ML14181A847
| ML14181A847 | |
| Person / Time | |
|---|---|
| Site: | Robinson  |
| Issue date: | 10/25/1996 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML14181A845 | List: |
| References | |
| 50-261-96-11, NUDOCS 9611040306 | |
| Download: ML14181A847 (38) | |
See also: IR 05000261/1996011
Text
U.S. NUCLEAR REGULATORY COMMISSION
REGION II
Docket No:
50-261
License No:
Report No:
50-261/96-11
Licensee:
Carolina Power & Light (CP&L)
Facility:
H. B. Robinson Unit 2
Location:
2112 Old Camden Rd.
Hartsville, SC 29550
Dates:
August 18 - September 28. 1996
Inspectors:
J. Zeiler, Acting Senior Resident Inspector
P. Byron, Resident Inspector
B. Desai, Senior Resident Inspector
G. Kuzo, Region II Inspector (R1.2, R1.3, R2,
R5, and R7)
M. Miller, Region II Inspector (M1.2)
C. Rapp, Region II Inspector (E8.1 and E8.2)
Approved by:
M. Shymlock. Chief. Projects Branch 4
Division of Reactor Projects
Enclosure 2
9611040306 961025
PDR ADOCK 05000261
a
EXECUTIVE SUMMARY
H. B. Robinson Power Plant, Unit 2
NRC Inspection Report No. 50-261/96-11
This integrated inspection included aspects of licensee operations,
maintenance, engineering, and plant support. The report covers a six-week
period of inspection; in addition, it includes the results of a maintenance,
service water followup, and effluents and radiological transportation
inspections by three Region II inspectors.
Operations
The licensee's preparations for Hurricane Fran were thorough. Although
activities were complicated by the considerable amount of equipment and
material which had been pre-staged onsite for the start of an upcoming
refueling outage. licensee management demonstrated conservative decision
making in removing and/or securing this material (Section 01.2).
The plant shutdown to begin Refueling Outage 17 was controlled and
conducted in a safety conscious manner. The operators followed the
applicable procedures and appropriately responded to plant problems
encountered (Section 01.3).
The decision to manually trip the reactor after encountering a turbine
Electro-Hydraulic Control System malfunction during unit shutdown was
justified.
Operator response to the trip was good and unit
stabilization was accomplished in a controlled manner. The root cause
of the trip was adequately identified and corrected. Adequate
resolution was performed or was planned prior to restart for other
unexpected plant equipment operation during or following the trip
(Section 01.4).
Reactor coolant system drain down activities were conducted in a
deliberate and controlled manner. A thorough pre-job briefing was
performed prior to the evolution. Important plant indications were
closely monitored by the operators (Section 01.5).
Fuel off-load activities were performed in a controlled manner. Good
communications were maintained between the Control Room and fuel
building operators (Section 01.6).
The first example of a violation of Technical Specification (TS)
6.5.1.1.1 was identified for failure to follow foreign material
exclusion area (FMEA) procedural requirements resulting in a loss of
control of foreign material exclusion inside the Spent Fuel Pool
Building during fuel off-load activities.
Ineffective supervisory
overview contributed to this problem. These deficiencies were similar
to previous problems indicating a continuing trend of ineffective FMEA
implementation requirements (Section 01.7).
An Auxiliary Operator was assigned five shifts as a Fire Brigade member
with an expired medical examinahion. Previous corrective actions to
ensure that operator medical qualifications were current prior to
2
individuals standing Fire Brigade and Control Room Shift Supervisor
watch duties were inadequate. This issue was identified as a Violation
of 10 CFR 50. Appendix B, Criterion XVI. for inadequate corrective
actions (Section 01.8).
Maintenance
The second example of a violation of TS 6.5.1.1.1 was identified when a
contractor electrical technician failed to follow modification procedure
requirements for obtaining operations permission and tagout clearances
prior to cutting power cables to valve SI-866A. This resulted in the
cable being cut while still energized. The licensee's stand down to
reemphasize work control expectations and requirements following this
and one other significant outage related work control error was
effective in preventing further serious problems (Section M1.1).
The maintenance and engineering departments were in the process of
implementing a thorough program to identify and correct repetitive
equipment failures (Section M1.2).
Engineering
Investigations of the A Main Steam Isolation Valve failure to close
during shutdown were thorough. The root cause was adequately addressed
and corrective actions planned were determined to be acceptable (Section
E1.1).
Plant Support
Radiological controls associated with low-level radioactive solid waste
stored temporarily on site met 10 CFR Part 20 requirements. Posting.
labeling, and physical controls for locked high radiation and very high
radiation area doors met regulatory requirements. Occupational
radiation exposure controls and evaluations for "hot particles" and for
potential internal exposure were adequate (Section R1.1).
One Non-Cited Violation of TS 6.11 for failure to follow radiation
protection procedures was identified. A breakdown in communication
among Health Physics technician staff contributed to contamination being
released offsite (Section R1.2).
Transportation and packaging activities for radioactive waste or
material shipments met 10 CFR 71.5 and 49 CFR requirements. Revised
Department of Transportation (DOT) guidance was properly implemented.
Training of personnel on the revised guidance was adequately performed
(Sections R1.3 and R5.1).
Audits of radioactive waste, effluent and transportation program
activities were thorough and met TS, 10 CFR Parts 20 and 71
requirements. Quality control activities associated with effluent
measurements were technically adequate (Sections R2.2. R7.1 and R7.2).
3
Actions to resolve a signal transmission problem with the public warning
system sirens following passage of Hurricane Fran were adequate (Section
P2.1).
The third example of a violation of TS 6.5.1.1.1 was identified
involving a discrepancy in the emergency procedure for performing off
site dose projections from the Control Room during accident conditions
involving releases of radioactive material (Section P3.1).
2
against high winds, stringing of hand lines for pre-established routes
to be used during the hurricane. verifying the operability of plant
equipment and components, and testing certain plant equipment such as
the emergency and dedicated shutdown diesel generators to ensure their
availability in the event offsite power were lost.
The inspectors reviewed the completed procedure attachment and conducted
an independent walkdown of the site to verify that preparations were
adequately implemented. The inspectors noted that licensee actions to
remove or secure items were aggressively pursued. All hurricane
preparations were completed on September 5. at 2:45 p.m. These
activities were well coordinated and thorough. even though they were
complicated by the large amount of material and equipment that had
recently been pre-staged for the upcoming refueling outage. Management
demonstrated conservative decision making in determining what pre-staged
material was removed and/or secured.
Based on weather projections that hurricane force winds would not be
expected near the site, management decided that a plant shutdown was not
necessary. On September 5, at approximately 8:00 p.m., the hurricane
made landfall several hundred miles to the north of the site, traveling
north-northwest. Maximum sustained winds of approximately 30-40 mph
were observed at the site, however, no significant damage occurred
onsite. Offsite power and communications were maintained throughout the
storm.
c. Conclusions
The inspectors concluded that the licensee's readiness for the
Hurricane's arrival was well coordinated and thorough. Management
demonstrated conservative decision making in determining what outage
pre-staged material was removed and/or secured onsite.
01.3 Shutdown for Refueling Outage Activities
a. Inspections Scope (71707)
The inspectors monitored shutdown activities that were conducted
September 7 to begin RFO-17. The shutdown was performed in accordance
with General Procedure GP-006. Normal Plant Shutdown from Power
Operation to Hot Shutdown. rev. 27.
Report Details
Summary of Plant Status
Unit 2 remained at essentially full power until August 27, when a coastdown
was initiated in preparation for starting Refueling Outage 17 (RFO-17). On
September 7. the unit commenced the outage shutdown from 89 percent power.
During the shutdown, a manual reactor trip was initiated from 28 percent power
after a turbine control system malfunction. Following the reactor trip, the
unit was placed in cold shutdown for refueling. On September 17. fuel off
load was completed and fuel remained removed from the core for the remainder
of the report period.
I. Operations
01
Conduct of Operations
01.1 General Comments (71707)
The inspectors conducted frequent control room tours to verify proper
staffing, operator attentiveness and communications, and adherence to
approved procedures. The inspectors attended daily operations turnover,
management review, and plan-of-the-day meetings to maintain awareness of
overall plant operations. Operator logs were reviewed to verify
operational safety and compliance with Technical Specifications (TSs).
Instrumentation, computer indications, and safety system lineups were
periodically reviewed from the Control Room to assess operability.
Frequent plant tours were conducted to observe equipment status and
housekeeping. Condition Reports (CRs) were routinely reviewed to assure
that potential safety concerns and equipment problems were reported and
resolved.
In general, the conduct of operations was professional and safety
conscious. Good plant equipment material conditions and housekeeping
was noted throughout the report period. Specific events and noteworthy
observations are detailed in the sections below.
01.2 Preparations for Hurricane Fran
a. Inspection Scope (71707, 71750)
Between September 4-6, the inspectors reviewed licensee preparations in
response for Hurricane Fran. This included a review of Operations
Management Manual (0MM) procedure OMM-021. Operation During Adverse
Weather Conditions, Rev. 15, and verification that the actions
prescribed by the procedure were properly implemented.
b. Observations and Findings
On September 4, at 7:15 a.m., the licensee began preparing for the
possible impact from Hurricane Fran. Preparations included completing
the actions for a hurricane warning in accordance with OMM-021,
Attachment 6.1. Hurricane Warning Check-off Sheet. Major activities
performed included: removal or securing loose material around the site
3
b. Observations and Findings
On September 7, at 8:30 p.m., the licensee commenced the shutdown in
accordance with GP-006. The inspectors monitored portions of the
shutdown from the Control Room. The inspectors verified that the proper
revision of the procedure was being used and that a pre-job brief was
performed prior to commencing activities. The inspectors noted.that
preparations were thorough and that activities were performed in a
controlled and deliberate manner. Both the Plant Manager and operations
management personnel were present in the Control Room and provided good
overview of the activities.
