IR 05000483/1997008
| ML20141H191 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 05/20/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20141H181 | List: |
| References | |
| 50-483-97-08, 50-483-97-8, NUDOCS 9705230212 | |
| Download: ML20141H191 (25) | |
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ENCLOSURE U.S. NUCLEAR REGULATORY COMMISSION f-
REGION IV
Docket No.:
50-483 I
License No.:
NPF-30 l
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Report No.:
50-483/97-08
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l Licensee:
Union Electric Company Facility:
Callaway Plant Location:
Junction Hwy. CC and Hwy. O'
Fulton, Missouri Dates:
March 17 through April 4,1997 Inspectors:
W. Wagner, Reactor inspector, Engineering Branch
- M. Runyan, Reactor Inspector, Engineering Branch Approved By:
Chris A. VanDenburgh, Chief, Engineering Branch Division of Reactor Safety ATTACHMENT:
Supplemental Information l
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9705230212 970520 PDR ADOCK 05000483 G
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SUMMARY l
Callaway Plant NRC Inspection Report 50-483/97-08 This inspection reviewed the licensee's corrective actior,rocesses to determine whether problems affecting plant safety were being identified and resolved by the licensee in a manner that would prevent recurrence. The inspection revealed that Callaway's corrective action processes were functioning satisfactorily.
Operations l
i The inspectols concluded that the licensee was effectively implementing their
procedure for maintaining operator workarounds by keeping workarounds to a minimum, ensuring timely corrective action, and maintaining minimal impact on
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plant operation (Section O2.1).
l The inspectors concluded that the majority of suggestion-occurrence-solution
reports assigned to operations were adequately dispositioned. Two reports had not j
addressed all possible events, but the inspectors concluded that this omission had a minor impact on the corrective actions taken to prevent recurrence. Also, the inspectors noted that the licensee had taken aggressive actions to reduce the number of valve mispositioning events; however, it was evident that previous efforts in this area had been ineffective (Section 02.2).
The inspectors concluded that operations involvement in the corrective action
process was good and appeared to be effective (Section 04.1).
The inspectors concluded that the quality assurance audit and surveillances of
operations were effective in identifying strengths and weaknesses of operation performance (Section 07).
Maintenance The inspectors concluded that work documents were being appropriately utilized
(Section M2.1).
The inspectors concluded that the majority of suggestion-occurrence-solutions
reports assigned to maintenance were adequately dispositioned. On one occasion, the inspectors noted that the licensee had not determined the root cause. This condition was treated as a noncited violation in Section E7.2 of this inspection report. The inspectors also noted one occurrence in which the Suggestion-Occurrence-Solution Report did not determine the totalimpact of the problem or consider the possibility that other equipment enay have been similarly affected (Section M2.2).
The inspectors concluded that the maintenance staff was supportive of the
corrective action program and confident in its effectiveness (Section M4.1).
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The inspectors concluded that the quality assurance audit and the self-assessment
were comprehensive efforts that produced recommendations which should enhance the maintenance program (Section M7.1).
The inspectors concluded that the licensee was effectively trending information
pertinent to the corrective action program. The backlog of unfinished work items was slowing increasing, but the licensee was monitoring this situation closely (Section M7.2).
Enaineerina The inspectors concluded that the licensee had satisfactorily reviewed external
reports of operating experience, with the exception that the licensee's response to one bulletin was weak (Section E2.1).
The inspectors identified two examples of poor root-cause determination for
suggestion-occurrence-solution reports that were treated as examples of a noncited violation in Section E7.2 (Section E2.2).
The inspectors concluded that engineering performed a creditable evaluation of the
request for resolutions in that each addressed the particular problem that had occurred (Section E2.3).
The inspectors concluded that the quality assurance audits of the engineering
design control process, and the corrective action prc, cess, were effective in identifying problems (Section E7.1).
I The inspectors concluded that root causes have not been consistently identified as
required by the corrective action procedure. This was identified as a noncited violation because the licensee's quality assurance audit had also identified this issue. The inspectors also identified several weaknesses in the corrective action procedure; however, the licensee was placing adequate emphasis to ensure improved performance in this area (Section E7.2).
Plant Support The inspectors concluded that the On-Site Review Committee and Nuclear Safety
Review Board were aggressively seeking out areas needing plant improvement (Section V).
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Report Details 1. Operations
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Conduct of Operations
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General Comments (40500)
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The objective of this inspection was to evaluate the effectiveness of the Callaway Plant controls in identifying, resolving, and preventing problems that degrade plant safety. This review was focused on the following areas:
l Safety review committee activities
Root-cause analysis
Corrective action l
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Self assessment Operating experience feedback
The inspection consisted of an extensive review of plant documents, employee interviews, and meetings with licensee personnel to discuss technical or
administrative questions.
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The inspectors conducted reviews of ongoing plant operations as it related to the l
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corrective action process, in general, the plant operations involvement in the
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corrective action process was good.
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Operational Status of Facilities and Equipment
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O2.1 Operator Workarounds a.
-Inspection Scoce (40500)
l The inspectors reviewed the licensee's procedure for ensuring timely corrective j
action of operator workarounds; Workarounds are defined as practices that require
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nuclear plant operators to take nonroutine actions to compensate or adjust for abnormal operating conditions. Workarounds are a concern because they can complicate operator responses to emergencies.
