IR 05000346/1985030

Insp Rept 50-346/85-30 on 850812-0909.Violations Identified: Lack of Design Control Measures to Validate Design of Limitorque Valves & Auxiliary Feedwater Pump Turbines.Test Procedures Inadequate for Limitorque Valves Test Program

ML20138L208
Person / Time
Site:	Davis Besse
Issue date:	12/13/1985
From:	Jackiw I NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20138L198	List: IR 05000346/1985030 ML20138L194
References
50-346-85-30, NUDOCS 8512190192
Download: ML20138L208 (11)

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U. S. NUCLEAR REGULATORY COfNISSION REGION II' . !

Report No. 50-346/85030(DRP)

Docket.No'. 50-346 License No. NPF-3

. Licensee: Toledo 1 Edison Company Edison Plaza, 300 Madison Avenue Toledo, OH 43652 Facility Name: Davis-Besse 1

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Inspection At: Oak Harbor, OH D Inspectio'n' Conducted: August 12 through September 9, 1985 Inspectors: W.~~G.-Rogers D. C. Kosloff B. L. Burgess Approved By: /2 /T I. 7. Jackig Chief- Date /

Redctor Pr4jects Section~28:

Insp'ection Summary

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Inspection on August 12 through September 9, 1985 (Report No. 50-346/85030(DRP))

- ? Areas Inspected: Special inspection of-the circumstances surrounding three events: .inoperability of an auxiliary feedwater flow rate instrument; the licensee's investigation of water hammer in the steam supply lines to the auxiliary feedwater system; and the loss ~of all.feedwater on June 9, 1985, including subsequent investigations into the equipment failures and-malfunctions that occurred during the event.' The inspection involved a total of 140 inspector-hours onsite including 50 inspector-hours onsite during

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off-shift Results: Numerous violations _were identified (failure to provide adequate design control. measures in the validation of the design of Limitorque valves and auxiliary feedwater pump turbines; failure to provide adequate test procedures to implement the established test program for some Limitorqu valves; failure to provide adequate maintenance instructions.and failure to follow established maintenance procedures; failure to establish a test program in accordance with the ASME Boiler and Pressure Vessel Code for two auxiliary Lfeedwater. valves; failure to take adequate corrective actions to resolve conditions adverse to quality to preclude recurrence of those conditions; failure to design the. Steam and Feedwater Rupture Control System in accordance with IEEE-279-for protection against single. failure; failure to provide

' adequate training associated with resetting the auxiliary feedwater turbine

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overspeed mechanism; failure.to provide adequate instructions for resetting the auxiliary feedwater turbine overspeed mechanism; failure to meet the

' Technical Specification limiting condition for operation associated with auxiliary feedwater flow rate instrument, FI4521; failure to follow an established administrative procedure and failure to provide adequate testing instructions associated with auxiliary feedwater flow rate instrumentation; failure to perform adequate inspection activities on hanger installations;

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failure to write nonconformance reports to document damage' found on auxiliary feedwater steam supply hangers; failure to adequately assess and evaluate the root cause of individual and collective damage to auxiliary feedwater piping

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supports; failure to report under 10 CFR 50.73 the extent of degradation associated with the auxiliary feedwater piping supports).

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DETAILS 1.- Persons Contacted Toledo' Edison

• L. Storz, Plant Manager S. Smith, Superintendent of Maintenance

=W. O' Conner, Operations Superintendent

~J. Ligenfelter, Technical Superintendent R. Peters, Nuclear Licensing Manager

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_*S. Wideman, Senior Licensing Specialist

• J. Wood, Facility Engineering General Superintendent

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.*B. Geddes, Associate Q.A. Auditor

• N.- Bonne'r,. Electrical Maintenan'ce Superintendent

. NRC

• Rogers, Senior Resident. Inspector

• D.' Kosloff, Resident Inspector

• B. Burgess,. Project Inspector

• Denotes those-personnel attending the September.11, 1985 exi The inspectors also interviewed other licensee employees, including-