During the shutdown, steam flashing occurred while isolating the four
Moisture Separator Reheaters (MSRs). When the first shutoff valve (to
the 1A MSR) was closed, all four of the MSR Timer Valves automatically
reopened and admitted steam to the MSRs. As result of the sudden
increase in MSR pressure due to the introduction of steam, condensate
was suddenly introduced to the high pressure feedwater (HPFW) heaters
via the high level drain lines which were still open at the time.
During this pressure transient, one of the snubber supports on the high
level drain line from the lB MSR to the 6B HPFW Heater was damaged.
This pressure transient appeared to be a recurring incident in that GP
006 contained warnings that potential pressure spikes could occur when
the MSR shutoff valves were closed. A CR was initiated by the licensee
to address this apparent valve coordination problem and a work request
was initiated to repair the damaged snubber.
At approximately 30 percent power, the operators received a control room
alarm indicating that vibration of the No. 1 turbine-generator bearing
had increased to 6 mils.
The operators properly referred to the alarm
response procedures and followed the appropriate actions. The
procedures required that the turbine be tripped if vibration increased
to greater than 14 mils. Although vibration remained at 6 mils, the
operators remained diligent in monitoring for any subsequent vibration
increase.
At approximately 28 percent power, the operators encountered a problem
with the Turbine Electro-Hydraulic Control (EHC) System which prevented
the turbine from unloading properly. As a result of this problem, the
reactor was manually tripped. Following the trip, the operators
successfully stabilized the unit and continued the plant cooldown in
accordance with GP-007, Plant Cooldown from Hot Shutdown to Cold
Shutdown, rev. 41.
Further details of the EHC problem and operator
response to the trip is discussed in Section 01.4.
c. Conclusions
The inspectors concluded that the shutdown was controlled and conducted
in a safety conscious manner. The operators followed the applicable
procedures and appropriately responded to plant problems encountered.
4
01.4 Manual Reactor Trio due to Turbine Governor Valve Failure
a. Inspection Scope (71707, 93702 and 40500)
On September 7, while the plant was being shutdown to start RFO-17, the
Turbine EHC System failed to respond in either automatic or manual
control modes. As a result of this malfunction, a decision was made to
manually trip the reactor. The inspectors monitored the licensee's
response to the EHC System problem and discussed the problem and
decision to trip the reactor with the operators and plant management
personnel. The inspectors observed operator activities associated with
the manual trip and unit stabilization. In addition, the inspectors
reviewed post-trip plant data and attended the post trip assessment
conducted by the Plant Safety Review Committee (PNSC).
b. Observations and Findings
On September 7, the operators were conducting a scheduled shutdown to
begin RFO-17. At 10:41 p.m., with the unit operating at 28 percent
power, the EHC Turbine Control System malfunctioned in automatic mode,
preventing the complete closure of the remaining turbine governor valve
- 1 (GV-1). After placing turbine control in manual mode, the operators
were still unable to close GV-1. Following discussions between the
operators and operations management personnel who were present in the
control room to monitor the shutdown, a decision was made to manually
trip the reactor. This decision was based on xenon buildup in the core
and the risk of tripping the turbine if EHC system troubleshooting was
attempted.
At 11:13 p.m., the reactor was manually tripped from 28 percent power.
The reactor trip caused a turbine trip resulting in the closure of GV-1.
Following the trip, the unit was stabilized at no-load temperature and
pressure. Operator response to the trip was good: actions to stabilize
the unit were performed in accordance with the applicable emergency
procedures. The inspectors monitored plant parameters and equipment
operation to verify that safety systems responded as expected to the
trip. Two minor equipment problems were noted. Immediately following
the trip, the A Main Feedwater Pump tripped on low feedwater flow
resulting in the start of the motor driven Auxiliary Feedwater Pumps.
This was thought to have been caused by the slow opening of the A Main
Feedwater Pump recirculation valve to the condenser. In addition, the
control rod bottom indication lights associated with rods B-10 and H-8
did not initially illuminate. All control rods were confirmed to be
fully inserted, therefore, this was an indication problem only. The
inspectors reviewed the licensee's post trip review report completed
following the trip and verified that these items were captured and would
be resolved prior to unit restart. Following unit stabilization, plant
cooldown to cold shutdown was continued. At 11:54 p.m., the licensee
notified the NRC of the event. This iotification met the 4-hour
reporting requirement of 10 CFR 50.72 b)(2)(ii).
5
The licensee's investigation determined that the cause of the turbine
control malfunction was a broken wire in the EHC controls to GV-1. The
broken wire interrupted the electrical signal from the EHC System to the
valve controller for GV-1. The cause of the broken wire was determined
to be from fatigue as a result of repeated termination and de
termination of the wire from its housing terminal block during previous
maintenance activities. The broken wire was repaired and the controller
housings for all governor valves were inspected to ensure that no other
similar wire degradations existed. The inspectors determined that the
licensee had adequately addressed the root cause and corrective actions
of the EHC control problem.
On September 25. the inspectors attended the PNSC meeting during which
the root cause of the EHC control problem was discussed. The system
engineer responsible for the EHC system thoroughly discussed the problem
with the broken wire in the EHC controller housing, corrective actions
to repair the wire and inspections performed on the other valve control
housings. The inspectors noted that limited discussions were conducted
on details of the post trip review report or other equipment problems
identified following the trip. However, a PNSC action item was
identified requiring a more thorough review of these items prior to
plant startup.
c. Conclusions
The inspectors determined that the decision to trip the unit was
justified based on the risk with troubleshooting the EHC malfunction.
Operator response to the trip was good and unit stabilization was
accomplished in a controlled manner. The licensee adequately determined
the root cause of the trip and corrected the equipment related failure.
Adequate resolution was performed or was planned prior to restart for
other unexpected plant equipment operation following the trip.
01.5 Drain Down of the Reactor Coolant System
a. Inspection Scope (71707)
The inspectors verified readiness and observed Control Room activities
associated with the drain down of the reactor coolant system (RCS) to -7
inches (i.e.. 7 inches below the reactor vessel flange) in accordance
with GP-008, Draining the Reactor Coolant System. rev. 43.
b. Observations and Findings
Prior to the drain down, the inspectors verified the adequacy and use of
procedures and controls for the following: risk outage management. RCS
temperature and level instrumentation availability, containment closure
capability. RCS inventory addition capability, and emergency power
availability and protection. Specific details of this review are as
follows:
6
Shutdown Risk Management Controls:
The inspectors reviewed PLP-055, Outage Risk Management, rev. 13.
This procedure provided administrative controls and personnel
responsibilities for ensuring that actions governing safe plant
operation during RCS drain down and reduced inventory conditions
were conducted. The procedure provided safety system equipment
availability requirements for all shutdown conditions. Shutdown
safety equipment requirements were summarized on a one page matrix
that was updated and distributed twice a day to ensure that
personnel were cognizant of current shutdown conditions and
equipment requirements. In addition, signs were placed on safety
equipment required for current plant conditions warning personnel
that the equipment was being "protected." The inspectors
performed walkdowns of selected safety equipment to verify proper
material conditions and that the warning signs were installed in
accordance with PLP-055. No discrepancies were identified.
Containment Closure Capability for Mitigation of Radioactive
Releases:
Containment closure was maintained and tracked in accordance with
Operation Management Manual procedure OMM-033, Implementation of
Containment Closure, rev. 3. The inspectors reviewed the
procedure and verified that containment penetrations were being
properly controlled to ensure timely closure if required. No
discrepancies were identified.
RCS Temperature Monitoring
The inspectors verified that at least two independent, continuous
indications of RCS temperature representative of core exit
conditions were operable. The operators planned to continuously
monitor the average of the five highest exit thermocouple values
via the licensee's ERFIS computer display in the Control Room.
RCS Level Indication Monitoring
The inspectors verified that at least two independent, continuous
water level indications would be operable during the drain down.
Below 5% in the pressurizer. GP-008 required two RCS local
standpipe and Control Room level transmitters with alarms be in
service. In addition, a continuous local standpipe watch was
required inside containment to verify accurate standpipe
indication. Once level reached -7 inches, the licensee planned to
set-up a camera in the Control Room to monitor the local standpipe
level indication. The inspectors verified that the standpipe
level transmitters had been calibrated via review of calibration
data sheets that were completed on September 4 and 6.
7
RCS Inventory Capability
The inspectors verified that at least two additional means of
adding water inventory to the RCS was required to be available.
PLP-055 required that at least one charging pump and safety
injection (SI) pump with a flowpath from the refueling water
storage tank be available prior to initiating drain down of the
RCS. The licensee planned to have all charging pumps and one SI
pump available for the drain down. The inspectors performed a
partial walkdown of these pumps and their flowpaths on
September 10 and did not note any conditions which impacted
operability.
Emergency Power Availability
PLP-055 required both emergency diesel generators (EDGs) to be
operable during the drain down. Offsite power was provided
through the startup transformer. The inspectors walked down the
EDGs and startup transformer. No adverse material conditions were
identified. The inspectors verified that there was no work
planned in the switchyard during the drain down.
