IR 05000528/1988032
| ML17304A809 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 11/30/1988 |
| From: | Coe D, Crews J, Fiorelli G, Polich T, Richards S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17304A806 | List: |
| References | |
| 50-528-88-32, 50-529-88-31, 50-530-88-30, NUDOCS 8812210023 | |
| Download: ML17304A809 (41) | |
Text
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
Re ort Nos:
Docket Nos:
License Nos:
Licensee:
50-528/88-32, 50-529/88-31 and 50-530/88-30.
50-528, 50-529, 50-530 NPF-41, NPF-51, NPF-74 Arizona Nuclear Power Project P.
0.
Box 52034 Phoenix, AZ. 85072-2034 Facilit Name:
Palo Verde Nuclear Generating Station Units 1, 2 8 3.
Ins ection Conducted:
September 18 through November 5, 1988 Inspector:
Inspector:
Inspector:
T. Polich, Senior Resident Inspector
%6~
~.o.
D.
Coe, Resident Inspector c
G. Fiorelli, Resident Inspector Inspector:
J.
Crews, Senior Reactor Engineer Approved By:
S.
Richards, Chief, Engineering Section 1< -
-SS Date Signed yL-3o -8$
Date Signed
<l-3o-86 Date Signed u-30-96 Date Signed
]i-ac) -SS Date Signed Summary:
Ins ection on Se tember 18 throu h November
1988 Re ort Numbers 50-528/88-32 50-529/88-31 and 50-530/88-30 Areas Ins ected:
Routine, onsite, regular and backshift inspection by the three resident inspectors.
Areas inspected included: previously identified items; review of plant activities; engineered safety feature system walkdowns; surveillance testing; plant maintenance; valve misalignment - Unit 1; fire in radwaste building - Unit 1; restoration of clearance
- Unit 1; signoffs not made as maintenance was performed-Unit 2; low pressure safety injection pump and associated motor operated valve outage Unit 3; review of licensee's event evaluation program; review of independent safety engineering group activities - Units 1,
and 3; review of startup testing results - Unit 1; followup licensee event reports - Units 1, 2 and 3; and review of periodic and special reports - Units 1, 2 and 3.
PDR AGOCK 05000
-2-During this inspection the following Inspection Procedures were utilized:
30703, 37700',
40500, 40700, 61702, 61705, 61706, 61707, 61708, 61709, 61710, 61726, 62700, 62703, 71707, 71709, 71710, 71881, 72700, 90712, 90713, 90714, 92701, 92702, 92703, 93702.
Results:
Of the 16 areas inspected, one violation was identified.
General Conclusions and S ecific Findin s
The first six of the following findings all point to either lack of knowledge of existing procedural guidance, laxity in using established procedures, or an apparent willingness to interpret procedural steps for convenience.
1.
Corrective actions associated with LER 87-25, Inoperable Auxiliary Feedwater Pumps, and related enforcement proceedings included issuing revised instructions for post-maintenance retests.
This procedure was issued on August 22, 1988.
It is reported for the second consecutive inspection report that the administrative certification of quality for a retest was not completed correctly.
2.
Operators at Unit 3 were observed interpreting a step in a surveillance test procedure for an auxiliary feedwater pump to mean that an "initial" tachometer reading may be taken thirty or more minutes after the pump is started.
Failure to achieve a minimum speed "initially upon starting" would render the pump inoperable, according to the surveillance procedure.
The inspector considered this to be an unauthorized change to a specified pass/fail surveillance test criteria.
3.
A chemist at Unit 1 returned a steam generator sample line to service following valve maintenance and left a drain valve open after removing the clearance tag.
Subsequent flow through the sample line resulted in steam and water issuing from the drain valve.
Operating Department Guideline 817,
"System Status Control", which requires a valve lineup checklist, was not used.
4.
A small fire occurr ed in the Unit 1 Radwaste Building. It was caused by welder's sparks which ignited a paper sack located within 35 feet of the welder.
The hot work permit, which certified this area free of combustibles, was initiated six days earlier and had not been revalidated or re-issued since that time.
It appeared that the applicable procedure intended that the hot work permit be reissued daily, however a violation was not issued because the procedure did not make clear just what was require "3-5.
The inspector observed that, during maintenance on an emergency diesel generator at Unit 2, the work order for this job had not been signed off in a stepwise manner as required by the licensee's Conduct of Maintenance-procedure.
This is the second consecutive inspection report to note non-adherence to this requirement of this procedure.
This is an apparent violation of the conduct of a maintenance procedure (NRC violati on 529/88-31-01).
6.
The inspector noted a disagreement between guality Control (gC)
and maintenance/operations management over the requirements associated with a gC "Mitness Point".
Some of the maintenance and operations supervision in one unit held the view that a gC
"Mitness Point" need not require gC involvement if maintenance could not locate a
gC inspector.
Site management upheld the gC interpretation of requirements in the licensee's equality Assurance (gA) instructions that gC must be notified in each case and will independently decide if their presence is required.
7.
The licensee's Event Evaluation Program was reviewed.
It appeared that, when issued in the future as a procedural set and followed strictly, this will be a comprehensive program.
The inspector was favorably impressed with existing component failure data trending.
8.
The activities of the Independent Safety Engineering Group (ISEG) were found to be generally supportive of improvements to plant safety.
However, ISEG devotes a relatively small amount of the group's time to in-plant surveillance.
The inspector suggested that the licensee consider increasing their effort in this area which may offer more pro-active safety improvement results, and is more in keeping with ISEG's Technical Specification charter.