. members of the technical, operations, maintenance, I&C, training, health physics and nuclear materials management department staf . Loss of Feedwater on June 9, 1985 The loss of feedwater event is described in detail in NUREG-115 Therefore, NUREG-1154 should be reviewed for the in-depth review and analysis of the event. Numerous inspection activities are continuing associated with equipment troubleshooting and corrective actions originating from the June 9, 1985 event. This inspection was conducted to identify all : violations.of regulatory requirements positively known at the end of this inspection period. Given the interim nature of this report further violations may be identified in the future..The inspector reviewed the following documents:

(a) Findings _of the Fact Finding Team (FFT) published in NUREG-1154 (b) -Portions of-the transcripts of interviews held with licensee personnel by the FFT

'(c) Selected action plans and root cause reports of the licensee

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on equipment which may have malfunctioned during the event (d) Previous inspection reports concerning the event lThe' sole purpose of these reviews was to identify violations of regulatory requirement l l

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. Main'Feedwater. Pump. Turbine and Controls: No' violations were identified related to this equipment.: . Steam and Feedwater RuptureLControl System (SFRCS): Violations

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.were identified related:to this equipmen The licensee. attributed'the closure of the Main Steam Isolation V'alves-

-on June 9, 1985, to. actuation of.the SFRCS.on a spurious steam generator-

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, (SG). low level indication caused'by a pressure pulse caused by closure of the main turbine stop valves. Prior to June 9, 1985, the. licensee

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was aware that this phenomenon'had caused SFRCS half-trips on April 24

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and June 2, 1985. The licensee had taken no corrective action following

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= these half-tripsito' attempt to eliminate this situatio . ,

?This,is considered an_ example of.a violation (346/85030-IIB 4) of-

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10 CFR.50, Appendix-B, Criterion.XVI which requires that equipment

. deviations or malfunctions ~ that ' affect quality be promptly identified

and corrected to preclude repetitio >

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-The inspector-reviewed the interaction of the SFRCS and auxiliary

' feedwater' (AFW) system _ as presented in- Chapter 15.4, '! Class 3 - Design Basis Accidents," of the Updated. Safety Analysis Report (USAR).

Section 15.4.4 discusses a double ended rupture'of.a steam lin '

7 Table 15.4.4-7 depicts:the pressure response of.both SGs to such~an

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event.~ During-.the initial seconds of the steam line' break, both SGs-

'are shown to depressurize below the SFRCS actuation setpoint_of 610 ipsig,: closing AF 599 and'AF 608. Once the unaffected (good)'SG is

repressurized,' the AFW supply valve'to the good SG, AF 599 or_AF 608,

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. would'open to allow both AFW trains. to feed the good SG. - Should this .7 AFW valve.not open~(a single failure) for any reason, the AFW system

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twould betincapable'of dissipating. decay heat generated by the Reactor

Coolant System. Sectio:t7.4.2.3.1 of the USAR, " Compliance with IEEE

~ Standard 279-1971," states that no single-failure prevents the SFRCS

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-from performing its_ protective function. ~10 CFR.50.55a(h)' requires t-that-protection systems meet the' requirements of the-applicable-

. revision to IEEE- 279. - Since the design' of the SFRCS made it susceptible

. to a single failure during a steam line' break accident,-the system does-notimeet all the requirements'of IEEE 279-1971. This is considered a-

' violation of'10:CFR 50.55a(h) which requires' protection systems to

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comply withfIEEE 279 (346/85030-IIIB).

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( . Auxiliary Feedwater (AFW) Pump Turbines and Controls: Violations rwere-identified related_to_this' equipmen >

The:inspectorireviewed the design specification for the AFW pump Section 7.1.8 of Specification 7749-M-36, " Auxiliary Feedwater Pumpa,"

states " Turbines shall be' designed in such a manner that water slugging

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from wet steam carry-over shall have no injurious effect on the wheel or

' thrust. Certification of.the adequacy of the. turbine design for this servi.ce_ condition is required."~-Section 7.3.1 establishes.50 to'1170

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psia of steam pressure as-the-operational; range for the turbines. On June 9, 1985,7both AFW pump turbines tripped on overspeed while operating

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within the design, steam pressure range. The overspeed trips were attributed to. water slugs from the steam supply. lines by one of three .