On September 10-12, the inspectors observed operator drain down
activities conducted in accordance with GP-008. An extensive pre-job
briefing of the evolutions was also performed prior to starting the
actual drain down.
During the drain down, a problem was experienced with the pressurizer
cold calibration level instrument LI-462 in that at 22%. level stopped
trending down even though the drain down was still in progress. The
operators secured draining in order to investigate the unexpected
instrument response. A decision was made to valve in the two standpipe
level instruments (normally performed at 5% pressurizer level) to verify
actual level.
When the standpipes were valved in, level indicated 96
inches which corresponded to approximately 10-15 percent pressurizer
level. A work request was written to investigate the level indication
problem with LI-462. The drain down to -7 inches continued with no
further problems encountered.
c. Conclusions
The inspectors concluded that drain down activities were conducted in a
deliberate and controlled manner. A thorough pre-job briefing was
performed prior to the evolution. Important plant parameters such as
RCS level and temperature were closely monitored by the operators.
01.6 Reactor Core Off-Load Activities
a. Inspections Scope (71707)
During September 17-19, the intpectors witnessed portions of fuel off
load activities from the Control Room, containment operating floor, and
8
Spent Fuel Pool Building (SFPB). The inspectors verified that
activities were being performed in accordance with GP-010. Refueling,
rev. 33. and that applicable TSs for conducting refueling activities
were met.
b. Observations and Findings
The inspectors verified that the following TS requirements were met for
conducting refueling activities:
Fuel movement was not initiated prior to 100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> after shutdown.
At least one airlock door was properly closed and containment
integrity established,
Two source range neutron monitors were continuously being
monitored, each with continuous visual indication in the Control
Room and one audible indication in containment,
At least one Residual Heat Removal Pump was operable.
Refueling cavity level was greater than 272 feet, 2 inches and
average RCS temperature was less than or equal to 140 degrees F,
Direct communication between the Control Room and refueling cavity
manipulator crane was maintained,
Boron concentration was being checked each shift and maintained
above 1950 parts per million, and.
the SFPB ventilation system was operating when handling fuel.
The inspectors also noted that good foreign material exclusion area
(FMEA) controls were setup in containment around the refueling cavity.
Physical barriers and signs were erected to ensure that personnel and
material were positively controlled. In addition, a monitor had been
stationed at the entry point to the FMEA to ensure that personnel
adhered to FMEA controls. While FMEA controls in containment were
considered good, several problems were identified with FMEA controls in
the SFPB. These problems are discussed in Section 01.7.
c. Conclusions
The inspectors determined that fuel off-load activities were performed
in a controlled manner that met or exceeded TS requirements. Good
communications were maintained between the Control Room and fuel
building operators.
9
01.7 Foreign Material Exclusion Area Discrepancies in Spent Fuel Pool
Building
a. Inspection Scope (71707)
While observing fuel off-load activities from the SFPB. the inspectors
noted several FMEA discrepancies. The inspectors reviewed the
licensee's FMEA requirements specified in PLP-047, Foreign Material
Exclusion Area Program, rev. 8, and discussed the discrepancies with
operations management.
b. Observations and Findings
On September 19, the inspectors observed several FMEA problems in the
SFPB. the majority of which resulted from an unauthorized change that
was made to the FMEA boundary. The FMEA boundary had previously been
established around three sides of the Spent Fuel Pool.
On September 17.
fuel handling personnel changed the boundary to exclude the transfer
conveyor control panel from the FMEA. In order to accomplish this, the
FMEA entry point was moved back an entire pool length. However,
personnel failed to update the FMEA material log to remove the material
and items that were logged within the original FMEA boundary.
Additionally, FMEA boundary tape had not been extended to cover either
the new boundary or entry point created by the change. Also, during
review of the FMEA personnel log, the inspectors identified one person
who had not signed out from the previous day.
This item was not
connected to the boundary change problem and appeared to be attributed
to a lack of attention to detail on the part of the person exiting the
FMEA.
The inspectors brought these items to the attention of the licensee.
Immediate corrective actions were implemented to regain control of the
FMEA in the SFPB. The boundary was restored to its original location
and a complete audit of the FMEA material log was completed. The
licensee indicated that several items could not be accounted for,
however, following a visual inspection of the pool, it was determined
that the items had not been introduced into the pool.
Sections 5.1.1 and 5.2.3 of PLP-047 provide the requirements for
establishing FMEA barrier tape and completing the Personnel Log upon
exiting. In addition, PLP-047 assigns responsibility for maintaining
proper FMEA controls to the Supervisor of the employees working in the
FMEA. The inspectors determined that the Shift Supervisors had not been
effective in ensuring that FMEA controls were maintained in the SFPB.
The inspectors noted that similar FMEA procedure discrepancies were
identified in the SFPB during the previous inspection period (See NRC
Inspection Report 50-26/96-10). indicating a continuing trend of
personnel inattention to detail and ineffective supervisory overview of
FMEA requirements.
10
This issue was considered the first of three examples of a violation of
TS 6.5.1.1.1 for failure to follow or inadequate procedures. This item
is identified as Violation (VIO) 50-261/96-11-01:
Failure to Follow or
Inadequate Procedures - Three Examples.
c. Conclusions
The inspectors concluded that personnel failed to follow FMEA procedure
requirements and supervisory overview of FMEA requirements was
ineffective resulting in a loss of FMEA controls inside the SFPB FMEA.
This issue was identified as a violation for failure to follow the
requirements of PLP-047. The deficiencies identified were similar to
previous problems which indicated a continuing trend of insensitivity to
FMEA requirements.
01.8 Operator Assigned to Fire Brigade with Expired Medical Examination
a. Inspection Scope (71707)
The inspectors reviewed the circumstances related to the assignment of
an individual to the Fire Brigade with an expired fire protection
medical examination (physical). The inspectors reviewed the similarity
of this incident to several previous incidents involving expired
physicals for operations personnel and discussed the incident with the
operations and Health Screening personnel.
b. Observations and Findings
On August 15, 1996. the licensee discovered that an Auxiliary Operator
(AO) had been assigned to the Fire Brigade on five previous shifts with
an expired fire protection physical. At the time of discovery, the AO
was in operator retraining class and was not performing shift duties.
On August 20. the AO completed the required physical.
The inspectors
reviewed the medical report for this physical. The individual was
screened for adequate physical and mental conditions required for Fire
Brigade members in accordance with standard 1582 B-3.3-1992 of the
National Fire Protection Association code.
The results of the physical
confirmed that the AO was medically qualified to resume Fire Brigade
activities. The licensee initiated CR 96-01883 to address the expired
physical.
The AOs yearly fire protection physical expired on July 31, 1996. The
inspectors reviewed logs and personnel time sheets for the individual,
as well as other operations personnel on the same shifts between July 31
and August 9, 1996. The inspectors determined that the AO had stood
five shifts during this period and had been assigned to the Fire Brigade
each shift. However, even without reliance on the AO with the expired
physical, the minimum required qualified Fire Brigade complement (five
members) had been available on each of the five shifts.
The licensee's on-site Health Screening organization maintains a
database for tracking and scheduling operator physicals. Physicals are
required to maintain the qualifications for the Fire Brigade (yearly).
respirator certification (18 months), and duties of a licensed operator
(bi-annual). The database contains two important fields that are
delineated as Expiration Date and Scheduled Date. The Expiration Date
field contains the earliest expiration date for any of the three
physicals tracked. The Scheduled Date is two months less than the
Expiration Date, and is used by Health Screening personnel to provide
prior notification to employees that their physical is going to expire.
For the most recent expired physical incident, the Health Screening
organization had previously entered the incorrect date in the Expiration
Date field. Instead of 7/31/96. a date of 10/31/96 was erroneously
entered.
The inspectors reviewed several previous incidents involving similar
occurrences where operations personnel were assigned to duties with
expired physicals. These incidents were documented in CRs 95-01756, 96
00525, and 96-00744.
CR 95-1756 documented the July 10, 1995. expired physicals of two AOs
who were assigned to the Fire Brigade on two consecutive shifts.
Corrective actions included development of the Health Screening database
discussed above which provided notification to the individuals two
months prior their physical expiring.
CR 96-00525 documented a February 1996 Nuclear Assessment Section (NAS)
audit of the Fire Protection Program. During this audit it was
identified that two AOs were assigned to the Fire Brigade with expired
physicals. The root cause of this incident was an erroneous date
entered in the Scheduled Date field. The erroneous date was exactly one
year later than the required schedule date. As a result of this
incident. Health Screening was required to validate that the correct
physical expiration dates had been entered for each of the operators.
The inspectors noted that this review failed to identify the erroneous
physical expiration date for the current incident with the expired AO
Fire Brigade physical.
The erroneous expiration date for the AO had
been entered well before this review was conducted. Other corrective
actions included a March 30. 1996 memo sent from the Operations Manager
to all Fire Brigade qualified personnel reminding them of their
responsibility to maintain their physical requirements current. In
addition, operations initiated the creation of a matrix to track
operator physical expiration dates due to the unreliability of the
Health Screening tracking system.
