IR 05000528/1989054
| ML17305A556 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 02/16/1990 |
| From: | Wong H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17305A554 | List: |
| References | |
| 50-528-89-54, 50-529-89-54, 50-530-89-54, NUDOCS 9003070014 | |
| Download: ML17305A556 (47) | |
Text
Re ort Nos.
Docket Nos.
License Nos.
Licensee:
~ U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
50-528/89-54, 50-529/89-54 and 50-530/89-54 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, 28
Ins ection Conducted:
December 18, 1989 through January 20, 1990 Inspectors:
Approved By:
T. Polich, Senior Resident Inspector D.
Coe, (Acting) Senior Resident Inspector J.
Ringwald, Resident Inspector J.
Sloan, Resident Inspector ong, e
Reactor Projects Branch,Section II a
e sgne Ins ection Summar
Ins ection on December
1989 throu h Januar
1990 (Re ort os.
an Areas Ins ected:
Routine, onsite, regular and backshift inspection by e
our ress ent inspectors.
Areas inspected included: previously identified items; review of plant activities; engineered safety feature system walkdowns; monthly surveillance testing; monthly plant maintenance; fuel reconstitution - Unit 1; 13.8 KV switchgear maintenance
- Unit 1; heated junction thermocouple probe obstruction - Unit 1; malfunction of the."D" 125 Volt battery to bus circuit breaker - Unit 1; refueling outage preparations
- Unit 2; blown fuse on power supply to valve AFA-HV-54 - Unit 2; "A" phase main transformer failure - Unit 3; auxiliary feedwater flow/pressure pulsations - Unit 3; sandblast grit found in instrument air hose to feedwater control valve - Unit 3; review of licensee event reports - Units 1, 2 and 3; and review of periodic and spec'ial reports - Units 1, 2 and 3.
During this inspection the following Inspection Procedures were utilized:
30703, 40500, 60705, 60710, 61726, 62703, 71707, 71710, 90712, 90713, 92700, 92701, 92702, and 93702.
Safet Issues Mana ement S stem (SIMS) Items:
None
Results:
Of the 15 areas inspected, one violation was identifi'ed.
The v)Vo Va >on pertained to corrective action at Unit 2.
General Conclusions and S ecific'indin s Si nificant Safet Hatters: "
None Summar of Violations:
One Summar of Deviations:
0 en Items Summar
None 8 items closed, 5 items left open, and 3 new items opene l
'
Persons Contacted:
DETAILS The below listed technical and supervisory personnel were among those contacted:
Arizona Nuclear Power Pro 'ect ANPP R.
J.
- J
- B H.
P.
P.
P.
E.
F.
- D.
P.
W.
F.
- D
- J W.
J ~
D.
C.
C.
G.
T.
E.
G.
- S R.
Adney, Allen, Bai 1 ey, Ballard, Bieling, Bradish, Brandjes, Caudill, Cogburn, Conway, Crawley, Firth, Garrett, Heinicke, Hughes, Ide, Larkin, Laskos, Levine, Harsh, HcLaren, Phillips, Rogers, Russo, Shell, Shriver, Simpson, Sowers, Terrigino, Younger, Plant Manager, Unit 3 Engineering 8 Construction Director Vice President, Nuclear Safety 8 Licensing equality Assurance Director Emergency Plan/Fire Protection Manager (Acting) Compliance Manager Central Maintenance Manager Site Services Director Standards and Tech.
Support Director Executive Vice President - Nuclear Nuclear Fuels Management Manager Training Manager Risk Management, Senior Engineer Plant Manager, Unit 2 Radiation Protection 8 Chemistry Manager Plant Manager, Unit 1 Security Manager guality Control Supervisor Vice President, Nuclear Power Production Plant Director Deputy Security Manager Maintenance Manager, Unit 1 Licensing Manager Assistant equality Assurance Director guality Systems Manager Work Control Manager, Unit 1 Vice-President of Engineering 8 Construction Engineering Evaluations Manager Management Services Supervisor 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 January 25, 1990.
Previousl Identified Items - Units 1
and
92701 92702 a.
Closed)
Followu Item 528/89-06-01:
"Control Element rive ec anism lr 00 ln nl S
ni This item concerned the licensee's evaluation of the failure of bolts holding the CEDM ACU's securely to the
top frame of the air plenum.
The "8" CEDM fan bolts had broken al1owing the fan to fall approximately 8 feet to the plenum floor.
This also damaged the power cables for the "D" fan.
The Root Cause of Failure engineering evaluation request (EER)(89-HC-005) is still open.
Results of the evaluation to date, according to the System Engineer, indicate that the root cause of this event is a failure of the fan bearing due to lubrication failure.
The existing, lubrication program for these fans meets the manufacturer's initial recommendation.
However, the manufacturer acknowledges that adjustments to the program may be necessary.
The Engineering Evaluation Department (EED) is evaluating the program, but has not yet determined what adjustments may be necessary.
Contributing causes to the failure included bolts of insufficient strength, nuts inadequately torqued, and may include the design of the fan housing which transmits the vibration of the motor bearings to the bolts.
An analysis of the bolting has been completed and the carbon steel SAE grade bolts have been replaced with Grade Five bolts with a heavy hex nut torqued to maximum pre-load.
