IR 05000528/1989049
| ML17300B229 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 12/19/1989 |
| From: | Wong H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17300B228 | List: |
| References | |
| 50-528-89-49, 50-529-89-49, 50-530-89-49, NUDOCS 9001040062 | |
| Download: ML17300B229 (45) | |
Text
Re ort Nos.
Docket Nos.
License Nos
~
Licensee:
Faci lit Name:
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
50-528/89-49, 50-529/89-49 and 50-530/89-49 50-528, 50-529, 50-530 NPF-41, NPF-51, NPF-74 Arizona Nuclear Power Project P.
Q.
Box 52034 Phoenix, AZ. 85072-2034 Palo Verde Nuclear Generating Station Units 1,283 Ins ection Conducted:
October 16 through November 12, 1989 Inspectors:
T. Polich, Senior Resident Inspector D.
Coe, Resident Inspector J.
Ringwald, Re'sident Inspector Approved By:
k J.
Sloan, Resident Inspector A/
ong le Reactor Project Section II
/2-Ie a
e cygne Ins ection Summar
Ins ection on October 16 throu h November
1989 (Re ort Nos.
Areas Ins ected:
Routine, onsite, regular and backshift inspection by t e t ree ress ent inspectors, plus various inspectors from the Region V
staff.
Areas inspected included: previously identified items; review of plant activities; engineered safety feature system walkdowns; monthly surveillance testing; monthly plant maintenance; high pressure safety injection (HPSI) flow balance problems - Unit 1 (f1726); improper flow transmitter calibration - Unit 1 (62703); calibration of a pressure switch on the "A" diesel generator (DG) - Unit 2 (62703); reactor trip on October 31, 1989 - Unit 2 (92703); control element drive mechanism control system (GEDMCS) coil grounds monitoring - Unit 2 (71707);
containment purge butterfly valve restraininq pin fai lure Unit 3 (62703);
loose flexible conduit fittings inside containment - Unit 3 (71707);
locked high radiation area (LHRA) gates found open - Units 1 and 3 (71707);
remote shutdown room communications device mounting-Units 1, 2, and 3 (71707); portable fire extinguisher maintenance-Units 1, 2, and 3 (64704);
review of licensee event reports - Units 1,
and 3; and review of periodic and special reports - Units 1, 2 and 3.
900l040062
$9l219 PPR ADOCK 050005"8 PD2
During this inspection the following Inspection Procedures were util-ized:
30702, 30703, 40500, 61726, 62703, 71707, 71710, 86700, 92700, 92701, 92702, 'and 93702.
Safet Issues Mana ement S stem (SINS) Items:
NONE Results:
Of the 17 areas-:inspected, 1 non-cited violation was ldent7Red.
This non-cited violation pertained to a procedural inadequacy at Unit 1.
General Conclusions and S ecific Findin s
Si nificant Safet Matters:
NONE Summar of Violations:
Summar
~ of Deviations:
0 en Items Summar
ONE (non-cited violation)
NONE 7 item(s) closed, 2 item(s) left open, and 3 new item(s) opene DETAILS 1.
Persons Contacted The below listed technical and supervisory personnel were among those contacted:
Arizona Nuclear Power Pro 'ect ANPP)
- R.
J.
R ~
- J
- B
- M.
- 1 P.
F.
Ap
- g P.
R.
F.
D.
D.
- D P.
Ag
- J
- J
- J Ag R.
T.
T.
C.
C.
J.
G.
G.
+R.
Adney, Allen, Badsgard, Bailey, Ballard, Bieling, Bradish, Brandjes, Buckingham, Caudill, Conway, Crawley, Firth, Flood, Garrett, Gouge, Hackbert, Heinicke, Hughes, Ide, Kjrby, Levine, LoCicero, Marsh, Page, Quan, Cogburn, Rogers, Russo, Scott, Shell, Shriver, Sowers, Younger, Plant Manager, Unit 3 Director, Engineering 8 Construction Nuclear Engineering Supervisor Vice President, Nuclear Safety 8=-Licensing Quality Assurance Director
=Emergency Plan/Fire Protection Manager Compliance Supervisor Central Maintenance Manager Operations Manager, Unit 2 Site Services D>rector Executive Vice President - Nuclear Nuclear Fuels Management Manager Training Manager Assistant Plant Manager, Units 2 and
Risk'anagement, Senior Engineer Operations Manger, Unit 3 Quality Audits 8 Monitoring Supervisor Plant Manager, Unit 2 Radiation Protection 8 Chemistry Manager Plant Manager, Unit 1 Nuclear Production Support Director Vice President, Nuclear Power Production Independent Safety Engineering Manager Plant Director Management-Services Hanager Management Information System Manager (Acting) Standards and Tech.
Support Director Licensing Manager Assistant Quality Assurance Director Operations Manager, Unit j.
Quality Systems Manager Compliance Manager Engineering Evaluations Manager Plant Standards and Control Manager The inspectors also talked with other licensee and contractor personnel during the course of the inspection.
- Attended the Exit meeting held with NRC Resident Inspectors on November 17, 198.
Previousl Identified Items - Units 1
and 3 (92701 92702)'a
~
b.