CR 96-00774 documented a licensed senior reactor operator who stood
seven shifts between March 2-12. 1996, without a current bi-annual
physical as required by 10 CFR 50.55. This incident was the subject of
a Non-Cited Violation (50-261/96-10-01) documented in NRC Inspection
Report 50-261/96-10. The contributing cause of this incident was again,
a data entry error in the Health Screening database. An expiration date
12
of 6/14/96 had been entered instead of 2/24/96 for the operator's NRC
physical. The 6/14/96 date was the expiration date for the operator's
respirator physical. Corrective actions for this incident involved
validation that the NRC physical expiration dates for all "licensed"
operators were correct. Also, a Night Order was issued April 19. 1996,
to reinforce expectations that individuals are responsible for
maintaining their qualifications current. On May 6, 1996, the
operations training matrix was completed and matrix reports were placed
in the Control Room for the operators to review so that they could check
on the status of their medical qualifications.
The licensee's investigation of the current incident determined that the
AO had not reviewed any of the monthly matrix reports placed in the
Control Room beginning in May 1996. The inspectors reviewed the matrix
report which was placed in the Control Room on June 26. 1996. The
portion of the report that provided the Fire Brigade qualifications
showed that the AO's Fire Brigade physical was due on July 31, 1996.
The inspectors considered that the AOs failure to review the report was
a contributing cause to this incident.
10 CFR 50. Appendix B. Criterion XVI. Corrective Action, requires in
part, that measures be established to assure that conditions adverse to
quality are promptly identified and corrected. The inspectors concluded
this issue was a violation of 10 CFR 50. Appendix B. Criterion XVI, in
that the licensee failed to take adequate corrective actions to ensure
that qualifications and conditions for standing watch duties are
maintained current for operations personnel.
This item is identified as
VIO 50-261/96-11-02:
Inadequate Corrective Actions to Prevent Expired
Fire Brigade Medical Physicals.
c. Conclusions
The inspectors concluded that previous corrective actions had not been
effective in ensuring that personnel medical requirements were current
prior to assigning individuals to watch duties. Data entry error in
the licensee's database for tracking medical requirements were not
promptly identified and corrected following initial indications of
problems. In addition, individuals failed to meet expectations for
maintaining the status of their own physical expiration dates. This
issue was identified as a violation of 10 CFR 50. Appendix B. Criterion
XVI.
08
Miscellaneous Operational Issues
08.1 (Closed) Licensee Event Report (LER) 50-261/94-16-01, Reactor Trip Due
to Loss of Load:
On August 2. 1994. with the plant at 100% power the
operators initiated a manual reactor trip when they observed rapidly
decreasing turbine generator. The licensee initiated an events team to
determine the cause of the loss of load. ACR 94-01142 initiated to
document the event and the event team findings.
13
The event team determined that the main turbine governor valves closed
with the unit at full power, resulting in a loss of electrical load. An
intermittent fuse failure in a control circuit that monitors the main
generator output breaker position and closes the governor valve if the
output breakers open with the unit at full load. The licensee
determined that faulty manufacturing caused the fuse failure. An
evaluation of the failed fuse (Bussmann MB010) revealed that it had a
cold solder connection. The licensee concluded that there was no method
available to preclude the installation of fuses with cold soldered
connections. The licensee determined that Limerick had experienced
similar fuse problems with the Bussmann KTN-10 and testing results
yielded a 30% failure rate. Bussman redesigned the fuse to provide a
larger base to make the soldered connection. The redesigned fuse
appears to have solved the manufacturing problem.
The inspectors reviewed the completed ACR 94-01142. including the event
team report. The licensee's actions appear to be adequate and this item
is closed.
II. Maintenance
M1
Conduct of Maintenance
M1.1 Refueling Outage Contractor Maintenance Discrepancies
a. Inspection Scope (62707)
The inspectors reviewed the circumstances associated with two outage
related contractor field work errors.
b. Observations and Findings
Failure to Follow Modification Instructions
On September 16, unit was in Cold Shutdown with the refueling
cavity filled and control rod unlatching ongoing. Two contracted
electrical technicians were performing cable replacement
activities associated with modification Engineering Service
Request (ESR) 95-00764. The technicians received turnover from
night shift personnel that the cable replacement associated with
valve SI-866A was ready to be performed. SI-866A is the RCS Loop
3 SI Pump Discharge Hot Leg Injection Valve. The valve was
closed, but was being maintained available for core inventory
addition in accordance with the risk management procedure PLP-055.
Due to a shift turnover communication error. the technicians
believed that the valve had already been tagged out of service
(i.e., permission granted from operations to perform the work and
clearance tag obtained). Valve tagout was required in accordance
with steps 16.1 through 16.4 of ESR 95-00764. The technicians
failed to review the "master" copy of ESR 95-00764 which would
have alerted them to the fact That these actions had not been
signed off and the valve was still energized. The technicians
14
proceeded to cut the valve cables in accordance with step 16.5 of
ESR 95-00764. After cutting the cables, the technicians noticed
electrical arcing and realized that the cable had been energized.
Immediately following the incident, the licensee stopped all work
on ESR 95-00764 to begin an investigation. Later, all electrical
work being performed by the contractor was stopped and a "stand
down" was performed. The stand down emphasized proper shift
turnover communications and management expectations that the
"master" modification copy be reviewed prior to starting work each
shift.
This issue was identified as the second of three examples of a
violation of TS 6.5.1.1.1 for failure to follow procedures. This
item is identified as VIO 50-261/96-11-01:
Failure to Follow or
Inadequate Procedures -
Three Examples
Partial Valve Disassembly Error
On September 18, an engineer monitoring the progress of Boric Acid
(BA) pipe replacement work observed a mechanical contractor worker
beginning to disassemble valve MOV-350, the charging pump suction
supply from the BA Blender. The engineer noted that red clearance
tags were hung on the valve and recognized that it was being
maintained part of the clearance boundary for integrity of the
cold leg injection flowpath in accordance with PLP-055. Breaching
this boundary would have rendered this flowpath inoperable. The
engineer directed the worker to stop work. At this time, one body
to bonnet stud had been removed and the nuts to another stud had
been loosened. The valve was immediately restored to its original
condition.
The inspectors determined that work had not yet progressed to the
point of breaching the actual integrity of the boundary. The
licensee's preliminary investigations attributed the cause of the
incident to worker confusion of his work assignment,
miscommunication between the worker and his supervisor, and
inattention to detail.
As a result of these significant and other minor outage related work
incidents, licensee management ordered a site-wide "Work Stand-Down."
The stand-downs were conducted on September 18-19 for all work groups.
The inspectors attended the operations stand-down conducted by the
Control Room Shift Supervisor with all shift operations personnel. At
this meeting. each of the specific work related problems were reviewed
including the cause and lessons learned. Proper work practices were re
emphasized regarding communications, attention to detail, and use of
STAR (Stop. Think. Act, and Review).
The inspectors judged the effectiveness of this stand-down was good. At
the end of the report period, no other significant outage-related work
error were identified.
15
c. Conclusions
The second example of a violation for failure to follow procedures was
identified when a contractor cut the power cable to valve SI-866A
without first obtaining operations authorization or obtaining a
clearance for the work. Another significant contractor work control
error involved the unauthorized partial disassembly of a boundary valve
for maintaining integrity of the charging pump suction line. The
licensee's stand-down to reemphasize work control expectations and
requirements following these incidents was considered effective in
preventing further serious problems.
M1.2 Equipment Repetitive Failure Program
a. Inspection Scope (62700
The inspectors reviewed plant documentation to identify equipment that
had repetitive failures. The repetitive failures were examined to
determine the root cause of maintenance problems and the corrective
action implemented by the licensee. The plant equipment "Repetitive
Failure List" was reviewed to identify the components that had recurring
corrective maintenance problems identified during 1994, 1995, and 1996.
The Maintenance Department's monthly report "Maintenance Inappropriate
Acts" for July 1996 was examined to review the licensee's self
assessment in this area. Several Condition Reports (deficiency reports)
were reviewed to determine the adequacy of Engineering evaluations in
support of maintenance. In addition, the plants "Top Ten" Equipment
Issues List was reviewed to determine if the licensee was addressing and
implementing corrective action for components that had recurring
maintenance problems.
b. Observations and Findings
The inspectors reviewed 94 work order (WO/JO) for 33 components and
systems listed in the "Repetitive Failure List". All the WO/JO reviewed
were for corrective maintenance that was performed within six months of
the previous work. In most cases, the repetitive work was performed
within months of the previous work. The systems with the most
repetitive work were Instrument air: HVAC (heating, ventilation, and air
conditioning) for the control room: and the Hypochlorite system. The
components with the most repetitive failures were instruments (DP
transmitters), air filter regulators, leaking valves, gaskets and seals,
battery chargers, and electronic instrument modules. The inspectors
identified that most of the repetitive failures were caused by aging of
the equipment such as the Hagan instrument modules or inadequate design
for the installation of the DP transmitters. Repetitive failures for
leaks in valve packing and gaskets and seals leaks in pumps were not
considered abnormal.
The components with the highest rework such as
electronic instrument modules, air compressors. filter regulators, air
condition equipment, and the Hypochlorite valves and piping have been or
are being replaced or upgraded. The licensee has an ongoing program to
16
replace the capacitors in the existing Hagan instrument modules. The
Hagan modules are also being replaced with a new type.
The licensee had identified most of the repetitive failures and was in
the process of implementing appropriate corrective action. These
repetitive failures were placed on the "Top Ten" Equipment Issues List
or identified in the monthly "Maintenance Inappropriate Acts" Report.