Si nificant Safet Matters:
None Summar of Violations:
Item 5 above.
Summar of Deviations:
None 0 en Items Summar
.
One item closed, two items left open, and one new item opene DETAILS Persons Contacted:
The below 1 isted those contacted:
technical and supervisory personnel were among Arizona Nuclear Power Pro 'ect ANPP
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A')hO Adney, Allen, Bel ford, Beyer, Brandjes, Buckingham, Butler, Churchman, Clark, Clyde, Dennis Doyle, Driscoll, Fernow, Gouge, Haynes, Ide, Johnson, Kame r, Kirby, LoCicero, Logan, McCabe, Minnicks, Moyers, Oberdorf, Ogurek, Pankonin, Papworth, guinn, Riley, Jr.,
Scott, Shriver, Sills, Simko, Sowers, Stover, Tr imb1 e, Waldrep, Younger, Zeringue, Manager, Plant Standards and Control Plant Manager, Unit 1 Supervisor, Fire Protection Supervisor, Work Control, Unit 3 Manager, Central Maintenance Operations Manager, Unit 2 Director, Standards and Technical Support Manager, Work Control, Unit 3 Compliance Engineer, Supervisor, Shift Technical Advisors Manager, Work Control, Unit 1 Consultant, Site Services Asst.
Vice President, Nuclear Production Manager, Training Operations Manager, Unit 3 Vice President, Nuclear Production Plant Manager, Unit 2 Senior Engineer, Nuclear Safety Executive Vice President, ANPP Administration Director, Site Services Manager, Independent Safety Engineering Supervisor, Central Radiation Protection Maintenance Manager, Unit 1 Maintenance Manager, Unit 3 Supervisor, Plant Standards and Control Manager, Radiation Protection, Unit 1 Manager, Radiation Protection, Unit 2 Supervisor, Construction Director, equality Assurance Director, Nuclear Safety 8 Licensing Lead Mechanical Engineer Manager, Work Control, Unit 2 Manager, Compliance Supervisor, Radiation Protection Standards Supervisor, Mechanical
& Civil Engineering Manager, Engineering Evaluations Acting Manager, Nuclear Safety Senior Engineer Lead, Shift Technical Advisor/HPES Operations Manager, Unit 1 Plant Manager, Unit 3
The inspectors also talked with other licensee and contractor personnel during the course of the inspection.
"Attended the Exit meeting held with Region V staff members J.
L.
Crews and A.
D. Johnson on October 21, 1988.
""Attended the Exit Meeting on November 4, 1988.
2.
Previousl Identified Items - Units 1
and 3.
92702 a 0 0 en Enforcement Item 528/88-07-02
"Review of Modification Inade uate".
Previous inspection report 528/88-29 stated that closure of this item required a licensee guality Systems and Engineering (gS&E) review of EERs to determine if other design basis changes were allowed to occur via the EER process.
This review determined that no design basis changes occurred among the 126 EERs sampled.
Furthermore, of the EERs sampled, gS&E subsequently determined that two of these EERs changed design without issuance of a proper design change document.
The licensee concluded that these occurrences were of an isolated nature and that the current revision 7 of the EER procedure, 73AC-OZZ29, gives the System Engineer explicit responsibility for initiating the proper design change documents.
During the inspector's review of this item, it was observed that the governing procedure, 73AC-OZZ29, "Engineering Evaluation Request",
omitted one category of non-conformance, which rendered the procedure difficult to use in deciding if the non-conformance resulted in a "modification" to a plant system and required adherence to the review requirements of Technical Specification 6.5.2.3.
In fact, this difficulty appeared to be the cause of an initial disagreement between the gS&E auditors and Engineering Evaluation Department (EED)
personnel over the definition of a "design change."
Subsequent to the inspector's inquiries into this matter, licensee management initiated a procedural change to account for this missing category.
Closure of this enforcement item is delayed pending completion of the licensee's commitment for their nuclear engineering department to review the gS&E review of EERs.
b.
0 en Enforcement Item 528/88-07-03
"Inade uate Retest".
The following licensee commitments were reviewed by the inspector (the numbers are related to the order in which commitments appeared in paragraph 4.b and 4.c of Appendix A to the licensee's reply to the Notice of Violation):
1)
Procedure 73PR-9ZZ04,
"Valve Motor Operator Monitoring and Test Program,"
was revised to require the use of the Controlled Motor Operator Data Base Limit and Torque
Switch Settings for any adjustments of these switches on any included valve.
The Data Base is specified on Controlled Drawing 13-J-ZZI-004 and includes safety related valves which are required to open under differential pressure per IE Bulletin 85-03 requirements.
This includes the auxiliary feedwater pump steam supply valves.
This action is complete.
As part of an August 1988 revision to the work control procedures, a Retest procedure,
"30AC-9WP04," was written to consolidate and strengthen previous retest guidance.
One of the changes intended to better assure quality retests was the requirement for the retest designator to complete a "Retest Evaluation Form" which certifies that the retest meets five quality criteria.
While performing a routine post-maintenance review of three Unit 3 work control packages, the inspector identified one work package in which the retest specified for a low pressure safety injection valve was changed during the pre-job technical review of the work package, but the Retest Evaluation Form still reflected the old retest.
The inspector determined that the change in retest was appropriate, but that a new Retest Evaluation Form was not filled out as required by the licensee's procedure.
The licensee is planning additional training on the new work control procedures, including the retest procedure.
This enforcement item will remain open unti 1 inspection findings indicate full implementation of the licensee's retest requirements.