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(1)/-AJwater-lockofthe~governorvalve. When the water cleared the  ;

turbine the valve was too

far open. Too much steam was then admitted to the turbine causing the overspee '

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l(2) Flashing.ofTthe water slug into steam inside the turbine causing the overspee ~ :(3)f The! water slug initially slowe'd the turbine down. The governor

.tried to compensate for this by opening further. When the water slug' cleared the turbine the valve was too.far open. Too much

' steam was then admitted-to the turbine causing the overspee ,

Whatever-the true mechanism, the overspeed trips are considered evidence

<that the design specification was not met. Failure to' meet the design 3 specification.is considered an example of.a violation (346/85030-IA2) of 110 CFR_50, Appendix B, Criterion.III, which requires that design contral measures _be established for-verifying the adequacy of desig The'inspectorLreviewed the problems associated with resetting the AFW

. pump turbines following the overspeed trips. The inspector determined that training provided did not address all actions necessary to ' assure overspeed trip reset. . Specifically,-no guidance was provided directing that the trip: linkage had.to be jerked to reset the tappet,.or on how Lto(verify that the. tappet-had reset. . .SP 1106.06, " Auxiliary Feedwater System,"-Section 4, which describes the actions necessary for resetting -

the AFW pump turbines did not prescribe jerking of the trip linkage or

. verification of. tappet reset. TheLinspector determined-that all personnel involved with the resetting operations were considered fully

' qualified on the AFW system. This training deficiency is considered a

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violationL(346/85030-IIIA) of 10 CFR 50, Appendix B, Criterion II which

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requires'that the' training of personnel performing quality activities assure that suitable proficiency be: achieved and maintaine c id .' Main Steam' Isolation Valves: No violations were identified related to this equipmen _Startup.Feedw$terValve;SP7A: No violations were identified -

related to this' equipment, JSource Range Nuclear Instruments (NI-1 and NI-2): The inspector D determined.that maintenance of nuclear instruments, NI-1 and NI-2, was:not performed in depth and did not identify the root cause of-the instrument malfunction ^

NI-1"and NI-2'have experienced numerous failures. Some of the-troubleshooting required by work orders developed to correct these failures only resulted in tapping a module in the cabinet and 1 performing a visual inspection. Following each maintenance activity,

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the technical specification surveillance test was parformed successfull The licensee did not increase the: depth of troubleshooting or the-

~ . testing. requirements even though the work done was inadequate to assure equipment' operability. Criterion XVI'of 10 CFR 50, Appendix B, requires that equipment malfunctions be promptly identified and correcte The

failures to do so with NI-1 and NI-2 are considered examples of a violation (346/85030-IIB 3) and (346/85030-IIB 2). ~ Turbine Bypass Valve, SP 13A2: No violations were identified

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related to this equipmen Power Operated Relief Valve: No violations were identified related to this equipmen Main Steam Safety Valves and Atmospheric Vent Valves: No j . violations were identified related to this equipment, ' Auxiliary Feedwater Containment Isolation Valves, AF 599 and 608:

Violations were identified related to this equipment.

I The. inspector determined that the design control measures established to

assure that valves AF 599 and 608 would function throughout their design pressure range were' inadequate. Design control measures were originally

- established for the torque switch settings (opening and closing) but no

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- controls were established for the torque switch bypass switch settings.-

- Torque switch setting and bypass switch setting are interrelated and equally important in establishing the operational range of valve

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performanc Consider a valve going from the open to the closed position. Stem and disk travel is stopped when a specified force is applied to the valve disk through contact with the valve seat. The force on the valve stem is sensed by the torque switch. When specified force is-sensed by the. torque switch, the torque switch

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- physically turns, interrupting' electric current to the operator moto '

- Opening this valve will; require a force in excess of the force which closed the valve. This additional force is needed to overcome

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- conditions such as friction, temperature. difference between stem and body, and' higher differential pressure than was present at-closur However, with the torque switch engaged this additional force cannot be applied and the valve will-not open. Therefore,.the torque switch must be bypassed, allowing more torque to be applied by the operator motor,