Both the Hypochlorite and Instrument Air systems were on the "Top Ten
list for corrective action. Components listed on the "Top Ten" included
DP transmitters and the Hagan electronic instrument modules which have
caused most of the repetitive failures in the instrument area.
The "Maintenance Inappropriate Acts" Report covered two areas, 1)
maintenance due to personnel errors and 2) inappropriate acts involving
rework. Both areas were self assessments to identify and correct
maintenance repetitive problems. Both areas had implemented Conditions
Reports (deficiencies) that were addressed by System Engineering in
support of maintenance. The inspectors reviewed seven Condition Reports
that were used for evaluations of personnel errors and thirteen
Conditions reports that were used for evaluations for rework caused of
by inappropriate acts.
Personnel errors were mistakes made during the
implementation of specified work.
Inappropriate acts were someone
performing something not specified on a work order or something
maintenance had no control over such as defective parts or wrong vendor
information. Some of these rework items for 1996 included items such as
five damaged components, three improper designs, three miss adjustments,
six inadequate decisions, and five defective replacement parts.
c. Conclusion
The inspectors concluded that Maintenance Department, with Engineering
support, was in the process of identifying repetitive failures. In
addition, several effective programs such as the "Top Ten List", the
"Repetitive WO/JO List", the "Equipment Failure List", and the
"Maintenance Inappropriate Acts" have been initiated by the licensee to
identify and minimize repetitive failures. The inspectors concluded the
licensee has effectively identified repetitive failures and was in the
process of implementing appropriate corrective action.
M8
Miscellaneous Maintenance Issues (92902)
M8.1
(Closed) LER 50-261/93-16-00, Ventilation System Outside Design Basis
Due to Positive Pressure Condition:
During the performance of
Operations Surveillance Test OST-411, Emergency Diesel Generator "B"
(Twenty Four Hour Load Test), licensee personnel questioned the airflow
from the Emergency Diesel Generator (EDG) "B" room to the Reactor
Auxiliary Building (RAB) hallway. Investigation revealed that the EDG
room recirculation damper was not opening as designed for the ambient
air temperature conditions. The EDG room recirculation dampers were
designed to change operating modes at an ambient air temperature of 55
degrees F (Winter and Summer modes). The EDG Exhaust Fan operates at
low speed and the recirculation damper opens when the ambient
17
temperature is below 55 F. allowing the warm air to recirculate back to
the EDG room. The EDG Exhaust Fan switches to fast speed and the Air
Recirculation Return Damper closes when in the summer mode. The outside
ambient temperature during the performance was less than 55 degrees.
The as found configuration resulted in the RAB pressure becoming
positive. The design of the RAB Ventilation System provides positive
control of the potentially contaminated RAB environment.
Investigation
by the licensee determined that a damper solenoid valve was miswired
which resulted in the solenoid not receiving an actuation signal.
This event resulted in the NRC issuing Unresolved Item (URI) 50-261/93
11-04. The URI was closed in Inspection Report 50-261/93-19. The
closure of the URI also closes this item.
M8.2 (Closed) LER 50-261/93-21-00, Technical Specification Violation Due to
Missed Channel Functional Test:
On November 30, 1993, a licensee
technician identified that the plant vent monitor (RMS-14) had not had
its technical specification required quarterly functional test within
the specified time period. The quarterly time limit for the channel
functional test was exceeded by nine days. The due date for the test
was October 29, 1993. However the plant was in an outage and the
licensee decided to reschedule the test until after plant restart.
Technical specifications allow the functional test period to be exceeded
by 25 percent, thus making its overdue date November 21, 1993. The
startup was delayed and the E&RC supervisor did not recognize that the
functional test had to be performed before startup.
On November 30, 1993, the licensee successfully performed the plant vent
channel functional test. There was no safety significance to the late
channel functional test. The licensee instituted a system in which all
surveillance/functional tests are scheduled and tracked in a single
system. The licensee addresses late surveillances at their morning
management meetings which the inspectors observe. There have been no
additional examples of overdue surveillances since the licensee
implemented their corrective actions. The inspectors have concluded
that the licensees corrective action was adequate and this item is
closed.
M8.3 (Closed) Inspector Followup Item (IFI) 50-261/94-028-03. Follow
Licensee's Activities to Enhance The On-Line Maintenance Scheduling
Process: The inspectors concluded that the licensee did not require
formal evaluations of increased risk due to on-line maintenance. The
licensee has incorporated a matrix which was based on an evaluation the
risk of performing maintenance on various combinations of two systems.
The inspectors reviewed Plant Program Procedure, PLP-056. Work Control
Process, Revision 11.
Section 3.3 states that the matrixes only apply
for combinations of one or two system trains at a time. Further
analysis is required if three or more system trains need to be
unavailable at the same time. Section 5.6.k states that Plant General
18
Manager approval is required for combinations not allowed by the matrix
or not otherwise evaluated as acceptable.
The inspectors have concluded that the licensee's program does require a
formal evaluation of risk significant maintenance and this item is
closed.
III. Engineering
El
Conduct of Engineering
E1.1 Main Steam Isolation Valve Failure to Close
a. Inspection Scope (37551)
The inspectors reviewed licensee investigations of the A Main Steam
Isolation Valve (MSIV) failure to close during unit shutdown. The
inspectors observed valve troubleshooting, visually inspected the valve
internals, and discussed with engineering their findings regarding the
failure.
b. Observations and Findings
On September 9. at 1:06 a.m., the operators attempted to close all three
MSIVs. At the time, unit cooldown was in progress and the RCS was at
2210 F. Repeated attempts to close the A MSIV from the control board
were unsuccessful.
The operators continued the cooldown reaching Cold
Shutdown conditions (2000 F) at 2:50 a.m. Initial licensee
troubleshooting results indicated proper functioning of the MSIV's air
operated solenoid valves, actuator, and packing clearances. Following
these activities, a more exhaustive troubleshooting plan was developed
by engineering for disassembling the valve.
Between September 9-10, the inspectors witnessed portions of the
licensee's disassembly of the valve to determine why it would not close.
The inspectors noted that activities were well controlled and
coordinated by engineering personnel to ensure that root cause data was
obtained. No evidence of problems were identified during removal of the
valve packing and actuator. When the valve bonnet was removed, the
licensee discovered that the outer edge of the valve disk was in contact
with the valve body at two locations. This caused the disk to wedge
between the disk hinge pin and the two points of contact on the valve
body. With only a slight tap on the top of the disk, it slammed closed,
indicating that it was not being held tightly.
The inspectors met with licensee engineers on several occasions to
discuss their investigations and results. The licensee determined that
the disk failed to close because it became thermally bound inside the
valve body. The licensee believed that the outer edge of the disk may
have been in slight contact with the inside valve body when the valve
was open during power operations. Following plant shutdown, the disk
and valve body cooled at different rates, resulting in the disk becoming
thermally bound.
19
The licensee believed that the unexpected contact between the disk and
valve body was attributed to a combination of effects. In 1978. a
heavier disk was installed to address potential dynamic concerns with
the closing forces. As a result, this may have changed the closeness of
the disk in relation to the top of the valve body. Additionally, in
1993, the valve spindle was replaced. The new spindle was slight
shorter than the old. Based on the valve design, a shorter spindle
would also have an effect of raising the disk inside the valve body.
The licensee believed that the combination of these changes caused the
disk to slightly contact the edge of the valve body. The inspectors
reviewed the licensee's evaluations and determined that they had
adequately determined the reason for the valve failure to close.
The licensee determined that this condition would not have caused a
problem at normal operating conditions since the disk and valve body
would have been at similar temperatures. Associated with this part of
the investigation, the licensee hired a contractor to perform an
independent engineering evaluation of the condition. This evaluation
was performed by Kalsi Engineering Inc. The inspectors reviewed the
preliminary report from the contractor which concurred with the
licensee's conclusions. The inspectors concluded that the licensee had
adequately resolved whether the valve was capable of fulfilling its
required safety function had an isolation signal been generated.
The inspectors reviewed the licensee's corrective actions to eliminate
the possibility of recurrence of the valve sticking in the open
position. The licensee planned to modify the A MSIV disk by grinding
the outer edge to provide greater clearance between the valve body and
disk to eliminate the chance of thermal binding. In addition, a longer
replacement valve spindle was to be installed, which would lower the
position of the disk in the valve body. These actions were going to be
performed prior to plant startup. The inspectors determined that these
actions were adequate to prevent recurrence. Similar disk to valve body
clearance checks were planned for the other two MSIVs. In addition,
testing will be performed on all MSIVs prior to startup.
c. Conclusions
The inspectors concluded the licensee had conducted a thorough
investigation and analysis of the valve failure. Investigation results
supported the licensee's determination that the valve would have closed
at operating conditions. Planned licensee actions for correcting the
disk to valve body interference problem in the A MSIV were determined to
be adequate.
E7
Quality Assurance in Engineering Activities
E7.1 Special UFSAR Review
A recent discovery of a licensee operating their facility in a manner
contrary to the Updated Final Safety Analysis Report (UFSAR) description
highlighted the need for a special focused review that compares plant
20
practices, procedures and/or parameters to the UFSAR descriptions.
While performing the inspection discussed in this report, the inspectors
reviewed selected portions of the UFSAR that related to the areas
inspected. The inspectors verified that for the select portions of the
UFSAR reviewed, the UFSAR wording was consistent with the observed plant
practices, procedures and/or parameters.