The newly revised Work Control procedure,
"30AC-9ZZOl,"
enlists the specific accountabilities of the work planner and of the Shift Supervisor/Releasing Organization for the adequacy of the retest or any subsequent changes.
This includes ensuring the retest is sufficient to meet Technical Specification operability requirements.
This action is complete.'dministrative procedures which control plant design changes, 73AC"9ZZ28, "Site Modifications," and 73AC-OZZ15,
"Plant Change Package,"
have been changed to clearly specify the System Engineer's responsibility for determining retest requirements and have added the Engineering Evaluations Department Supervisor as a retest concurrence signature within the change/modification package.
This action is complete.
Procedure 73AC-OZZ29, "Engineering Evaluation Request (EER)," has been revised and now includes explicit responsibilities assigned to the EER Evaluations Supervisor and Lead Manager.
Specifically, this includes the Evaluator Supervisor's responsibility for ensuring cross discipline review when appropriate, and for the
administrative and technical content of the EER.
Also, the Evaluator Manager's responsibility now explicitly includes approval of all "repair" or "accept-as-is" dispositions, since these could possibly change plant design.
This action is complete.
6)
In addition to the revision of the above work control and design change procedures to explicitly include the scope of each review, 73AC-9ZZ04, "Surveillance Testing Procedure,"
was found to detai 1 sufficient scope for each review.
This action is complete.
7)
The licensee commitment to review their procedures in accordance with ANSI N18.7 - 1976 is an ongoing action that is followed by the routine inspection program.
Based on the incomplete action specified in 2) above, this item remains open.
Closed Enforcement Item 528/88-07-04
- " A Hold oint Lacks ualitative uantitative Acce tance Criteria.
The following licensee commitments were reviewed by the inspector (the.numbers are related to the order in which commitments appeared in paragraph 4.d of Appendix A of the licensee's reply to the Notice of Violation).
1)
The licensee's gA instructions for Work Order review, GI417.12.03 and gA02.02, have been changed to add a cautionary note to require gC holdpoints to have clearly specified qualitative and/or quantitative acceptance criteria.
The inspector reviewed Work Order packages for planned and corrective maintenance on selected motor operated valves and found gC holdpoints to be adequate in this regard.
This action is complete.
2)
The need for clearly specified acceptance criteria on gC holdpoints has been emphasized to the guality Engineers and to the guality Control personnel now charged with the review of work control packages.
This action is complete.
3)
The licensee's gA instruction for day to day responsibilities of gC personnel has been changed to add guidance that gC inspectors shall accept only that work included in the work document, and that inspection results can only be based on directly observed and verified work.
This action is complete.
4)
It has been emphasized to gC inspectors that non"specific or otherwise unsatisfactory holdpoint acceptance criteria must be pursued to final resolution.
The inspector discussed this policy with selected gC inspectors and found their understanding to be adequate.
This action is complet )
The Quality Systems and Engineering (QS8E) department supervisors and engineers have been directed to complete several technical staff training courses designed to improve their overall understanding of fundamental theory, plant modification procedures, codes and standards, and regulatory requirements.
This training appears to strengthen the integrated plant knowledge level of QSKE personnel.
This action is complete based on the licensee's plan for completing this training and on its implementation, which is in progress.
The inspector indicated to licensee management that the procedural changes noted in paragraphs 2a, 2b, and 2c above appear to be responsive to the issues raised by the enforcement action.
However, other extensive. changes to the Work Control and EER procedures occurred at the same time and did not have a direct bearing on these enforcement issues.
Therefore, the inspector cautioned licensee managers to ensure their organizations remain sensitive to the particular issues associated with this enforcement action, that being primarily the need to ensure adequate reviews, checks, and testing of work activities.
Item 2c is closed.
3.
Review of Plant Activities.
71707 a.
Unit 1 Unit 1 operated at essentially 100K until October 8, when power was reduced to 85K to conduct control element assembly calculator (CEAC) surveillance tests.
Power was further reduced to 65K because of misalignments of Control Element Assemblies (CEAs) 64 and 65, which occurred during the monthly CEA functional tests.
Power was increased to lOOX on October
following repairs.
Power was again reduced to 50K on October 18 to replace a plugged inlet strainer on the "A" main feedwater pump and to repair leaking tubes in the 28 and 2C low pressure feedwater heaters.
Power was returned to 100K on October 28 and maintained until the end of the inspection period.
b.
Unit 2 Unit 2 operated at essentially 1001 during this entire inspection period.
c ~
Unit 3 Unit 3 operated at essentially 100K during this period, with the exception that on September 22 power was reduced to approximately 20K for the purpose of locating and repairing a
main condenser tube leak.
Power was returned to 100K on September 25 and maintained until the end of the inspection perio l E
d.
Plant Tours The the following plant areas at Units 1, 2 and 3 were toured by inspector during the course of the inspection:
Auxiliary Building Containment Building Control Complex Building Diesel Generator Building Radwaste Building Technical Support Center Turbine Building Yard Area and Perimeter The following areas were observed during the tours:
0 eratin Lo s and Records Records were reviewed against Technical Specification and administrative control procedure requirements.
2.
Monitorin Instrumentation Process instruments were observed for correlation between channels and for conformance with Technical Specification requirements.
3.
observed for conformance with 10 CFR 50.54.(k),
Technical Specifications, and administrative procedures.
4.
E ui ment Lineu s Various valves and electrical breakers were verified to be in the position or condition required by Technical Specifications and administrative procedures for the applicable plant mode.
This verification included routine control board indication reviews and the conduct of partial system lineups.