(Closed)
Enforcement Item (528/89-16-01):
"Failure to o
ow m> n) stra i ve on ro roce ures o
rove urve>
ance ri er>a rior'
se
-
n1 s
The inspector reviewed the licensee's Reply to Notice of Violation (102-01315-MFC/TDS/JJN).
The violation ensued from the failure to properly review and formally approve a
change to surveillance test criteria as required by administrative control procedure 01AC-OAP01, "Format and Content for Nuclear Administrative and Technical Procedures."
The licensee issued approved changes to the surveillance tests in question and emphasized the requirements of 01AC-OAP01 to all Engineering and Plant Standards personnel.
Routine inspection of surveillance acti vities have revealed no further problem.
This itern= is closed.
(Closed)
Enforcement. Item (529/89-06-01):
"Failure to o
ow era
>n roce ures on rs u es o
n ineere Safet Features Actuation S stem ESFAS Actuation nit 2.
The inspector reviewed the 'licensee's corrective actions as described in the Reply to Notice of Violation (102-01264-MFC/TDS/JJN).
The violation ensued from the failure of a licensed Control Room Operator to ensure the closure of a steam generator economizer valve following a reactor trip with feedwater control in manual.
The corrective actions included a re-emphasis of the procedural requirements, as well as incorporation of these into simulator training scenarios.
The inspector discussed these requirements with several operators and was satisfied they had received training in this area.
This item is closed.
C.
(Closed Enforcement Item (529/89-06-03):
"Contaminated rea ot oste
-
n> t The inspector reviewed the licensee's corrective actions as described in the Reply to Notice of Violation (102-01264-MFC/TDS/JJN).
The violation ensued from the discovery of radioactive contamination on a Unit 2 Boric Acid Nakeup Pump skid which exceeded the licensee's procedural threshold for establishing a posted boundary.
At the time of discovery, the skid was bounded only by cautionary yellow and magenta adhesive backed tape on the skid foundation, with no personnel barrier or posting.
The licensee's corrective actions included an immediate posting of the area as required, and a Night Order requiring all RP technicians to review the Radiological Posting procedures and the event "Problem Report" for lessons learned.
This was documented via a signoff shee Other corrective actions included documenting all posting changes in the RP log for a period of four months and a
daily visual verification by an RP'Supervisor, also documented in the RP log, of all such changes to ensure the posting requirements are met.
The inspector considered these measures adequate.
This item is closed.
(Closed)
Unresolved Item (529/89-28-01):
"Work Sco e
an es n ica e
na e
ua e
or annin ni an goosed)
Enforcement Item (530/89-06-01):
"Failure to on uct ua it on ro eview or itiona ork nstructions to ua i e ate or ctlvlties
-
nit 3.
The enforcement item ensued from the movement of a reactor vessel temporary level indicator (tygon tube) without the required gC concurrence.
The inspector reviewed the
.
licensee's, Reply to Notice of Violation (102-01264-WFC/-
TDS/JJN)
and concluded that the actions taken by the licensee appeared adequate.
These included an immediate gC verification check of the modified tygon tube position and an engineering concurrence.
In addition, the licensee changed procedure 30DP-9WP02,
"Work Planning", to clarify the intent thai
~an changes to a quality related work order which received initial gC review would also be reviewed by gC.
The event was reviewed by System Engineers, Mork Control Planners, and Operations personnel.
Additionally, the inspector questioned several work group supervisors and was satisfied they understood this requirement.
This item is closed.
The unresolved item involves a question raised by the maintenance inspection team (NRC Report 529/89-28)
regarding a pen and ink change made to quality related Mork Order (WO) No.
357019, which the maintenance team inspector noied implied a lack of review of the change by the several levels who approved the original WO.
The inspector reviewed the completed WO No, 357019 and noied that the pen and ink change in question (Step 13.a)
had been initialled by two individuals, one of whom was denoted as a
gC representative.
The governing procedure, 30DP-9WP02, allowed additional work instructions which were non-scope and non-intent changes to be approved by a Work Group Supervisor or Planner, and by gC.
Since the initials were dated 5/13/89, it appeared that these requirements had been met, in that the physical work was completed on 5/19/89.
Thus,'he documentation reflected an acceptable review while the WO was still active.
The inspector had no further questions and considered this item close e.
(Closed)
Followu Item (529/89-30-01):
"Missed Procedure te
>
e as in enerator se
nl The inspector reviewed Human Performance Evaluation (HPES)89-018,
"Turbine Trip on Over-Excitation."
The evaluation appeared to be thorough with respect to the casual factors of the event, and the recommended corrective actions were appropriate.
While the corrective actions are not all complete, they have been initiated and are being tracked by the licensee.
In a review of the HPES log, the inspector determined that all but 4 of 22 evaluations initiated from January through August of 1989 were closed.
None of the 11 evaluations initiated since then have been closed, except one which was cancelled.
All but 4 of the 33 evaluations initiated in 1989 have been closed or are currently under management review.
The inspector concluded that the HPES program was being managed satisfactorily, and that most evaluations are being closed within 60-90 days of an investigator being assigned.
This item is closed.
f.
(0 en) Followu Item (529/89-30-03):
"Mork on Nitro en e
u ator er er a ns ruct1ons
-
nest The inspector reviewed the licensee's evaluation of causal factors for this event and considers them to be accurate and complete.
The proposed corrective actions appear to appropriately address the identified causes.
