IR 05000482/1993029
| ML20059C320 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 12/28/1993 |
| From: | Yandell L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20059C302 | List: |
| References | |
| 50-482-93-29, NUDOCS 9401050106 | |
| Download: ML20059C320 (42) | |
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APPENDIX B U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
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NRC Inspection Report: 50-482/93-29
Operating License: NPF-42
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Docket:
50-482
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Licensee: Wolf Creek Nuclear Operating Corporation P. O. Box 411
Burlington, Kansas 66839 l
Facility Name: Wolf Creek Generating Station (WCGS)
Inspection At: Coffey County, Burlington, Kansas
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Inspection Conducted: October 24 to December 4, 1993 i
i Inspectors:
G. A. Pick, Senior Resident Inspector
J. F. Ringwald, Resident Inspector l
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Approved:
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L. A. Yandell,' Chief, Project Section B Date
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Division of Reactor Projects
Inspection Summary
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Areas Inspected:
Routine, unannounced inspection including plant status, j
operational safety verification, maintenance observations, surveillance
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observations, cold weather preparation, followup on corrective action for violations, and onsite review of a licensee event report (LER).
l Results:
A violation of Technical Specification 6.8.1.a with four examples
occurred because control room operators failed to properly conduct
licensed duties (Section 2.3).
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t The operations manager committed to review and correct slave relay tests
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prior to their next performance with a deadline for all reviews by
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March 31, 1994 (Section 2.3.3).
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A violation of Technical Specification 6.8.I.a with two examples
occurred because the procedure for controlling equipment tagging j
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9401050106 931229 PDR -ADDCK 05000482
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(clearance orders) failed to provide adequate guidance to personnel
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acting as a supervisor (Section 2.8).
The NRC identified a violation of 10 CFR Part 50, Appendix B,
Criterion XVI in that the licensee failed to apply the corrective actions for an earlier clearance order restoration deficiency documented
on a performance improvement request -(PIR) to all affected maintenance groups (Section 2.8).
The inspector identified a noncited violation because instrumentation
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and control (I&C) technicians failed to properly disposition a work l
request (WR) as specified by procedure (Section 4.3).
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During a service water self-assessment, the licensee identified that
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personnel had made an inaccurate reportability determination of low essential service water (ESW) flow through safety-related components
from potentially degraded conditions in 1990. The licensee issued an-
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LER that included information on operability of components based on i
engineering judgement (Section 2.1).
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The inspector notified the licensee of a potential manner to~ violate
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containment integrity that had been identified at another licensee's
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facility. The licensee then found their procedure for sampling the.
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containment atmosphere had weaknesses that had allowed containment i
integrity to be violated. The licensee determined the-event to be
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reportable (Section 2.2).
l The inspectors identified several strengths in the operations area that
indicated operations personnel had increased their awareness of the corrective action process. Operations personnel lowered their threshnid
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for initiating PIRs, identified problems and found procedure weaknesses
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prior to occurrence, and responded well to deficiencies (Sections 2.4.1 and.2.4.2).
l The Vice President Plant Operations initiated a half-day work stand down
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to emphasize the need to eliminate personnel errors and underscore the
importance of resolving problems as more important than productivity (Section 2.4.3).
The inspector found a security officer reading unauthorized material in:
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the central alarm station. Tt.e security manager implemented aggressive corrective actions (Section 2.5).
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System engineering provided strong support for operations as evidenced
by their operability determination of auxiliary feedwater pumps and in
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evaluating apparent vibration anomalies in the main turbine (Sections 2.6 and 2.9).
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l The licensee determined that.an individual assigned as a fire brigade
member had not completed the required training. The licensee determined
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the deficiency to be reportable as a violation of Technical Specification 6.2.2.e (Section 2.7).
The licensee implemented a comprehensive and thorough response to a
turbine trip alarm that did not trip the turbine (Section 2.9).
The licensee developed an effective procedure to control the power
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rerate activities.
Personnel implemented the rerate activities in a
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safe, controlled, and cautious manner (Section 2.10).
The inspector found that nonlicensed operators performed their shift l
rounds in accordance with licensee procedures and management l
expectations (Section 2.11).
The inspectors determined that maintenance personnel implemented their I
activities well, followed procedures, used calibrated instruments, and followed proper radiation work practices (Section 3).
j The inspector found that the licensee had a good program to assure the
warehouse could support the needs of maintenance personnel. Material i
availability affected accomplishment of a small fraction of scheduled
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work. Generally, the inspector found the warehouse to be well
maintained, and the licensee promptly corrected the only deficiency identified (Section 3.3).
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The inspectors determined that the licensee had a strong inservice test
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program for pumps and valves.
Engineers appropriately dispositioned i
out-of-specification data (Sections 4.1, 4.2, and 4.4).
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The inspectors noted that I&C technicians ensured that they properly
implemented procedures during surveillance testing and calibration
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activities (Sections 2.10, 4.3, and 4.5).
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The inspector found that the licensee implemented an outstanding cold
j weather protection program (Section 5).
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The licensee implemented thorough, comprehensive corrective actions that
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addressed the issues identified in violations (Section 6).
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Summary of Inspection Findings:
Violation 482/9329-01 was opened (Section 2.3).
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Violation 482/9329-02 was opened (Section 2.8).
- Violation 482/9329-03 was opened (Section 2.8).
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A noncited violation was identified (Section 4.3).
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Violations 482/9231-02, 482/9301-01, 482/9301-03, 482/9308-04,
482/9316-03, 482/9319-01, and 482/9324-01 were closed (Section 6).
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Violation 482/9316-01 was reviewed but not closed (Section 6.3).
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LER 482/93-009 was closed (Section 7).
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Attachment 1 - Persons Contacted and Exit Meeting
Attachment 2 - Allowed Cycle 7 Operating Window j
Attachment 3 - ACRONYOS
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DETAILS
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1 PLANT STATUS (71707)
The plant operated at 100 percent of rated thermal power (3411 megawatts)
until November 18, 1993, when the licensee decreased reactor power to
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95 percent.
On November 10, 1993, NRC approved License Amendment 69 that increased the maximum allowable core power from 3411 megawatts thermal to 3565 megawatts thermal, and the licensee implemented Amendment 69 on
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November 18, 1993. The licensee rescaled instruments and changed setpoints to
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ensure compliance with the new Technical Specifications limits associated with
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departure from nucleate boiling limits and overpower and overtemperature reactor trips. On November 21, 1993, the licensee initiated the power ascension from 90.9 percent of 3565 megawatts rated thermal power. The licensee returned to 97 percent power on November 30, 1993, and remained at this power level until the end of the inspection period.
2 OPERATIONAL SAFETY VERIFICATION (71707)
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The inspectors performed this inspection 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 operation.
l The methods used to perform this inspection included direct observation of activities and equipment, observation of control room operations, tours of the facility, interviews and disr.ussions with licensee personnel, independent verification of safety system status and Technical Specifications limiting i
conditions for operation, verification of corrective actions, and review of
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facility records.
2.1 Service Water Assessment Issue
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2.1.1 Degraded ESW Flow As part of a service water system self-assessment, the licensee reviewed past commitments and resolution of corrective action documents. On October 19, 1993, the licensee concluded that they incorrectly determined in February 1991 the reportability of degraded ESW flows, which potentially existed in
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May 1990. The licensee initiated Defect / Deficiency Report 90-021 in May 1990 to document that ESW flows through selected components might not meet design basis requirements. At that time, the licensee concluded that Defect / Deficiency Report 90-021 was not reportable because the condition was
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considered to have occurred at the time of discovery and the condition was corrected before the plant returned to power operation.
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However, Memorandum TS 91-0003 dated January 28, 1991,- documented that
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problems encountered during Refueling Outage IV (Refuel IV) flow balancing were an indication that low-flow conditions probably existed prior to when the
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plant was shutdown for Refuel IV.
The licensee had performed the flow
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ba%ncing after implementing Plant Modification Request 2LJ, " Service Water and Essential Service Water Erosion and MIC Control." The plant modification added backpressure orifices in the ESW return lines to service water to help ensure adequate service water flow to the ultimate heat sink during normal operations to prevent microbiological induced corrosion. After installing the orifices and balancing the service water flows, the-licensee started ESW to verify proper flows. The licensee found that the ESW pumps reached maximum i
flow with decreasing discharge pressures indicating pump runout.
Subsequently, the licensee balanced ESW flows to prevent pump runout. After
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the ESW flow balancing, licensee personnel noted that the design flow through containment coolers could not be obtained without decreasing flows through some components below design-basis values.
The licensee evaluated the low flows and determined the components to be operable.
In October 1993, the licensee concluded that the information contained in Memorandum TS 91-0003 indicated that flow had definitely degraded through the Auxiliary Feedwater (AFW) Pump B room cooler, diesel. generator coolers, penetration room coolers, spent fuel pool room coolers, containment air coolers, control room air conditioning Unit B, and Centrifugal Charging Pump B room cooler. The licensee notified the NRC in accordance with 10 CFR 50.72 and will report their evaluation of the problem in LER 482/93-014.
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The licensee identified several contributing causes for the failure to
identify the degraded system flows prior to 1990.
The licensee's method of
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using annubars to identify flows gave erroneously high readings.
LER 482/91-002 provided detailed description of this deficiency (refer to
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Section 2.1.2).
Minimal margin existed for system degradation because acceptance criteria during startup did not account for accuracy of test equipment. When personnel modified ESW flow through a component, personnel
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failed to verify that ESW flows through other components remained within l
acceptable limits.
The locked valve program documented ESW valve positions as
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a function of flow instead of a physical valve position.
A teleconference among the licensee, the NRR project manger, and Region IV personnel resdited in an understanding that the licensee would submit LER 482/93-014 by December 10, 1993, to allow time to evaluate operability for components with probable low flows prior to Refuel IV.
2.1.2 Historical Information NRC Inspection Report 50-482/88-200 identified that in 1987 the licensee failed to perform an effective operability determination with respect to
degraded piping in the Train A ESW System. The licensee did not evaluate operability and operated the facility from February 13 to July 1,1987, without documenting an adequate basis for remaining operable.
Subsequently,
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in response to escalated enforcement (EA-88-282 dated February 1, 1989), the licensee restructured the plan-of-the-day meeting, placed an engineering representative on the plant safety review committee, and revised engineering procedures to require immediate control room notification whenever a
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nonconformance impacts the ability of a component to function. As documented in NRC Inspection Report 50-482/91-22, Section 3.2, Procedure KPN E-314,
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" Disposition of Field Change Documents," prescribed methods and responsibilities for processing corrective WRs, procurement evaluation requests, field change requests, engineering evaluation requests, and
nonconformance reports processed within the engineering division to assure engineers consider operability.
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The licensee initiated LER 482/91-002 because low flow to the containment coolers violated Technical Specification 4.6.7.3 limits.
Prior to June 3, 1989, the licensee found that their method of using annubars to measure flow i
resulted in inaccurate readings. The licensee performed Procedure TP TS-15,-
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" Essential Service Water Pump Test," and Procedure STS EF-925, " Containment l
Coolers Flow Verification," using local differential pressure readings that provided accurate flow.