5.
E ui ment Ta in Selected equipment, for which tagging requests had been initiated, was observed to verify that tags were in place and the equipment was in the condition specified.
6.
General Plant E ui ment Conditions Plant equipment was observed for indications of system leakage, improper lubrication, or other conditions that would prevent the systems from fulfillingtheir functional requirements.
7.
Fire Protection Fire fighting equipment and controls were observed for conformance with Technical Specifications and administrative procedures.
8.
for conformance with Technical Specifications and administrative control procedure.
~Secorit Activities observed for conformance with regulatory requirements, implementation of the site security plan, and administrative procedures included vehicle and personnel access, and protected and vital area integrity.
10.
Plant Housekee in Plant conditions and material/equipment storage were observed to determine the general state of cleanliness and housekeeping.
Housekeeping in the radiologically controlled areas was evaluated with respect to controlling the spread of surface and airborne contamination.
ll.
Radiation Protection Controls Areas observed included control point operation, records of licensee's surveys within the radiological controlled areas, posting of radiation and high radiation areas, compliance with Radiation Exposure Permits, personnel monitoring devices being properly worn, and personnel frisking practices.
During several general tours of the Unit 1 auxiliary building, the inspector noted that higher than normal airborne activity existed.
This activity was determined to be partly due to equipment leaks allowing radioactive gases to escape into the building.
This condition appears to have existed for a prolonged period of the time.
In the exit meeting, licensee management was informed that actions should be considered on a priority basis, to identify and repair equipment leaks.
While activity levels were well below regulatory limits, concentrations of airborne gases which required one-half hour time periods for decay, before personnel could be released because of contaminated clothing, were not considered a
normal plant condition.
No violations of NRC requirements or deviations were identified.
4.
En ineered Safet Feature S stem Walkdowns " Units 1
and 3.
71710 Selected engineered safety feature systems (and systems important to safety) were walked down by the inspector to confirm that the systems were aligned in accordance with plant procedures.
During the walkdown of the systems, items such as hangers, supports, electr ical cabinets and cables, were inspected to determine that they were operable, and in a condition to perform their required function Unit 1 Accessible portions of the following systems were walked down during this inspection period.
~Set em o Auxiliary Feedwater o "B" and "0" Class lE Batteries Unit 2 Accessible portions of the following systems were walked down during this inspection period.
~Set em o Auxi 1 iary Feedwater o High Pressure Safety Injection o
Low Pressure Safety Injection o Containment Spray Unit 3 Accessible portions of the following systems were walked down during this inspection per iod.
~Sstem o Auxiliary Feedwater o High Pressure Safety Injection o
Low Pressure Safety Injection o Containment Spray No violations of NRC requirements or deviations were identified.
5.'urveillance Testin
- Units 1 2 and 3.
61726 a 0 Surveillance tests required to be performed by the Technical Specifications (TS) were reviewed on a sampling basis to verify that: l) the surveillance tests were correctly included on the facility schedule; 2)
a technically adequate procedure existed for performance of the surveillance tests; 3) the surveillance tests had been performed at the frequency specified in the TS; and 4) test results satisfied acceptance criteria or were properly dispositioned.
b.
Portions of the following surveillances were observed by the inspector during this inspection period:
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l
Unit 1 o 32ST-9PK01 Seven Day Surveillance Test of Station Batteries o 41ST-1ZZ33 Mode 1 Surveillance Logs Unit 2 o 42ST-2SI06 Iodine Removal System - S.C.A.P.
Discharge Flow and Pressure Test o 42ST-2ZZ23 CEA Position Data Log Unit 3 o 43ST-3AF02 Auxiliary Feedwater Pump AFW-P01 Operability During the inspector's observation of the conduct of 43ST-3AF02 at Unit 3, it was noted that one of the surveillance acceptance criteria specified was a minimum speed that must be achieved initially upon starting the turbine driven auxiliary feedwater pump.
This initial starting data, to be taken locally with a portable tachometer, was not taken initially after the pump was started.
Control room operators intended to run the pump and allow completion of a shaft packing gland adjustment prior to taking a speed reading.
Since an unsatisfactory initial speed would have rendered the pump inoperable according to the test procedure, the inspector questioned the appropriateness of delaying this reading beyond the initial start of the pump.
Licensee management responded by re-conducting the test in accordance with the specified requirement.
The inspector observed that control room personnel were, in effect, modifying a surveillance procedure without th'e appropriate documented management approval.
Enforcement was not considered warranted because the technical specifications do not address monitoring of the initial speed, and the licensee's actions to address the issue were prompt.
No violations of NRC requirements or deviations were identified.
6.
Plant Maintenance - Units 1 2 and 3.
62703 During the inspection period, the inspector observed and reviewed documentation associated with maintenance and problem investigation activities to verify compliance with regulatory requirements, compliance with administrative and maintenance procedures, required gA/gC involvement, proper use of safety
tags, proper equipment alignment and use of jumpers, personnel qualifications, and proper retesting.
The inspector verified that reportability for these activities was correct.
b.
The inspector witnessed portions of the following maintenance activities:
Unit 1 Descri tion o Auxiliary Feedwater Pump AFN-P01 Rotating Element Replacement.
Unit 2 Descri tion o Auxiliary Feedwater Pump AFN-P01 Rotating Element Replacement.
o Diesel Generator
"A" Jacket Cooling Water Pump Seal Replacement.
o Troubleshoot and Repair of SG-UV-138A Auxiliary Feedwater Pump Steam Supply Bypass Valve.