Prior to this event the torquing of the nuts was left to the "skill of the craft" and averaged the suggested 35 foot-pounds.
The torque is now clearly specified to be 75 foot-pounds.
Following completion of Unit 1 reactor vessel head stacking, EED will test the fan and housing, using a
contractor to monitor eight channels of vibration and six channels of bolt stress.
The results of this testing will determine whether additional measures or structural modifications are necessary.
The current schedule for completion of the testing and closeout of EER 89-HC-005 is April 30, 1990.
The inspector also noted that a parallel evaluation was performed to bound the potential impact of this event in that the plenum material and structure were determined to be of sufficient strength as to prevent a
dropped fan from getting outside the plenum where it could impact safety-related equipment.
The inspector further noted that 41A0-1ZZ42, "Loss of HVAC," requires the operators to borate to OX power and open the reactor trip breakers if all CEDN ACVs are lost and to cool down to less than 450 degrees F if they cannot be restored within 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />.
The inspector discussed this with a Unit 1 Shift Supervisor who was knowledgable of this requirement.
The inspector concluded that the root cause evaluation to date has resulted in a clearly specified plan to complete the long term investigation and implement corrective actions as indicated, and that the completed and scheduled actions appear appropriate.
This item is close b.
(Closed)
Followu Item (528/89-06-02):
"Feeder Breaker a> ure o rl
-
n)
This item concerned the failure of 13. 8 KV feeder breaker 1E-NAN-S02A to trip open on a trip signal, apparently due to the failure of the preventive maintenance (PM) task procedures for medium voltage circuit breakers to reflect.
the manufacturer's recommendations and the failure of the preventive maintenance to be performed for two years.
All corrective actions for this item are complete as reflected in Inspection Report 50-528/89-43, Paragraph 2b, except the performance of the PM on all applicable circuit breakers prior to startup.
This item is complete for Units 2 and 3 and will be complete for Unit 1 prior to startup.
Unit 1 Restart Action Items 13 and 15 require these PM tasks to be complete or technically justified in accordance with the Preventive Maintenance Program if not complete prior to startup.
These Restart Action Items will be reviewed as part of the Unit 1 restart and therefore this item is considered closed.
c.
(0 en Enforcement Item (528/89-30-01:
"Ex ired amma e
tora e
ermsts -
nit This item involved three expired flammable storage permits which were found on flammable storage lockers in Unit l.
Upon discovery the licensee evaluated and renewed the three permits which had expired and walked down all flammable storage permits finding no additional expired permits.
In addition, an investigation was performed to determine the cause of these events, which revealed several problems.
While the investigaton was in progress, the resident inspector identified that one of the original permits was still posted after the Notice of Violation was issued.
The licensee conducted a further review of the entire flammable material storage permit program identifying that the program had one organization to review and approve Temporary Flammable Material Storage Permits and another responsible for posting and removing the permit.
The licensee responded by implementing a
computer tracking program which enables timely notification of responsible organizations as expiration dates approach.
The Fire Protection organization was also tasked with walking down selected areas of all three units on a 24-hour basis to verify that storage permits are correctly posted and current.
Four long term corrective actions were committed to in the Reply to the Notice of Violation dated September 27, 1989.
The inspector discussed the status of the four corrective actions with the Fire Protection Supervisor.
Three items were incorporated into the review of all Fire Protection Department activities by an outside contractor.
The contractor's final report was received on January 27, 1990, which is after the date committed to previously, but appears appropriate based on the expanded scope of revie The revision of procedure 14AC-OFP03 has been also delayed until April 19, 1990 in order to implement the contractor's recommendations.
Instruction change requests to revise work planning/work control procedures were initiated on December 20, 1989, based on the contractor's draft report.
In addition, the contractor has been tasked to perform some procedure'riting which should be completed by February 1, 1990.
Further, Site Modification 13-SM-ZZ-001 has been initiated and funded for Fire Protection Engineering.personnel to design permanent storage lockers, analyze, fire loadings, and install these lockers in the plant.
The remaining corrective action is ongoing and tracked as Regulatory Commitment Tracking System (RCTS) Item No.
039557.
The inspector discussed this with the gA Monitoring Supervisor who indicated that twe1ve monitoring reports were complete.
The gA Monitoring Supervisor's Intention was to stop the monitoring and close the RCTS item on December 31, 1989, based on an observed improvement of this area in the field and the originally scheduled implementation of the other corrective actions as discussed above by December 31, 1989.
Since the completion date for revision to 14AC-OFP03 has been moved to April 15, 1990, the gA Monitoring Supervisor's intention was to close this RCTS item at that time.
When the inspector discussed the rationale of terminating the monitoring program designed to evaluate the effectiveness of corrective actions on the date the corrective actions would be finally fully in place, the gA Monitoring Supervisor responded that he would continue this program
"at least" until it is fully in place.
The inspector then discussed this issue with the Compliance Manager and was assured that this RCTS item would not be closed until at least three months had elapsed since the 14AC-OFP03-revisions are fully in place.
Licensee management also stated that periodic gA monitoring of this area would continue indefinitely as part of the monitoring program.