-allowing the valve to open. Bypassing the torque switch is accomplished by removing the' switch.from the operator motor electric circuit during a

.percent age of valve' stem trave If the percentage of valve stem travel is not large enough the valve disk may not be completely off its seat, requiring forces in excess of the torque switch setting to be applied to

- the valve stem. .This condition would cause the torque switch to engage-

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and keep the valve from opening further. Stem movement percentage must also account for backlash 'in the internal gears' of the vCve operator and stem movement that occurs before the stem starts pulling upwardly on the valve dis l

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In 1983, torque switch bypass switch design measures were establishe The measures were based on calculation methods that were not validated by a testing program. The calculation methods did not allow for all the forces affecting these valves at design differential pressure. This breakdown in design control for these valves is considered an example of a violation (346/85030-IA1) of 10 CFR 50, Appendix B, Criterion III which requires that design control measures be established which verify the adequacy of the design. This design deficiency could affect any motor operated valve which is required to function with a large differential pressure across the valve sea The inspector determined that conditions described in IER 85021 regarding AF 599 and AF 608 torque switch bypass switch settings constituted a violation. Steps 7.3.1 and 7.3.2 of maintenance procedure MP 1410.32,

" Removal and Repair of Limitorque Valve Controls," provided ambiguous and therefore inadequate procedural guidance for setting the torque switch bypass switches. Based upon these instructions, it is questionable whether the mechanic would set the torque switch bypass switch improperly (on stem travel) or properly (on disk travel). This is considered an example of a violation (346/85030-IIA 2) of 10 CFR 50, Appendix B, Criterion V which requires, in part, adequate procedures for the performance of activities affecting qualit The inspector determined that the improper installation of the torque switch spring locknut on AF 599 identified in IER 85021 constituted a violation. If the locknut is not installed properly, the torque switch will not properly sense the force being applied to the stem and the torque switch will allow too much or too little force to be applied-between the valve's disk and seat. Locknut installation was performed as a " skill of the craft" activity as authorized and delineated in Section 5.3.1 of AD 1844.00, " Maintenance." This is considered an example of a violation (346/85030-IIA 4) of 10 CFR 50, Appendix B, Criterion V which requires, in part, proper implementation of procedures affecting qualit The inspector reviewed the pre-operational testing of AF 599 and AF 608 performed in conjunction with the testing of SFRCS. Test Procedure, TP 273.01, " Auxiliary Feedwater System Preoperational Test," Revision 1, dated November 18, 1976, did not identify the inability of these valves to open at design differential pressure. A review of operational testing revealed the same results. The inspector reviewed the post-maintenance testing requirements for valves AF 599 and AF 608. The only testing requirements specified in Surveillarce Test, ST 5071.02, " Auxiliary Feedwater System Refueling Test," Revision 11, dated May 16, 1985 were that these valves stroke within a specified time frame and not leak when closed under a pressure test to assure containment integrit CFR 50, Appendix B, Criterion XI requires that the testing program established by the licensee demonstrate that components will perform satisfactoril However, the procedures (surveillance and test) did not implement all the requirements established for a Test Program. These procedural deficiencies are considered examples of a violation (346/85030-IIA 1) of 10CFR50, Appendix B, Criterion V which requires, in part, adequate procedures for performing quality activitie _ ___ _ _

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The inspector reviewed the licensee's ASME Boiler and Pressure Vessel Code,Section XI (Code) valve inservice test program. Valves AF 599 and AF 608 were-designated: passive. The valves are required to stroke closed and then one of'them must reopen in certain analyzed steam line. break accidents. These valve position changes mean the valves meet the definition of active as stated in Subarticle IWV-2100 of the Code. The formal test program requirements are less stringent for passive valves than for' active valves-as shown in Table IWV-3700 of the Code. The licensee was test exercising.these valves at each refueling outage, not at each cold shutdown as required by the Code. The. failure to identify

.AF 599 and AF 608 as passive in the Code valve inservice test program is considered a violation (346/85030-IIC) of 10CFR50, Appendix B,