Unit 3 Descri tion o
Low Pressure Safety Injection Pump "A" Mechanica'1 Seal Replacement o Containment Spray Pump "B" Mechanical Seal Replacement.
o Planned Maintenance on several Motor Operator Valves related to the above pump outages.
No violations of NRC requirements or deviations were identified.
7.
Valve Misali nment - Unit l.
71707 On September 20, 1988, Unit 1 was at approximately 100K power when work was completed on the shell coil assembly of the steam generator
¹2 cold leg blowdown sample isolation valve, SCN TV 263.
Tag removal was authorized as part of the restoration procedure.
The assistant shift supervisor contacted Chemistry to restore the system and to remove the tags under their jurisdiction.
The clearance was obtained by the chemistry shift lead technician,
.who assigned a
chemist to remove the tags.
The chemist proceeded to remove tags from valves in the non-contaminated area, and then entered the.west electrical penetration room of the auxiliary building to remove the tag from the sample line drain valve, SCN VM 54, a valve which had been used to drain the system for repair work.
The chemist did not make a hands-on check of the valve position.
The chemist then proceeded to the control room to request Operations to remove the tag from the containment isolation valve SG UV 223.
The tag was removed and the clearance was cancelle The chemist who had removed the tags requested operations to open the 82 steam generator cold leg blowdown sample path.
Valves SG UV 222 and SG UV 223 were opened.
Shortly following restoration of blowdown sampling, radiation protection reported they had noticed noise and steam coming from the west electrical penetration room.
The area auxiliary operator (AO) was dispatched to the area and blowdown sampling was secured from the control room following his reporting of the problem.
The AO closed the valve and blowdown sample flow was re-established without further incident.
The valve involved was not one of the two containment isolation valves controlled by Technical Specifications.
A discussion of the matter was held with the technician by the inspector.
The inspector was informed by the technician that he could not account for what caused him to leave the valve open, the cap off, and yet remove the tags, except that the technician thought he saw the cap installed.
From discussions with personnel and record reviews, the inspector concluded that the chemist had entered the electrical penetration room area on the date of the incident.
From an investigation into the matter by the licensee, it was determined that due to inadequate system restoration/lineup following maintenance, a drain valve on the steam generator
blowdown sampling line was left open.
This valve became the source of a steam leak when the line was returned to service.
An immediate corrective action by the licensee was to re-instruct the chemistry staff that when an approved procedure is not involved in the restoration of a system, a valve lineup checklist authorized by the supervisor is to be used in accordance with Operating Department Guideline 817 "System Status Control," as would have been required in this case.
A new procedure is currently being developed for the chemistry staff of all three units to be used to control system configuration.
Shen completed, the licensee's evaluation of the incident will be documented in a special engineering evaluation report.
The need for timely documentation of events involving root cause determinations was discussed with the licensee.
No violations of NRC requirements or deviations were identified.
8.
Fire in Radwaste Buildin
- Unit 1.
93702 On October 25, l988, a small fire occurred in the Unit 1 Radwaste Building.
An apparently empty paper bag was ignited by arc welder sparks from work in progress approximately 16 feet overhead.
The bag was located within a locked high radiation area in the vicinity of storage casks for used filters and resin.
The fire was initially reported by the welder's helper, who was acting as a fire watch, to the Radiation Protection (RP) Technician providing coverage for the two workers.
The RP Technician then made a fire notification to his Supervisor.
Mhen the RP Technician had completed dressing out the welder'
helper and had equipped him with a fire extinguisher for entry into
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the area where the fire occurred, it had burned out.
Subsequent air samples and a survey of the burned residue confirmed that the bag was non-contaminated and posed no radiological hazard.
Since the fire was extinguished within 10 minutes, no emergency notification was made.
The hot work permit for this job certified that the floor was swept clean of combustibles within 35 feet above and below the work area, and was valid from October 19, 1988 to October 31, 1988.
The licensee's Hot Work Authorization Permit procedure, 14AC-OZZ03, states that hot work permits should be valid for only 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> during piant operation.
This procedure aliows a single 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> extension of a hot work permit, but only if the conditions certified by the permit are reva'lidated by signature on the original permit.
In addition, the procedure requires that hot work jobs worked on the same shift (i. e.
days only) over more than one day should have the hot work permit reissued and revalidated daily prior to the work being conducted.
Howevers there apparently is no mechanism for identifying which permits are clearly for use on one shift only.
The original permit exceeded the allowable limits and was not revalidated, and since the job was conducted on the day shift only, this appears to violate the intent of the Hot Work Authorization Permit procedure.
However, because the procedure was not written in a format containing clearly stated requirements, the inspector concluded that a violation could not be written.
The licensee agreed that the procedure needed to be strengthened.
(Followup Item 528/88"32-01).
The inspector discussed this incident with 'licensee management and emphasized the need to maintain housekeeping in the RCA, especially in hot work areas.
Additionally, the inspector discussed with the licensee the licensee's initial investigation that failed to address the weaknesses in the hot work procedures.
Restoration of Clearance
- Unit 1.
62703 During a tour of the Unit 1 diesel building on October 20, the inspector noted that the "A" emergency diesel air compressor room vent fan was de-energized and tagged out.
Followup on the clearance revealed that preventive maintenance work involving the tightening of set screws and bolts on the blower had been completed on September 27..
The inspector determined that the equipment could have been returned to service at that time, however, no action had been taken to restore the clearance until it was brought to the licensee's attention by the inspector.
Although the equipment was non-safety related, the licensee was informed that the matter should be reviewed to confirm that the problem of allowing equipment to be inoperable longer than necessary was not pragmatic.