The inspector had no further questions, however, this item will remain open until the inspector can review the final program to ensure all commitments are incorporated.
{Closed) Followu Item 529/88-42-03):
"Reactor Power u
ac
-
nest The inspector reviewed Special Plant-Event Evaluation Report (SPEER)
No. 88-02-011,
"Reactor Power Cutback Due to Main Turbine Trip - December 22, 1988."
This open item reviews the concerns and corrective actions resulting from the SPEER.
The inspector concluded that the SPEER
.identified and addressed the major concerns associated with equipment and personnel performance during the even The SPEER identified two operational concerns which.were considered significant by the inspector.
First, the STA failed to maintain an overall understanding of plant conditions during the transient in that he did not notice a power increase.
Consequently, he was ineffective in fulfillingthe STA function.
Second, the Primary Operator did not understand or recognize how reactor coolant system temperature was being maintained and consequently took improper action by withdrawing control element assemblies to raise power.
The Shift Supervisor did not provide close enough oversight to redirect this effort.
The event and SPEER demonstrate the importance for operators to understand which systems are controlling important plant parameters at all times.
Shift supervision and STAs must maintain awareness of plant conditions, particularly during transient conditions, in order to quickly recognize and act responsively to provide mitigating direction when necessary.
The licensee counselled the STA, the Primary Operator and the Shift Supervisor involved.
The inspector considered overall corrective actions to be appropriate and adequate for this event.
This item is closed.
(Closed)
Followu Item (529/89-06-02
"Blown Fuse on ower u
o a ve
-
-
-
n>
This open item stems from a control power fuse which blew due to an incorrectly sized light bulb burning out.
A long term engineering project of preparing and validating a complete light bulb replacement list was initiated but is only about 10X complete.
Due to the extended delay of
'the engineering organization's projected schedule for completing this effort, the Unit 2 Operations department independently developed its own list, which has been in place since about May 1989.
A recurrence of this event is discussed in Paragraph 12.
This followup item will be closed based on opening the enforcement item discussed in Paragraph 12.
The licensee's corrective actions will be followed as part of the Notice of Violation discussed in that paragraph.
This item is close Closed)
Followu Item (529/89-21-02
- "Review of Ade uac o
oca anua era son o
an ui men
-
ni This open item stemmed from the inadequacy of manual operating instructions for the atmospheric dump valves on Unit 3, and was a Unit 2 restart=issue.
The inspector reviewed the licensee's summary of training program modifications resulting from the licensee's analysis of manual tasks which are important to safety or infrequently performed.
Additionally, the inspector noted that by April 1, 1990 the instr'uctions for valves with local-manual operation capability were scheduled to be enhanced and incorporated into the unit specific procedures 4XDP-XOPOl "Manual Operation of Air Operated Valves."
The licensee's completion of this analysis and establishment of a schedule for completing procedural-improvements demonstrates satisfactory progress in addressinq this issue.
The unit specific procedures had been previously issued with improved instructions for the original valves of concern, and this followup item was to assure that other such valves were identified and scheduled for incorporation into existing procedrues.
This item is therefore closed.
g.
0 en) Followu Item (529/89-30-03):
"Work on Nitro en e
u a or er er a nstructions
-
ni The guality Assurance (gA) evaluation of the programmatic controls regarding vendors and vendor recommendations was completed by the licensee.
This evaluation concluded that current programmatic controls are unsatisfactory, but that the inadequacies are documented in Corrective Action Reports (CARs) CS-89-0058 and CS-89-0059.
The gA department is following implementation of corrective actions to these CARs.
This item will remain open pending review of the closure of the referrenced CARs.
h.
(Closed) 89-09-P
CFR Part 21 Re ort of Deficienc With on ro srcust o
oo er mer enc
>ese enera or nest't one
)
e own The licensee for NMP reported a deficiency in the EDG control circuit designed by Stone and Webster Engineering Corporation.
The licensee for Palo Verde Nuclear Generating Station (PVNGS) determined that the control circuit for the six Cooper EDGs on site was not subject to this design deficiency by virtue of having a different design.
This item is closed.
(Closed) 89-10-P
CFR Part 21 Re ort of Automatic Switch om an-wa o eno>
a ve as ure.
The vendor reported a deficiency in the angle of the valve seats on certain models of their 2-way solenoid valves
which could cause the valves to fail either open or closed.
The licensee determined that, of the affected models, only one was in use at Palo Verde.
This model was installed only in the Turbine Cooling system.
Based on the inspector's inquiry into the status of this report, the licensee initiated an Engineerinq Evaluation Request to determine the impact of the deficiency on the Turbine Cooling system.
The inspector noted that ANPP had not received this report until the inspector gave it to them because the vendor had misidentified the applicable ANPP facility.
Based on the licensee's determination that the affected valves were not present in any safety-related system, this item is closed.
0 en) 89-18-P
CFR Part 21 Re ort of Deficienc With ABB ower is ri u ion nc.
urren rans ormer nca su an a eria
.
The vendor reported a softening of the epoxy-anhydride encapsulant material in CTs due to high humidity conditions.
The licensee initiated EER-89-XE-28.to evaluate the potential impact on installed CTs.
This item will remain open until the evaluation can be reviewed by the licensee.