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Observations and Findinas
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l The inspectors found that licensee's procedure for ensuring timely corrective action for workarounds was addressed in Callaway Plant Policy UEND-WORK CONTROL-01, "Workarounds," Revision 001, dated July 15,1995. This policy established the procedure for identifying and maintaining a workaround list to i
ensure a timely corrective action for workarounds.
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The inspectors reviewed the current workaround list and found that nine operator
l workaround items were listed. The inspectors noted that two of the nine items on the workaround list were safety related. The inspectors found that one of the two
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-safety-related items was completed during this inspection. The other safety-related-workaround item (involving a pressurizer block valve) was scheduled for completion -
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during the next refueling outage. This item involved the pressurizer block valve
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leaking vapor through the packing leak off line to the containment atmosphere. To compensate for this vapor leakage, the pressurizer block valve was backseated to j
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The inspectors determined that current workarounds would not impact plant operation, such as, nuclear safety, emergency operating procedures, off-normal procedures, or safe shutdown capability. The inspectors verified that each operator
workaround was tracked and had a scheduled date for completion.
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Conclusions j
The inspectors concluded that the licensee was effectively implementing their l
procedure for maintaining operator workarounds by keeping workarounds to a l
minimum, ensuring timely corrective action, and maintaining minimalimpact on
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plant operation.
02.2 Ooerations Suocort of Suaaestion-Occurrence-Solution Reports
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Insoection Scooe (40500)
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The inspectors reviewed ten suggestion-occurrence-solution reports that were assigned to operations for resolution. These reports are listed in the attachment to this inspection report, i:
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Observations and Findinas i
i The inspectors found the responses to the following two suggestion-occurrence-j l.
. solution reports were weak, in that not all possible events related to the occurrence
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were addressed:
Suaaestion-Occurrence-Solution Reoort 96-0377: This report identified that a
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throttled butterfly valve, which was supplying essential service water to the "B" centrifugal charging pump room cooler was clogged. The clogged butterfly valve
caused the room cooler to emit hot air. Although not required by the licensee's i
i administrative procedure, the inspectors noted that the licensee did not consider the impact of the as-found condition in the event of a design basis accident, such as whether the as-found heat-up rate for the room would have necessitated operator action to mitigate environmental consequences.
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Suacestion-Occurrence-Solution Report 95-2222: This report identified that the suction valves for essential service water to the component cooling water system had been closed for maintenance work and that this configuration resulted in the l
component cooling water system being declared inoperable. Specifically, this configuration prevented the designed backup function use of essential service water l
to provide cooling in the event of loss of inventory in the component cooling water
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system. The inspectors found that the licensee did not review the maintenance l
history to determine if, when, or how often this inoperability had occurred in the past. Additionally, the suggestion-occurrence-solution report did not discuss whether other inventory backup systems were similarly affected by inappropriate maintenance activities. The licensee stated that other backup systems were more explicitly addressed in Technical Specifications and that this type of inoperability was not likely to have occurred.
Valve Miscositionina Events: During the process of selecting suggestion-occurrence-solution reports for review, the inspectors noted a large number of valve mispositioning events. The licensee's trend information indicated that the rate of mispositioning events had remained high over the past several years. The licensee stated that their staff recognized this problem in 1995 and formed a valve mispositioning task team. The inspectors interviewed members of this team and
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reviewed meeting minutes, which indicated that the licensee was aggressively pursuing resolution of this persistent problem area. For example, the licensee formed a supplemental task team of operations personnel that were meeting weekly and were in the process of formulating a comprehensive action plan to address a multitude of mostly human factors issues that were thought to contribute to the valve mispositioning events. One concrete corrective action was to replace certain T-head air valves, that had often been inadvertently bumped out of position, with a locking valve design. In summary, the inspectors found that past corrective actions by the licensee in response to valve mispositioning events had been somewhat ineffective, but that the more global approach presently being taken by the task team appeared sufficient to effectuate good results. In light of the current state of the problem, the inspectors found this effort appropriate in both scope and intensity.
c.
Conclusions The inspectors concluded that the majority of suggestion-occurrence-solution reports assigned to operations were adequately dispositioned. Although two reports had not addressed all possible events, the inspectors concluded that this had minor impact on the corrective actions taken to prevent recurrence. The licensee was taking aggressive actions to reduce the number of valve mispositioning events. The licensee recognized that aggressive corrective action was needed because it was evident that previous efforts in this area had been ineffective.
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Operator Knowledge and Performance
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l 04.1 Interview of Ooerations Personnel
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Insoection Scooe (40500)
l-l The inspectors interviewed operations personnel to determine their knowledge and.
l involvement of the corrective action process.
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Observations and Findinas
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i The inspectors interviewed two operations personnel concerning their perceptions of l
the corrective action program. Their response was mostly positive. They stated l
that there was complete freedom to write suggestion-occurrence-solution reports and felt that their concerns were being properly handled. They indicated that the j
move to a computer-based system for suggestion-occurrence-solution reports was
l originally a hurdle to overcome from a human factors perspective (since they did not I-possess good typing skills), but that with practice, the system had become easier to
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use. Overall, the operators considered the corrective action program to be i
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operating satisfactorily.
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Conclusions The inspectors concluded that both individuals were supportive of the corrective action process and confident in its effectiveness.
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. Quality Assurance in Operations
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Inspection Scoce (40500)
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The inspectors reviewed Audit AP96-003, " Quality Assurance Audit of Operations,"
dated March 22,1996, and reviewed 23 surveillances to determine the level of
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quality assurance involvement in operations.
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b.