In this case the Foreman failed to check that the clearance was restored prior to signing the work order indicating that the work was complete.
No violations of NRC requirements or deviations were identifie.
Si noffs Not Made As Maintenance Was Performed - Unit 2.
62703 The inspector observed maintenance being performed on the Unit 2 "A" diesel generator on October 18, 1988.
The inspector reviewed work order 320449 and observed that no work steps contained in the work instructions had been initialled, even though the job had proceeded to the point that a temperature control valve was being disassembled.
The NRC inspector asked the Quality Control (QC)
inspector present what step was being performed and if the clearance had been walked down to ensure the system was safe to work.
The QC inspector indicated he had personally observed the clearance walkdown and the workers were on Step 7.
The QC inspector further indicated he was waiting for a QC holdpoint.
The NRC inspector questioned why the QC inspector did not point out to the workers that the completed steps of the work document were not initialled.
The QC inspector indicated he was only required to sign off the holdpoint, regardless of whether the previous steps were initialled or not.
The NRC inspector then asked the mechanic if he had completed the clearance walkdown prior to starting the work.
The mechanic indicated he had done so.
He then initialled the step and all other completed steps in the work order.
The Unit 2 Work Control Manager subsequently arrived at the work site and the inspector related the observations and conversations to him.
A similar failure to perform work order sign-offs as the work was completed was identified at Unit 2 in Inspection Report 50-529/88-28, Section 12.
As noted in that report, the Unit 2 Maintenance Manager discussed the occurrence with all maintenance supervisors.
Further, ANPP procedure 30DP-9MP01,
"Conduct of Maintenance",
dated August 22, 1988, was discussed with the workers.
That procedure states.in Step 3. 8. 6,
"Work instruction steps, sections of steps and data sheets shall be properly documented at the time of performing the step or soon thereafter if conditions do not permit."
The failure to follow procedures is a violation of Technical Specification 6.8. l.a and is considered another example of
- management's expectations not being met in both the maintenance and quality control areas (Violation 529/88-31-01).
The inspector discussed this incident with both Unit 2 management and QC management.
The mechanics and QC inspector involved in this incident have been instructed in management's expectations in their respective areas.
Low Pressure Safet In ection LPSI Pum and Associated Motor 0 crated Valve (MOV Outa e
Unit 3.
62703 Between October 4 and 6, Unit 3 personnel conducted planned maintenance on the Train "A" LPSI pump and several associated MOV ~
~ I
~
The mechanical seal was replaced on the LPSI pump and routine maintenance was performed on the MOVs.
During the post maintenance review of the work packages, the inspector noted one work order in which two Quality Control (QC)
"Witness Points" were missed.
The job foreman made a written statement in the work order that QC could not be contacted.
A QC
"Witness Point" is a point during work progression which is less significant than a "Hold Point" and, according to licensee procedures,'eed not be witnessed by QC if QC determines that independent witnessing is not necessary.
The inspector questioned the documentation in that QC had not been permitted to make an independent decision on whether or not to witness the point.
Subsequent investigation by the licensee and independent verification by the inspector determined that the duty QC inspector had, in fact, been notified and had made the decision not to witness based on his priorities at that time.
However, the inspector became aware that some work control and plant management personnel held the view that if a foreman was unable to contact QC after a "best effort" attempt, that work may proceed past the witness point without QC involvement.
This view was not in agreement with that of Quality Control organization.
Quality Control expects to be notified in each case and is responsible for determining the need for their presence at that point.
Licensee management has resolved this disagreement by supporting the view that QC must make these decisions.and therefore is required to be notified in each case.
The inspector observed that this disagreement with QC had existed at plant management levels.
However, site management acted quickly to reaffirm QC's independent role.
In addition, a procedural revision is planned to clarify this point.
The inspector had no further questions.
No violations of NRC requirements or deviations were identified.
Review of Licensee's Event Evaluation Pro ram.
40500 During the period of the current inspection, the licensee's program and procedures relating to event evaluation, including root cause determination and post-trip review, were examined.
Discussions were held with licensee management and supervisory personnel responsible for event evaluation activities.
'The following findings and observations resulted.
a.
Root Cause Evaluation During the period of approximately the past year the licensee has devoted substantial effort in the development and implementation of a root cause program, particularly with regard to equipment and component failures.
The development and implementation of this program has been focused for the most part within the Engineering Evaluations Department, which reports on-site to the Director, Standards and Technical Suppor During the year 1988, through mid-October, approximately 400 root cause evaluations were initiated.
Based upon this rate, through the balance of 1988, the licensee's root cause program would cover in excess of approximately 530 component/equipment failures per year.
Essentially all root cause evaluations to date have been conducted by System Engineers within the Engineering Evaluations Department.
The licensee also participates in the INPO Human Performance Evaluation System (HPES).
During 1988, through mid-October, a
total of 14 HPES evaluations of personnel/procedure errors were initiated.
These evaluations are currently conducted by the Shift Technical Advisor (STA) group.
This group was recently reassigned from the Engineering Evaluations Department to the Plant Standards and Controls Department, which also reports on-site to the Director, Standards and Technical Support.
Essentially all System Engineers and STA's have attended contractor (EG8G) administered training in Root Cause Analysis.
Selected records, including reports of root cause analysis and the HPES were examined by the NRC.inspectors for the period'988.
The inspectors observed that the quality of these reports had improved substantially during the course of the year.