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While performiag the ESW flow balancing during Refuel IV, the licensee
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identified that administrative controls of locked ESW system valves specified
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flows instead of designating valve positions in degrees open, turns open, or
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lhe licen;ee recognized that specifying flows was insufficient
since personnel had no easy method to return valves to their original position
once manipulated. After ifentifying the number of turns open, turns closed, L
or degrees open, the licensee compared the new valve positions to initial
startup valve positions. The comparison resulted in most valves being further
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open indicating system degradation. After Refuel IV the licensee incorporated
the newly determined locked valve positions into Procedure ADM 02-102,
" Control of Locked Component Status," that corrected the identified weaknesses
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for ESW system locked valves.
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2.2 Lontainment Integrity f
On October 18, 1993, the inspector informed the licensee that the Callaway l
facility had no requirement to isolate the containment radiation monitor i
filter lines that exit containment while changing the particulate filters and i
determined the deficienc" to be reportable. The licensee demonstrated to the
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inspector that ProceA C5 91-006, " Sampling of Containment Atmosphere for Particulate and Iodi Coac ntration," Revision 5, contained requirements to i
close the isolation se rior to changing the particulate filters.
i Subsequently, the lic
.,ce issued Procedure Change MI 93-1274 that added a i
note to Procedure CHM 01-006, Step 3.4.
The note explained-that the purpose _
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for closing the radiation monitor isolation valve was in Modes 1-4 to prevent
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- gas in the containment from blowing onto the individual changing the filters.
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In Modes 5 and 6, the valves should be closed to maintain containment t
integrity during fuel movement.
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After issuance of the procedure change, several chemistry technicians
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acknowledged that they had not followed the note during Modes 5 and 6 and that
containment integrity had been violated during changeout of the particulate filters. The licensee initiated PIR 93-1210 to ensure corrective actions
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The licensee determined the incident to.
reportable as a violation of Technical Specification 3.4.9.c.
The licen
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personnel had not isolated the radiation monitor lines when changing the particulate filters during fuel movement on numerous occasions since initial
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startup. Technical Specification 3.9.4.c specifies that each penetration providing direct access from the containment to the outside atmosphere must be
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capable of automatic isolation or isolated by a blind flange or manual valve during movement of irradiated fuel within containment.
The licensee promptly reviewed similar sample line configurations to determine if other deficiencies existed. The licensee identified that
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Procedure CHM 01-004, " Sampling Containment Atmosphere for Gas and Tritium,"
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Revision 10, resulted in both the normal and alternate sample methods creating r
a release path from inside to outside the containment when containment integrity was required. Specifically, a flow path from the postaccident sampling system inlet to the fuel building exhaust duct or, alternatively, the -
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auxiliary building existed. The. licensee evaluated the safety consequences of the worst case accident (fuel handling accident) and determined the potential
increase to an offsite release would be 5 percent of design values and well below 10 CFR Part 100 limits.
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After chemistry personnel identified these deficiencies, the department
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stopped work for a %-day period to evaluate the root cause, increase
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attention to detail, and improve job performance. Chemistry department personnel determined the root cause to be failure to follow procedure with the following. contributing factors:
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Procedures either too detailed or not specific enough,
Personnel not held accountable,
Procedures do not cover every circumstance resulting in situations when
steps must be interpreted,
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Management asked for quality but emphasized production, and
Difficult to process nrocedure changes.
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The licensee implemented the following actions to address the above
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deficiencies and concerns. The chemistry manager established a schedule to correct chemistry-department procedures. The chemistry manager requested chemistry personnel to review the 64 sampling procedures by December 24, 1993; 23 administrative procedures by January 31, 1994; and 127 analytical procedures by October 31, 1994. Management issued Memorandum PS 93-0444 that i
emphasized:
(1) hold personnel accountable for not following procedures,
(2) management would support personnel taking extra -time to correct procedures
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at the expense of' productivity, and (3) personnel must use the present. system to revise procedures no matter how cumbersome. The chemistry manager changed
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Procedure ADM 04-001, " Chemistry Group Organization," Revision 13, to' require that procedures be out and used when manipulating plant equipment.
If a procedure cannot be followed, personnel are to stop work and contact their supervisor.
For other activities, the procedure must be reviewed prior to and
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available while implementing the tasks.
The inspector verified that Memorandum PS 93-0444 provided the plant. support
manager's expectations to plant support personnel.
The inspector verified
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that Procedure ADM 04-001 described the chemistry group procedure adherence i
requirements.
From discussions with the chemistry manager, the inspector
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found that the manager expected the analytical procedures to be revalidated for accuracy daring use. The inspector found the licensee's actions to be
very responsivo. The root cause determination and planned corrective actions i
thoroughly addvsud the problem.
2.3 Operator P +formance
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t 2.3.1 Pressuriz(r 5 ray Valve
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f On October 29, 1993, a licensed operator noticed anomalous pressurizer spray
line temperature indication for Valve BB PCV455B and reactor coolant system Loop 1 pressurizer spray valve while performing the quarterly flux map
surveillance. The operator was performing the surveillance in accordance with Procedure STS RE-013B, "Incore-Excore Detector Axial Flux Difference
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Calibrations," Revision 2, that required operators to turn on the pressurizer backup heaters in Step 5.1.2 to assure boron mixing. After personnel actuate i
the heaters, the pressurizer spray valves actuate to maintain programmed
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reactor coolant system pressure. The operator determined from troubleshooting
that Valve BB PCV455B failed to function upon demand. On November 1, 1993,
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I&C personnel found the 90-degree ball valve handle partially turned, which
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isolated the actuator air supply. The licensee restored the valve to service,.
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verified that the valve functioned properly, and initiated PIR 93-1250. As
part of the PIR review, personnel investigated how and when the valve was closed and evaluated why operators did not notice the closed spray valve during earlier tests.
The inspector found that the operator questioned the valve operation because
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the valve position indicator did not change from closed to intermediate
similar to Valve BB PCV455C, reactor coolant system Loop 2 pressurizer spray.
valve, even though both controller demand position meters had increased the a
same amount. After the operator reviewed computer trends of controller demand, limit switch position, and pressurizer spray line temperature, the
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-individual noted that the Loop 1 spray line indicated loof cooler than the
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Loop 2 spray line/ reactor coolant system cold leg temperatures. Next, the e
operator plotted controller demand, limit switch position, and the computer i
generated valve position.
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Since the computer indicated that the valve opened, the operator reviewed the I
logic inputs for the computer point.
The operator found that the inputs included a constant at 15 percent demand and the controller demand position.
The operator concluded that the computer point would indicate that the valve
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opened anytime the demand exceeded 15 percent. The operator initiated PIR 93-1241 because he believed, until his investigation, that the computer indicated actual valve position. System engineers d termined that the computer points functioned, as designed, but had vague point descriptions.
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The licensee left the point design as-is but clarified the computer point.
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Because of the large number of computer points, the licensee.will address point description deficiencies as they occur to ensure efficient use of
resources. The inspector concluded that the licensee' established an
appropriate approach since a majority of point designators are correct.
Reactor engineers performed Procedure STS RE-013B on May 20, July 30, and i
October 29, 1993.
From review of pressurizer snra.v line temperature trends, the licensee found that until May 14, 1993, the spray lines had.a 3-4af temperature differential. The licensee noted that the temperature
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differential approached 11of and remained in this condition until personnel i
supplied air to Valve BB PCV455B. The licensee identified that mechanics
performed a hot torque of the valve packing box on May 9, 1993, in accordance with WR 03050-93. The licensee postulated that the mechanics inadvertently bumped the valve. At the end of the inspection period, operations personnel had not completed their review of this event. Operations personnel continued
to review human factors aspects related to this event to determine why i
personnel did not identify this deficiency during previous STS RE-013B
performances.
The pressurizer spray valves actuate after both sets of backup pressurizer
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heaters are on for any length of time. The inspector concluded that
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Valve BB PCV455B status lights did not change from closed to open as required i
for the demand placed on the valve during previous test performances.
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Operations personnel agreed with the inspector's conclusions.
Procedure ADM 02-040, " Conduct of Onduty Operations Personnel," Revision 9, l
Step 3.2, specifies, in part, that onduty personnel must be particularly j
attentive of instruments and controls located within the area at all times.
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The inspector determined the failure of personnel to notice the anomalous indications during two previous surveillance tests to be Example 1 of a
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violation of Technical Specification 6.8.1.a (482/9329-01).
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2.3.2 Inappropriate Containment Purge
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On November 6, 1993, licensed operators initiated PIR 93-1314 after
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determining that they purged the containment approximately 1 1/2 hours after i
the containment purge permit expired.
Immediate actions included securing the
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containment purge and verifying that low radiation levels existed.
PIR 93-1314 documents the error as operator inattention to detail and notes a
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contributing cause to be the failure of chemistry personnel to highlight that
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the containment purge permit expired in 2% hours after delivery to the
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control room. The licensee evaluated reportability as part of RER 93-050 and determined the evaluation not reportable under 10 CFR 50.72 or 10 CFR 50.73
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criteria. The licensee identified that personnel did not follow the
requirements of the offsite dose calculation manual and determined that no unmonitored release occurred.
The licensee verified that containment
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radiological conditions remained unchanged prior to, during, and following the i
purge.
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r As immediate corrective actions, the licensee changed Procedure ADM 04-023,
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" Radioactive Release," Revision 22, and Procedure SYS GT-120, " Containment
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Mini Purge System Operations," Revision 12, to require that chemistry l
personnel inform the control room of containment purge permit the time and date that they initiate containment purges in
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limitations / expiration time and mandated that control room personnel record
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Procedure SYS GT-120.
Procedure ADM 02-040, Step 3.2, specifies, in part, that onduty operations
personnel must remain cognizant of their immediate areas of responsibility.
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The inspector determined the failure of control room personnel to recognize the time that the purge permit expired to be Example 2 of a violation of i
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Technical Specification 6.8.1.a (482/9329-01).
2.3.3 Out-of-Position Steam Generator Sample Valve On November 8, 1993, the licensee initiated PIR 93-1312 to document that-control room personnel found Valves BM HV019, Steam Generator A upper sample
isolation, and BM HV022, Steam Generator D upper sample isolation, open.
Operators had closed the valves at 10:30 p.m. on November 7, 1993. The operator recognized that normally the valves are closed since they are _used
for sampling the upper section of Steam Generators A and D when in wet layup.
The operators reviewed previous activities and found that an operator opened
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the valves at approximately 2 a.m. on November 5, 1993. The valves had
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remained open for approximately 3 days.
From discussions with licensee personnel, the inspector noted that the licensee determined that the operator who restored from a slave relay test opened the valves to a position he thought appropriate. The inspector determined the failure of personnel to promptly identify that the Steam Generators A and D isolation valves were out of position to be Example 3 of a violation of Procedure ADM 02-040, Step 3.2, and Technical Specification 6.8.1.a (482/9329-01). The inspector verified that Procedure CHM 01-095, " Sampling of the Steam Generator
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Blowdown (SJ Panel) and Lineup of SJ RE-02, SG Liquid Radiation Monitor,"
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Revision 6, Step 1.2, specified that these valves should be open when steam
generators are full or in wet layup.