The status of these corrective actions was reviewed with the following observations:
o Maintenance Personnel Briefing - The inspector queried a Unit 2 mechanic and found him to be aware of the requirements for appropriate review and documentation of vendor recommendations.
o
,
Procedural Change - The Inspector confirmed that appropriate changes had been made to procedure 30DP-9MP01,
"Conduct of Maintenance."
o equality Controls - The licensee has deferred completion of its evaluation of programmatic controls until November 30.
The inspector will review this evaluation when available.
This item will remain open pending review of the equality Assurance Department evaluation of programmatic control (Closed} Enforcement Item (530/89-16-01):
"Inaccurate or rec
>on urve ln eac or oo ant s
em ral n era ion roce ure
-
ni This item ensued from the inclusion of an incorrect mid-loop operation reactor vessel level indication correction curve, which accounted for ihe change in indicated level due io flow in ihe shutdown cooling line to which the level indicator was connected.
The licensee's immediate corrective action was to replace the inaccurate curve with ihe correct curve.
Further corrective action responsibilities resulted from an investigation (IIR 3-3-89-019) performed by ihe licensee.
This investigation concluded that the procedure writer and the Engineering Evaluations Department (EED) System Engineer (SE) reviewer had sufficient information available to detect ihe erroneous data, but did noi do so.
Furthermore, ihe licensee determined the need for. more clearly stating assumptions and limitations associated with Nuclear Engineering Department (NED) supplied technical data, and more clearly defined review responsibilities for technical and cross-discipline reviews of procedures.
Finally, the procedure writer was to be counseled on attention. to detail.
The inspector noted the following:
Although the event occured in late March, the IIR, 3-3-89-019, was not issued until October 5, 1989, approximately six months later, which-the inspector noted exceeds the guideline of 28 days in 79PR-OIP01,
"Palo Yerde Nuclear Generating Station (PVNGS) Incident Investigation Program."
Although the procedure writer was to be counseled, the report states that an EED review by a System Engineer (SE)
also failed to identify the error.
The repol i made no recommendation to also counsel the SE.
The recommended programmatic enhancements noted above are intended to address ihe issue of exchange and review of information between the engineering and standards organizations.
Based on ihe immediate correciive action taken, this enforcement item is closed.
However, the licensee's long term corrective action as defined by IIR 3-3-89-019 will be followed as part of item 530/89-16-04, which reflects a licensee management commitment made in May 1989, to review ihe policies and controls associated with the exchange and review of information beiween the engineering and standards organizaiion.
The 'licensee acknowledged the inspector's comments, and noted that the SE involved has since left the company.
Additionally, the inspector noted that a more recent
h.
example of 'an improper instrument calibration due to use of improper calibration data, as reported elsewhere in this report (see paragraph 8),
was an indication of further programmatic deficiencies in the inclusion of engineering supplied data to work orders used in the field.
The licensee committed to reviewing this area as an aspect of their previously committed review.
(0 en) Followu Item (530/89-16-04):
"Review of n sneersn an ar s
n er ace
ns s
This item remains open to track the licensee's corrective action resulting from Incident Investigation Report 3-3-89-019 as described above under Enforcement Item 530/89-16-01.
3.
Review of Plant Activities (71707 71710 93702)
a 0 Unit j.
Unit 1 remained in Mode 6 (refueling with the entire core off-loaded in the spent fuel pool) throughout this inspection period.
Resolution of the High Pressure Safety Injection (HPSI) failed surveillance dominated plant activities (see paragraphs 7 and 8).
Also, replacement of restraining pins in Henry Pratt Co. butterfly valves used in Containment Purge (CP), Essential Cooling Mater (EM)
and Nuclear Cooling Mater (NC) systems resulted from shattered pins discovered in Unit 3 (see paragraph 12).
The replacement Reactor Coolant Pump Motors were also fully installed and successfully test run during this period.
Unit 2 Unit 2 entered this period in Mode 3.
Resolution of problems with Control Element Drive Mechanism Control System (CEDMCS) coil grounds, incorrect size High Pressure Safety Injection (HPSI) flow orifices, and brittle restraining pins in the containment purge isolation valves, prevented restart until October 30.
On October 31, the reactor tripped from 66K power as a result of three independent problems in the plant protection system (PPS).
PPS channel
"C" was in bypass due to a failed reactor coolant pump lA speed sensor, and PPS channel
"D" was tripped due to a failed connector from the excore Nuclear Instrumentation (NI) middle detector to the linear range drawer, when the channel
"B" PPS input from the NI middle detector was interrupted due to an apparent intermittent failure of the linear calibrate switch (see paragraph 10).
Following the trip the plant was cooled down to Mode 5 to replace potentially brittle restraining pins in the nuclear cooling water and essential cooling
water systems and remained in this mode for the rest of the reporting period.
c.
Unit 3 Unit 3 remained in Mode 5 throughout this inspection period.
Activities related to completion of the refueling outage were testing of the Hain Steam Isolation Valve System (HSIVS), Feedwater Isolation Valve System (FMIVS),
Atmospheric Dump Valves (ADV's), and Control Element Drive Mechanisms System (CEDHS)..