Observations and Findinas The inspector's review of Audit AP96-003 found that this audit was performed as a regularly scheduled biennial review of operations. The audit was performed by the licensee's quality assurance group with assistance from the independent safety engineering group and the training department. The inspectors found that the audit results were generally favorable, with strengths in the areas of operator turnovers,
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i pre-evolution briefings, operator knowledge, and handling of transients and off-
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normal events. Negative findings included problems with computer software used by the reactor operator when making reactivity changes and a failure to return clearance tags to the reactor operator after the tags were cleared. The inspectors j
considered the audit to be adequate in scope and sufficiently self-critical.
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The licensee responded to the audit findings through the use of the suggestion-occurrence-solution system for both suggestions (observations) and occurrences (findings) from the report. The inspectors verified that the audit findings were addressed by suggestion-occurrence-solution reports.
The inspectors also looked at quality control surveillances of operations and found that approximately 23 surveillances of operations activities were performed since the beginning of 1995. The surveillances looked generally at ongoing evolutions of a short duration. The inspectors considered the surveillances to be of satisfactory quality.
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Conclusions The inspectors concluded that the quality assurance audit and surveillances of operations were effective in identifying strengths and weaknesses of operation performance.
11. Maintenance M2 Maintenance and Material Condition of Facilities and Equipment M2.1 Review of Work Documents a.
Insoection Scope The inspectors reviewed six work documents to determine whether corrective
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actions were being inappropriately utilized in lieu of suggestion-occurrence-solution
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reports, design modifications, or other approved mechanisms. A list of work documents reviewed by the inspectors is included r. the attachment to this l
inspection report.
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Observations and Findinos The inspectors found all of the work documents reviewed to have been appropriate for the identified problem and adequately dispositioned.
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Conclusions l
The inspectors concluded that work documents were being appropnately utilized.
M2.2 Maintenance Support of Succestion-Occurrence Solution Reoorts l
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Insoection Scoce (40500)
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l The inspectors reviewed 14 suggestion-occurrence-solution reports that were assigned to maintenance for resolution. These reports are listed in the attachment to this inspection report.
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Observations and Findin_m The inspectors found, that on the following two occasions, the suggestion-
l occurrence-solution report did not determine the root cause or consider the total j
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l Suaaestion-Occurrence-Solution Reoort 96-1487: This report identified a cracked -
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endbell in the motor for Motor-Operated Valve BBHV8351D (reactor coolant pump seal water supply isolation hand control valve). The crack allowed moisture
intrusion into the motor; however, no failures of the valve were recorded. The
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inspectors found that the licensee did not determine a root cause of the crack
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though it was thought that a material defect in combination with a unintentional l-mechanical strike may have caused this defect. The licensee did not inspect other motors at that time to see if any others had cracked endbells and did not I
metallurgically test the defective endbell to determine if a manufacturing defect l
existed. This prevented a full scoping of the issue and a determination as to whether a 10 CFR Part 21 issue may have existed. The failure to identify the root cause of this significant condition adverse to quality is the first example of a noncited violation, as discussed in Section E7.2 of this inspection report (50-
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483/9708-01).
Suaaestion-Occurrence-Solution Reoort 96-1620: Identified a manufacturer-installed spacer that had separated from the internals of Feedwater Isolation J
Valve AEFVOO42. The valve remained operable with the spacer missing. However, the suggestion-occurrence-solution report did not address the impact on the feedwater system or downstream systems with the spacer loose in the flow stream.
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Through interviews, the inspectors learned that the licensee had considered the adrift spacer as a potential concern and had concluded that the spacer, or its parts, had been removed during a steam generator cleaning in the Spring of 1995.
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However, the licensee did not notify the vendor of this event and stated that a 10 CFR Part 21 report was not required because nothing was rendered inoperable.
The inspectors determined the suggestion-occurrence-solution report was weak,
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because the report did not document the spacer being adrift, and good engineering i
practice would have dictated notification of the vendor so that the vendor could have alerted affected licensees to the potential for the spacers to become
separated.
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Conclusions The inspectors concluded that the majority of suggestion-occurrence-solution reports assigned to maintenance were adequately dispositioned. However, on one occasion the inspectors noted that the licensee had not determined the root cause.
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The inspectors also concluded that one suggestion-occurrence-solution report did not determine the total impact of the problem or evaluate the possibility that other equipment may have been similarly affected.
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M4 Maintenance Staff Knowledge and Performance M4.1 Interview of Maintenance Personnel a.
Inspection Scoce The inspectors interviewed two maintenance craft personnel to determine their I
perceptions of the corrective action prograrn.
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Observations and Findinas The inspectors found that both of these individuals stated that they did not normally initiate suggestion-occurrence-solution reports, but rather relayed the information to their supervisors to accomplish this task. Also, both agreed that there was no hesitancy on their parts to initiate corrective actions and that once a suggestion -
occurrence-solution.. sport was written, they had confidence that management would apply adequate resources to correct the problem.
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The inspectors concluded that both individuals were supportive of the corrective action program and confident in its effectiveness.
M7 Quality Assurance in Maintenance M7.1 Quality Assurance Audits and Self Assessments a.
inspection Scoce The inspectors reviewed Quality Assurance Department Audit Report AP95-006,
" Quality Assurance Audit of Maintenance /Callaway Support Organization (CSO)
Activities," dated June 16,~1995. The inspectors also reviewed a recent self-assessment of the licensee's implementation of the maintenance rule.
b.