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The licensee determined that Procedure STS 1C-640B, " Slave Relay Test K640
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Train B Motor Driven Auxiliary Feedwater Pump Start," Revision 3, did not identify the as-found positions of components to be actuated. Consequently, the procedure did not have a fully effective restoration section. Out of a
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-12-l total of 68 slave relay procedures, 8 procedures had detailed as-found component position and restoration sections. The operations manager committed
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to upgrade the slave relay test procedures by March 31, 1994.
2.3.4 Out-of-Position ESW Valve
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On November 12, 1993, the licensee initiated PIR 93-1393 to document that operators found Valve EF HV043, ESW A to air compressor, closed. The licensee determined from review of computer data that _ Valve EF HV043 was closed for. a maximum of 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br />, and that restoration fi0m Clearance Order 93-2115-KA most likely caused the valve to go closed.
The valve isolates on a differential r
pressure of 20 psi.
PIR 93-1393 documented that inattentiveness of control room operators allowed i
the valve to remain closed for a long period of time. No significant safety
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issues resulted from the valve being closed because control room personnel did j
not operate the compressor during the period. The valve remained closed
l thrcugh a shift turnover. The inspector determined the failure of control room operators to promptly identify the out-of-position ESW valve to be Example 4 of a violation of Procedure ADM 02-040, Step 3.2, and Technical Specification 6.8.1.a (482/9329-01).
From discussions with personnel on both operating crews involved with failing-l to quickly notice the incorrect Valve EF.HV043 indication, the inspector
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determined the operators implemented strong, comprehensive corrective actions.
The crew that-isolated the compressor implemented corrective actions that
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include:
(1) the offshift reactor operator will review all procedures prior.
to performance for adequacy, and (2) operators increased their attention to
the panels. Also, the operations manager assigned this crew responsibility
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for assuring the slave relay tests get upgraded.
l The second crew implemented actions that ensured greater familiarity with
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control panels, including more frequent control panel walkdowns (every i
15 minutes), and a review of other watchstander panels to break the monotony.
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This crew also arrives at least 15 minutes earlier for shift turnover, and has
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implemented more systematic control panel review practices that included
reviewing for symmetry of system alignments.
Both crews will make
presentations to two additional crews on the event and the corrective actions -
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implemented. On December 6, 1993, the operators provided information to-
licensee management at the plan-of-the-day meeting.
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2.4 Operator Issues Meetino and Licensee Actions Beina Implemented
On November 9,1993, the licensee met with NRC personnel to discuss actions to
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address operations personnel errors, especially control room personnel, and
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actions being implemented to minimize the error rate.
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2.4.1 Corrective Actions The corrective actions being implemented by the licensee as discussed at the November 9,1993, meeting included personnel and organization changes, placing
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an established onsite manager on shift to provide coaching and to assess supervisory skill needs, changing the plan-of-the-day meeting to ensure
managers provide greater focus to address plant issues, and adding a shift engineer to supplement the operating crews.
l During November 1993, the licensee placed WCGS managers on shift to coach the
shift supervisors / supervising operators. The operations manager requested
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that the coaches review the following:
quality of control panel walkdowns,
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shift turnovers and communications; whether issuance of PIRs was appropriate; personnel control of evolutions; needs of shift supervision for supervisory
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and leadership skills; and whether a questioning attitude had developed.
Short-term actions implemented included: having shift supervisors / supervising i
operators develop additional guidance that included performance standards;
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increased accountability for personnel errors; and conducting more frequent shift supervisor / supervising operator meetings to reinforce management expectations of supervisory duties, board awareness, and onduty conduct. The performance standards being developed by shift supervisors / supervising
operators included: definition of a questioning attitude,. interactions and communications with regulatory agencies, operations raanagement competency expectations on simulator dynamic examinations, dress code, and required communications with the radwaste and water treatment operators.
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2.4.2 Operations Performance
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Throughout the period, the inspectors monitored control room activities.
Personnel performed more _ formal, thorough shift turnovers and control panel
wal kdowns. Operators initiated an increased number of PIRs to ensure generic corrective actions could be addressed with many issues identified prior to problems occurring.
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On November 16, 1993, the inspector noted that a nonlicensed operator observed that a feedwater isolation valve control air line had vibrated free and was
chafing.
The operator reported this and immediately wrote a WR to reattach the tubing clamp to stop the chafing. The inspector considered this to be a good example of nonlicensed operator vigilance.
On November 17, 1993, the inspector observed a shift briefing that occurred at
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2:45 a.m.
The shift supervisor initiated the shift briefing to gather all
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crew members together in order to report on status, provide any additional
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needed coordination, and to remind personnel to use the STAR (stop, think,
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act, and review) concept as part of safe operation. The inspector considered this to be a good initiative for this crew and considered the briefing to i
accomplish the stated goals.
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-14-On November 24, 1993, the inspector informed the operations manager about defects found in the containment sump screens at another facility.
The operations manager directed a licensed operator who was performing the routine, biweekly containment inspection to review the condition of WCGS containment sump screens.
The licensee identified minor discrepancies in both the Train A and B sump screens.
In a memorandum dated November 24, 1993, syste'n engineers evaluated the anomalies and determined the sump to be operable.
2.4.3 Work Stand Down On November 4,1993, the Vice President Plant Operations initiated an %-day work stand down to ensure personnel :muld review the personnel errors that occurred in their departments.
Doc lent managers reviewed personnel errors that occurred from August-0ctober 1991; the STAR process; use of procedures; general requirements, such as housekeeping, temporary equipment, and communications; and effectiveness of corrective actions. Managers determined from the feedback that employees felt that management stopping work to address these type of issues indicated a sincere attitude toward correcting problems.
2.5 Inappropriate Reading Material in the Central Alarm Station On November 2,1993, the inspector entered the central alarm station and observed the onduty security officer reading a catalog. The officer immediately placed the catalog face down on a magazine. When the inspector asked the security officer about his management's expectations.for reading this type of material, the officer stated that they could possess the material and read it during breaks. The officer further stated that the catalog advertised security-related equipment and was related to work activities.
The inspector subsequently questioned the security manager who immediately stated that this was inappropriate. The security manager informed the inspector that reading of nonwork-related material while on duty conflicted with management expectations but was not specifically prohibited by the security plan.
The security manager initiated PIR 93-1271 to assure documentation and resolution of the deficiency. The security manager stated that he had discussed his expectat ions in this area in July 1993. The security manager further identified several corrective actions being implemented. The licensee disciplined the officer, sergeant, and lieutenant and briefed security shift lieutenants on the security manager's expectations regarding reading material. The security manager issued a letter to all security personnel regarding the incident and revised the policy to prohibit the possession of unauthorized reading material on post or in route to post assignments. The inspector concluded that reading unauthorized material did not meet management expectations and that the licensee implemented aggressive corrective action.-
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2.6 AFW Pump Operability On November 5,1993, the licensee received information that indicated safety-related pumps with horizontal motors might not meet the design-basis
seismic qualifications. The Callaway facility ' informed WCGS that personnel found structural taper 91ns (dowels) for their safety-related pumps mi', sing.
t Engineers designed the taper pins to withstand horizontal seismic forces and for alignment.
Consequently, WCGS inspected their safety-related pumps for
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the presence of the taper pins.
The licensee determined that the safety injection pumps and the centrifugal charging pumps had the taper pins installed. Both motor-driven AFW (MDAFW) pumps and the turbine-driven AFW (TDAFW) pump had taper pins missing. The design stress report for the MDAFW pumps indicated three taper pins installed in the pump and two taper pins installed in the motor.
Each of the MDAFW pumps only had two taper pins installed at the pump and no taper pins installed at the motor. The TDAFW pump design stress report indicated four taper pins installed at the pump and two taper pins installed at the turbine. The TDAFW pump had two taper pins installed at the pump and no taper pins installed at the turbine.
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Subsequently, the shift supervisor implemented the process to determine
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operability of components that are indeterminate, as described in
Procedures ADM 02-024, " Technical Specification Operability," Revision 1; and
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KGP-1215, " Evaluation of Nonconforming conditions of Installed Plant
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Equipment," Revision 2.
Additionally, the licensee initiated RER 93-049 so that personnel would evaluate reportability and initiated WRs 06152-93, 06153-93, and 06154-93 to establish and implement corrective actions.
The licensee concluded that the pumps remained operable. The original seismic design assumed only the taper pins withstood the horizontal seismic loads and took no credit for the hold down bolt strength. The calculations. demonstrated the ability of the hold down bolts and frictional forces to maintain the pumps operable during a seismic event without any taper pins installed. The E
licensee determined the event was not reportable.
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t During the independent verification of the calculations, the licensee found that the personnel who performed the TDAFW pump operability evaluation had incorrectly referred to the MDAFW pumps stress data. This error did not
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adversely impact the ultimate operability determination. The licensee initiated PIR 93-1343 to identify the root cause and implement corrective
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actions. The licensee determined miscommunication during turnover and the urgency of the evaluation contributed to the deficiency. The licensee determined that during future evaluations, well rested, uninvolved personnel
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will independently review the calculations prior to issuing operability-
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determinations. The inspector determined that the system engineering manager will make these expectations knows to the system engineering supervisors.
The
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system engineering manager ~ expects personnel to consider these factors during
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the detailed review stage, as described in Procedure KGP-1215, Attachment 1,
" Guidelines for Initial Engineering Evaluation," Step 7.
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The inspector independently reviewed the calculations.
The inspector concluded that the licensee used appropriate methodologies and technical I
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Subsection F-1335 and Subsection NF-3322. The engineers used methods i
throughout the calculations that ensured the calculations had conservative
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margins.
For example, the engineers assumed minimum bolt torque values and minimum yield strength for the hold down bolts.
Instead of using the fuel
building seismic response, as originally designed, the licensee used the
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actual design basis seismic response of the turbine building in the calculation. The engineer added conservatism by using the highest peak response spectrum force at a frequency of 8-12 hertz instead of the lower,
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more realistic force for a rigid structure.
1% inspector concluded that the licensee responded to the potential it. operability of the safety-related pumps in an outstanding manner. The licensee quickly determined the condition of their pumps and promptly utilized their process to determine pump operability.
Even though an error occurred during the calculation process, personnel issued a PIR to correct the problem.
I The engineers used good engineering practices and included many conservatisms into the calculation.
2.7 Nonoualified Watchstander
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On November 12, 1993, the licensee determined that a nonlicensed operator stood as a fire brigade member without all required training being completed.
The licensee issued PIR 93-1376 to ensure personnel addressed programmatic weaknesses.
Subsequent reviews by the licensee found that the individual had
attended training but failed to sign the attendance sheet.
From interviews, the fire protection trainer determined the individual knew the material and l
recalled seeing the individual in class.
i During the review of training records, the licensee found that another
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individual had not attended a training session in the third quarter but was a
.i fire brigade member on November 1, 1993.
The licensee determined that the
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following weaknesses contributed to the deficiency:
(1) personnel did not f
verify status on the computer as required, and (2) personnel failed to update
Special Order 3, " Fire and Hazardous Material Qualification List,"
Revision 19, prior to the beginning of the quarter.