Also,.butterfly valves manufactured by the Menry Pratt Co. in the Containment Purge '(CP), Essential Cooling Mater (EM), and Nuclear Cooling Mater (NC) systems underwent a replacement of restraining pins after some were found shattered (see paragraph 12).
d.
Plant Tours The following plant areas at Units 1, 2 and 3 were toured by the inspector during 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:
1.
0 eratin Lo s and Records Records were reviewed aga)nst ec naca peel )cation and administrative control procedure requirements.
Node 3 Surveillance Lo
- Unit 2 61726)
The inspector observed the Control Room Operator perform portions of the Hode 3 Surveillance Log 42ST-22231.
The operator properly took readings and recorded them as he went.
Upon completion of this activity, the inspector reviewed the log and confirmed that acceptance criteria had been met.
Step 8.2 of the surveillance requires the 'containment sump level to be monitored over an unspecified time interval to determine the rate of level change, in accordance with Technical Specification 4.4.5.2. 1.6.
The inspector asked the operator what time interval was used for this purpose, and where the guidance was documented.
The operator could not find any guidance, but stated that he monitored the level for at least one hour, in order to obtain reasonable
2.
3.
4 ~
accuracy in the calculation.
Mhile this operator's practice appears to. be satisfactory, the inspector expressed concern that formal guidance was not provided.
The inspector asked the shift supervisor if any guidance existed, and though the Shift Supervisor stated the same
"thumb rule," no formal guidance could be located..
The licensee is evaluating the need for enhanced procedural guidance.
The inspector concluded that licensee actions were appropriate and had no further questions.
Nonitorin Instrumentation Process instruments were o serve or corre a ion etween channels and for conformance with Technical Specification requirements.
Shift Mannin
'Control room and shift manning were o serve or conformance with 10 CFR 50.54.(k),
Technical Specifications, and administrative procedures.
E ui ment Lineu s
Yarious valves and electrical rea ers were verified to be in the position or condition required by Technical Specifications and administrative procedures for the applicable plant mode.
5.
6.
7.
8.
9.
E ui ment Ta in Selected equipment, for which tagging reques s had been initiated, was observed to verify that tags were in place and the equipment was in the condition specified.
General Plant E ui ment Conditions Plant equipment was o serve or
>n ications o
system leakage, improper lubrication, or other conditions that would prevent the systems from fulfillingtheir functional requirements.
Fire Protection Fire fighting equipment and controls f
'thT hi Specifications and administrative procedures.
An Unresolved Item was identified regarding records of portable fire extinguisher maintenance.
(See paragraph 14).
/
Plant Chemistr Chemical analysis results were reviewe or conformance with Technical Specifications and administrative control procedures.
Securit Activities observed for conformance with regu a ory 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 ma er>a 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.
11.
,Radiation Protection Controls Areas observed inc u
e con ro porn opera ion, 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.
The inspector identified an area where scaffolding made it possible to enter the Radiological Controlled Area (Unit 2 Auxiliary Building roof) without crossing posted barriers.
The licensee immediately responded by posting the roof railing.
No violations of NRC requirements or deviations were identified.
4.
En ineered Safet Feature S stem Malkdowns - Units
2 and
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, electrical cabinets and cables, were inspected to determine that they were operable, and in a condition to perform their required functions.
Accessible portions of the following systems were walked down during this inspection period.
Unit 2 o
Boration Flowpaths Unit 3 o
Boration Flowpaths No violations of NRC requirements or deviations were identified.
5.
Monthl Surveillance Testin
- Units l 2 and 3 (61726)
a.
Selected surveillance tests required to be performed by the Technical Specifications (T/S) were reviewed on a sampling basis to verify that:
1) 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 T/S; and 4)
test results satisfied acceptance criteria or were properly dispositioned.
Specifically, portions of ihe following surveillances were observed by the inspector during this inspection period:
Unit 1 P
d
~di t.t o 41ST-12235 RMS Surveillance - Mode 5-6 Logs.
o 73TP-9SI04 'PSI Flow Testing.
Unit 2 Procedure Descri tion o 73ST-2CL01
"Containment Leakage Type "B" and "C" Testing," for valve 2JNCBUY0401.
Unit 3 P
d
~DI t.t o 73ST-3XI01 Section XI Testing on MSIY Bypass SGE-UY-169 o 73ST-3XI22 Section XI Testing on ADY 184 No violations of NRC requirements or deviations were identified.
6.
Monthl Plant Maintenance - Units 1 2 and 3 (62703)
a ~
b.
During the inspection period, the inspector observed and reviewed selected documentation associated with maintenance and problem investigation activities listed below 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.
Specifically, the inspector witnessed portions of the following maintenance activities:
11'nit
Descri tion o
Install HPSI flow transmitter FI-390 Unit 2
~II i t.i o
Clean and Inspect
"D" Core Protection Calculator.
o Calibrate
"A" Diesel Generator Turbocharger Low-Low Pressure Switch.
o
"A" Atmospheric Dump.Valve Monthly Functional Test.
Unit 3 Descri tion o
Atmospheric Dump Valve label plate installation.
P 7.
Hi h Pressure Safet In'ection HPSI) Flow Balance Problems-n)t During September, 1989, surveillance test 73ST-1XI29 failed on low hot leg HPSI flow.
The subsequent investigation led to surveillance test 73ST-9SI01,
"Emergency Core Cooling System (ECCS) Flow Balance Test," which failed on cold leg flow and combined cold and hot leg flow.