E8
Miscellaneous Engineering Issues (37551 and 92903)
E8.1
(Closed) IFI 50-261/95-20-01, Justification of Time Required to
Establish Alternate SI Pump Thrust Bearing Cooling: The licensee had
taken credit in their plant specific analysis (PSA) for establishing
alternate cooling to the Safety Injection (SI) pump thrust bearings to
mitigate the consequences of a total loss of service water. The
licensee stated this action could be accomplished within 45 minutes;
however, there was no justification to support this 45 minute time
allowance. The inspectors reviewed the licensee's PSA for a total loss
of service water and found that the analysis determined that core
uncovery would occur within 2.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. The inspectors determined that
this 2.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> would be sufficiently bounding to support the 45 minute
allowance to establishing alternate cooling to the SI pump thrust
bearings.
The inspectors reviewed the assumptions made in the PSA to support the
2.5 hour5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> conclusion. One of the assumptions was that reactor coolant
pumps (RCPs) were tripped within one minute after a loss of all cooling:
either from seal injection or by the thermal barrier. The inspectors
reviewed the applicable plant procedures to determine if the one minute
assumption in the PSA was supported by plant procedures. Although
specific guidance on the one minute RCP trip was not available, further
discussions with the licensee indicated that the operators would enter
the Emergency Operating Procedure (EOP) network first due to inability
to provide cooling to turbine building loads resulting in a forced
manual reactor trip. The necessary guidance to trip the RCPs was
contained in the EOPs.
Furthermore, the licensee stated that tripping
the RCPs was a simplifying assumption and the smallest time step allowed
was one minute. Because of the large margin in the time to core
uncovery (2.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />), the inspectors determined the allowance of 45
minutes to establish alternate cooling to the SI pump thrust bearings
was adequately supported.
E8.2 (Closed) IFI 50-261/95-20-02, Evaluation of Air Operated Valves "Smart
Failures":
This issue addressed the potential for non-conservative
valve positioning resulting from failure of non-safety related
controllers and positioners rather than a complete loss as addressed in
Generic Letter (GL) 88-14. The licensee provided documentation that a
safety-related positioner was downstream of any non-safety related
controllers or positioners. This ensured the valve positioned correctly
even in the event of a failure of a non-safety related device. The
presence of this safety-related positioner adequately addressed the
concern. Furthermore, the licensee was not required by GL 88-14 to
analyze for such failures: only for a loss of instrument air.
21
IV. Plant Support
R1
Radiological Protection and Chemistry Controls (71750)
R1.1 Tours of the Radiological Control Area
a. Inspection Scope (71750)
The inspectors periodically toured the radiological control area (RCA)
during the inspection period. The inspectors reviewed and discussed
"hot particle" events and reviewed selected skin dose evaluations
associated with the current refueling outage.
b. Observations and Findings
Radiological control practices were observed and discussed with
radiological control personnel including RCA entry and exit, survey
postings. locked high radiation areas, and radiological area material
conditions.
Locked high radiation area controls were verified to be implemented in
accordance with TS requirements. Posting of radioactive waste
(radwaste) storage areas were proper and containers holding radioactive
waste, materials or contaminated equipment were labeled adequately.
Within the RCA, general housekeeping was considered acceptable.
The inspectors reviewed four skin dose assessments associated with "hot
particle" contaminations during the current outage. The inspector
verified that the assessments were conducted in accordance with
corporate procedure DOS-NGGC-005, Skin Dose from Contamination, Rev. 0,
dated June 7. 1996. For the worker assessments reviewed, a maximum skin
dose of 1880 millirem (mrem) was calculated.
c. Conclusions
Posting and labeling of radiation areas or containers of radioactive
material were conducted in accordance with 10 Part 20 requirements.
Licensee programs to assess "hot particle" skin exposures during the
current outage were adequate.
R1.2 Release of Worker from Site with Clothing Contamination
a. Inspection Scope (83750)
The inspectors reviewed the licensee evaluation and corrective actions
documented in Condition Report (CR) 96-01983 addressing an August 27,
1996 personal contamination event resulting in a subsequent release of a
worker with slightly contaminated clothing from the site were reviewed
and discussed in detail.
22
b. Observations and Findings
Licensee CR 96-01983 documented an August 27, 1996, contamination event
involving several individuals and which subsequently resulted in the
release of one individual from the site whose clothing was contaminated
slightly above background. The evaluation identified that on August 27,
1996, three painters were contaminated during preparation (needle gun
paint removal) of the Spent Fuel Pool deck area floor in preparation for
painting. Surveys of adjacent areas, and loose contamination and
airborne surveys conducted during the job evolution did not indicate any
significant contamination for the area. However, upon exiting the
Radiologically Controlled Area (RCA) all the painters alarmed the
personnel contamination monitors. Following decontamination activities,
two of the painters did not clear the monitors nor meet frisker limits,
i.e. having contamination greater than 100 corrected counts per minute
(ccpm) above background. The clothes of the two painters were
confiscated. For the third painter, a senior RC technician conducted a
frisk which identified contamination levels of approximately 20-40 ccpm.
The RC technician allowed the individual to exit the RCA with the
identified counts erroneously attributed to noble gas contamination.
Upon leaving the restricted area, the same painter alarmed the portal
detectors corresponding to the right foot and leg.
The same RC
technician responded and allowed the individual to leave the restricted
area without a required frisk being conducted based on the individual
not having re-entered the RCA. The next day, all painters involved in
the needle gun activities were sent for whole body analysis. Upon
exiting the restricted area, the same painter who alarmed the portal
monitor the previous night, re-alarmed the restricted area portal
monitors. Followup surveys conducted in the low radiation background of
the restricted area boundary indicated contamination, approximately 120
ccpm, on the painter's shoes. Further, followup whole body analyses
identified an intake of Cesium-137 resulting in Committed Effective Dose
Equivalent of approximately 1 mrem to each individual.
TS 6.11 requires, in part, procedures for radiation protection to be
prepared consistent with the requirements of 10 CFR Part 20 and to be
approved, maintained and adhered to for all operations involving
personnel radiation exposure. From review of procedure and survey
guidance the licensee identified the following examples of failure to
follow procedures which contributed directly to release of the
contaminated clothing from the site:
The lead technician improperly identified the contamination as
noble gas contrary to guidelines for radon progeny discrimination
detailed in Health Physics Procedure-005. Control of Personnel
Decontamination Techniques. Rev. 31 and Survey Instrument
Calibration Procedure -011, Calibration and Operation of the NE
Technology Delta 3 Portable Ratemeter, Rev. 1.
23
The lead technician failed to follow Plant Program Procedure-031.
Contamination Monitoring Program for Personnel/Personal Effects,
Rev. 16, in that, a frisk was not conducted after the individual
alarmed the restricted area portal monitor.
In addition, the licensee's evaluation identified a procedure weakness
in that fixed-contamination surveys were not conducted prior to
initiating needle gun activities although the exact radiological
contamination history was unknown and repainting had been conducted for
the area. Licensee corrective actions included immediate notification
of RC technicians regarding the sequence of events and lessons learned,
proposed revisions to procedures for performing fixed contamination
surveys prior to conducting abrasive work, evaluation of training needs
for the staff, improve documentation by RC personnel regarding
unusual/abnormal conditions and evaluation of techniques for abrasive
removal of paint to reduce radiological hazards. The inspectors
identified the failure to follow procedures as non-cited violation (NCV)
50-261/96-11-03: Failure to follow procedures for personnel
contamination surveys, consistent with Section IV of the NRC Enforcement
Policy.
c. Conclusions
An NCV was identified for failure to follow procedures for personal
contamination control activities in accordance with TS 6.11.
R1.3 Radioactive Waste and Material Transportation Activities
a. Inspection Scope (86750. T12515/133)
The inspectors reviewed RC program activities associated with packaging
and shipping of radioactive material and waste to either vendor
processing facilities or directly to a licensed burial facility. The
review included evaluation of shipping and packaging activities for the
following radioactive material shipments.
A November 17, 1995, Reportable Quantity (RQ) Radioactive
Material, Low Specific Activity. N.O.S. 7, UN2912.
A December 29. 1995, RQ Radioactive Material. Low Specific
Activity, N.O.S. 7, UN2912,
An August 12, 1996. RQ. Radioactive Material. Fissile, N.O.S. 7,
UN2918,
A September 19, 1996 Radioactive Material Shipment, Low Specific
Activity, N.O.S. 7, UN2912,
The inspectors verified and evaluated implementation of revised
49 CFR Parts 100-179 and 10 CFR Part 71 regulations. In addition, the
inspectors evaluated licensee response to a simulated accident scenario
involving a September 18. 1996 radioactive material shipment.
24
b. Observations
Licensee shipping paper documentation met the applicable regulatory
requirements. One potential weakness for management consideration was
restricted visibility of the emergency phone number on some shipping
papers reviewed. The inspectors verified that licensee was a registered
user of the shipping casks and that the appropriate Certificates of
Compliance were maintained at the facility and used to develop the
licensee procedures used to conduct the reviewed shipping activities.
In addition, the inspectors verified that changes to 49 CFR Parts 100
179 and 10 CFR Part 71 regulations were implemented as required.
The response to the simulated emergency scenario was satisfactory,
requiring approximately 15 to 18 minutes for operators in the control
room to provide all the required information to the inspectors.