Observation and Findinas The inspectors found that the results of Audit AP95-006 were generally positive in that no significant safety problems or concerns were identified. The inspectors noted that some of the findings included a need to perform more root-cause analysis on maintenance human performance problems, housekeeping shortcomings, and an overabundance of work package discrepancies. Both recommendations and findings i
from the audit were addressed by suggestion-occurrence-solution reports.
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The inspectors found that the self-assessment of the licensee's implementation of the maintenance rule was conducted by the licensee's sponsored team that included members from outside utilities. The licensee's team found that the maintenance
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rule was satisfactorily implemented though some enhancements of the program involving increased plant staff awareness and involvemer.t were suggested. At the time of the inspection, the licensee was in the process of incorporating the assessment recommendations into suggestion-occurrence-solution reports.
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- Conclusions The inspectors concluded that the quality assurance audit and the self-assessment were comprehensive efforts that produced recommendations which should enhance the maintenance program.
M7.2 Trendina a.
Inspection Scone The inspectors reviewed two reports generated by the licensee that identified trends based on a review of various plant reports.
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Observations and Findinas
" Quality Assurance Department Semiannual Trend Analysis Report, January - June 1996," dated October 16,1996, analyzed suggestion-occurrence-solution reports generated from January 1,1992, to June 30,1996. This analysis showed that the number of occurrences reported on suggestion-occurrence-solution reports had been relatively constant over this period, but the number of suggestions offered in these reports had declined substantially. Over the past 18 months, suggestion-occurrence-so!ution report generation rates had increased for security events, but had declined for operability concerns and nonconforming materials. The report showed a graph of open suggestion-occurrence-solution reports over the past 6 years. The backlog of open suggestion-occurrence solution reports had increased steadily over this period from about 450 to 600 reports. The report also trended suggestion-occurrence-solution reports generation rates for various plant groups, with the most dramatic increases seen in the areas of operations and industrial safety. The report analyzed trends associated with plant groups or major functional areas, and included various recommendations associated with perceived weak areas.
l During the first half of 1996, the licensee identified repeat equipment failures j
associated with the rod position indication system, the auxiliary building ventilation l
high temperature switches, and steam generator cation conductivity increases
during resin transfers. The report listed recurring problems occurring in the areas of l'
operations, surveillance, engineering, fire protection, radiation protection, industrial safety, and physical security. The inspectors considered the licensee's review of recurring problems to be a strength in their trending program.
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" Quality Assurance Department Trend Analysis of Non-conforming Material Reports (NMRs), 2nd Half, 1992-1996," dated February 25,1997, anal'/ zed suggestion-
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occurrence-solution reports of nonconforming materials generated from mid-1994 to the end of 1996. The inspectors found that this report did not identify any adverse trends or generic concerns, but did identify certain areas needing additional scrutiny and offered suggestions for improvement in certair; areas.
The inspectors noted that the backlog of open suggestion-occurrence-solution reports had risen steadily from approximately 450 to approximately 600 over the past 18 months. This appeared to be associated with an increased generation rate of saggestion-occurrence-solution reports. The licensee was expected to continue to monitor the backlog and to take necessary actions to ensure that a timely and appropriate response is taken for every suggestion-occurrence-solution report.
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Conclusions The inspectors concluded that the licensee was effectively trending information pertinent to the corrective action program. The backlog of unfinished work items was slowly increasing, but the licensee was monitoring this situation closely and appeared to have it under control.
Ill. Enaineerina E2 Engineering Support of Facilities and Equipment E2.1 Enoineerina Suncort of Operatina Exoerience a.
Insoection Scone (40500)
The inspectors reviewed the following issue involving external information of a generic nature: Westinghouse Technical Bulletin ESBU-TB-96-03-RO, "RHR Pump Seizures at Watts Bar," dated June 20,1996.
The inspectors also reviewed the licensees response to the following items:
NRC Information Notice 96-48, "MOV Performance issues"
A January 11,1996 Westinghouse letter, regarding " Erosion of Globe
Throttling Valves Causing Runout of CCP Pumps" Limitorque Maintenance Update 96-01, "SMB, SB, SBD-2 Spring Spacers"
b.
Observations and Findinas The inspectors found that the Westinghouse bulletin stated that utilities should limit residual heat removal pump temperature transients, as shown in Table 1 of the bulletin, in order to lessen the likelihood of pump seizures. The licensee revised Procedure OTN-EJ-00001, " Residual Heat Removal System," Revision 12, to
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o sequence certain operational steps to lessen the rate of temperature changes.
However, the inspectors noted that the recommended limits of Table 1 were not l
included in the procedure and that no requirements were included for the operators l
to ensure that the temperature limits were not exceeded. This was considered a weakness in the response to the Westinghouse bulletin. The inspectors found the licensee's response to the other items to be adequate.
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Conclusions
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The inspectors concluded that the licensee had satisfactorily reviewed external l
reports of operating experience with the exception that the response to the Westinghouse bulletin was weak.
E2.2 Enaineerina Succort of Suaaestion-Occurrence-Solution Reoorts a.
Inspection Scoce (40500)
The inspectors reviewed 16 suggestion-occurrence-solution reports that were assigned to engineering for resolution. These are included in a list of suggestion-occurrence-solution reports in the attachment to this inspection report. The inspectors reviewed the reports and arranged meetings with licensee engineers to discuss questions that arose during the reviews.
b.