The licensee reported this event as LER 482/93-016 for failing to meet
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Technical Specification 6.2.2.e.
As corrective actions, the licensee will:
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Standardize procedures to assure qualified fire brigade watchstanders
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are consistently identified,
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Establish Special Order 3 as the main information source to identify l
watchstanders and update it monthly instead of quarterly,
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Enhance the computer program and use the program as a backup to Special l
Order 3, and l
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Change the fire protection program procedure to address the upgrades.
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2.8 Clearance Order Issues On November 12, 1993, the licensee determined that personnel entered a condensate demineralizer vessel to inspect the liner without a clearance order in place to protect personnel safety.
The inspector reviewed this incident by interviewing the individual who
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performed the investigation and reviewing documentation. As described in PIR 93-1407, the water treatment coordinator identified the deficiency when a field engineer que:tioned him about the liner inspections. After the water treatment coordinator learned that mechanics entered the vessel to' perform'
maintenance, he >nformed the mechanics and notified the control room that the
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work occurred without a clearance order in place. The licensee determined that a mechanic incorrectly signed the restoration section of Clearance
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Order 93-2114-AK indicating that personnel completed the work related to WRs 03649-92 and 04490-93. The following day the mechanics implemented WR 04490-93 without verifying the clearance order remained in effect.
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As an immediate corrective action, the licensee issued a note to all mechanical maintenance personnel on November 12, 1993, that described the event.
The licensee promptly implemented the following additional corrective actions:
Personnel were directed to sign for themselves and not transfer the
responsibility, if at all possible, after personnel complete work and need a clearance order restored, and If responsibility must be transferred, the person signing the
restoration must either visually verify the equipment is in a safe condition or contact the individual working on the equipment before i
signing the clearance order restoration.
The licensee found that an offgoing senior mechanic, at the end of the
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workday, requested another senior mechanic to sign the restoration section of Clearance Order 93-2114-AK related to WR 03649-92 indicating all the work was complete.
In addition, the offgoing senior mechanic indicated that the clearance order had other WRs associated with it. The individual.who signed the restoration section asked the offgoing mechanic whether he completed all-the work. The offgoing mechanic responded with a statement indicating all work was complete. The licensee determined the offgoing mechanic intended to j
indicate that only his portion of the work was complete. However, the person who signed the restoration section understood the individual to mean that all
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work activities were completed.
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The inspector reviewed Procedure ADM 02-100, " Clearance Order Procedure,"
Revision 28, which provided a method to ensure personnel safety and equipment protection. Also, the inspector interviewed licensee personnel about the appropriateness o# an individual restoring a clearance order for other l
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individuals and what limitations exist. The clearance order program allows
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individuals to sign for personnel within their group, as supervisors, and assigns the person who signs the clearance order responsibility for ensuring the personnel understand the protection provided.
The individuals may sign for other personnel if they are listed as a supervisor in Operations Special Order 5, " Safety Tagging."
Procedure ADM 02-100, Step 7.1.5.2, specifies that clearances issued for equipment that may be turned over to a different work crew for completion may be accepted and released by individuals acting in the capacity of an
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established supervisor onsite.
Procedure ADM 02-100, Step'7.1.5.2.1 specifies only those individuals specifically authorized by name and/or title in an operations special order may accept or release a clearance as a supervisor onsite. The inspector considered these steps inappropriate to the circumstances because they contained insufficient guidance to preclude personnel performing work without a clearance order in place. The failure of Procedure ADM 02-100 to assure personnel properly release a clearance order is
Example 1 of a violation of Technical Specification 6.8.1.a (482/9329-02).
During the review of this deficiency, the inspector found that PIR 93-0982
documented a similar situation related to restoration of Clearance
Order 93-1745-GL, which involved electricians.
Clearance Order 93-1745-GL
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controlled work activities on an access tunnel supply fan and some associated dampers. The licensee determined that on September 2,1993, personnel i
prematurely signed the clearance order as. ready to restore. The inspector
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found from discussions with licensee personnel that electricians working on
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the access tunnel supply fan, as specified by WR 51647-93, contacted a lead electrician and informed him that they had completed the work. Upon arrival at the control room to have the shift supervisor sign the WR, the electricians
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saw the lead electrician they had previously contacted leaving the control
room after restoring the clearance. Jer. However, prior to going to the
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control room, the electricians had learned that other personnel had not completed the damper work. The electricians informed the shift supervisor that some work remained to be completed, as specified in WR 51649-93. The
shift supervisor did not allow restoration of the clearance order.
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The licensee limited corrective actions regarding this event to electrical i
maintenance personnel.
From discussions with the licensee, the inspector i
found that the licensee initiated PIR 93-0982 because they recognized that the
clearance order could have been lifted while personnel worked on affected
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components in the field.
The electrical maintenance manager. considered this i
event a near miss but limited corrective actions to electrical maintenance
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personnel. The corrective actions listed below were implemented.
j An employee will sign on the clearance order for each job being
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performed,
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Personnel will list clearance order numbers next to affected WRs in the
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log book located on the electrical maintenance lead's desk, and i
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complete their work and will relay status of other ongoing work to the
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supervisor / lead / senior at the lead desk.
Corrective Actions for PIR 93-0982 did not include I&C, mechanical maintenance, and modifications personnel.
From review of the corrective actions implemented by electrical maintenance, the inspector determined that had the actions been implemented by all affected maintenance groups the deficiency on November 12, 1993, might have been avoided.
Procedure KGP-1210, " Performance Improvement Requests," Revision 9, Step 6.3, specifies requirements for processing nonsignificant PIRs that include considerations such as:
(1) evaluator to review PIR and determine what.
s corrective actions are to be implemented, if any, and (2) other groups affected. Step 6.3.1, specifies, for nonsignificant PIRs, that personnel shall review the PIR and determine what corrective actions, if any, should be implemented. The scope and depth of the evaluation should be appropriate to the circumstances. Also, the inspector found that Procedure KGP-1210,
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Attachment 3, " Problem Significance Screening Additional Guidelines," Item 10, specifies, in part, that incidents in which the normal configuration of the plant is altered in an unintended manner should be considered significant. An example would be a clearance order not providing the intended protection.
Based on the above criteria, the inspector determined that PIR 93-0982 should have been considered significant and actions taken to ensure generic
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corrective actions implemented.
r This failure to adequately address a deficiency identified by a PIR is a violation of 10 CFR Part 50, Appendix B, Criterion XVI for failure to take i
action to prevent recurrence by implementing corrective actions as required by
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Procedure KGP-1210 (482/9329-03).
On December 2, 1993, the licensee initiated PIR 93-1565 after the licensee
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identified a deficiency related to implementing Clearance Order 93-2077-HF.
As mechanics arrived at the control room to obtain permission to start work specified by WR 06149-93 and verify Clearance Order 93-2077-HF was in effect, l
the shift supervisor informed the mechanics that operations had restored i
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Clearance Order 93-2077-HF. The work remaining to be completed, as specified in WR 06149-93 involved replacing the manway for THF03B, low total dissolved solids collector tank. Discussions among the shift supervisor, the mechanical j
supervisor, and the craft personnel identified that the optimal course of
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action involved replacing the manway without instituting another clearance order. The shift supervisor contacted the water treatment coordinator and
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informed him not to process water through the Train B low total dissolved l
solids collector tank to allow the manway to be installed. The inspector-l reviewed the approach taken by the shift supervisor in this situation and determined these actions to be appropriate.
i The licensee determined that on December 1, 1993, a lead mechanic worked on an
instrument isolation valve in accordance with WR 05234-93 within the boundary
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of Clearance Order 93-2077-HF. After completing the work activities for WR 05234-93, the lead mechanic (listed as a mechanical supervisor in Special Order 5) signed for restoration of the clearance order both for himself and
for another individual listed as a mechanical supervisor. The licensee determined from discussions with the lead mechanic that he mistakenly signed for restoration of the clearance order because he saw only one WR listed on the first page but failed to recognize that the WR had a different number than the one the individual had implemented. The deficiency compromised personnel safety and prevented the tank from fulfilling the design function. The failure of Procedure ADM 02-100, Steps 7.1.5.2 and 7.1.5.2.1, to assure personnel properly release a clearance order is Example 2 of a violation of Technical Specification 6.8.1.a (482/9329-02). The inspector considered
Steps 7.1.5.2 and 7.1.5.2.1 inappropriate to the circumstances because they provided insufficient guidance to prevent restoring from a clearance order prior to all work being implemented.
As immediate corrective actions, the mechanical supervisor informed the shift supervisor that mechanical maintenance personnel would no longer sign as
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supervisor on clearance orders, as specified in Special Order 5.
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Subsequently, the licensee deleted from Special Order 5 the requirements ~
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allowing craft personnel to sign onto clearance orders as a supervisor. The licensee conducted meetings with personnel informing them of this policy and procedure changes.
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2.9 Voltage Spike on 125 Vdc Turbine Control Trip Bus
On November 14, 1993, as operators stroked a control valve in accordance with Procedure STS AC-002, " Main Turbine Control Valve Cycle Test," Revision 7, they noticed a control valve failed to respond. The licensee initiated a WR to correct the problems and found a control circuit card in the l
electrohydraulic control system with an intermittent signal. The licensee replaced the card as specified in WR 06287-93. When retesting the control a
valves, the vibration monitoring circuit indicated that High Pressure Turbine
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Bearing I had high vibrations. The licensee indicated that this vibration alarm normally occurs during control valve testing. When a nonlicensed operator reset the turbine vibration signal at Panel AC-121, turbine vibration
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monitoring cabinet, Annunciator ll3A, turbine vibration Hi Hi turbine trip, alarmed.
The following turbine trip annunciators remained in alarm on the
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Electrohydraulic Control Panel AC-Il9:
turbine supervisory l
instrument vibration light,125 Vdc trip, and mechanical trip solenoid.
Operators suspended Procedure STS AC-002. After verifying a valid voltage
spike occurred without a turbine trip, the licensee reset the turbine trip
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The licensee determined that voltage had spiked for
approximately 0.1 seconds, long enough to actuate the alarm lights but not sufficiently long enough to fully actuate the 125 Vdc mechanical trip solenoid or the three 24 Vdc cross-connect relays. The cross-connect relays function
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to deenergize the electric trip circuit as a backup to the mechanical
solenoid.
Because of the spurious voltage spike, the licensee disabled the vibration monitoring panel to the turbine electrohydraulic control system i
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-21-panel by disconnecting leads in accordance with Temporary Modification 93-56-AC. The licensee initiated PIR 93-1377 to assure resolution of this issue. The licensee placed a computer mimic of the vibration monitoring points on a control room view screen so that manual actions could be implemented, as necessary, for high vibrations.
After personnel disconnected Panel AC-121 from Panel AC-Il9, I&C technicians attempted unsuccessfully to recreate the voltage spike.
The Vice President Plant Operations initiated Incident Investigation 93-04 to review the cause of the main turbine high vibration trip annunciator without a turbine trip. The charter required the five-member team to evaluate:
Adequacy of immediate actions,
Availability of other turbine trips,
Cause of turbine trip annunciator without a turbine trip, and a
Lessons learned and corrective actions.