Licensee representatives stated that the observed response time resulted
from the operators contacting onsite RC supervision prior to completing
a full response to the inspector. Further, operators were trained to
respond directly to an transportation accident event, as necessary. The
inspectors noted that licensee evaluation of this area was continuing
and that supplemental training accident scenarios would focus on
increasing the operators' timeliness in providing the required emergency
response information.
c. Conclusions
Transportation and packaging activities for radioactive waste or
material shipments met 10 CFR 71.5 and 49 CFR 100-179 requirements. The
licensee was implementing, as required, revised Department of
Transportation (DOT) guidance.
R2
Status of Radiation Protection and Chemistry Equipment and Facilities
R2.1 Radiation Monitor System Installation and Operation
a. Inspection Scope (84750)
The inspectors reviewed and evaluated the adequacy of installed process
and effluent Radiation Monitoring System (RMS) detectors, particulate
and iodine samplers, electronics, sampling lines and flow meters, as
applicable, to meet UFSAR commitments and to implement Offsite Dose
Calculation Manual (ODCM) and 10 CFR Part 20 requirements. The
evaluation included, as applicable. RMS equipment walk-downs with
comparisons against configuration control documents, design change
notices and vendor design specifications. Further, the installed sample
line bend radii and piping specifications were evaluated against
recommendations detailed in American National Standards Institute (ANSI)
N13.1-1969, American National Standard Guide to Sampling Airborne
Radioactive Materials in Nuclear Facilities. General comparisons were
made between radiation monitor local and remote readout data, where
possible.
25
The following RMS samplers or detectors (Rs), and associated equipment
were included in the review: Spent Fuel Pool area (R-5): Drumming Room
area (R-8); Failed Fuel process (R-9); Containment Atmosphere
particulate (R-11)
and gas (R-12); Plant vent gas, particulate and
iodine (R-14); Service Water header (R-16); Component Cooling water
process (R-17): Liquid Waste effluent discharge (R-18); Fuel Handling
Building lower (R-20) and upper (R-21) exhaust; Steam Line discharge (R
31 A. B & C); and Containment High Range Monitor (R-32 A&B).
b. Observations and Findings
For the RMS equipment reviewed, no significant issues regarding design
specifications, installed system equipment and sample line
configurations, and operating parameters were identified. Housekeeping
practices associated with RMS equipment skids, cabinets and general
areas were appropriate.
No significant differences were identified for comparisons of data
supplied at local and remote, e.g., Main Control Room. RMS readouts.
Sample flow rates were within limits specified within vendor manuals.
c. Conclusions
The RMS equipment was designed, installed, operated and maintained
appropriately.
R2.2 Radiation Monitor System Calibrations
a. Inspection Scope (84750)
Approved guidance and resultant data for selected RMS detector
calibrations were reviewed and discussed. For each detector reviewed,
source calibration Environmental and Radiation Control (E&RC)
Surveillance Test Procedure (STP) packages for the previous two
surveillances conducted prior to the onsite inspection were reviewed,
evaluated and discussed with licensee representatives. The following
RMS detectors and associated electronics were included in the review:
Main Control Room area (R-1): Spent Fuel Storage Pool area (R-5):
Containment Atmosphere particulate (R-11)
and gas (R-12): and
Containment High Range Monitor (R-32B).
The RMS source calibration guidance and results were evaluated against
applicable sections of the UFSAR, Technical Specification (TS) and ODCM
requirements. In addition. STP guidance for the R-32 monitor was
compared against special calibration requirements specified in
NUREG 0737, Clarification of Three Mile Island (TMI) Action Plan
Requirements. Table II.F.1-3 Containment High Range Monitors (CHRMs).
b. Observations and Findings
From the RMS detector source calibration reviewed, no concerns nor
issues were identified. Further, the inspectors verified completion of
26
in situ special calibrations by electronic signal for the CHRMS in
accordance with TMI Action Item II.F.I-3 specifications. No significant
trends in the calibration data were observed and all surveillances were
conducted at the required frequencies. Traceability of calibration
sources and calibrator equipment to National Institute of Standards and
Technology (NIST) was demonstrated.
c. Conclusions
The RMS detector source calibrations were technically adequate,
conducted at required frequencies and results were within established
limits.
R5
Staff Training and Qualifications in Radiation Protection and Chemistry
R5.1 Training of RC Staff on Transportation Requirements
a. Inspection Scope (86750. TI 2515/133)
The training provided to RC staff to meet the requirements of
49 CFR Part 172 Subpart H were reviewed and discussed with licensee
representatives. Further, training details provided to staff regarding
implementation of recent Department of Transportation (DOT) changes to
49 CFR Parts 100-179 were evaluated.
From discussion with applicable RC staff members, the inspector
evaluated the training effectiveness regarding recent DOT changes
implemented for 49 CFR Parts 100-179.
b. Observations and Findings
Review of training records verified that RC staff members involved in
handling and packaging of radioactive materials were receiving hazardous
material (hazmat) training within the required frequencies. From review
of training material presented to staff in March 1996, the inspectors
verified that recent DOT changes to shipping and packaging requirements
were covered in the course material.
From discussion of shipping
procedures and shipping papers, the inspectors determined that
responsible licensee representatives were knowledgeable of the recent
DOT changes.
c. Conclusions
Hazmat training provided to personnel handling radioactive materials was
conducted at the appropriate frequency. and included recent changes to
DOT regulations. The training provided was effective.
27
R7
Quality Assurance in Radiation Protection and Chemistry Activities
R7.1 Radiological Measurement Quality Control
a. Inspection Scope (84750)
The inspectors reviewed implementation of the counting room quality
control (QC) activities to meet the intent of Regulatory Guide (RG)
4.15. Quality Assurance for Radiological Monitoring Programs (Normal
Operations) - Effluent Streams and the Environment. Specifically, the
results of the following cross-check radiological analyses were reviewed
and discussed with cognizant licensee representatives:
1995 quarterly cross-check analysis results for strontium (Sr)-89.
Sr-90, and iron (Fe)-55 Vendor Analyses
1995 quarterly and 1996 first quarter cross-check analysis results
for gamma-spectroscopy analyses
Selected 1996 Daily Gamma Spectroscopy System Performance Data.
.The use of correction factors, as applicable, for RMS sample line
particle deposition and iodine plate-out were reviewed and discussed.
The review included calculations and actual test data used to evaluate
particle deposition and iodine plate-out in RMS sample lines. Finally,
the licensee evaluation of design limitations for the.plant vent gaseous
effluent monitor under accident conditions as identified in NRC
Information Notice 86-30. was reviewed and discussed.
b. Observations and Findings
No significant concerns nor negative trends were identified from review
of the counting room gamma-spectroscopy QC performance data. In
addition, no issues regarding inter-laboratory cross-check analyses were
noted.
From discussions with licensee representatives, the inspectors were
informed that airborne effluent measurement data did not include
correction factors for iodine plate-out nor for particulate deposition
in sample lines. The inspectors noted that particulate and iodine
radionuclides are routinely monitored by the Containment Atmosphere
(R-11) and the Plant vent (R-14) sampling systems. Licensee
representatives provided a March 1987 study which compared results from
a particulate filter and charcoal cartridge on the R-11 RMS to a
containment grab sample. For the particulate radionuclides, the ratio
of R-11 sampler to Containment Volume (C-11/CV) grab sample values
ranged from .8 to 1.4. For the iodine radionuclides, the C-11/CV ratios
ranged from 1.10 to 1.13. For the R-14 monitor, a preliminary
evaluation of changes to the system indicated that the monitor upgrade
would not affect sample line deposition with approximately 100 percent
of particulates transmitted to the sample collector. However, no
calculations were provided with the evaluation nor were any estimates of
28
iodine plate-out provided. Subsequent evaluation of sample line
deposition using Deposition Software for Characterizing Aerosol Particle
deposition in Sampling Lines. Revision 2. calculated a transmission
factor of approximately 99.5 percent. The inspectors noted either
calculations or test studies evaluating RMS sample line particulate
deposition and iodine plate-out needed to be formally documented and
approved.
In addition, the licensee was unable to provide data prior to the end of
the onsite inspection, regarding qualifications of the R-14 electronic
equipment for doses expected during accident conditions. A preliminary
calculation indicated that expected doses, approximately 850 rads. would
be less than the 1000 rads operating limit specified by the vendor.
The inspectors informed licensee representatives that calculations
ensuring the R-14 monitor was qualified to expected doses during
accident conditions, as well as data associated with evaluation of
sample line particulate deposition and iodine plate-out. would be
reviewed during subsequent inspections.
c. Conclusions
Gamma spectroscopy and inter-laboratory cross check QC activities were
implemented appropriately and met the intent of RG 4.15. A need to
review documentation associated with sample line particulate and iodine
plate-out calculations and qualification of the R-14 monitor to expected
doses during accident conditions was identified as IFI 50-261/96-11-04.
R7.2 Licensee Self-Assessment Activities
a. Inspection Scope (84750, 86750)
During the inspection period, the following audit reports regarding
Chemistry, RC: and Radioactive Waste (Radwaste) processing, packaging
and transportation program activities required by TS, 10 CFR Part 20,
and 10 CFR Part 71 were reviewed and discussed with licensee
representatives.
