groups

• Work control program

+ Control room delays

. Tools

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