(0 en) 89-24-P
CFR Part 21 Re ort and Information 0 ice
"
n erna iona nc.
i ressure win ec a ve ai ure.
The vendor initially reported the failure of one of their check valves at Comanche Peak Steam Electric Station.
The Part 21 report indicated that initial investigation of the failed valve showed
"no defects or failure to comply."
Based on this, the licensee determined no further evaluation was necessary.
The NRC issued Information Notice 90-03 on January 23, 1990 related to the check valve failure and this item will remain open pending evaluation of the Information Notice by the licensee.
0 en 89-25-P
CFR Part 21 Re ort of Deficienc With imi or ue
-
an
-
o or era or or ue wi c es.
The vendor reported a deficiency with the above torque switches on certain motor operators with specified serial numbers.
The licensee initiated EER 89-XE-059 to evaluate this condition for impact on installed motor operators.
This item will remain open until the evaluation is complete by the license.
Review of Plant Activities (71707 71710 93702)
a4 b.
C.
Unit 1 Unit 1 entered the inspection period in Mode 6.
Mode
was entered on January 9,=1990, after fuel loading was completed.
The unit continued refueling outage activities in Mode 5 for the duration of the reporting period.
Unit 2 Unit 2 operated at essentially 100K power during the reporting period.
Plant activities involved principally outage preparation and performance of 18 month surveillances.
Unit 3 Unit 3 began the inspection report period in Mode 3.
On December 22, 1989, Unit 3 returned to Mode 4 to complete a
modification to the turbine driven Auxiliary Feedwater (AFW) pump (see paragraph 14).
The unit was returned to Mode 3 on December 24, 1989, and the AFW pump was tested satisfactorily.
Additionally, on December 24, the. NRC issued a letter to ANPP which authorized entry of Unit 3 into Mode 2 in accordance with the provision of the Confirmatory Action Letter dated June 28, 1989, (see paragraph 15).
Operators started up the reactor on December 26, 1989, going critical at 1755 and began conducting reactor physics tests.
On December 30, 1989, an internal fault occurred in the "A" phase main transformer shortly after the main generator was synchronized to the grid.
The reactor was manually shutdown to Mode 3.
Reactor operation resumed on January 18, 1990, while final preparation and testing of the newly installed phase
"A" main transformer was completed (see paragraph 13).
Mode 1 was entered at 2147 on January 19, 1990, and the unit remained in that mode until the end of the inspection period.
d.
Plant Tours The following plant areas at Units 1, 2 and 3 were toured by the inspector during the inspection:
o Auxiliary Building o
Containment Building o
Control Complex Building o
Diesel Generator Building o
Radwaste Building o
Turbine Building o
Yard Area and Perimeter The following areas were observed during the tours:
l
0 eratin Lo s and Records
- Records were reviewed agains ec naca pec>>cation and administrative control procedure requirements.
Monitorin Instrumentation
- Process instruments were o serve or corre a ion between 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
- Various 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.
E ui ment Ta in
- Selected equipment, for. which agging 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 >ca sons o
system leakage, improper lubrication, or other conditions that would prevent the systems from fulfillingtheir functional requirements.
Fire Protection
- Fire fighting equipment and
~b df f
ithT hi Specifications and administrative procedures.
Plant Chemistr
- Chemical analysis results were revs ewe 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.
Plant Mousekee in
- Plant conditions and ma erma equipmen 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.
Radiation Protection Controls
- Areas observed inc u
e con ro po)n 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.
On January 8, 1990, a Unit 2 lead radwaste'upport operator was found to be contaminated as he was exiting the site.
The resident inspector followed the licensee's actions to assure that the extent of the contamination was identified and appropriate controls established.
Region V based health physics inspectors will follow licensee actions with respect to this event.
No violations of NRC requirements or deviations were identified.
4.
En ineered Safet Feature S stem Walkdowns - Units j.
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 1
0 Containment ESF Sump "B" Control Room HVAC "A" Unit 2 o
Condensate Storage Tank o
Auxiliary Feedwater Trains "A" and "B" Unit 3 o
Safety Injection Tanks A, B, C and 0.
No violations of NRC requirements or deviations were identified.
5.
Monthl Surveillance Testin
- Units 1 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
b.
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 the following surveillances were observed by the inspector during this inspection period:
Unit 1 Procedure Descri tion o 41ST-1ZZ35 RMS Surveillance Mode 5-6 Logs Unit 2 Procedure o 32ST-9PEOl
~di tt 18 Month Surveillance Test of Diesel Generator o 31ST-9DG01 Diesel Engine 18 Month Surveillance o 42ST-2SI10 Unit 3 High Pressure Safety Injection Pump Operability Test C.
P d
~II Itt o 73ST-3ZC01 Tendon Integrity The inspector was involved with the NRC Licensing Plant Manager regarding the licensee's request to be temporarily exempted from surveillance requirements for the control element drive mechanisms with grounded coils on Unit 2.
On January 5, 1990, NRC:NRR issued a temporary waiver of compliance for temporary relief from T/S surveillance requirement 4. 1.3. 1.2 for CEA's No.
27 and 41 for a period of 30 days by which time a T/S amendment could be approved.
No violations of NRC requirements or deviations were identified.
6.