Observations and Findinas The inspectors noted that many suggestion-occurrence-solution reports failed j
to discuss the possibility that other equipment may have the same problem as that identified in the suggestion-occurrence-solution report, such as alternate train features or similar components in other systems. For example, Suggestion-Occurrer e-Solution Report 96-1620 discussed a dislodged spacer in Valve AEFV0042 (Steam Generator D feedwater supply isolation), but did not address the fact that the other three feedwater isolation valves had been inspected at the same time, thereby assuring that the identified discrepancy was isolated to Valve AEFV0042. In addition, the inspectors noted:
Suaaestion-Occurrence-Solution Report 96-0630: This report identified that the differential pressure conditions for Butterfly Valve EFHV0025 (service water to Essential Service Water Train A downstream hand control valve) were incorrectly determined because the valve stroke time was not considered in conjunction with the sequence of operation of the service water and essential service water pumps during an accident. The original differential pressure of 81 psig was revised to 139 psig. The inspectors had two concerns related to how the licensee generically
handled this concern. Although this problem could exist with any type of valve that l
may have a long stroke time, including gate and globe valves, the licensee limited j
its review for similar problems to butterfly valves only (i.e., the differential pressure calculations of gate and globe valves were not reviewed to determine if a similar mistake was made).
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Within the butterfly valve population of 40 valves, the calculations for 10 valves were checked. No additional problems were identified in this sample. Although the licensee did not have a policy dictating the criteria for what constitutes a sufficient sample, the review of 10 from a population of 40 v,as sufficient in this case to l
reasonably bound the concern as an isolated incident. tio,vever, the actual l
population of concern was much greater than 40, because both gate and globe
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valves may have been similarly affected. In response to the inspector's concern, l
the licensee reopened Suggestion-Occurrence-Solution Report 96-0630 to l
reexamine the adequacy of the corrective actions, i
i Suaaestion-Occurrence-Solution Report 95-0080: This report !dentified that during l
testing of Motor-Operated Valve ALHV0009 (motor-driven auxiliary feedwater pump to Steam Generator B hand control valve, auxiliary feedwater thrcttle valve), the torque switch failed to make up during valve closure. An overthrust and overtorque condition existed, but it did not cause a structural concern since the !evels were well within the one-time ratings for Limitorque actuators. The inspectors were concerned with the anomalous behavior of the springpack, which at a torque setting of 3.0 had gone solid and prevented sufficient deflection to trip the torque switch.
l The licensee stated that the torque switch setting had been incrementally increased during testing to achieve a desirable thrust output and that this had been the first test at a setting of 3.0. The licensee stated that the springpack thrust collar had been the component that limited deflection in this event. The actuator had a limiter plate set at 3.0, meaning that 3.0 was the maximum setting possible with the plate installed. The licensee reset the torque switch to 2.75 and retested the motor-operated valve satisfactorily. The only additional action the licensee planned l
to take was to replace the limiter plate with one set at 2.75 to prevent an j
l madvertent resetting back to 3.0.
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l The inspectors were concerned with the licensee's handling of this event. By i
resetting the torque switch to 2.75 and noting satisfactory operation, the licensee l
not only established the operability of the valve, but had decided to operate the l
valve within a potentially very marginal condition. The inspectors determined that
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this marginal condition of operation existed because the licensee had not established where, between the settings of 2.75 and 3.0, the springpack would l
bottom out. The specific concern was that a slight change in operation of the
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springpack could cause the condition to recur. In this case, the motor-operated
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valve would failin the closed position and auxiliary feedwater flow from that train l
would be lost. The inspectors observed that a better response to this event would i
have been to install a heavier springpack allowing for a torque switch setting that afforded a comfortable margin from the limiting setting. However, the inspectors l
did not question the operability of the valve because of the satisfactory demonstration of the valve's operability during subsequent testing and exercising.
Suaaestion-Occurrence-Solution Reoort 95-2013: This report identified a spurious motor-operated valve failure. The inspectors identified a concern unrelated to the specific response to this suggestion-occurrence-solution report. Specifically, the licensee had a normal operating practice of permitting declutching of motor-operated valves to the manual mode of operation without declaring the motor-operated valves
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inoperable, in these instances, the i%nsee used the manual mode of operation to solve a short-term problem with pack.ing or seat leakage. The licensee declutched
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the motor-operated valve actuator, manually placed the valve in its intended l
configuration with the valve handwheel, then stroked the valve electrically to. verify
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its capability to operate, and then repeated the process, leaving the valve in manual, l
The inspectors considered this a poor practice because:
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The mechanism within Limitorque actuators that automatically reclutches a-
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l motor-operated valve into electric operation is not safety-related equipment -
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Many instances have occurred at nuclear plarns where motor-operated valves have failed to automatically reclutch.
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Standard industry practice is to consider a declutched actuator to be inoperable.
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The manual repositioning of a valve to the same position as that originally set during the " proof test" was not an exact practice and can result in large differences in unseating thrusts.
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Stroke times can be incrementally increased by the need for the actua tor to first engage electrically before stem movement occurs.
Suaaestion-Occurrence-Solution Report 96-1260: This report identified a Crosby
relief valve that failed a bench test because of a pitted seat and disc. The licensee
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believed that the valve was received in this condition from the vendor, dether than return the valve to Crosby, the licensee relapped the valve on site and placed it in I-the warehouse. The inspectors were concerned that this action prevented vendor
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notification of the potential defect in the valve. This information is useful because the vendor's manufacturing process could be deficient, resulting in other valves
with pitting that could pass bench testing and be installed in a safety-related I
application. Although the inspectors determined that the licensee was not required to notify the vendor or issue a 10 CFR Part 21 report because the defective part l
was never installed, the licensee failed to identify the root cause of this significant condition adverse to quality. As such, this is the second example of a noncited violation discussed in Section E7.2 of this inspection report (50-483/9708-01).
