ML17059B355
| ML17059B355 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point |
| Issue date: | 11/25/1996 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17059B353 | List: |
| References | |
| 50-220-96-10, 50-410-96-10, NUDOCS 9612030145 | |
| Download: ML17059B355 (72) | |
See also: IR 05000220/1996010
Text
U.S. NUCLEAR REGULATORY COIVIIVIISSION
REGION I
Docket/Report Nos.:
50-220/96-06
50-41 0/96-06
License Nos.:
NPF-69
Licensee:
Niagara Mohawk Power Corporation
P. O. Box 63
Lycoming, NY 13093
Facility:
Nine Mile Point, Units
1 and 2
Location:
Scriba, New York
Dates:
July 28 - September
7, 1996
Inspectors:
B. S. Norris, Senior Resident Inspector
T. A. Beltz, Resident Inspector
R. A. Skokowski, Resident Inspector
Approved by:
Lawrence T. Doerflein, Chief
Projects Branch
1
Division of Reactor Projects
9b22030145 9bli25
ADQCK 05000220
8
EXECUTIVE SUIVIMARY
Nine Mile Point Units 1 and 2
50-220/96-10
8t 50-410/96-10
July 28 - September 7, 1996
This integrated inspection report includes reviews of licensee operations,
engineering,
maintenance,
and plant support.
The report covers
a 6-week period of resident inspection.
PLANT OPERATIONS
During the Unit
1 shutdown of July 28, the inspectors
noted difficulties with respect to the
operator's ability to control reactor vessel water level, and confusion on the part of the
Station Shift Supervisor
(SSS) regarding the proper action when one control rod was at an
indeterminate position.
The SSS briefing for the shutdown was weak and did not include
significant detail or a discussion of past problems.
Management oversight of the Unit
1 reactor startup on August 20 was good, and the pre-
evolution brief by the Operations Manager was detailed and safety-focused.
The control
room staff demonstrated
a questioning attitude and the briefing appeared
synergistic.
The
presence
of a Quality Assurance
(QA) auditor and a Unit 2 senior reactor operator (SRO) in
the control room during the startup was a positive attribute.
Unit 1 experienced two control rod drive (CRD) uncouplings during the period.
The actions
taken each time were appropriate.
The decision to declare one of the CRDs inoperable due
to recurring uncouplings,
and the inability to verify coupling at the projected critical rod
height during the planned startup was appropriate
and conservative.
MAINTENANCE
The troubleshooting,
repair, and post-maintenance
testing activities associated
with
repetitive failures of a Unit 2 main steam line (MSL) radiation monitor were methodical,
thorough,
and appropriate.
However, removal of the LCO required trips to conduct post-
maintenance
testing, prior to declaring the MSL radiation monitor operable,
appears to be a
violation of TS.
NMPC disagrees with this position and submitted
a letter to the NRC
Office of NRR for clarification of the requirements.
In addition, the need to remove LCO
required trips to complete the testing to determine operability is not limited to the MSL
radiation monitors at Unit 2, and may be generic to other plant systems.
(URI 96-01-01)
The Unit
1 shaft-driven feedwater pump friction clutch failed to engage
during a power
ascension,
Following repairs and post-maintenance
testing, the system was improperly
restored because
of personnel
error.
This resulted in the clutch trying to engage while the
output shaft was secured with a maintenance
pin, causing damage to the clutch
mechanism.
When personnel
removed the pin, the shaft started to rotate, which could
have caused
serious personal injury. Not withstanding the near miss, the technical
meetings were thorough and safety-focused.
Plant management
was actively involved
with numerous technical and operational concerns.
The final repairs appeared
appropriate
and technically sound.
0V
Executive Summary (cont'd)
Unit 2 started
a shutdown because
both divisions of the control building chilled water
system were inoperable due to low service water flow through the chillers.
NMPC's
determination of the low setpoint for the service water flow trip was inadequate
design.
(URI 96-10-02)
The work orders were technically correct and the adjustments
were
performed correctly and without incident.
The NMPC procedure for procedure
changes
was inconsistent with the requirements of the
Unit 2 TSs, which require two members of the unit management
staff to approve the
change,
at least one of whom holds an SRO license.
The procedure allowed approval by a
"procedure owner" if the change was considered
editorial.
One of the possible editorial
corrections allowed was one-for-one changes to existing information, if the change was
supported
by the reviews and approvals for the design document.
This is a violation of TS 6.8.3
(VIO 96-10-03).
A strong procedure review and approval process should have
identified this.