R-ERC-94-02, Environmental and Radiation Control Assessment, dated
January 10, 1995
R-ERC-95-01, Environmental and Radiation Control Assessment, dated
January 05, 1996
In addition, the experience of the individuals conducting audits of the
subject E&RC program areas was reviewed and discussed.
b. Observations and Findings
The audits met TS required frequencies and addressed ODCM. effluent,
Chemistry, RC, radwaste and transportation program guidance and
implementation. Both compliance-based and performance-based strengths,
29
issues, weaknesses and recommendations were documented. The audits
included review and followup of previously identified items.
From discussions with licensee management, the inspectors determined
that auditor teams included experienced individuals from outside of the
H.B. Robinson facility.
c. Conclusions
Audits for the E&RC program activities were thorough and comprehensive,
and met TS, 10 CFR Part 20, and 10 CFR Part 71 requirements.
P2
Status of Emergency Preparedness Facilities, Equipment, and Resources
P2.1 Testing of Public Warning System Following Hurricane
a. Inspection Scope (71750)
The inspectors reviewed the licensee's actions to test the Public
Warning System sirens located in the surrounding counties following
Hurricane Fran.
b. Observations and Findings
On September 6, the licensee conducted a silent test of the Public
Warning System sirens to ensure that there was no damage as a result of
the strong storm winds from Hurricane Fran.
This test involved sending a test actuation signal to each of the sirens
from the primary activation point. Receipt of the signal, and therefore
affirmation that the sirens would actuate, was confirmed by reading a
local counter at each of the sirens.
During this test, the licensee identified that a significant number of
sirens in Darlington County did not receive the test signal.
As a
result of the potentially inoperable siren conditions, the licensee
implemented their offsite emergency management procedures for backup
public warning in the affected areas. Also, in accordance with 10 CFR
50.72(b)(1)(v), the licensee provided a 4-hour NRC notification due to
meeting the criteria for a major loss of offsite communication
capability. Later that same day, another silent test was conducted from
the alternate activation location. The results of this test confirmed
that all but one siren was operating properly.
Subsequent licensee investigations determined that the cause of the
original failures was a malfunctioning tone encoder used to transmit the
test signal from the primary activation location. In that the alternate
activation equipment had been operable, the sirens could have been
actuated during the time that the primary tone encoded equipment had
failed. The primary tone encoder was later replaced and an acceptable
silent test was performed to demonstrate siren operability.
30
c. Conclusions
The inspectors concluded that licensee actions to test and address
potential problems with the Public Warning System following the
aftermath of Hurricane Fran were adequate.
P3
Emergency Preparedness Procedures and Documentation
P3.1 Discrepancies in On-shift Dose Assessment Procedure
a. Inspection Scope (71750)
The inspectors reviewed the licensee's capability to conduct on-shift
dose assessments during accident situations. This included a review of
emergency procedures and discussions with operators, emergency
preparedness (EP), and computer support personnel.
b. Observations and Findings
10 CFR 50.47 requires that licensees have the capability to perform dose
assessments at all times in order to support emergency response efforts
during accident situations involving actual or potential releases of
radioactive material.
This requirement makes it necessary to have
personnel on-shift who are capable of performing dose assessment
calculations.
The inspectors reviewed emergency procedure EPRAD-03, Dose Projections.
rev. 0. The Control Room operators are responsible for performing dose
projections until the Dose Projection Team, who are part of the
Emergency Response organization, arrive onsite and are prepared to
provide this function. The procedure provided instructions for
accessing a dose calculation computer program called "HBRDOSE" via
several different options. The first and primary option included
accessing the program via an Emergency Response Facility Information
System (ERFIS) terminal computer. If the ERFIS link was operational,
the system would retrieve the input data automatically. If this link
was not operational, the operators would be required to enter the input
data manually. If for any reason that the program access through ERFIS
was unable, the procedure indicated that a computer with the program
installed on its hard drive could be used.
In order to ensure that the operators were capable of accessing the
program, under worst case conditions, the inspectors requested the
Control Room operators to demonstrate use of the program assuming that
ERFIS was out-of-service. The operators indicated that the dose program
was installed on several of their non-ERFIS Control Room computers.
When the operators attempted to access the program via the backup method
in accordance with step 1.1.8 of the procedure. they were unsuccessful.
The Information Technology (IT)
Manager, who's organization provides
computer support, was contacted to discuss the problems encountered.
After a lengthy discussion, the operators were able to eventually access
the dose program from a different computer subdirectory than that
31
specified by EPRAD-03. The licensee indicated that the procedure would
be revised to correct the steps for backup access to the program.
Also, during the unsuccessful attempts to access the program, the Shift
Supervisor produced a computer disk that was stored in his desk that
contained the dose program. This disk was loaded into a Control Room
computer and the program was successfully run, however, the inspectors
noted that the program was not the correct revision. The Shift
Supervisor indicated that the disk had been in the desk for a
considerable time. The disk was later confirmed to be an uncontrolled
copy of the program and was subsequently removed from circulation and
destroyed. The licensee's search for other uncontrolled disks did not
result in any being found. A site wide memo was later distributed
reminding personnel that unauthorized or uncontrolled computer disks
should not be in circulation. The inspectors determined that adequate
corrective actions were taken or planned for this uncontrolled disk
issue.
The inspectors determined that the instructions contained in EPRAD-03
were inadequate for accessing the dose projection program using the
backup method from the Control Room. While the inspectors agreed that
it was highly unlikely that the ERFIS related access to the program
would be unavailable, it was a possibility. As such, the operators
needed to have a reliable backup method for accessing the program and
performing the necessary dose calculations in a timely manner (i.e..
prior to Emergency Response Team arrival). This issue was identified as
example three of Violation VIO 50-261/96-11-01:
Failure to Follow or
Inadequate Procedures - Three Examples.
c. Conclusions
The inspectors concluded that the licensee had established procedures
and controls for the capability to conduct on-shift dose assessments
during accident situations. A procedure discrepancy was identified with
the backup method for accessing the computer software for calculating
dose projections in the Control Room. This issue was identified as
example three of a violation for inadequate procedures.
V. Management Meetings
X1
Exit Meeting Summary
The inspectors presented the inspection results to members of licensee
management at the conclusion of the inspection on October 8. 1996. Interim
exits were conducted on August 23, 28, and September 20, 1996. The licensee
acknowledged the findings presented.
The inspectors asked the licensee whether any materials examined during the
inspection should be considered propriet'ary. No proprietary information was
identified.
32
PARTIAL LIST OF PERSONS CONTACTED
Licensee
J. Clements, Manager, Site Support Services
D. Crook. Senior Specialist, Licensing/Regulatory Compliance
C. Hinnant, Vice President, Robinson Nuclear Plant
J. Keenan, Director, Site Operations
R. Krich. Manager. Regulatory Affairs
B. Meyer, Manager. Operations
G. Miller, Manager, Robinson Engineering Support Services
R. Moore, Manager. Outage Management
J. Moyer. Manager. Maintenance
D. Stoddard. Manager, Operating Experience Assessment
R. Warden, Acting Manager, Nuclear Assessment Section
T. Wilkerson, Manager, Environmental Control
D. Young, General Manager, Robinson Plant
NRC
J. Zeiler, Acting Senior Resident Inspector
P. Byron. Resident Inspector, Surry
33
INSPECTION PROCEDURES USED
IP 37551:
Onsite Engineering
IP 62700:
Maintenance Implementation
IP 62707:
Maintenance Observation
IP 71707:
Plant Operations
IP 71750:
Plant Support Activities
IP 83750:
Occupational Radiation Exposure
IP 84750:
Radioactive Waste Treatment, and Effluent and Environmental
Monitoring
IP 86750:
Solid Radioactive Waste Management and Transportation of
Radioactive Materials
IP 92902:
Followup - Maintenance
IP 92903:
Followup - Engineering
IP 93802:
Prompt Onsite Response to Events at Operating Power Reactor
T12515/133: Implementation of Revised 49 CFR Parts 100-170 and 10 CFR Part
ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
Type
Item Number
Status
Description and Reference
50-261/96-11-01
Open
Failure to Follow or Inadequate Procedures
-Three
Examples (Sections 01.7. N1.l, and
P3.1)
50-261/96-11-02
Open
Inadequate Corrective Actions to Prevent
Expired Fire Brigade Medical Physicals
(Section 01.8)
50-261/96-11-03
Open
Failure to follow procedures for personnel
contamination monitoring (Section R1.2)
IFI
50-261/96-11-04
Open
Review Licensee RMS Sample Line
Particulate Deposition and Iodine Plate
out Evaluations: and R-14 Qualification to
Expected Accident Doses (Section R7.1)
Closed
e
Item Number
Status
Description and Reference
LER
50-261/94-16-01
Closed
Reactor Trip Due to Loss of Load (Section
08.1)
LER
50-261/93-16-00
Closed
Ventilation System Outside Design Basis
Due to Positive Pressure Condition
(Section M8.1)
34
Type
Item Number
Status
Description and Reference
(cont'd)
LER
d
21~26
3-
00 Closed
Technical Specification Violation Due to
Missed Channel Functional Test (Section
M8.2)
IFI
50-261/94-028O03 Closed
Follow Licensee's Activities to Enhance
The On-Line Maintenance Scheduling Process
(Section M8.3)
IFI
50-261/95-20-01
Closed
Justification of Time Required to
Establish Alternate SI Pump Thrust Bearing
Cooling (Section E8.1)
IFI
50-261/95-2002
Closed
Evaluation of Air Operated Valves "Smart
Failures" (Section E8.2)
50-261/96-11-03
Closed
Failure to follow procedures for personnel
contamination surveys (Section R1.2)