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The licensee determined that the 0.1 second voltage spike would not necessarily have caused an actual trip signal.
The investigating personnel based their conclusion on the redundancy ineluded in the trip system to accommodate failures (mechanical trip with electrical trip backup) and an extremely low probability of the mechanical trip relay and three electrical relays all malfunctioning.
The licensee believes that a microprocessor board in the turbi, vibration monitoring panel faulted because the high vibration alarms and, ips are microprocessor driven. The licensee will replace the microprocessor board and return the microprocessor board to the vendor for evaluation of the failure mechanism. The licensee initiated an engineering evaluation request to have the feasibility of installing a time-delay relay external to Panel AC-121 evaluated.
Presently, Panel AC-121 has a 6-second time delay internal to the cabinet to account for spurious high vibration signals. The proposed configuration would maintain, in series, a 3-second internal time delay to account for spurious high vibration signals and a 3-second time delay externally to prevent software faults from generating nuisance trip signals that could potentially trip the turbine.
From discussions with the team leader of the investigation, the inspector found that the team considered the initial response to the event appropriate since the operator suspended the test and obtained appropriate technical expertise to identify a root cause. The team found the compensatory measures taken by the operators satisfactory after disabling the ability to automatically trip the turbine on high vibrations. The team's review determined that since the, pike originated in the vibration panel, the other turbine trips remained operable. At the end of the inspection period, the team had not yet identified any lessons learned and had determined the proposed corrective actions to be appropriate. The inspector will review the final report when it is issued.
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i 2.10 Power Rerate During this inspection period the licensee implemented License Amendment 69 to License NPF-42 that authorized an increase in the maximum rated core power from 3411 to 3565 megawatts thermal.
The inspector observed several of the activities associated with this rerate. The licensee developed Temporary Procedure TP TS-154, " Power Rerate and T-Hot Reduction," Revision 0, to coordinate, sequence, and control the many activities that needed to occur to implement this change with the plant in Mode 1.
The inspector reviewed this procedure and found it to be well organized and thorough. The' inspector considered the coordination of activities to be good. Activities involved-with the power rerate included rescaling instruments, altering setpoints, and altering the programmed Tave.
In addition to the power rerate, the licensee-reduced the upper bound for T-Hot, outlet core temperature.
Licensee management developed a detailed. schedule for implementing these activities.
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No schedule pressure existed during the performance of these activities as evidenced by the several day delay before implementation and the controlled manner in which personnel performed activities.
The inspector observed personnel perform several activities supporting the rerate that included:
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STS IC-500G, " Channel Calibration dT/Tavg and Pressurizer Pressure
Protection Set IV," Revision 7 STS IC-204A, " Analog Channel Operational Test of Tavg, dT and
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Pressurizer Protection Set IV," Revision 1 INC C 1016, "7300 Summing Amp Card NSAl and NSA2," Revision 8
Several operations crew briefings
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The inspector concluded that personnel performed all observed activities in a safe, controlled manner. The inspector noted minor human factors and minor procedural weaknesses during the performance of the I&C activities; however,
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the I&C technicians performed the tasks well and appropriately compensated for.
the weaknesses.
During the power ascension on November 22, 1993, the licensee achieved
95.5 percent of the rated core power of 3565 megawatts thermal with Tave maintained at program and turbine control valves fully open. The lower Tave resulted in lower secondary steam pressure and flow. The licensee had anticipated this occurring because of discussions with another facility that had done the same power rerate, but these disucussions were held after startup from Refuel VI.
The licensee determined that their statistical analyses supporting the power rerate allowed for a plus 3 F increase in Tave above Tref.
Further, the
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operating window identified in Attachment 2 based on their analyses. On l
November 23, 1993, the licensee increased Tave to 2.3*F above Tref; however, i
because of operator concerns about the numerous Loop 4 temperature deviation alarms caused by the upper plenum anomaly, the licensee reduced Tave to 1.50F
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above Tref. The upper plenum anomaly is a rapid temperature increase in adjacent loops created by turbulence in the core upper plenum (refer to NRC Inspection Report 50-482/93-14, Sections 2.1.2 and 4.2).
The licensee evaluated whether operating procedures, instrument scales, or control circuit
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setpoints should be changed in order to operate with Tave greater than Tref.
i At the higher core thermal power and with Tave greater than 1.5aF above Tref, the licensee determined that the upper plenum anomaly caused the Loop 4 low-Tave deviation setpoint of 3*F and the Loop 4 low delta-T deviation setpoint
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of 2of to be exceeded. The precautions, limitations, and setpoint document provided by the NSSS vendor specified that the setpoints for these parameters may be adjusted to just beyond the range of normal operating variations.
Consequently, reactor engineers changed the alarm setpoints for both the Loop 4 low Tave and low delta-T deviations to 3.5*F and 2.5aF, respectively.
The inspector discussed with licensee personnel control systems that would be altered to allow for better plant response with Tave greater than Tref by greater than 3 F instead of 2aF.
The licensee implemented a change to the steam dump control circuits to prevent a constant steam dump demand signal from being present if they operate with Tave greater than Tref by 2.3*F to 2.8af.
Engineering determined that the allowed deadband for Tave to be
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greater Tref by 2af could be increased to 3*F.
The inspector verified that i'
the precautions, limitations, and setpoint document allowed adjustments during power operations to optimize the steam dump control system response. The inspector found from review of an engineering disposition and discussions with the design engineer that the plant response on a load reject would not be-
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affected on a total loss of load; however, the system response for a normal
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power decrease would result in the steam dumps opening later.
Engineering
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reviewed this operating condition because operators preferred to operate l
without the demand signal present.
The licensee initiated evaluations of the core design and accident analyses in order to increase Tave that would reverse some of the T-Hot reduction i
benefits.
The licensee intends to submit a Technical Specifications change
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after completing the analyses.
Increasing the designed Tave will allow the licensee to operate with control rods in automatic for better plant response.
2.11 Operator loo Reviews j
The inspector reviewed this area to verify that nonlicensed operators
performed their shift duties in accordance with procedures and licensee i
management expectations. The inspector selected rooms that contained safety-related equipment in the below listed daily log procedures:
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CKL ZL-001, " Auxiliary Building Reading Sheets," Revision 23
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CKL ZL-004, " Turbine Building Reading Sheets," Revision 21
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CKL ZL-009, " Site Reading Sheets," Revision 14 l
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The inspector verified that the licensee performed the quarterly audits of logkeeping versus security door access records as specified in NRC Inspection Report 50-482/92-28. The inspector selected 13 rooms for a period of
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20 consecutive days, October 12-31, 1993, representing 1040' required door
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entries.
The inspector determined that on most occasions personnel implemented the expectations of the operations manager for obtaining required log data listed in NRC Inspection Report 50-482/92-28. These expectations include:
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Making use of the log to document any discrepancies, such as the
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inability to complete logs because of ongoing activities; Documenting when other personnel complete another individual's logs for
any reason; Key carding in and out of rooms; and
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Completing two tours per shift for all rooms.
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The inspector found that personnel properly performed their shift log taking
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duties. The inspector identified apparent discrepancies on two separate occasions between the security computer and the daily reading sheets.
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However, upon review of the log sheets, the inspector determined that on the.
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first occasion the watchstander documented an inability to complete all of the
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first round because of involvement with auxiliary boiler troubles. On the
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second occasion the smooth logs indicated that a different individual, who had
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entered the rooms in question, relieved the designated watchstander.
j On November 4, 1993, a nonlicensed operator initiated PIR 93-1292 because the
.j door to the main steam isolation valve room failed to let the individual
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access the room because the reader misread the badge.
Security informed the
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individual that the error message was "0007 NRC Badge Inactive." The licensee determined that the error message occurred because the individuals badge had
cracked.
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2.12 Conclusions During a service water system self-assessment review of prior commitments, the l
licensee identified that personnel made an inappropriate reportability
determination in 1991 on a.1990 issue. The licensee determined that low ESW
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flows could have potent' ally made components inoperable. The licensee used available data and made engineering judgement determinations of operability of the ESW' supplied components.
Current licensee programs provide assurance that ESW supplied components are operable and degrading conditions can be identified.
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After the inspectors informed the licensee about the potential to violate I
containment integrity, the licersee determined that they had violated containment integrity and issued LER 482/93-015. The inspector concluded that the licensee demonstrated a proactive attitude during review and correction of the containment integrity deficiency.
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A violation was cited for four instances of control room operators failing to closely monitor control panel instruments and controls and properly perform i
licensed duties. The licensee took prompt, strong corrective actions in response to each individual event.
Because of ongoing actions being implemented to improve operator performance, as described at a
November 9,1993, meeting with the licensee, no response to the violation is
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required. Also, the operations manager committed to review and correct the remainder of the slave relay tests prior to their next performance with a deadline for all reviews by March 31, 1994, which contributed to one of the
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instances of operator inattentiveness.
The licensee implemented strong, generic, corrective actions to address
operator attention to detail concerns. The licensee placed managers onshift
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to coach the crews, and altered the plan-of-the-day meeting to focus on
problems. The shift supervisors / supervising operators participated in development of performance standards. Throughout the period, operations personnel increased the number and quality of PIRs being initiated.
Licensee personnel demonstrated an increased awareness of their problems and improved
documentation of the issues. Because of the large number of personnel
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inattention to detail problems, the Vice President Plant Operations established an %-day work stand down for personnel to review the errors in
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their department and develop solutions to minimize the errors.
After the inspector identified that a security officer read unauthorized reading material in the central alarm station, the licensee took immediate,
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aggressive corrective actions. Overall, the inspectors found the licensee response to potential inoperability of safety-related pumps to be excellent, and system engineers provided outstanding support. The inspector l
independently assessed the calculations and determined the licensee used
appropriate conservatisms to assure sufficient design margin. The licensee
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determined that they had a nonqualified fire brigade member contrary to
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Technical Specification 6.2.2.e.
The licensee determined the event to be reportable, took immediate corrective actions, identified the root cause, and
implemented additional corrective actions.
A violation with two examples related to clearance orders _was identified. _The first example involved personnel performing work inside a condensate'
i demineralizer vessel _without a clearance order in place.
The licensee
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implemented immediate corrective actions that included reminding personnel of
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their responsibilities related to signing onto a clearance order as a supervisor.
The second example involved personnel restoring from a clearance
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order as a supervisor prior to all work being complete. A manway for the Train B low total dissolved solids tank was not in place that could have
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The licensee no longer allowed maintenance personnel to sign onto clearance orders as a supervisor by removing the authorization from Special Order 5.
The NRC identified a violation of 10 CFR Part 50, Appendix B, Criterion XVI occurred because the licensee failed to apply the corrective actions for an earlier clearance order restoration deficiency documented on a PIR to all affected maintenance groups.
During this period, the licensee performed a very well controlled, deliberate implementation of activities related to rerate of the maximum core rated thermal power.
Because of physical limitations of the nozzle blocks in the high pressure turbine, the licensee achieved 95.5 percent of the maximum rerated thermal power. The licensee adjusted Tave above Tref and adjusted control systems within allowable ranges to maximize the thermal output. The licensee also implemented a T-Hot reduction to extend the life of the steam generators.