Suaaestion-Occurrence-Solution Report 96-1663: This report identified internal l
l body damage to Check Valve AEV0120 (Steam Generator B feedwater supply check l
valve) located between the feedwater isolation valves and the steam generator.
Because the defect did not exceed the minimum wall thickness of the valve body,
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the licensee stated in the suggestion-occurrence-solution report that a root-cause
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determination of this problem was not necessary. When questioned, the licensee
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stated that this was not consistent with their general policy to determine a root
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l cause for every occurrence. The inspectors agreed with the licensee and considered the response to this suggestion-occurrence-solutiori report to be deficient because adverse conditions causing a sub-limiting defect may at another occasion cause a limiting defect. The inspectors did not have a significant concern with these check valve's long-term performance because the licensee intended to replace them with a differently designed valve.
The failure to identify the root cause for this significant condition to quality is a third example of a noncited violation discussed in Section E7.2 of this inspection report (50-483/9708-01).
Suaaestion-Occurrence-Solution Reoort 95-2140: Identified that a hand switch, which was required to be in the closed position for remote shutdown, had not been tested on a periodic basis since installation in 1984. The corrective action was to include the hand switch in the preventive maintenance program to test the switch at an 18-month frequency, this test was scheduled for completion by the end of July 1997. The inspectors found that the hand switch was installed at the request of the NRC in 1984. The inspectors performed a search of the Technical Specifications, Final Safety Analysis Report, Safety Evaluation Report, and the license commitment to the NRC request, and found that there were no requirements or commitments to periodically test the switch, c.
Conclusions The inspectors identified two examples of poor root-cause determinations for suggestion-occurrence-solution reports that are treated as noncited violations. As discussed in Section E7.2 of the inspection report, the inspectors concluded that root causes have not been consistently identified as required by the corrective action procedure. The inspectors also identified several weaknesses in the corrective action procedure; however, the licensee was placing adequate emphasis to ensure improved performance in this area (Section E7.2). The licensee had adequately responded to the inspectors concerns for two suggestion-occurrence-solution reports; however, the licensee's disposition of Suggestion-Occorrence-Solution Reports 95-2013 and 95-2140 were less than desirable even though no regulatory requirements prohibited their practice.
E2.3 Enaineerina Sucoort for Reauest for Resolutions a.
Inspection Scope (40500)
The licensee issued a request for resolution as a means to identify potential problems and improvements requiring engineering evaluation. The inspectors reviewed 12 request for resolutions to determine the quality of the engineering l
evaluations and to determine if assigned priorities reflected the importance of the l
item, b.
Observations and Findinas
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The inspectors found that all 12 request for resolutions had appropriate engineering evaluations, c.
Conclusions The inspectors concluded that engineering performed a creditable evaluation of the request for resolutions in that each addressed the particular problem that had occurred.
E7 Quality Assurance in Engineering Activities E7.1 Quality Assurance Audits and Self Assessments a.
inspection Scope (40500)
The inspectors reviewed Quality Assurance Audit Report AP96-002, " Quality Assurance Audit of Design Control," dated February 29,1996. The inspectors also reviewed Quality Assurance Audit Report AP96-010, " Quality Assurance Audit of Corrective Action."
b.
Observations and Findinas The inspectors found that Audit AP96-002 focused on the design change process, quality-related software control, procedure designation, and corrective action to
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NRC Inspection Report 95-11. Generally, design control was found to be effectively implemented. Significant findings from this audit included a missed 10 CFR 50.59 i
i screening for a request for resolution and several request for resolutions that were niiscategorized. None of the request for resolutions in question were determined by the licensee to require a forrnal safety evaluation.
The inspectors noted that the quality assurance audit of the corrective action process was performed from July 8 to September 3,1996, using licensee
employees and employees from four other nuclear utilities. Although the overall conclusion was that the Callaway Plant corrective action programs were effective, several notable concerns were identified. In the area of problem identification, the audit team identified an overabundance of problem reporting mechanisms and a tendency to not bring potential operability issues to operations until a complete analysis had been performed. In the area of problem analysis, the audit team found i
that the engineering review team was not utilizing a structured root-cause process and may in some cases be too close to the issues to objectively surface the underlying root causes, in the area of problem resolution, the audit team discovered
that some safety significant conditions were not being formally evaluated for 10 CFR 50.59 safety evaluations.
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Conclusions
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i The inspectors concluded that the quality assurance audits of the engineering design control process, and the corrective action process, were effective in identifying problems.
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E7.2 Root-Cause Analysis
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Insoection Scope (40500j For the condition reports listed in the attachment to this inspection report, the inspectors reviewed the root-cause analyses performed by the licensee. In addition, the inspectors reviewed the requirements of Procedure APA-ZZ-00500.
b.