Severe hot leg flow indication oscillations (plus-or-minus 100 gpm) also complicated: this issue due to the 545 plus-or-minus
gpm acceptance criteria.
Investigation and adjustment of various components followed, and left questions as to whether the problems were resolved.
At this point the Unit 1 Plant Manager stepped in and demanded that the test be repeated.
When it failed, the Unit j. Plant Manager insisted that System Engineering apply whatever additional resources were necessary to identify which system component was malfunctioning.
System Engineering requested additional support from Corporate Engineering and other support groups as well as Combustion Engineering and the component vendors.
A series of troubleshooting and repair events identified a difference between the design and insialled hot leg "A" Train flow orifice size.
The flow transmitter was calibrated to the incorrect orifice size and this accounted for the low combined cold and hot leg flow rates.
This same orifice size discrepancy was identified at Units 2 and 3 as well.
An emergency T/S change was requested and granted to increase the tolerance of the hot leg flow criteria.
Due to varying hot leg injection valve coast distances after the open direction limit switch was triggered to stop valve travel, the EOPs for hot leg injection, 42RO-*ZZ07 and 42RO-*ZZOS
(~ representing the unit numbers:
1, 2,or 3), were changed to require the operator to manually balance cold and hot leg flow.
The open limit switches for SIA-UV-321 and SIB-UV-331 were also moved up to a hot leg injection limit of 600 gpm to give the operator full control'of these valves to balance flow.
The low cold leg flow rate was attributed to marginal system design and incorrect operator time averaging while reading the four cold leg instruments simultaneously.
During this entire troubleshooting'and repair process, a number of other small problems were identified and corrected.
After all these problems were resolved, the testing was repeated satisfactorily.
No violations of NRC regulations or deviations were identified in that the system remained capable of performing its safety function, and the licensee identified and corrected the deficiencies.
Im ro er Flow Transmitter Calibration - Unit 1 (62703)
A Rosemont 1152 transmitter was improperly calibrated due to poor communication of technical information from Engineering to the field.
Once the inco'rrect flow orifice was discovered at FI-390 (see paragraph 7),
an EER concluded that the larger than designed orifice should be left in the system.
Plant Change Requests (PCR).were issued to revise the technical manual and the Instrument Calibration Data List.
An Instruction Change Request was also issued to revise the PM tasks to calibrate these transmitters.
After all these documents were issued, Mor k Order No.
389785 was issued to calibrate the FI-390 transmitter.
Due to an involved series of mis-communications, the work order was issued with the old incorrect flow calibration curve.
The HPSI testing which ensued failed as a
result and the licensee evaluation of the failed testing revealed the mis-calibration.
A Problem Resolution Sheet (PRS)
was initiated per 79PR-OIPOl,
"PYNGS Incident Investigation Program",
on November 14, 1989, after the Inspector asked the Unit 1 Assistant Plant Manager if a
PRS had been initiated.
This event is similar to the Unit 3 incorrect level correction curve used during mid-loop operations which was the subject of a Violation in report 89-16.
The resulting Open Item, 530/89-16-04, is still open.
This violation is not being cited because the criteria specified in Section V.G of the Enforcement Policy were satisfied (non-cited violation 50-312/89-08-01).
'
'
Calibration of Pressure Switch on the "A" Diesel Generator (DG)-
nl On October 25, the inspector observed ihe performance of Mork Order (MO) 382491, which controlled ihe calibration of the "A" DG turbocharger low-low pressure trip pressure switch.
In reviewing the MO package, the inspector noted that even though the MO description was "calibrate pressure switch per attachments,"
the actual MO instructions contained no steps to perform the calibration.
The last step of the MO instruction was followed by a table containing acceptance criteria and space to record data, a space for the signature of the performer, and restoration steps.
The inspector asked the technicians doing the calibration how the MO instructions tied in with actually doing the calibration.
The technicians mentioned the front page of the MO, which listed a procedure (36MT-9ZZll), a technical manual (N018-389),
and the equipment identification and description.
Neither the referenced procedure nor the technical manual were included in the MO package; however, the technician stated that the procedure
"was available if needed."
The inspector queried the work planners and an I8C foreman on this same issue.
Neither felt that additional MO instructions were necessary.
The inspector asked what criteria is used to determine if a referenced procedure needs to be included in the work package (as instructions or as an attachment).
This item.
is left to the judgment of the planners, procedure writers (Standards),
and foremen.
In this case, the type of switch is very common and the procedure is straight forward.
Additionally, the technician performing the work was experienced, and an opportunity was given to raise questions before the job.
The inspector concluded that this work had been saiisfactorily performed in accordance with applicable procedures.
Reactor Tri October
1989 - Unit 2 (92703)
On October 31, with Unit 2 ai about 66K power, the reactor t~ipped at 4:46 PN, MST.
Both plant systems and operators responded as expected following the trip, and the plant was stabilized in Node 3.
The trip was classified as uncomplicated, and did not require emergency classification.
At the time of the trip, the plant was holding p'ower and attempting to resolve problems in the plant protective system (PPS)
encountered during the power ascension.
At 5X reactor power during the ascension, an imbalance of axial shape index (ASI) between ihe different channels of the core protection calculator (CPC's)
was noticed by plant operators.