Monthl Plant Maintenance - Units 1 2 and 3 (62703 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.
b.
Specifically, the inspector witnessed portions of the following maintenance activities:
Unit 1 Descri tion o
Preventive Maintenance of 13.8 KV Switchgear NAN-S03 (see paragraph 8)
Unit 2 Descri tion o
Normal Chiller "A" Cooler Hot Gas Bypass Temperature Switch Calibration o
High Pressure Safety. Injection Pump "A" Vibration Measurement Unit 3 Descri tion o
Steam Bypass Control Valve SGN V1008 Positioner Adjustment Il o
Feedwater Downcomer Check Valve SGN V431 Repair Retest 7.
Fuel Reconstitution - Unit 1 60710 The inspector observed portions of the fuel, reconstitution effort.
This reconstitution was required because a stuck fuel assembly event during the core reload may have resulted in some permanent deformation of the tabs in the grid spacers which hold the fuel rods laterally and prevent flow induced vibration.
This event was extensively described in a previous NRC inspection report.
During the reconstitution, two events resulted in delays and one required the institution of additional controls to ensure that the reconstitution was completed successfully.
The first event was the dropping of a cord tension relief bracket made of aluminum into the spent fuel pool.
The bracket had been tied to the spent fuel bridge with nylon cord.
The knot, which was required for gC Zone III integrity, had come loose and the bracket and cord fell into the pool. and down into an empty spent fuel rack location.
The bracket and cord were retrieved and an additional twice per shift walkdown of the reconstitution area on the bridge was instituted to ensure that
r,
only the required tools were present and were being stored or secured appropriately.
These corrective actions were implemented before reconstitution continued and neither dropping nor retrieving the bracket had any physical impact on any fuel assembly.
The second event involved the misplacement of a fuel rod in a fuel grid spacer assembly.
The reconstitution teams used identical metal templates over the grid spacer assemblies on both the old and new assemblies to help the teams identify and place the fuel rods in the proper locations.
The location of the misplaced fuel rod was the mirror image of the correct location.
The reconstitution team used independent verification and an underwater camera to check the proper tool placement.
Even with these controls in place, three different individuals failed to notice the error and the wrong fuel rod was withdrawn.
After 2 other fuel rods were moved, the operators moved the tool to the hole where the incorrect rod had been withdrawn earlier and discovered there was no rod to
~
~
~
~
~
~
rasp.
A review of the prior rod moves revealed the problem.
econstitution was halted until a complete investigation and critique could be held.
The assistant plant manager led the investigation and the investigation concluded that while fatigue and equipment problems were not a factor, the operators were not attentive to the details of the task at hand.
All involved individuals were counselled and the event was thoroughly reviewed before the error was corrected and reconstitution was continued.
While not judged a significant contributor to the error, an underwater camera was repositioned to give the operators a better view of the fuel rods.
While Inspection Report 50-528/89-50 discussed licensee personnel failures to inform appropriate management of events involving problems during fuel movement, the inspector concluded that management notification and response following the latest event appears to have been appropriate.
No violations of NRC regulations or deviations were identified.
13.8 KV Switch ear Maintenance - Unit 1 (62703)
Preventive maintenance of the non-class 13.8 KV switchgear NAN-S03 was performed under Work Order No.
393193 on January 19, 1990, and witnessed in part by the inspector.
When performing a visual inspection of the grounding cables, the contract electrician incorrectly traced the cables and thereby missed inspecting a portion of the system until the inspector questioned his conclusions.
The electrician also did not understand how to operate the Digital Low Resistance Ohmmeter (DLRO); even with the aid of a second electrician, the DLRO remained non-functional until the inspector asked if the charger jack cap needed to be installed to provide appropriate feedbac Further investigation revealed that the contract electrician had received some informal hands-on training on the use of the DLRO, but that formal training had not been conducted.
After, discussing this activity with the cognizant supervision, the licensee reperformed the work.
Additionally, the licensee committed to reindoctrinating the contractor electrician on the observed areas of weakness, and to adding the DLRO operation to its formal maintenance trasning program.
No violations of NRC regulations or deviations were identified.
Heated Junction Thermocou le Probe Obstruction - Unit 1 93702 On January 14, 1990, the "B" Train heated junction thermocouple (HJTC) probe was unable to be inserted fully into its required position due to an obstruction in its guide tube.
The HJTC probe could be inserted to just below the upper guide structure support plate, where it became obstructed at what the licensee believed to be a weld location.
The licensee is investigating the obstruction to determine appropriate corrective actions.
The inspector is closely following these actions and will update the status in the next periodic inspection report.
No violations of NRC regulations or deviations were identified.
Malfunction of the
"D"- 125 Volt Batter to Bus Circuit rea er -
ns On the afternoon of January 2, 1990, electricians in Unit 1 were preparing for a discharge test on the "D" Class 1E battery.
The equipment used to load the battery failed and the licensee intended that the battery be restored to its normal lineup by racking in and closing the battery output breaker to reestablish a float charge.
The breaker was open when it was racked in, however the breaker went closed as soon as the closing springs charged.
No manual closing action was initiated by the electricians, thus the breaker should have remained open after the closing springs were charged and latched, Work Order (WO) No. 401523 was initiated to troubleshoot and rework the breaker as required.