Observations and Findinas Section 7.1 of Administrative Procedure APA-ZZ-00500, " Corrective Action Program," Revision 27, states, in part, that "Each action department assigned to an SOS is responsible for providing a professional response that addresses root cause...." However, as discussed in Sections M2.2 and E2.2 of this inspection report, the inspectors identified three suggestion-occurrence-solution reports for which a root cause was not documented as required. These involved Suggestion-Occurrence-Solution Reports 96-1487 (cracked endbell on motor-operated valve),
j 96-1260 (pitted seat on relief valve), and 96-1663 (inte.nal body damage on check valve). As a result of additional review, the inspectors identified the following three i
suggestion-occurrence-solution reports, which did not address the root-cause of the condition
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l Suaaestion-Occurrence-Solution Report 95-0035 (incorrect Fuses in Circuit): During a fuse inspection, the licensee discovered several fuses that were of incorrect size or type installed. An evaluation concluded that the as-found fuses did not cause any operability concerns for the circuits involved and the fuses were replaced with the correct design fuses. Although the licensee stated that the cause was unknown j
as to why incorrect type and incorrect size of fuses were found during the fuse inspections, this was viewed as an inadequate root cause of this condition.
l Suaaestion-Occurrence-Solution Reoort 95-1955 (Makeuo Valve Miscositioned):
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The licensee found that reactor makeup water isolation valve (BGV0178) was in the locked closed position and subsequently restored the valve to the normal open i
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position. Although this event was being studied by the valve mispositioning task j
team, a root cause of this condition had not been identified.
l Suonestion-Occurrence-Solution Report 96-1473 (Defect in Reactor Coolant System Pioe Flanael: During an inservice examination of Pipe Flange PBB01D, the licensee noted two recordable indications. The licensee evaluation concluded that the l
indications were not of concern as they were not in the gasket seating area of the
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mating surface. The licensee evaluation also found that there was no raised metal which could affect the sealing capability of the pump flange. The licensee further concluded that a root cause of these indications was not required.
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in each case, the inspectors determined that the examples did not constitute an
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operability concern. In addition, the inspectors noted that Audit AP96-010 of the corrective action program performed from July 8 through September 3,1996, had identified that root causes were not being identified in all cases as required by the administrative procedure. The inspectors verified that each of the suggestion-occurrence-solution reports addressed above were identified by the licensee's corrective action audit as having deficient root causes. As a result, the licensee initiated Suggestion-Occurrence-Solution Report 96-1200 to address this issue and
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analysis process. Therefore, the inspectors concluded that the failure to address the individual root causes of the significant conditions to quality as required by Administrative Procedure APA-ZZ-00500 was a licensee-identified violation of 10 CFR Part 50, Appendix B, Criterion V, " Procedures." However, this licensee-identified violation is being treated as a noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy (50-483/9708-01).
The inspectors identified the following additional weaknesses in Administrative l
Procedure APA-ZZ-00500:
The procedure does not address when a formal root-cause analysis should be
performed or considered, other than to evaluate human performance occurrences.
The procedure did not identify when a suggestion-occurrence-solution report
was significant, in that 10 CFR Part 50, Appendix B, Criteria XVI, requires a
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root-cause determination for a significant condition adverse to quality.
The procedure did not require suggestion-occurrence-solution report
dispositions to consider alternate train or other components for similar l
problems. The suggestion-occurrence-solution report form did not require
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consideration of generic implications, such as alternate train or other components, for similar problems.
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Conclusions The inspectors concluded that the licensee's root-cause analysis program was not being effectively implemented, in that there were several examples where the root cause of the concern was not being addressed as required by the corrective action procedure. The inspectors also concluded that there were several weaknesses in
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the corrective action administrative procedure.
l E7.3 Safety Review Committee Activities
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Insoection Scoce The inspectors evaluated the offectiveness of the On-Site Review Committee and the Nuclear Safety Review Board by reviewing committee minutes and audits conducted from February 22,1996 to March 7,1997.
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Observations and Findinas The inspectors found that the On-Site Review Committee was aggressively seeking out areas needing plant improvement. For example, the On-Site Review Committee's review of Suggestion-Occurrence-Solution Reoort 96-1239 (blowdown valve inadvertently opened), and Suggestion-Occurrence-Solution Report 96-0051 (B-main feedwater relief valve not controlling steam generator level) determined that additional review was required to determine generic implications to prevent recurrence of similar plant problems. Suggestion-Occurrence-Solution Rer, ort 96-0045 (value used for measuring borated water to safety injection accumdators) was reopened, at the request of the On-Site Review Committee to 4: ermine what other components would have the same potential impact. The m,pectors reviewed the actions taken in response to the On-Site Review Committee requests and found that they were addressed in a satisfactory manner, in reviewing the On-Site Review Committee meeting minutes, the inspectors noted a good questioning attitude and interface between the On-Site Review Committee
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management members for areas of expertise such as operations, maintenance, and nuclear engineering.
The insoectors found that Nuclear Safety Review Board also demonstrated a good questionir g attitude regarding their review of plant problems, c.
_Q.pnclusio,n The inspe: tors concluded that the On-Site Review Committee and Nuclear Safety Review Board were aggressively seeking out areas needing plant improvement.
VI. Manaaement Meetinas X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the in:pec'.. r on April 4< 1997. The licensee acknowledged the findings presented. The inapectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.