Excore power channels
"B" and "D" were declared inoperable
because the middle excore neutron detectors were reading 0 X, inconsistent with all other indications.
Shortly thereafter, the Channel
"B"- and "D" linear calibrate switches were exercised, resulting in restoration of normal function on channel
"B" only.
Affected trip parameter s on PPS channel
"D" were then placed in bypass and excore power channel
"B" was declared operable.
About 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> later, at 12:46 PM, channel
"C" LO DNBR and Hi LPD trip circuits actuated.
The channel
"C" trips were determined to be caused by a loss of speed signal from Reactor Coolant Pump (RCP)
1A.
Channel
"D" was then manually secured in a tripped condition while attempts to restore channel
"C" were in progress, However, approximately
hours later channel
"B" DNBR and LPD trips were received, satisfying the 2 of 3 coincidence logic and tripping the reactor.
The channel
"D" middle detector input coaxial connector was found to have failed due to an open in the connector.
This has been attributed to handling of the connector during routine survei llances.
The connector was replaced.
The channel
"C" RCP speed sensing problem was traced to the probe at RCP "lA".
The probe was found to contain an internal short to ground and was replaced.
The trip on channel
"B" has been attributed to an intermittant fai lure of the Linear Calibrate switc These switches have a
long history of failure in this application, with nine Engineering Evaluation Requests (EER's) having been generated since 1987.
The EER's have determined that these switches build up high resistance on the silver contacts due to extremely low currents (0. 1ma) being insufficient to keep the contacts clean; Though a recommended design change was proposed in early 1989, the inspector concluded that approval and implementation of the change had not been aggressively pursued by the licensee.
This is of particular concern in view of the licensee's determination that the switch is marginal for use in this application, and the manufacturer's statement that the switch is not designed for the low current application.
The licensee determined in early 1989 that the observed failures of the linear calibrate switch did not present a safety concern.
However, the low priority placed on correcting this long standing generic design deficiency indicates to the inspector the licensee's willingness to live with problems.
As a result.of this event, the licensee expedited the procurement of replacement switches with gold-plate contacts.
Additionally, a temporary plant modification was made to jumper around the troublesome switch contacts.
Appropriate-surveillance procedures have been revised if they were affected by the modificatio The Plant Review Board (PRB) met on November 2, to consider the facts, as known at ihe time.
The PRB approved entry into Mode 2 based on there being no change to the root cause of the trip during the remainder of the post trip investigation, and based on the Plant Manager calling each of the PRB members for concurrence before restart.
The inspector closely monitored the incident investigation.
It was noted that leadership of the investigation was aggressive in pursuing the relevant facts, appropriate personnel were involved in the investigation, the significance of various concerns and issues was recognized and identified, and the interim investigation report detail was frequently reviewed for accuracy and completeness.
Even though the PRB approved restart before the investigation was complete, individual PRB members were afforded the opportunity to review the final investigation report prior to approval by the Plant Manager.
The inspector.
reviewed procedure, 74AC-OP01, "Incident Investigation Category 1 and 2 Incidents,"
and concluded that the investigation and PRB involvement were in accordance with the procedure.
Mith respect to the linear calibrate switch problems, ihe inspector concluded that the licensee had not aggressively pursued implementation of corrective action to -improve the
.
reliability of the switches.
The inspector concluded that the licensee's corrective actions were satisfactory.
No violations of NRC req'uirements or deviations were identified.
Control Element Drive Mechanisms Control S stem CEDMCS) Coil roun s
onstorsn
-
nit Following the October 14 Unit 2 reactor startup attempt, during which grounds were observed on two CEDMs, the licensee justified continued operation of Unit 2 in part by committing to monitor Control Element Drive Mechanisms Control System (CEDMCS) for potential coil grounds during Control Element Assembly (CEA) manipulations.
A video tape was prepared for use in training Auxiliary Operators
{AO's) on how to monitor ground detection equipment for potential. Control Element Drive Mechanism (CEDM) coil grounds.
The CEDM circuitry is such that some CEDM's are "positive firing" and some are "negative firinq." Initial discussions with the cognizant system engineers indicated that positive firing CEDM s with grounded coils would cause only a positive (clockwise) deflection of the ground detector instrument.
Negative firing CEDM's with grounded coils would cause a
negative (counterclockwise) deflection, unless the ground was low-resistance enough to cause the indicating needle to "bounce off" the low peg.
These behaviors were observed in CEDM's 27
and 41 during troubleshooting following the October 14 siartup attempt.
The inspectors questioned ihe system enqineers about why the detector would exhibit these characteristics.
Upon further review, the engineers concluded that both positive and negative firing CEDM's with grounded coils could cause ground detector needle deflection in either direction, and that the direction of deflection was affected by timing considerations in the circuits in addition to the negative or positive firing characteristic.
The training video, which was first shown on October 18, about two days after the erroneous information was identified, contained information describing the earlier understanding of the ground detector behavior.
This behavior is still considered most probable.
During a NRC/licensee telephone conference on October 20 to discuss the Justification for Continued Operation (JCO), the licensee stated that any deflection in either direction would be considered indication of a possible CEDM coil ground, although neglible deflection was acceptable as a normal indication of an ungrounded 'circuit.