However, to further maximize the thermal output of the reactor to t
overcome the physical limitations of the turbine, the licensee began performing analyses for operation at a higher Tave and will request a Technical Specifications change based on their analyses.
The licensee performed a prompt detailed review into the cause and implications of a voltage spike on the 125 Vdc turbine trip bus without a turbine trip. The inspector performed a detailed review of nonlicensed operator log taking and identified no problems.
3 MAINTENANCE OBSERVATIONS (62703)
l During the inspection period, the inspectors observed and reviewed the
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selected maintenance and activities listed below to verify compliance with l
regulatory requirements and licensee procedures, required quality control department involvement, proper use of safety tags, proper equipment alignment and use of jumpers, personnel qualifications, appropriate radiation worker practices, calibrated test instruments, and proper postmaintenance testing.
Specifically, the inspectors witnessed portions of the following maintenance activities:
Emergency light test
Component cooling water pump and room couler maintenance
Repair of Centrifugal Charging Pump B inboard bearing oil leak
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Lubrication of Centrifugal Charging Pump B oil transfer pump
Changing of Centrifugal Charging Pump B motor outboard bearing oil,
Valve Operation Test Evaluation System diagnostics evaluation of Motor-
Operated Valve (MOV) EJ FCV611, Residual Heat Removal B miniflow valve Packing adjustment on MOV EJ FCV611
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Oil change in Residual Heat Removal Pump B motor upper and lower
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.l The inspectors found that personnel implemented all aspects of the listed maintenance attivities in a very good manner.
3.1 Emergency Light Tests On November 3, 1993, the inspector observed electricians performing the I
quarterly preventive maintenance check of Special Scope II/I Emergency i
Light A-7 in the auxiliar., building. The craft personnel performed the work
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activities in accordance with supplemental work instructions attached to WR 52104-93.
The inspector found the craft personnel knowledgeable of the
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supplemental work instruction requirements.
f 3.2 Component Cooling Water Pump and Room Cooler Maintenance
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On November 3, 1993, the inspector observed electricians take an oil sample
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for Component Cooling Water Pump D in accordance with WR 52085-93. The electricians used the proper oil, Mobil DTE 26. Tl:e craft personnel followed the guidance listed in Procedure MPH 05-001, " Preventive Maintenance Lubricant Sampling and Replenishment at Various Frequencies," Revision 5.
The inspector observed electricians perform preventive maintenance and
inspection of the Train B component cooling water room cooler as specified by WR 52090-93. WR 52090-93 referenced Procedure MPE RC-001, " Room Cooler Maintenance," Revision 2, as guidance for implementing the maintenance.
The
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inspector discussed the maintenance activity with the electricians and found them to be knowledgeable and verified that Procedure MPE RC-001 provided detailed guidance for performing the maintenance.
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The licensee initiated PIR 93-1296 because the craft personnel requested that
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operators remove Clearance Order 93-2026-GL and declare the train operable
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prior to meggering the room cooler fan motor, as specified by WR 52089-93.
Subsequently, the electricians contacted the control room, obtained Human Do
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Not Operate administrative control, and meggered the room cooler fan motor.
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3.3 Maintenance Procurement The inspector reviewed the maintenance procurement process and the following licensee documents:
KGP-1250, " Requisition & Procurement Process," Revision 7
ADM 01-059, " Conditional Release," Revision 13
i ADM 01-071, " Identification and Control of Materials, e
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Parts, and Components," Revision 7
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ADM 01-122, " Material Return to Stores," Revision 2
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ADM 01-123, " Refurbished Items / Reusable Parts," Revision 1
ADM 08-216, " Maintenance and Modification Material
Storage and llandling," Revision 4 Wolf Creek Customer's Guide to Procurement
The inspector concluded that the above procedures provided strong programmatic
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guidance to assure control of safety-related material prior to use.
Field-
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observations of several aspects of this program revealed that knowledgeable
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licensee personnel followed their program.
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The inspector discussed the procurement process with licensee maintenance personnel.
Personnel expressed concerns about the unavailability of parts and the inability to link available spare parts with the equipment requiring
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naintenance. The maintenance personnel indicated improvement in both of these areas has occurred. Maintenance personnel further indicated that the l
procurement process imposed an administrative burden. Outage procurement
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practices have required the maintenance organization to order all material they might possibly need during-the outage. After the outage, maintenance
' i personnel must decide which unused components should be placed in the warehouse or returned to the vendor.
The inspector discussed the procurement process with integrated plant
scheduling. The integrated plant scheduling personnel indicated that
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personnel did not schedule routine work until all needed material was available.
During the 13 weeks ending on November 14,.1993, 19 of 2126 scheduled WRs were either completed late or rescheduled because of parts problems. This represented 19 of 223 late or rescheduled WRs. The inspector
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concluded that material unavailability affected some work activities but did i
not predominantly contribute to late or rescheduled work.
l The inspector attempted to determine the percentage of emergent work items t
that could not be worked immediately because of unavailability of material in the warehouse; however, licensee personnel did not track this information.
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response to the inspector's question, the licensee evaluated emergent work l
during 1993 and found that of the 228 Priority 1 and 2 emergent work requests
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there were 257 material needs, and 233 of these were immediately filled from
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the warehouse.
The remaining 24 were filled within 3 days.
Purchasing ana.
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materials services tracked numerous measures of material support including
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their ability to obtain Priority 1 and 2 material requests and warehouse i
material that have insufficient quantities on hand.
The inspector noted an
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improving trend in several of the material support tracking parameters that i
suggested improvement in the ability of the licensee to_. support maintenance i
needs. The inspector concluded that material unavailability concerns were
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decreasing and Priority I and 2 work requests were not substantially impacted i
by material unavailability.
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The inspector inspected the warehouse. The warehouse workers demonstrated i
good knowledge with regard to parts locations, storage requirements, radiation
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protection requirements, temperature and humidity limitations, and procurement procedures. The inspector noted that the licensee appropriately marked fire extinguishers in the warehouse and checked them with the same frequency as fire extinguishers in the plant.
The inspector obtained warehouse personnel l
assistance in inspecting Fire Protection Cabinets FPC 17 NQ and FPC 20 NQ.
When personnel opened the cabinets, the inspector noted a very strong odor.
The licensee determined that the material was monoethylamine, initiated PIR 93-1546, and moved all of the monoethylamine containers to a single J
cabinet to ensure better monitoring. Warehouse personnel transferred several R
improperly sealed containers to the environmental department for disposal.
The licensee reviewed the amount of material on hand and is reevaluating the appropriate stocking level. As corrective action, the licensee will perform quarterly inspections to review warehouse conditions that includes the fire l
protection cabinets. The inspector inspected the container for the spare l
reactor vessel o-ring and noted that the bag containing the paperwork for the l
o-ring was no longer completely affixed to the crate. The inspector concluded that documentation could potentially become separated frcm the crate. The warehouse personnel immediately secured the bag using different tape.
Tha inspector identified good warehouse conditions and noted some minor weaknesses.
3.4 Conclusions
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Overall, the inspectors found that qualified personnel appropriately performed maintenance activities and observed excellent communications among personnel.
No clearance order weaknesses occurred related to the activities observed by the inspectors. The inspectors noticed that personnel demonstrated an increased willingness to generate PIRs. The inspectors found that licensee procedures provided good programmatic guidance to procure and control safety-related components, personnel were knowledgeable about the parts and materials processes, improving trends existed in the ability of the warehouse to support plant needs, and generally, there were excellent controls of material in the warehouse.
The inspectors found one minor deficiency in the licensee's procurement program. Combustible materials in warehouse combustible material cabinets were not tightly closed. The licensee intends to initiate quarterly inspections of warehouse combustible material cabinets.
4 SURVEILLANCE OBSERVATIONS (61726)
The inspectors reviewed this area to ascertain that the licensee conducts surveillance of safety-significant systems and components in accordance with Technical Specifications and approved procedures.
4.1 AFW Pump B Test On November 3, 1993, the inspector observed the inservice pump test of AFW B performed in accordance with Procedure STS AL-102, "MDAFW Pump B Inservice
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Pump Test," Revision 16. The inspector noted that the test engineer performed a good, thorough prejob brief.
The inspector verified that data met acceptance criteria and personnel used
calibrated test instruments. The inspector observed coordination of
activities at the pump. The test engineer and a station operator utilized
excellent communications when setting the pump discharge pressure.to obtain
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ll the reference flow.
Personnel waited the required 5 minutes prior to measuring the pump vibrations.
4.2 AFW Valve Test
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On November 4, 1993, the inspector observed personnel perform a retest of l
MOV AL HV005, MDAFW pump discharge to Steam Generator D isolation valve, as i
specified in Procedure ADM 05-200, "ASME Code Testing of Pumps and Valves,"
Revision 3.
The valve opened 1.2 seconds too fast when stroked in accordance
with Procedure STS AL-201, " Auxiliary Feedwater System Inservice Valve Test,"
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i Revision 12. During the retest, the valve opened 0.3 seconds too fast. As specified in the retest procedures, the licensee performed an evaluation of
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the valve condition.
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The licensee overhauled MOV AL HV005 during Refuel VI and determined the open stroke time to be 24.9 seconds. During subsequent tests, the valve stroked
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open in 18.1, 20.0, and 20.9 seconds.
Each of these stroke times exceeded the alert low-limit time of 21.2 seconds. During performance of previous tests, the valve passed the ASME Section XI requirements. On November 4, 1993, the
first valve stroke time was 20.0 seconds and fell below the alert low-limit
range and required the retest. The evaluation determined the test to be acceptable. The inservice test engineer determined the 24,9 second stroke i
time to be anomalous and considered 19.7 seconds to be the new baseline value.
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The inservice test program engineer averaged the three previous test values to
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obtain the new baseline value. The inservice-test program engineer documented the need to establish a new baseline value in accordance with OMA-1988, i
Part 10, " Inservice Testing of Valves in Light Water Reactor Power Plants,"
for MOV AL HV005 in the pump and valve events log as specified by ADM 05-200.
l 4.3 Hydrogen Analyzer A Test i
On November 15, 1993, the inspector observed calibration of a containment hydrogen analyzer in accordance with Procedure STS10-912, " Containment
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Hydrogen Analyzer GS 065A Calibration Test," Revision 11. The inspector noted
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that this test satisfied Technical Specification Survsillance
Requirements 4.3.3.6 and 4.6.4.1.
The inspector verified the adequacy and
calibration of test equipment. The inspector confirmed that 1&C technicians
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used the latest revision of the surveillance procedure and that the procedure provided appropriate guidance. During the test the inspector and I&C technicians noted that the local cabinet meter did not respond during the span test. The three other indications correctly read 9 percent hydrogen suggesting a problem with the meter. The I&C technicians stopped the surveillance, notified the shift supervisor, and initiated WR 06316-93.
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During troubleshooting, the I&C technicians touched the back of the meter, which immediately responded and read 9 percent hydrogen.