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l ATTACHMENT I
SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED l
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Licensee R. Affolter, Plant Manager J. Beck, Licensing Engineer l
G. Belchik, Supervisor, Planning D. Bettenhausen, Supervisor, Quality Assurance Engineering H. Bono, Supervising Engineer, Site Licensing l
M. Evans, Superintendent, Health Physics F. Forck, Quality Assurance Scientist J. Gloe, Superintendent, Maintenance
P. Habbs, inservice Testing Engineer G. Hughes, Supervising Engineer, independent Safety Engineering Group J. Lancaster, independent Safety Engineering Group Engineer
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J. Laux, Manager, Quality Assurance
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C. Naslund, Manager, Nuclear Engineering N. Neher, Quality Assurance Engineer
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A. Passwater, Manager, Licensing and Fuels / Nuclear Safety Review Board Chairman l
G. Randolph, Vice President, Nuclear Operations l
M. Reidmeyer, Licensing Engineer l
C. Slizewski, Supervisor, Engineering Technical Support J. Wehen, Acting Supervisor, Quality Assurance NRC i
D. Passehl, Senior Resident inspector ITEMS OPENED, CLOSED, AND DISCUSSED i
Opened 50-483/9708-01 NCV Licensee identified Failure to Address Root Cause of Concerns
in all Cases as Required by Procedure (E7.2).
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i 50-483/9708-01 NCV Licensee Identified Failure to Address Root Cause of Concerns in all Cases as Required by Procedure (E7.2).
LIST OF DOCUMENTS REVIEWED Plant Procedures Procedure Revision Title Number APA-ZZ-00500
" Corrective Action Program"
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APA-ZZ-00501
" Root Cause Analysis" l
APA ZZ-00090
"The Nuclear Safety Review Board" I
l APA-ZZ-00091
"The On-Site Review Committee"
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APA-ZZ-00107
" Review of Current industry Operating Experience" Suggestion-Occurrence-Solution (SOS)
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SOS No.
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Engineering i
95-0080 Overthrust of MOV during testing j
96-1663 Check valve interior damage 95-0860 Diesel generator operability concern
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96-1209 MOV failure to stroke open 95-0035-Incorrect fuses in circuit 95-1952 Ability of charging pumps to charge during high pressure RCS transient l
96-0117 Turbine-driven auxiliary feedwater pump trip on overspeed
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96-0004 AOV stroke time abnormally short 97-0120 Generic Letter 96-06 concerns 96-1183 Containment air space
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95-0839 Water hammer events j
l 95-2013 MOV burnup attempting to open l
96-0394 Orifice plates not installed l
96-0618 MOV trips attempting to open
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96-0630 Error in closing differential pressure for MOV 96-0937 Error in assigning IST maximum flow rate
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Maintenance 96-1620 Valve spacer missing 96-1487 Motor broken endbell 96-1473 Defect in RCS pipe flange 96-1260 Relief valve leaks by 96-1044 Motor-operator declutch shaft bent 96-0531 Circuit breaker failed instantaneous current trip test i
96-0346 M&TE out of tolerance 96-0080 MOV overthrust and overtorque 96-0394 Chiller lines clogged 96-0412 Overheating of circuit breaker 96-0377 ESW outlet valve to cooler clogged 96-1932 High breakaway torque for check valve 96-0813 Class 1E A/C Unit trip due to ground fault 96-0403 Condenser lines clogged Operations 95-0030 Operators manipulate wrong fuses 95-0216 Instrumentation valves mispositioned 95 1955 Makeup valve mispositioned 96-0153 Radwaste Valves mispositioned 96-0192 Flow indication root valve mispositioned i
95-0291 Repetitive mispositioning occurrences 96-0442 Valve inadvertently stroked during surveillance 96-1202 Root causes without corrective actions 96-1907 Debris in containment 96-0377 ESW outlet valve to cooler clogged by debris Miscellaneous
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95-0711 Damaged limitorque motor 95-0915 Snubber locked up 95-1380 Missing check valve cover pin 95-1390 Upgrading circuit breaker 95-1828 Globe valve nonconformances 95-1936 Reduction in B train RHR flow rates 95-2018 Limitorque motor overheating proNems 95-2140 Testing of remote shutdown ec,aipment 96-0045 Si accumulator boron concentration 96-0051
"B" steam generator level deviation alarm 96-0317 Rad-monitor (GEG925) spiked high 96-0466 Rad-monitor (GERE0092) spiked into " alert" range
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96-1051 Rad-monitor (GERE0092) spiked high 96-0678 Resin spill frc~, ah Integrity Container (HIC)
96-1075 Valve closure ume outside normal stroke time range 96-1133 EHF Filtration not in service
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96-1239 Blowdown valve inadvertently opened 96 1328' Insufficient heat exchanger test instructions Request For Resolution (RFR)
RFR No.
Title
.I 8627 Overthrusted MOVs.
17046 Changeout of motor 17163 Substitute actuator springpack 17204 Opening diesel generator fire doors 17454'
Effect of inoperable snubber on piping system
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14572 Reevaluate MOV differential pressure L
16944 Review Design Basis for Pressure Limits 17005
' Operability Evaluation for Nitrogen Accumulator.
17231'
Frazil Ice Concerns
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l 17534 Operability of "A" Train Containment Spray l
17616 Evaluate Operability of EDG NE02 l
17689 Low CCW Flows to RCPs and Seal Water Heat Exchanger l
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Work Documents
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W176089
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W177709-W184025
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W179768 j
W171509 W583999 Miscellaneous Documents Operatina Experience Review
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1/11/96 Westinghouse, erosion of globe throttling valves cause runout of CCP pumps, Need to see licensee response 6/20/96 Westinghouse Technical Bulletin RHR pump seizures (Watts Barr)
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Limitorque Maintenance Update 96-01 SMB, SB, SBD-2 spring spacer location
NRC Information Notice 96-4P, "MOV Performance issues" i
Nuclear Engineering Quality Assurance Assessments
OPS-Assessment-02, Revision 000, " Event Free Operation" j
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l UNED Work Control-01, Revision 001, "Workarounds"
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