Electricians examining the breaker found a small spring disengaged from its proper position.
If properly positioned, the spring would have acted upon a solenoid operated armature and at the conclusion of the charging cycle would cause a pawl on the armature to engage and hold the closing spring in a charged state and prevent the breaker from closing.
The electricians restored the spring to a position which was identified on the next shift to be the incorrect position according to a technical manual photograph.
However, even with the spring in the incorrect position, the breaker tested satisfactorily.
On January 4, 1990, the NRC inspector questioned the cognizant system engineers as to possible impact on operability of the t
affected breaker as well as whether this condition could exist on similar breakers in the other units.
An MNCR was initiated, but was not validated by Quality Control (QC).
The QC representative invalidated the MNCR based on a provision of 60AC-OQQ01, "Control of Non-Conforming Items," which states that "deviations or discrepancies which can be corrected within the scope of a work order or procedure in process" do not require initiation of an MNCR.
Work Order No. 401523 was still open and was used to invalidate the MNCR.
The inspector concluded that the licensee's program to control non-conforming conditions appeared to allow valid non-conforming conditions to not be properly evaluated in the MNCR process if the condition is discovered during implementation of an open WO or if a WO is initiated prior to the MNCR. It appeared to the NRC inspector that the MNCR program, which was three months old at the time, was not well understood by maintenance personnel tasked with initiating MNCRs, nor by the QC organization tasked with initial evaluation of the reported condition.
In addition, the inspector noted the following:
o The "condition" reported by MNCR 90-PK-001 was that "the breaker is closing immediately after the springs are charged."
This was not a description of the physical non-conforming condition as intended by procedure 60AC-OQQ01, "Control of Non-Conforming Items."
o The "requirement" specified on the MNCR was to "reposition the closing coil armature tension spring."
This was not the "requirement" that the non-conforming condition failed to meet, but rather was a recommended action.
Thus, the inspector concluded that the MNCR was not documented as intended by 60AC-OQQ01.
Based on the NRC inspector's discusions with licensee personnel, system engineering initiated a Root Cause of Failure (RCF)
EER and work requests to verify the condition of the remaining Unit 1 breakers and those in Units 2 and 3.
Inspection of the other breakers revealed correct spring positions (as confirmed by the vendor) in all but two breakers in Unit 3.
In one of these, the spring was not in the groove provided on the post upon which the spring is tensioned, and in the other, the spring was tensioned against an adjacent post.
In both cases the spring was acting on the proper mechanism, but not in strict conformance with the technical manual.
These were restored to their proper configuration.
At the end of this reporting period, the licensee s investigation had not determined a root cause of failure.
The inspector observed the action of the spring during breaker operation and concluded that normal operation would not generally cause a mispositioned sprin e f
The licensee acknowledged the inspector's concerns and indicated that as part of an overall preplanned review of the implementation of the MNCR program, procedure 60AC-OQQ01 would be clarified as necessary, and further guidance to all organizations tasked with program implementation would be implemented during planned "Quality Talks."
The inspector will review the licensee's changes to procedure 60AC-OQQOl, "Control of Non-Conforming, Items" and the 'Quality Talk" guidance upon completion (Inspector Followup Item 528/89-54-01).
No violations of NRC regulations or deviations were identified.
Refuelin Outa e Pre arations - Unit 2 60705 General preparations for the late March 1990 refueling were reviewed by the inspector.
Management involvement in the preparations appears to be adequate.
The outage schedule addresses refueling cavity water level, boration flow path availability and other important parameters appropriate for the planned plant conditions.
The outage organization and lines of communication have been defined.
Procedures are in place for required surveillances.
No violations of NRC regulations or deviations were identified.
Blown Fuse on Power Su
to Valve AFA-HV-54 - Unit 2 93702 On December 12, 1989, the "A" Auxiliary Feedwater (AFW) train was declared inoperable due to the loss of control ~ower to AFA-HV-54 (steam supply throttle/trip valve to the
'A" AFW pump turbine).
Control Room operators noted abnormal control board indications for the valve (one light out and the other light very dim).
The same indications were observed at the local panel.
Electricians found a fuse in the indication and control circuit blown.
Additionally, the indication bulb which was out was also blown.
This bulb, and one other in the circuit, were found to be for 28 volt service instead of the required 120 volt.
The bulbs and fuse were replaced, surveillance test 73ST-2XI05 was performed on the'alve, and the system was declared operable.
Loss of the control power to AFA-HV-54 does not render the auxiliary feedwater pump inoperable as this valve remains in the "open" position during system operation and is not required to move to provide steam to the AFW pump turbine.
Overspeed protection is not lost as the governor controls are supplied by a different power supply.
The automatic reset of the trip-throttle valve following an overspeed trip is affected by the loss of power to AFA-HV-54.
Without control power, re-opening this valve would require manual operator 'action.
The pump was declared inoperable until the bulb and fuse replacements were complet This same event occurred in Unit 2 on February 12, 1989, (see Inspection Report 529/89-06, and Followup Item 529/89-06-02, statused in this report).
The February 12, 1989 event involved the same piece of equipment and light bulb which was found blown in the most recent event.