The I&C technicians
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closed WR 06316-93 and dispositioned the WR as N/A in Block 15. The I&C technicians satisfactorily completed the surveillance test. The inspector questioned the disposition of WR 06316-93 and the adequacy of the surveillance. The licensee initiated WR 06434-93 to replace the meter. The inspector noted that Procedure ADM 01-057, " Work Request," Revision 7, Step
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7.15, states, "The Disposition Category is N/A when the WR is:
A.
CLOSE in Process.
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Used to implement a Temporary Modification.
C.
Not
Corrective." Since WR 06316-93 did not meet any of these criteria, a
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disposition of N/A was not appropriate. This resolution preempted the operability, reportability, and engineering reviews that might be triggered after completion of the work. This violation of Technical Specification 6.8.1.a was not cited because the criteria specified in
paragraph VII.B.1 of the NRC Enforcement Policy were satisfied. The licensee initiated PIR 93-1589. The I&C manager stated that the immediate actions included expressing his expectations to I&C supervisors and lead personnel that potentially degraded equipment should be evaluated / monitored until i
personnel verify proper operation before closing a WR.
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4.4 Safety Injection Pump A Test On November 23, 1993, the inspector observed the inservice pump test of Safety Injection Pump A performed in accordance with Procedure STS EM-100A, " Safety Injection Pump A Inservice Test," Revision 10. The inspector noted that this procedure satisfied Technical Specification Surveillance Requirements 4.0.5 and 4.5.2.f.2 for the pump and for four system valves. The inspector further noted that personnel properly used calibrated vibration and pressure test equipment. The inspector noted satisfactory radiation protection practices
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and noted good coordination between operations and engineering personnel. The test personnel followed the procedure and controlled the testing i
appropriately.
The inspector noted that during the venting of the pump suction test gage, the vent flow path did not vent the gage nor approximately 6 inches of tubing.
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Engineering noted that the ASME Section XI code, IWP-4210, states, in part,
"If the presence or absence of liquid in a gage line could produce a
difference of more than % percent in the indicated value of the measured
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pressure, means shall be provided to ensure or determine the presence or
absence of liquid as required for the static correction used."
Informal calculations were inconclusive and communication with the test gage vendor did not provide a basis to conclude that the effect of the unvented section met
the code requirements. The licensee issued PIR 93-1580 to address this issue.
The licensee established a test rig in the I&C shop to evaluate the error
introduced by incomplete venting. The inspector concluded that the incomplete
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venting of the test rig had not been considered. The inspector further
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concluded that the licensee's actions subsequent to the inspector's questions were appropriate.
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4.5 Reactor Protection System Actuation Loaic Test On November 16, 1993, the inspector observed Procedure STS IC-211A, " Actuation
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Logic Test Train A Solid State Protection System," Revision 16. The inspector
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noted that. this test satisfied Technical Specification Surveillance Requirements 4.3.1.1, Table Items 17-20, and 4.3.2.1, Table Items Ib, 2b, 3a2, 3b2, 3c2, 4b, Sa, and 6b.
The inspector noted that the procedure appropriately implemented the surveillance requirements and I&C technicians followed the procedure.
Procedure STS IC-211A, Step 6.4, referred to Reactor
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Trip Bypass Breaker Cubicle BYA and push-button switches on this cubicle; however, this cubicle was not labeled. The Logic A knob pointer was not properly aligned with the panel indicator marks. The I&C technician compensated for the misalignment by carefully counting the number of switch positions to ensure proper positioning of the switch. The inspector concluded that the I&C technician carefully performed the test.
l 4.6 Reactor Coolant System Inventory Test On November 17, 1993, the inspector observed portions of Procedure STS BB-004,
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"RCU Water Inventory Balance," Revision 10.
The inspector noted that this
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satisfied the Technical Specification Surveillance Requirement 4.4.6.2.1.d.
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During the test, the inspector noted that operators did not record the date
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and time of the data collection on data sheets. After the inspector
questioned this practice, the supervising operator issued PIR 93-1433 to
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document the failure to record date and time on the data sheets. This PIR evaluation would review other affected procedures to ensure that date and time
are recorded. The inspector concluded that personnel properly performed the j
test and that the test met the Technical Specifications requirements.
4.7 Conclusions
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The inspectors found that, generally, the licensee implemented inservice pump and valve tests in an outstanding manner.
Personnel properly performed the
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test, properly installed test instruments, and appropriately evaluated a
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stroke time that exceeded acceptance limits.
During a hydrogen analyzer calibration, the inspector identified a noncited violation. While performing the test, personnel questioned the operability of the local meter because they received no indication while adjusting the span; however, after the meter
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indicator appeared on scale, the technicians closed the related WR without
verifying that the meter functioned. The inspectors found the procedures for implementing surveillances to be good and overall noted very good communications.
I&C personnel paid attention to details and performed testing in a deliberate, systematic manner.
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5 COLD WEATHER PREPARATION (71714)
The inspector performed this inspection to evaluate licensee actions implemented to protect plant equipment during cold weather. The inspector determined that Procedure STN GP-001, " Plant Winterization," Revision 9, provided detailed guidance for implementing cold weather protection. The
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procedure provided precautions regarding proper operation of heat tracing, space heaters, and steam supplied to various outdoor water storage tanks. The inspector verified that Procedure ADM 02-300, " Reading Sheets and Shift Rounds.
Instructions," Revision 14, provided general guidance for operators conducting rounds to monitor heat trace circuits.
The inspector independently verified that operators correctly placed in service the plant heating steam supplied to various safety-related air supply
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units.
The inspector verified that the licensee supplied power to the heat
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trace circuits.
The inspector determined the licensee had provided auxiliary
steam to outdnor tanks. The inspector reviewed a listing of required maintenance activities and determined that the licensee implemented the activities.
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On November 7, 1993, an operator implementing STN GP-001 identified that the procedure failed to energize ana/or deenergize, as appropriate, unit area heaters on the fuel building refueling floor. The individual initiated
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PIR 93-1313 to document the above deficiency. The operator addressed that other procedures did not include energizing and/or deenergizing the unit area heaters.
Subsequently, the operator energized the heaters and changed Procedure STN GP-001 to include guidance for the refuel floor unit area heaters.
The inspector found that the licensee implemented an outstanding cold weather protection program. A licensed individual demonstrated a questioning attitude and awareness of the corrective action process when the individual changed the appropriate procedure and initiated a PIR to document a failure of the plant winterization program to address the refueling floor unit area h r ers.
6 FOLLOWUP ON CORRECTIVE ACTION FOR VIOLATION', (92702)
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6.1 (Closed) Violation 482/9231-02:
Inadeauate Postmaintenance Test Procedures This violation was cited because postmaintenance testing for H0V BN HV8812B, refueling water storage tank to Residual Heat Removal B suction, failed to
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identify that personnel improperly adjusted Limit Switch Rotor 3.
The failure i
to properly adjust Limit Switch Rotor 3 would have caused difficulty in placing Residual Heat Removal B in shutdown cooling.. The licensee determined that the surveillance procedure used during the postmaintenance test did not
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require that personnel verify proper engineered safety features status panel light actuations. At the time of the incident, the inspector reviewed licensee actions implemented to correct affected MOV Setpoint Document Sheets.
The licensee stated they would include. verifying engineered safety features status light indications during postmaintenance testing. Also, the licensee
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established a database that listed'postmaintenance test requirements.
The inspector determined from discussions with licensee personnel that personnel developed postmaintenance test requirements by component.
Licensee personnel reviewed inservice tests, Technical Specifications surveillance
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In addition, licensee personnel reviewed completed WRs to identify other postmaintenance tests that should be listed in
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the database.
The inspector verified that Procedure ADM 08-240, " Post
i Maintenance Testing," Revision 2, referenced the postmaintenance database and provided guidance for use of the database.
The inspector sampled selected i
valve inservice test procedures to verify that the tests had personnel verify i
that engineered safety features status panel lights illuminate.
6.2 (Closed) Violation 482/9301-01:
Failure to Follow Procedures /Wrono Train -
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This item involved I&C technicians manipulating switches in the wrong train of
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protection set cabinets that resulted in the tripping of the improper protection bistables. As immediate corrective actions, the licensee halted-the testing, corrected the error, completed the testing properly, and initiated PIR 93-0051 to assure they implemented additional corrective
actions.
The licensee discussed the event during I&C department meetings and routed the
~l completed PIR to all I&C technicians as required reading. The licensee reemphasized the STAR program to encourage personnel to use self-verification and thoughtful, disciplined, deliberate actions in carrying out work
activities. The licensee implemented positive discipline for the I&C
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technicians involved. The I&C technicians made presentations to operating crews and licensee senior management regarding the STAR program including how i
it could have prevented the event. The inspector concluded that the licensee's corrective actions were appropriate.
6.3 1 Closed) Violation 482/9301-03:
Inadeouate Procedure
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This item involved the inadvertent draining of the refueling water storage
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tank because Procedure STS EJ-100A did not reclose Valve BN V004, safety injection test header to refueling water storage tank isolation, at the
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conclusion of the test that provided the drain path. When this condition was
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identified, the licensee shut Valve BN V004 and initiated PIR 93-0084.
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The licensee revised Procedures STS EJ-100A and STS EJ-100B to verify
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Valve BN V004 closed and verify Valve EM V120, safety injection test header to recycle holdup tank isolation, open at the conclusion of the test. The
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licensee reviewed and revised other applicable procedures, as appropriate, and created Procedure SYS EM-002, " Safety Injection System Depressurization," to formalize safety injection system header depressurization.
The licensee conducted training on the new procedure and on this event during licensed and nonlicensed operator requalification. The licensce revised drawings to indicate Valve BN V004 normally shut and Valve EM V120 normally open.
6.4 (Closed) Violation 482/9308-04:
Inadequate Work Instructions
This violation was cited becaJse the applicable maintenance instructions failed to prevent safety-related piping from being deflected beyond 1/2 inch as designated by the design specifications. After mechanics identified the
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deficiency, the licensee performed an operability evaluation that identified l
the system remained operable and performed an engineering evaluation that
determined the added piping fatigue.
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The licensee implemented a design change that realigned the piping. The licensee updated the Updated Safety Analysis Report to reflect the added pipe
fatigue usage factor.
In response to the violation, the licensee stated they would train mechanics on the design specification requirements and would modify Procedure STS MT-005, " Pressurizer Code Safety Valve Operability,"
Revision 5, to require match marking the mating flanges.
The inspector verified that the licensee updated the Updated Safety Analysis Report to reflect the added pipe fatigue usage factor, modified Procedure STS MT-005 to reflect match marking the mating flanges, and trained i
the mechanics on the design specification.
From review of the presentation
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package, the inspector found the training to be excellent. A qualified i
instructor presented training on the cause of the misalignment and design
specifications that identify permissible pipe deflection, and provided a
sample problem to reinforce the information presented.
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6.5 (0 pen) Violation 482/9316-01:
Improper Mode 3 Entry with Hand Switches'
j in Pull-to-lock
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This violation was cited after the licensee determined they had operated with
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the handswitches for both MDAFW pumps in the pull-to-lock position for i
approximately 13.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. This rendered the pumps unable to perform their j
design function and exceeded the allowed outage time specified in Technical
Specifications for this period. Contributing factors included a failure to
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perform adequate shift turnover briefings, failure to perform thorough main control board walkdowns, and a failure to use the equipment out-of-service
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log in all plant operating modes. The primary cause resulted from operator
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inattention to detail.