Sources of input for root cause analysis include the licensee's programs and procedures for the identification and trending of:
(2)
(3)
failures of components covered by Limiting Conditions for Operation (LCO) of the facility Technical Specifications; major event evaluations, including post-trip reviews and special plant event evaluation reports (SPEER);
quarterly component failure data trending reports; and (4)
component failures or other events identified by plant System Engineers in their review of system performance and maintenance activities associated with plant systems to which they are assigned.
The NRC inspectors were favorably impressed with the licensee's program for component failure data trending.
This program is implemented by the Risk and Reliability Analysis group within the Engineering Department.
The program involves the review of all corrective maintenance work orders associated with components in a data base which is comprised of g-Class components, NPRDS covered components, and selected non-g components identified by the plant Engineering Evaluations Department.
On a quarterly basis components are identified for root cause evaluation in accordance with predetermined statistically significant failure rates.
A review of the quarter 1988, revealed that a total of 1909 corrective maintenance work orders had been reviewed during the period
~
~ I
covered by the report.
Of this number of work orders reviewed, 552 were reported to involve component failure or degraded conditions, which met the criteria for component fai lure trending.
It was observed by the NRC inspectors that this program and its data base may well serve as a valuable source of component reliability data, not only for the identification of needed root cause analysis, but for plant specific PRA analyses and Reliability Center ed Maintenance (RCH) program development.
The facility records also included a third quarter 1988 report by the Risk and Operability Analysis group entitled, Com onent Failures Associated With Human or Procedural Errors.
This report was based upon a review of corrective maintenance work orders for the same component failure data trending discussed above.
The report indicated that 26X (142 of 552) of component failures involved human and/or procedural errors during the quarter.
The report assigned the 142 occurrences of human/procedural error to the following four categories",
as indicated:
-
Foreign/wrong part; poor design and/or misapplication.
123
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Inadequate repair; lack of or improper maintenance, installation or restoration.
-
Procedural fault; lack of, not followed, or incorrect.
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Failure directly due to human error.
Licensee representatives stated that information provided in these quarterly reports is also evaluated to determine the need for root cause analysis.
" - Categories are those used in the Nuclear Plant Reliability Oata System (NPRDS) program.
In some instances multiple human/procedural errors occurred resulting in component failure.
Post"Tri Review Pro ram Licensee procedures relating to post-trip review were examined.
The NRC inspectors concluded that the current procedures, if properly implemented, provide sufficient instruction and direction for the conduct of a thorough review of circumstances associated with reactor trips; including evaluation of the cause of plant trips, response of the plant protection and engineered safety features systems, and the basis and authorization for plant restar Develo ment of an Incident Investi ation Pro ram At the time of the current inspection licensee personnel were in the process of developing a comprehensive incident investigation program.
Management representatives stated that a principal objective of such a program is to ensure that appropriate administrative controls are exercised so that there is consistency in all investigations performed.
The program is
'intended to be broad in scope, covering events ranging from those which require implementation of the Emergency Plan at the classification level of Alert or higher, or which may result in a Level I violation of NRC requirements (Category 1) to those involving near-miss situations in which no actual safety consequences occur (Category 4).
A draft program description, procedure 79PR-OTS01,
"PVNGS Incident Investigation Program,"
together with draft implementing procedures had been prepared.
Management's current goal is to have this program developed, reviewed and approved for implementation by the end of 1988.
The NRC inspectors examined the draft program description and draft implementing procedures, with particular attention given to those procedures covering Category 1, 2, and 3 events, and incident investigation methods.
The following findings and observations resulted:
(1).
The draft Incident Investigation Program represents an ambitious, comprehensive plan to ensure that appropriate investigations are conducted of a wide spectrum of events ranging from near-misses to those with actual or potential safety significance.
The program as presently described should substantially increase the focus on events involving human and procedural errors'2)
Licensee management representatives stated during the course of the current inspection their intent that investigations of all events focus on a determination of root cause.
This was not made clear in the draft program description or in the procedure covering investigations of Category 1 and 2 events.
(3)
Training in investigation methods/root cause techniques for individuals, other than System Engineers and STA's, who will be involved in investigations should be given high priority by management.
(4)
Other licensees in Region V have found the formation of a small (4-6 person)
dedicated root cause group with expertise in root cause methods to be beneficial in terms of taking a lead role in event evaluations/root cause determinations for significant events, and in assessing the adequacy of event evaluations/root cause determinations by all parts of the organizatio (5) It was not clear in the draft procedures reviewed that all action items resulting from event investigations will be identified for tracking to insure their completion and for periodic trending analysis.
(6)
The resources impact of the proposed investigation program had not been assessed.
This would appear particularly important in terms of the impact the program may have on the operations and other line departments.
(7)
Senior management should make a special effort to communicate their support and their expectations of the proposed investigation program to the entire ANPP organization.
(8)
There does not appear to be a formal mechanism for the tracking and feedback of requests for changes to the training programs, similar to that which exists for requests for changes to procedures.
The findings of the inspection in this area were discussed with those licensee representatives indicated in Paragraph 1,
on October 21, 1988.
No violations of NRC requirements or deviations were identified.
13.
Review of Inde endent Safet En ineerin Grou ISEG Activities - Units
2 and 3.
40700 The inspector reviewed the licensee's commitments with respect to the composition, duties, and responsibilities of the Independent Safety Engineering Group (ISEG).
According to Technical Specification 6.2.3. 1, the ISEG functions as a collection point for industry advisories, NRC issuances, and other sources of plant operating experiences't then disseminates this information and ensures the responsible departments resolve each issue within their cognizance.