. Criterion XI, Test-Control. The inspector determined that the more

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. stringent test program required for active valves would not have identified any of the problems associated with AF 599 and AF 60 The inspector reviewed the corrective maintenance performed on valve AF 599 following the failure of the valve to reopen on March 3, 1984, during refill'of_a depressurized steam generator. The depressurized steam generator event is documented in IER 8400 To correct the failure of AF 599 to reopen, the licensee decreased the close torque switch setting. However, the licensee did not determine the root cause of the valve's inability to reopen. Adequate corrective actions would have identified the root cause of the failure of AF 599 and prevented subsequent failure. .This is considered an example of a violation (346/85030-IIB 1) of 10 CFR 50, Appendix B, Criterion XVI which requires equipment malfunctions affecting quality be promptly identified and correcte Auxiliary Feedwater Pump Turbine Steam Supply Valve, MS 106:

Violations were identified related to this equipmen The inspector determined that the maintenance procedure, MP 1410.32,-

.used to set the torque' switch bypass-switches of AF 599 and AF 60 was also used to set the bypass switches of MS106. Therefore, the'

xinadequate procedure violation (346/85030-IIA 2) also applies to MS 10 .The torque- switch locknut was found installed improperly on MS 10 In this instance the locknut caused a significant imbalance.in the torque switch. The locknut installation was performed as " skill of the craft."

The improper locknut installation is considered another example of a tviolation (346/85030-IIA 4) of 10 CFR 50, Appendix B, Criterion V, which requires in part,. proper implementation of procedures affecting quality.

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The inspector reviewed the post-maintenance testing. requirements used after the improper locknut installatio The testing requirements established by the licensee (stroke time testing) were performed

'following the maintenance activities which improperly installed the

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locknut. -The testing did not identify the unbalanced torque switch which is a violation (346/85030-IIA 1) of 10 CFR 50, Appendix B, Criterion V.for not establishing post-maintenance testing requirements which adequately implement the test program of Criterion X _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _

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control power circuitry of MS 106 was not in accordance with drawing E46B-548, Sheets 54A and 548, (Revision 3) which requires a 10 amp fuse be installed. The improper fuse installation is considered an example-of-a violation-(346/85030-IIA 3) of 10 CFR 50, Appendix B, Criterion V,-

which requires,-in part that activities affecting quality be accomplished in'accordance:with appropriate drawing . Transfer of Auxiliary Feedwater Suction from Condensate Storage Tank to Service Water: No violations were identified related to this equipmen Operator Performance: No violations were identified. As a result of the preliminary document review three areas were identified as needing in-depth inspection to determine if a violation existed.

L The three areas are presented below with the results of the inspectio '(1) No senior licensed individual in the control-room: While the assistant shift supervisor was in the turbine building placing the startup feedwater pump in service, the shift supervisor left the control room for a few minutes to issue a locked valve key to an equipment operator. -The key was necessary'to allow manual. operation of valves AF 599 and AF 608 which were-chained and padlocked. Both actions were necessary to restore feedwater to the steam generators during the recovery from the reactor tri Therefore, for two minutes during the event a senior licensed operator was not present in the control roo CFR 50.54(m)(1) requires the presence of the senior licensed operator during recovery from an unplanned shutdow CFR 50.54(x) allows the licensee to take reasonable action that departs from a licensed condition in an emergency provided senior 1icensed operator approval is received. Based on a review of the situation the inspector determined that 10 CFR 50.54(x) was applicable in this instance. A review as to_whether the reporting requirements associated with 10 CFR 50.54(x) were met will be followed up in a future inspectio .(2) Time delay in'the initiation of High Pressure Injection / Makeup (HPI/MU) Cooling: EP1202.01, Emergency Procedure for a RPS, SFAS, SFRCS Trip or SG Tube Rupture, Section 6 discusses the

. operator actions associated with lack of heat' transfe Step 6.1 requires MU/HPI cooling be established if both steam generators have a steam pressure of $960 psig decreasing or a level or 58 inches. For about five minutes during the event this criteria was met on the steam pressure parameter. It is apparent from the transcripts that'the personnel in the control room were unaware that the criteria for HPI/MU cooling was ever, met during the event. A major contributing factor in the operating shift's unawareness was that thetinstrumentation used.to determine the need for HPI/MU cooling.is-not conducive