The licensee's actions taken to preclude dropping of multiple control element assemblies due to grounds was subsequently considered to be acceptable by the NRC Regional Office staff after discussions with NRR.
Following the reactor startup on October 30, the inspector reviewed procedure 42TP-2SF01,
"CEA Operation While Monitoring for Ground Faults," which had been approved on October 21.
This procedure contained information consistent with the training video but not completely consistent with the information provided to the inspector prior to the October
telephone conference.
The inspector noted that the procedure had been reviewed by the system engineer on October 20 but that comments generated by this review did not include a correction of this information.
Additionally, the procedure stated that viewing the video was considered adequate training for the AO's doing the monitoring.
The inspector interviewed two AO's who actually did the monitoring and found their understanding of the "no needle deflection" criterion to be acceptable.
Also, the Shift Supervisor was interviewed regarding the content of the pre-shift brief.
The inspector concluded that the brief had been effective and that operations personnel were knowledgeable regarding appropriate indications and actions for potential CEDM coil grounds.
The inspector concluded that the system engineer's review had noi been thorough enough and thai he had failed to communicate his revised understanding of the system to the Standards department and Training department.
The procedure and training video have since been revised to ensure technical accuracy.
No violations of NRC regulations or deviations were identifie Containment Pur e Butterf1 Yalve Restrainin Pin Failure-Following a failed Local Leak Rate Test (LLRT) on October 17, 1989, for two 42 =inch containment purge valves, the licensee discovered, upon investigation, that a thrust bearing stud pin had fragmented on both valves, allowing the disk to work itself off-center during valve 'opening and closing operations.
Subsequent investigation revealed that these valves were manufactured by the Henry Pratt Co.
and various sizes of these valves, which utilized the same type stud pin, were located in 33 places'throughout each unit.
These valves were located in the Containment Purge (CP), Essential Cooling Mater (EM), and Nuclear Cooling Mater (NC) Systems.
The pins were fabricated from 420 stainless steel (SS)
and the licensee concluded that hydrogen embrittlement was the most likely cause of failure.
The licensee opened, inspected, and replaced all such pins in the Pratt valves, with the exception of ten EM valves in each unit which were determined not to provide a safety function, and four CP valves in Unit 2 which were given a temporary modification, which added an additional pin to serve the same function as the original pin and which was intended to expedite the Unit 2 restart.
The replacement pins were made from 302 SS which was determined to be not susceptible to the embrittlement experienced by the 420 SS pins.
The inspector reviewed a number of the associated INCR's, EER's, and ECE's, and concluded that the licensee's actions appeared to be adequate to resolve the deficiency with the Pratt valves.
Additionally, the inspector noted that the licensee was conducting a further search for 420 SS throughout safety related plant systems.
The inspector noted the well coordinated efforts of corporate engineering, the vendor's involvement, and extensive use of independent laboratories io confirm ihe mode of fai lure.
No violations of NRC requirements or deviations were identified.
Loose Flexible Conduit Fittin s Inside Containment - Unit 3 During a routine independent walkdown inside Unit 3 containment, the inspector noted several loose fittings associated with the termination of flexible conduit into Barton pressure transmitters for Class lE instrumentation.
The inspector verified that the design basis of the conduit and fittings was to provide physical support for the enclosed instrumentation leads.
Thus the flex conduit was required io meet seismic qualification standards, but not environment qualification standards.
The inspector noted that the Barton
transmitters in question were environmentally qualified for service inside containment without reliance on the flex conduit.
The licensee responded by torquing all such fittings associated with flex conduit inside the Unit 3 containment to the required 4.0 foot pounds.
The inspector observed the torquing of the last fitting and concluded that with the proper torque applied, the conduit appeared secure.
Later in the inspection period, the inspector was walking down the Unit 2 containment with the RP Manager and together noted similar loose fittings in Unit 2.
The licensee was preparing to conduct a torque check on all such fittings following the discovery in Unit 3 and completed this check following this latest observation of loose fittings in Unit 2.
At the end of this report, the licensee stated their intention to conduct a similar check in Unit 1 before the end of the Unit j. refueling outage.
The inspecto'r concluded that the licensee's response was adequate.
No violations of NRC requirements or deviations were identified.
Locked Hi h Radiation Area (LHRA) Gates Found 0 en - Units
an On November 6, 1989, a Unit 3 licensee Radiation Protection (RP) Technician discovered a
LHRA gate open and unguarded without authorization during a routine tour.
The area inside the gate, the "A" Shutdown Cooling Heat Exchanger room, was not occupied at the time of this discovery.
Then, on November 9, 1989, a licensee RP Technician in Unit 1 discovered another LHRA gate open and unguarded without authorization during a routine tour.
Once again the area inside the gate, the High Level Storage Area of the Radwaste Building, was not occupied at that time.
The licensee's review indicated that no authorized entries had taken place, in either case, since the last time each door had been checked.
The licensee took immediate action in both cases to chain lock the wire cage doors closed.
Following the Unit 1 event, the licensee took further action to chain lock all LHRA gates.
The licensee further initiated a Category 2 investigation to determine appropriate engineering, RP, and security actions necessary to preclude recurrence.
The inspector considered these initial actions to be prompt and aggressive.
The licensee's long term corrective action will be based'on the results of the investigation, which was not complete at the end
,
of this inspection report.