The ISEG provides independent review of these responses and in some cases conducts their own investigations and makes recommendations.
The ISEG also monitors plant activities in progress to independently verify the activities are performed correctly and that risk of human error is minimized.
Plant systems are walked down periodically to identify any potential nuclear safety hazards.
Finally, ISEG is often requested to perform investigations into issues of interest to plant and site management.
The inspector reviewed operating event report files, the computerized item tracking system, ISEG member qualifications, and recent monthly activity summary reports.
In addition, the inspector discussed ISEG activities with several members and accompanied one member on a safety system walkdown of the Auxiliary Feedwater System in Unit 2.
The inspector made the following observations.
1)
The present ISEG staff is comprised of five engineers and one manager.
This meets the Technical Specification's
t
minimum requirement.
However, at this staffing level, the Operating Event Report (OER) program, which collects and tracks industry advisories, has maintained a significant backlog of over seventy open items.
In order to reduce this backlog, the licensee has contracted for three additional engineers for a period of six months.
2)
One ISEG engineer, while performing a safety system walkdown, properly identified several items for further followup, including a poorly locked throttle valve and specific areas in need of housekeeping improvement.
3)
Special Investigations and Reviews, which require root cause of failure analysis, are not always consistent in the methodology used to perform the analysis.
However, licensee management has, in draft form, a package of procedures intended to standardize this kind of evaluation for all ANPP organizations involved with root cause of fai lure analysis.
Additionally, training is scheduled for all ISEG engineers in root cause analysis methodology.
The inspector noted that a majority of the time available for ISEG activities was being spent on the resolution of concerns generated from outside the ISEG organization.
This includes Special Investigations (SI) or Reviews (SRs)
requested by site or plant management.
The inspector considers that, although resolution of these SI/SRs can be an important contributor to maintaining and improving plant safety, this function is sometimes performed at the expense of daily in-plant surveillance of activities.
This in-plant surveillance is a primary function of ISEG, according to Technical Specifications, and is intended to place ISEG in a pro-active role for identifying potential safety concerns and personnel error risks.
Licensee management should carefully consider the impact on routine observation of plant activities when tasking ISEG wi'th special investigations or reviews.
The degree and quality of routine plant activity observations has been the subject of several recent management meetings and enforcement conferences between Region V and ANPP.
Licensee management acknowledged these comments and indicated that efforts to staff one additional ISEG position should improve their in-plant surveillance time once this position is filled.
Additionally, the six month contractor support for the OER Program should also assist in this goal.
No violations of NRC requirements or deviations were identified.
14.
Startu Testin
- Unit 1.
72700 The inspector reviewed the results of the following tests performed before or during the Unit 1 startup from its refueling outage.
This
r c
review was to verify that the results either met the acceptance criteria or were properly resolved.
72PY"9RX01 Reload Criticality and Low Power Physics Tests.
o Control Element Assembly (CEA) Worth o
Shutdown Margin 72PA-1ZZ07 Reload Power Ascension Test.
Power Coefficient Isothermal Temperature Coefficient Moderator Temperature Coefficient Core Power Distribution 72PA-9RX01 Power Calibration.
o Excore Instrumentation/Heat Balance Power Comparison 73ST"9RX01 CEA Drop Time.
o Rod Trip Times vs Technical Specifications The inspector noted that the signoff of the statement that the power ascension testing had been completed and found acceptable for continued operation in procedure 72PA-1ZZ07 had not been done.
The reactor engineering supervisor informed the inspector that all test results had been reviewed and were found acceptable.
The signoff indicated that, in addition to the test results review, all administrative items were completed.
This portion was still not finalized.
The inspector suggested this be given priority effort to complete.
No violations or deviations were identified.
15.
Followu of Licensee Event Re orts - Units 1 2 and 3.
The following LERs were reviewed by the inspector.
Based on the information provided in the report, it was concluded that reporting requirements had been met, root causes had been identified, and corrective actions were appropriate.
The below listed LERs are considered closed.
Unit 1 LER NUMBER DESCRIPTION 87"14"LO Reactor Trip During Main Feed Pump Turbine Testing.
87"22"LO Fuel Handling Crane Used Prior to Performance of a Surveillance Tes LO 88-11-LO COLSS Rendered Inoperable.
Reactor Trip-Operator Inadvertently Opened Unit Main Generator Motor Operated Disconnect.
88-12-LO 88-13-LO Surveillance Late.
Auxiliary Feedwater Motor Driven Pump Degradation-Stress Corrosion Cracking/Hydrogen Embrittlement of Shaft Sleeve.
88-21-LO Reactor Trip Due to High Pressurizer Pressure.
No violations of NRC requirements or deviations were identified.
16.
Review of Periodic and S ecial Re orts - Units 1 2 and 3.
90712 Periodic and special reports submitted by the licensee pursuant to Technical Specifications 6.9. 1 and 6.9.2 were reviewed by the inspector.
This review included the following considerations:
the report contained the information required to be reported by NRC requirements; test results and/or supporting information were consistent with design predictions and performance specifications; and the validity of the reported information.
Within the scope of the above, the following reports were reviewed by the inspector.
Unit 1 o
Monthly Operating Report for September, 1988.
Unit 2 o
Monthly Operating Report for September, 1988.
Unit 3'
Monthly Operating Report for September, 1988.
No violations of NRC requirements or deviations were identified.
The inspector met with licensee management representatives periodically during the inspection and held an exit on November 4, 1988.
During the exit meeting, the inspector emphasized the items of poor procedural compliance of Sections 2.2, 5, 7, 8, 9, and 1