The licensee's previous corrective actions were intended to encompass all safety-related systems and other important systems.
The licensee committed to correcting the Plant Equipment Light Bulb Index, which had been a causal factor in the first event.
The licensee's engineering organization projected over a year to complete the development of a validated Index.
Because operations supervision considered this delay excessive they undertook an independent effort and verified the Index for all critical systems in about three months.
The engineering effort is still progressing, but the schedule has slipped and this effort is estimated at only ten percent complete.
Apparently no corrective actions were implemented between the February event and the time the interim Index was completed, in about June 1989.
Final corrective actions are not expected to be implemented until at least 1991.
The licensee has been unable to determine when the incorrect bulbs were installed which.led to the December 12, 1989 event.
Because using incorrectly sized indicating light bulbs can potentially affect the operability of equipment or disable normal equipment controls (e. g., by blowing control power fuses),
the inspector considers it important for the licensee-to have effective controls on light bulb replacement.
Even though current Index lists may be adequate, it is apparent that the extent of corrective actions from the previous occurrence was insufficient to prevent recurrence.
This appears to be a violation of NRC requirements (529/89-54-01).
The inspector noted that even with accurate Index lists, operators must use sufficient care to select the proper bulbs during replacement.
In response to this most recent occurrence, the licensee checked all the light bulbs in the storage bin for the 120 volt bulbs to ensure only correct bulbs were present.
The licensee stated that all safety systems containing swapable bulb types were checked to confirm the proper bulbs were installed.
Additionally, a Night Order was issued stressing to operators the correct procedure for bulb replacement.
The licensee committed to proceduralizing the'updated Plant Equipment Light Bulb Index.
A description of this event was sent to the other units, and auxiliary operators were briefed on the event and on the proper bulb replacement procedure.
The interim Index has also been implemented on Units I and 3, and the Engineering Evaluations Department has determined that the list is adequate for interim use.
One apparent violation of NRC requirements was identifie "A" Phase Main Transformer Failure - Unit 3 (93702
.
On December 30, 1989, while at 11K reactor power with the main generator supplying power to the grid, the Palo Verde Unit 3 phase
"A" main transformer experienced an internal fault at 4:30 PM (MST).
Unit 3 was being returned to power operation following its first refueling outage.
The internal fault caused excessive internal pressure within the phase
"A" transformer, splitting several seams in the housing and draining or spraying out all, of the internal oil and causing smoke to come from the transformer.
One of two main transformer ceramic insulator bushings cracked, and a surge capacitor bank inside the turbine building was damaged.
The fault caused an immediate trip of the main generator output breakers and the reactor was stabilized at approximately 13%
power.
Site fire protection personnel responded and activated the transformer deluge system in addition to forcing water and foam into an opening in the upper section of the transformer housing.
Smoke and an occasional flame were seen emanating from the transformer.
The licensee declared the fire out within 10 minutes and therefore did not de'clare an Unusual Event.
Although in Units 1 and 2 some non-safety-related alarms came in and some non-safety-related equipment tripped due to a momentary under-voltage condition caused by the grid disturbance, there was no impact to any safety-related electrical busses or equipment.
Unit 3 was returned to Mode 3 at 1:20 AM (MST) 'on December 31, 1989.
The licensee s investigation included an inspection, analysis, and recommendation by the transformer vendor.
The vendor's report concluded the actual cause of the internal fault was indeterminate due to extensive internal damage, but that the most likely cause was a phenomena called streaming electrification, and is associated with the oil flow through the transformer.
The licensee completed installation and testing of a new transformer and, at the vendor's recommendation, modified the cooling oil pump starting sequence to minimize streaming electrification.
The inspector reviewed the licensee's Incident Investigation Report (IIR) 3-3-89-037 dated December 30, 1989, which identified issues related to clarifying the definition of a
"fire" for event declaration purposes, back leakage through a
feedwater check valve, non-class electrical system response,.
operation of the alarm tripper system (RONAN) and Transient Data Acquisition System (TDAS),'nd use of portable radios.
The inspector noted that each of these areas were addressed with either an Instruction Change Request (ICR), Work Request/Order (WR/WO), Engineering Study (ES), or Engineering Evaluation Request (EER).
The inspector forwarded the vendor report on the possible cause for transformer failure to the NRC Region V office and the
l I
t
Office of Nuclear Reactor Regulation for further evaluation as deemed appropriate.
The licensee's actions in this event and their event classification will be reviewed by a Region V
based Emergency Preparedness inspector during a future inspection.
The inspector concluded that the licensee appeared to identify the significant issues and initiated appropriate corrective action.
The Unit 3 main transformer >as returned to service at 0021 on January 21, 1990, when the main generator was synchronized to
.the grid.
No violations of NRC regulations or deviations were identified.
Auxiliar Feedwater Flow/Pressure Pulsations - Unit 3 (93702).
As reported in NRC Inspection Report 530/89-50, the Unit 3 Turbine Driven Auxiliary Feedwater Pump AFA-POl experienced flow/pressure pulsations resulting in a "knocking" noise within the mini-recirculation piping.
The licensee determined, through analysis of test measurements, that the pulsations were related to a resonance condition peculiar to the Unit 3 piping configuration and the new rotating assembly installed during the refueling outage.