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.to quick and accurate identification of the necessity for HPI/MU coolin Also, based on a review of the transcripts, HPI/MU. cooling would have been initiated within one minute of

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the time that feedwater was actually returned to one of the steam generators if feedwater had not-been returne (3) Lack of. training.for manual actuation of SFRCS: A review of the operator's records was performed. This review revealed that the operator had been trained on manual actuation o the SFRCS on low level. However, the training did not address

.the ramifications of actuating the wrong pushbuttons. The actuation of the wrong pushbuttons is considered a personnel error. A contributing factor to the error was the close

. proximity the switches are to the floo . Auxiliary Feedwater Flowrate Instrument The inspector concluded the review of LER 85-12 which began in

.IER 85022. _ IER 85022 should be reviewed for a detailed description-of the event. The inspector determined that auxiliary feedwater flow rate. instrument FI 4521 was inoperable.from April 1 to June 2, 198 During this period, the licensee considered this instrument operabl From' April 13 through June 2, 1985, the facility was in Modes 1, 2

or Technical Specification 3.3.3.6, Pott Accidant Instrumentation, requires ~FI.4521 be in service, or the unit be placed in hot shutdown

'30 1/2 days from:the time the instrument became inoperabl Technical '

Specification 3.3.3.6 is applicable only in Modes 1, 2 and Therefore, unresolved item (346/85022-10) has been escalated to a violation (346/85030-IVA) of Technical Specification 3.3. The inspector determined that maintenance personnel did not tag the electrical wires disconnected from FI 4521 as required by administrative procedure AD 1823.00, " Jumper and Lifted Wire Control." This failure to follow procedure was the primary reason Technical . Specification 3.3. was violated. Therefore, unresolved item (346/85022-08) has been escalated to an example of violation (346/85030-IVB1) of 10 CFR 50, Appendix B, Criterion V, which requires, in part, that activities affecting quality be accomplished in accordance'with the applicable procedur The maintenance error was not identified during post-maintenance testing because the designated test requirements were inadequate. Both maintenance work orders used to control the work required only that the instruments meet the established calibration tolerances. A specific 4 surveillance test or loop check was not specified. Therefore, unresolved-item (346/85022-09) has been escalated to an example of a violation ;

(346/85030-IVB2) of 10 CFR 50, Appendix B, Criterion V which requires, in part, that adequate procedures be prescribed for activities affecting qualit I

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4. Auxiliary Feedwater Piping Supports IER 85013 contains the details of the inspector's review of the situation. The violations associated with that review are summarized below:

(a) _ Documentation of some piping support damage was done on uncontrolled sketches and not on a nonconformance report. This is a violation of 10 CFR 50, Appendix B, Criterion )Y (346/85030-VB).

(b) Once the damage was identified the safety evaluations for some nonconformance reports and a facility change request did not

' investigate the cause of the piping damage. Consequently measures to prevent recurrence were not developed. This is a violation of 10 CFR 50, Appendix B, Criterion XVI (346/85030-VC).

'.c) Numerous deficiencies identified in the walkdowns of the auxiliary feedwater. piping supports such have been identified during the original construction quality control inspections or during the IEB 79-14 piping support walkdown These inadequate inspections are considered violations of 10 CFR.50, Appendix B, Criterion X (346/85030-VA).

(d) Only those piping support failures which rendered the auxiliary feedwater system inoperable were reported under 10 CFR 50.73 to the NR As a result of this interpretation of the reporting requirements, a substantial number'of lesser damaged piping supports were not reported under 10 CFR 50.73. This is a violation of 10 CFR 50.73 (346/85030-VD).

5. Exit Interview The inspector met with licensee representatives (denoted in Paragraph 1)

throughout the month and at the conclusion of the inspection and summarized the scope and findings of the inspection activities. The licensee acknowledged the findings. After discussions with the licensee, the inspectors have determined there is no proprietary data contained in this inspection repor . - . .

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