Inspection Unresolved Item (528/89-49-01).
Remote Shutdown Room Communications Device Mountin
- Units 1 an On November 8, the 'inspector noted that a radio communications device was installed in each of the Remote Shutdown rooms in each unit.
These devices do not appear to be securely mounted.
The inspector observed that if the device came loose, it could possibly strike the instrumentation and controls on the exposed remote shutdown panels, thereby damaging instrumentation or actuating (or defeating actuation of) critical plant equipment.
Additionally, they are mounted on a piece of.plywood, approximately 1" x'6" x 16" in size.
In Units 1"and 2, this wood was not fire coated.
The inspector informed the Engineering Evaluation Department of the potential seismic and fire protection concerns.
The seismic question has not yet been answered, and the inspector will follow up on this item (528l89-49-03).
The licensee fire protection engineering group checked records and determined that the mounting board.had been included in the fire loading calculations for the rooms, and that this was not a concern.
However, it was confirmed that the boards were not fire coated.
UFSAR Design Basis Five for Fire Protection states that "noncombustible and heat-resistant materials shall be used wherever practicable throughout the plant."
Because fire coating is a good practice and is consistent with the UFSAR, the licensee initiated a work order to have the wood mounting boards fire coated.
No violations of NRC regulations or deviations were identified.
Portable Fire Extin uisher Haintenance
- Units
2 and
In late September, the inspector observed that the monthly inspection signoffs were absent from the monthly inspection tags on three portable fire extinguishers.
Additionally, one extinguisher was discovered which had no inpection or maintenance tags.
This was brought to the attention of the site fire prevention department supervision.
After several discussions with these supervisors, the inspectors were informed that the monthly inspection tags were not required by NFPA 10, "Portable Fire Extinguishers,"
and that the required monthly inspection records would be maintained on computer printouis in the department's offices.
The monthly tags were to be removed from the extinguishers, leaving only the annual maintenance tag on the exiinguishers.
The inspector reviewed the computer printouts in the Fire Department's office and found all extinguisher inspections to be curren Procedure 14FT-9FPOl, Revision 0, PCN 2, "Fire Protection Equipment Testing for the Power Block," contained the following requirement for portable fire extinguishers:
8.5. 1 Nonthly - Record visual inspection on inspection tag and on the computer readout.
The inspector concluded that the licensee was noi maintaining portable fire extinguisher inspection records in accordance'ith procedure 14FT-9FP01.
The inspector noted that PCN 3 was made on October 3 to procedure 14FT-9FP01.
This change deleted the procedural requirement for keeping monthly inspection records on tags attached to the portable extinguishers.
This procedure also does not require the use of annual maintenance tags, although
. this is a requirement of NFPA 10.
On October 17, the inspector noted that many extinguishers had no tags at all, and that the rest of those inspected (approximately 20 extinguishers)
had only annual maintenance tags.
All of the annual maintenance tags inspected were expired, bearing dates in 1987 or early 1988.
The inspector discussed the details of this observation with the cognizant supervisors.
These supervisors stated thai they were trying to comply with NFPA 10 while, at the same time, reducing the risk of noncompliance by removing unrequired tags which are vulnerable to being muti lated or removed without their concurrence.
They appeared to be unaware of the NFPA 10 requirement for annual maintenance tags, even though the inspectors had discussed this with them two weeks earlier.
As a result of these discussions, the fire prevention department supervisors stated that they would obtain adhesive labels with the required annual inspection record to attach to ihe extinguishers.
This had not been accomplished as of the end= of the inspection period.
During the course of this review, the inspector noted licensee efforts to improve control of portable fire extinguishers, including implementation of a color banding system to distinguish permanent portable fire extinguishers from those to be used for fire watches.
Although no violations of NRC requirements or deviations were identified, the inspector concluded thai the licensee's fire protection personnel do not appear to have a full understanding of this NFPA requirement, Review of Licensee Event Re orts - Units 1 2 and 3 (90712 an The following LERs were reviewed by the Resident Inspector Unit 2 LER NUMBER DESCRIPTION 89-,04-LO
"Technical Specification Action Requirement Performed Late Due to Personnel Error."
This
- report relates to a failure to supply the onsite Class lE electrical distribution system from two physically independent circuits.
Based on information provided in the report, it was concluded by the inspector that reporting requirements had been met, root causes had been identified and initial corrective actions were appropriate.
The inspector also reviewed Incident Investigation Report (IIR)
No. 3-2-89-028, Unit 2 Being Powered from NAN-X02," in order to learn what final corrective actions had been determined.
Control board modifications, not mentioned in the LER, were identified, including mimic changes and the.
addition of an annunciator.
The inspector confirmed that these additional corrective actions had been implemented and concluded that they were appropriate.
This LER is closed.
18.
Review of Periodic and S ecial Re orts - Units
2 and:3 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.
Mithin the scope of the above, the following reports were reviewed by the inspector.
Unit 1 o
Monthly Operating Report for September and October, 1989.
Unit 2 o
Monthly Operating Report for September and October, 1989.
Unit 3 o
Monthly Operating Report for September and October, 1989.
No violations of NRC requirements or deviations were identifie '
19.
~E"it M ti The inspector met with licensee management representatives periodically during the inspection and held an exit meeting on November 17, 198 '