Through additional tests with an added
"micro-recirculation" flow path in parallel with a portion of the normal mini-flow path, the licensee was able to eliminate the pulsations.
Subsequently, the licensee installed a
Temporary Modification micro-recirculation line to maintain long-term pump reliability and to allow time to investigate a
more permanent solution, and performed testing to confirm that the additional flow through the added line was within the design bases analyses of the AFM system.
Throughout the licensee's investigations, the inspector noted the availability of a frequently updated action plan with assigned responsibility, coordinated participation of several licensee groups such as maintenance, work control-, operations, system engineering, nuclear engineering, PRB, and outside groups such as the pump manufacturer and an independent pump consultant.
The inspector noted that mechanical work practices associated with removal and reinstallation of the pump rotating element included a segregated tool lay down area and an overhead canopy above the open pump casing to prevent foreign objects from entering.
In addition, the inspector reviewed weld inspection documents following Temporary Modification installation and found 'no discrepancies.
The inspector noted that even though the pump could meet surveillance test acceptance criteria, the licensee pursued a
course of action involving a significant coordination effort and resource expenditure to eliminate this problem.
The
inspector concluded the licensee's actions appeared to be commensurate with the importance to safety of the auxiliary feedwater system.
No violations of NRC regulations or deviations were identified.
Sandblast Grit Found in Instrument Air Hose to Feedwater Contro a ve -
nest 3 02
.
During investigation of an air leak on January 18, 1990, at an instrument air hose supplying air to 3-SGN-FV-1113, downcomer feedwater control valve to No.
2 Steam Generator, the licensee discovered a significant quantity of foreign material in the air booster relay attached to the hose.
The licensee determined the substance to be sandblast grit used by the hose manufacturer to clean the brazed end fittings.
The hose had been recently purchased and installed on January ll, 1990.
The licensee retrieved the remaining hoses from the warehouse and determined that no other such hoses had been installed in the plant.
Grit was also found in the retrieved hoses.
In addition, the licensee sampled seven different locations in the instrument air system upstream of the feedwater control valves.
All such samples met cleanliness standards.
The inspector discussed this occurrence with the Instrumentation and Control (I8C) and Mechanical Shop Supervisors and with the Unit 3 Maintenance Manager.
The Work Order (WO) requirements specified maintenance of "Class C"
cleanliness standards in accordance with licensee procedure 31MT-9ZZ09 and to prevent any foreign material entry in accordance with 30AC-9WP01.
The WO clearly presumed that components being installed met cleanliness requirements prior to installation and that the concern was primarily entry of outside foreign material into the system or component.
Because the hoses in question were supplied with plastic end cap covers, this further emphasized only the concern regarding foreign material entry.
The above individuals acknowledged these observations and the inspector concluded that the WO instructions did not explicitly-require a cleanliness verification of the hose and therefore one was not performed.
Licensee management stated that requirements for cleanliness verification by the supplier would be added to future purchase orders for air hoses.
In addition to a training session to cra'ft personnel and adding training on cleanliness flushes to formal maintenance training, the Conduct of Maintenance procedure would be changed to include cleanliness flushes when appropriate.
The inspector will review the formal training and changes to the Conduct of Maintenance procedure upon completion (Fo1 1 owup Item 530/89-54-01).
No violations of NRC regulations or deviations were identified.
Entr Into Mode 2 - Unit 3 (93702).
21, The Confirmatory Action Letter (CAL) issued by the NRC Regional Administrator on June 28, 1989, required that Unit 3 undertake
'ctions in specified areas prior to restarting the reactor following the March 3, 1989 trip.
Since that time; numerous corrective actions have been taken, and which= provided the basis for the NRC to authorize the restart of Unit 2 under the terms of the CAL.
The licensee commited to 204 actions specific to preparing Unit 3 for restart.
The inspector reviewed a
selected sample of approximately ten percent of these items for completion.
This review included areas such as ADVs, Steam Bypass Control Valves, Electrical Distribution, and Emergency Lighting.
This review culminated in the lifting of the CAL on December 24, 1989.
No violations of NRC regulations or deviations were identified.
R Review of Licensee Event Re orts - Units 1 2 and 3 (90712 an The following LERs were reviewed by the Resident Inspectors.
Unit 1 LER NUMBER DESCRIPTION 84-01-LO This LER Corrective Action is awaiting completion of EER 89-FP-037 and EER 89-FP-139 scheduled for completion by March 31, 1990.
This LER will remain open until these EERs are complete and reviewed by the Resident Inspectors.
Unit 2 LER NUMBER DESCRIPTION 89-08-LO/Ll
"Improper Performance of Surveillance Test for Startup Channel 2".
This item is considered closed.
Review of Periodic and S ecial Re orts - Units 1 2 and
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 informatio Mithin the scope of the above, the following reports were reviewed by the inspector.
Unit 1 o
deathly Operating Report for December 1989.
Unit 2 oOfonthly Operating Report for December 1989.
Unit 3 oHonthiy Dperating Report for December 1989.
No violations of NRC requirements or deviations were identified.
19.
Exit Meetin (30703 The inspector met with 1icensee management representatives periodically during the inspection and held an exit meeting on January 25, 199 A
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