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The licensee's immediate corrective actions included restricting activities that distract control room turnovers, implementing requirements for control room personnel to maintain control room professionalism and formality, and
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management expressing performance expectations and requirements. The licensee
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implemented additional actions to address the deficiency that included
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reenforcing information in operations procedures that address conduct of
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operators, the supervising operator presenting to his peers the importance of STAR concepts and how the event could have been prevented, changing i
Procedure ADM 02-105, " Equipment Out of Service Log," Revision 9, to clearly i
reflect how the facility uses the equipment out-of-service log and clearly
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defining the conditions for placing safety-related pumps in the pull-to-lock
position.
To prevent recurrence the licensee committed to perform the following activities:
review general operating procedures to ensure performance steps
are included in the procedure body, create a list of Technical Specifications i
that become effective upon mode changes, present general operating procedure
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changes during requalification training, have quality assurance personnel review control room activities, and assign personnel to perform an independent assessment of operations.
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The inspector reviewed memorandums issued by operations management that i
required control room quiet time between 6:30 and 7:30 a.m./p.m.,
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professionalism and thoroughness in onduty conduct, and clear, concise
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communications. The inspector verified the licensee modified Standing Order 24, " Operations Performance Standards," Revision 8, to specify the
philosophy for placing pumps in the pull-to-lock position. The inspector j
verified that the licensee changed Procedure ADM 02-105 to clearly specify i
operating modes when equipment out-of-service log entries should be made.
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The inspector found that Procedures ADM 02-010 " Shift Relief and Turnover,"
Revision 19, and ADM 02-040 provided good information regarding expectations
and behaviors of operations personnel.
Procedure ADM 02-010 described what
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management expected personnel to review and become familiar with prior to assuming shift responsibilitie.
Procedure ADM 02-040 provided information about activities allowed to be erformed by personnel while at the controls.
The inspector reviewed the results of Quality Assurance Surveillance S-2060, i
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" Control Room Shift Turnover." The auditors performed the evaluation at the request of the operations manager to assess actions implemented in response to this violation. The auditor found that persormel limited access to the.
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control room and limited nonbusiness conversations. A couple of instances
occurred when operators failed to review standing and special orders prior to
assuming the shift, as required by Procedure ADM 02-010. The auditor initiated PIR 93-0915 to assure corrective actions would be implemented. As j
corrective action, instead of requiring the shift supervisor to denote receipt
of revised standing and special orders in the shift supervisor log book, the
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licensee places revised special and standing orders in required reading.
l The licensee will train operators on the revised general operating procedures
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prior to the next refueling outage. The inspector verified the licensee revised the general operating procedures to clearly list Technical
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Specifications that become effective upon mode changes.
The inspector reviewed the independent performance assessment of plant j
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operations. The Vice President Nuclear Assurance led the. operations
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assessment team that evaluated the areas listed:
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Management effectiveness and organization culture e
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Training and outage preparations
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Organizational structure
Frequency, type, and error trends within plant operations
e The assessment report identified several strengths: dedicated operations's
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personnel, plant scheduling provided strong daily planning, system engineers provided valuable assistance to the operators, and the quiet time resulted in l
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Items that required attention
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included: marginal control room staffing, narrow pool of personnel eligible
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to become a shift supervisor, ill defined outage interfaces and organization,
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poor control room environs, no individual accountability, other managers did
not respect the operations chain of command, and too many personnel errors / missed Technical Specifications surveillances.
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The inspector found that the operations assessment personnel performed a
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detailed, comprehensive review.
The assessment report discussed the above strengths and weaknesses and many other recommendations.
From discussions with licensee management, the inspector found they intend to address the problems identified by the assessment. The inspector found that the licensee l
will supplement the operating crews around March 1994. The operations manager
selected nine engineers to become shift engineers-(shift technical advisors).
The licensee placed six of these engineers in shift technical advisor training
who will become part of an operating crew and the other engineers were placed l
in the licensed training program.
The inspector determined the licensee implemented several personnel moves to provide operations knowledge to other
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organizations and enhance operations with other areas of expertise.
Recently,
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the licensee promoted the operations manger to be Assistant Vice President
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Plant Operations. Additionally, senior reactor operator licensed personnel were assigned positions in the training department and maintenance organization. This item remains open until the licensee completes required training prior to Refuel VII and the inspector verifies improvements in i
operator performance resulting from current licensee corrective measures.
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D 6.6 (Closed) Violation 482/9316-03:
Failure to Ensure Checklist GEN 00-002-1B (Mode 4 to Mode 3 Checklist) Completed This violation was cited because personnel failed to follow plant procedures when completing Checklist GEN 00-002-1B, " Mode 4 to Mode 3 Checklist." The licensee stated in their response that the checklist' title was very similar to
another checklist title, Mode Change Checklist Mode 4 to Mode 3, that
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specified surveillances necessary to be current prior to changing modes.
Consequently, personnel confused the two checklists and identified
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Checklist GEN 00-002-1B as complete although the pumps remained in the pull-to-lock position.
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The inspectors verified that the licensee modified Procedure GEN 00-002, " Cold Shutdown to Hot Standby," to eliminate the confusion. The licensee included.
all action steps such as placing the MDAFW pumps in service in the procedure body.
6.7 (Closed) Violation 482/9319-01:
Failure to Follow Radiation
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Protection Procedures This violation was cited because of two examples of failure to follow procedure.
The first example occurred because workers exhibited poor
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judgement and removed a radiation area posting. The licensee stated corrective actions for the deficiency included counseling the individuals-i e
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that personnel read the required reading.
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The second example occurred because plant procedures did not require the
results of special surveys to be routed to the senior health physics
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technician so that the status board could be updated. The licensee stated
they would change Procedure RPP 02-210, " Radiation Survey Methods," to require health physics technicians to update the status board and transmit
radiological status surveys to the shift technician. The inspectors found
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that the licensee revised Procedure RPP 02-210, " Radiation Survey Methods,"
i Revision 6, to require that health physics technicians route radiation survey sheets to the health physics shift technician and update the radiological conditions on the status board.
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6.8 (Closed) Violation 482/9324-01:
Inadeauate System Operatin_g Procedure
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The violation occurred because operations personnel operated Safety Injection Pump A without component cooling water being supplied to the lube oil cooler.
The violation required no response because of licensee actions taken to
identify the root cause and the corrective actions implemented. The licensee immediately corrected the affected procedure to ensure operators started a component cooling water pump prior to the safety injection pump.
l The inspector verified that the licensee fully implemented corrective actions not completed by September 11, 1993. The inspector verified Standing Order 5,
" Operation of Pumps," Revision 1, specified that personnel assure cooling flow
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initiated, that the licensee added PIR 93-0903 to required reading, and that
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the licensee corrected Procedure STS BG-210, "CVCS Inservice Check Valve
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Test," Revision 11, to reference another procedure that ensured operators supply component cooling water to the centrifugal charging pump oil cooler.
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7 ONSITE REVIEW OF LICENSEE EVENTS REPORTS (92700)
(Closed) LER 482/93-009:
Receipt of Inadvertent Safety Injection Signal Due to Operator Error
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On May 4, 1993, when operators restored from Procedure STS KJ-001B, j
" Integrated D/G and Safeguards Actuation Test-Train B," Revision 11, a steamline low pressure safety injection signal occurred. The inadvertent e
signal occurred because a reactor operator reset the signal instead of blocking the signal as directed by the senior reactor operator. The operators
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had reset several engineered safety features actuation signals. The senior
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reactor operator wanted to verify the block signal functioned; however, he i
erroneously directed the reactor operator to reset the signal.
The licensee r'
determined that had the personnel referred to Procedure SYS SB-120,
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" Enabling / Disabling of SSPS and Lifting /Relanding of P-4 Leads," Revision 1, Step 4.1.1.1 that directed personnel to block the signals, the error would
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have been avoided.
As immediate corrective actions, the licensee reset the
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engineered safety features actuation and restored from the test.
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Corrective actions to prevent recurrence required the individuals to review the circumstances surrounding the event. After identifying the problems, the individuals discussed the event and the' STAR self-check process with
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operations management and the other operating crews as part of the positive discipline program.
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The inspector reviewed Procedure SYS SB-120 and agreed with the licensee's conclusion that the operators would have likely depressed block instead of reset had they referred to the procedure.
From discussions with the senior i
reactor operator who made the presentations regarding STAR, the inspector
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concluded the individual identified aspects that could have prevented the event and should prevent future events if implemented among all the crews.
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for example, the personnel failed to refer to Procedure SYS SB-120 even though
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they had questions about restoring from the tests. Also, the reactor operator busy with charging to the reactor coolant system performed the task directed
without considering the plant conditions. Had personnel taken their time to
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review their activities and possible effects and taken time to review
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applicable procedures (i.e., useo STAR), the licensee concluded the event
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would not have occurred.
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ATTACHMENT 1 t
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1 PERSONS CONTACTED W. W. Adams, Supervisor, Warehouse
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R. J. Brickell, Supervisor, Material Control i
K. B. Clair, Supervisor, Maintenance Planning C. W. Fowler, Manager, Maintenance and Modifications
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M. A. Gayoso, Controller / Treasurer W. M. Lindsay, Manager, Quality Assurance
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R. L. Logsdon, Manager, Chemistry P. M. Martin, Assistant Manager of Operations
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0. L. Maynard, Vice President Plant Operations B. T. McKinney, Manager, Operations R. A. Meister, Senior Engineering Specialist, Regulatory Compliance R. W. Miller, Supervisor, Plant Scheduling
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K. J. Moles, Manager, Regulatory Services W. B. Norton, Manager, Nuclear Engineering C. E. Parry, Director, Performance Enhancement F. T. Rhodes, Vice President Engineering C. E. Rich, Jr., Manager, Electrical Maintenance i
E. W. Schmotzer, Manager, Purchasing and Material Service R. L. Sims, Operations Support Supervisor
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t B. B. Smith, Manager, Modifications
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C. M. Sprout, Manager, System Engineering L. W. Stevens, Supervisor, Nuclear Safety Engineering
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J. D. Weeks, Assistant to Vice President Plant Operations
S. G. Wideman,-Supervisor, Licensing M. G. Williams, Manager, Plant Support
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The above licensee personnel attended the exit meeting.
In addition - ine
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personnel listed above, the inspectors contacted other personnel during this
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inspection period.
2 EXIT MEETING An exit meeting was conducted on December 10, 1993. During this meeting, the inspectors summarized the scope and findings of the report. The licensee
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acknowledged the inspection findings documented in this report. The licensee did not identify as proprietary any information provided to, or reviewed by,
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the inspectors, t
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ATTACHMENT 3 ACRONYMS AFW auxiliary feedwater ESW essential service water I&C instrumentation and controls LER licensee event report MDAFW motor-driven auxiliary feedwater MOV motor-operated valve PIR performance improvement report Refuel IV Refueling Outage IV RER Reportability Evaluation Request STAR stop, think, act, and review TDAFW turbine-driven auxiliary feedwater WCGS Wolf Creek Generating Station WR work request