This is the second example in less than a year where the NRC identified a
programmatic procedure that departs from the requirements of the license.
The other
example was implementation of temporary modifications prior to completion of the required
safety evaluations.
Three maintenance
related issues were associated
with poor personnel performance.
A
Unit
1 operator pulled the wrong fuses during application of a markup, resulting in the
inadvertent scram of a control rod; a Unit 1 operator made a calculational error during
completion of a core spray topping pump surveillance, resulting in a six week delay in
identifying that the pump differential pressure
was higher than the acceptance
criteria;
and a Unit 2 Instrumentation
and Controls (l&C) Supervisor incorrectly changed
a work
order, resulting in maintenance
on the wrong division of the hydrogen/oxygen
(H,/0,)
monitoring system.
In each case, the procedures
were not properly implemented.
(VIO 96-10-04)
ENGINEERING
On August 28, 1996, Unit 2 operators entered the EOPs due to a positive pressure
in the
reactor building.
During a surveillance on the standby gas treatment system, including the
emergency recirculation ventilation subsystem,
the test damper closed and the normal inlet
damper opened.
This placed the recirculation system in parallel operation with the normal
ventilation exhaust fan; thus, less air was available for removal by the normal ventilation
fan.
An interlock caused the inlet damper to open if the test damper closed while the
system was running.
The operators responded
appropriately to the transient, and the
operability determination was adequate
for normal operations;
however, the adequacy
of
the surveillance procedure, with regards to the potential for a failure of the test damper to
result in a challenge to secondary containment integrity, is unresolved.
(URI 96-10-05)
General Electric (GE) informed NMPC that the cycle specific safety limit minimum critical
power ratio (SLMCPR) for both units may be more limiting than previously determined for
generic calculations.
Both units implemented administrative limits until the completion of
the GE cycle specific analysis.
After receipt of the GE analysis, both units updated the
core monitoring computer to reflect the change
in the SLMCPR.
e
TABLE OF CONTENTS
page
EXECUTIVE SUMMARY
TABLE OF CONTENTS
.
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IV
SUMMARY OF ACTIVITIES
Niagara Mohawk Power Corporation (NMPC) Activities ....
Nuclear Regulatory Commission
(NRC) Staff Activities
I. OPERATIONS
01
Conduct of Operations........
~ ~........
~
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~
01.1
General Comments
01.2
Unit
1 Shutdown to Repair the Shaft Driven Feedwater
Pump
.
01.3
Unit 1 Startup .......
~ . ~........
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02
Operational Status of Facilities and Equipment ..
~ ~.... ~........
02.1
Unit 1 Control Rod Uncouplings
02.2
Unit 2 RCIC Walkdown
08
Miscellaneous
Operations
Issues ..
~
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-08.1
(Closed)
Unit
1 Special Report: ¹12 Drywell High Range
Gamma Radiation Monitoring System Inoperable
08.2
(Closed)
Unit 1 Special Report: ¹12 Drywell High Range
Gamma Radiation Monitoring System Inoperable
08.3
(Closed)
VIO 50-220/95-03-01:
Operator Actions Contrary to
Procedures
08.4
(Closed)
URI 50-220/95-03-02:
Procedures
not Consistent
with Technical Specifications
08.5
(Closed)
URI 50-220/95-16-01:
Weak Initial Operability
Determinations
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4
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4
6
6
II. MAINTENANCE
M1
Conduct of Maintenance
M1.1
Unit 2 Main Steam Line Radiation Monitor Failures
M1.2
Unit 2 LPCS Pump Suction Valve Leak Rate Testing
M2
Maintenance
and Material Condition of Facilities and Equipment
M2.1
Repairs to Unit 1 Shaft Driven Feedwater
Pump ..........
M2.2
Unit
1 Control Rod Scram Solenoid Pilot Valve Diaphragm
Replacement......
~ .. ~.................
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M2.3
- Unit 2 TS Required Shutdown due to Both Divisions of the
Control Building Chilled Water System Inoperable
.
~ .
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M3
Maintenance
Procedures
and Documentation ....
M3.1
Procedure
Changes
Not in Accordance with TS Requirements
M4
Maintenance Staff Knowledge and Performance ..
M4.1
Personnel
Performance
~ ~........ ~....
M4.2
Unit
1 Inadvertent Scram of a Single Control Rod.........
M4.3
Calculation Error During Unit
1 Core Spray Surveillance
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8
9
11
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IV
I
Table of Contents (cont'd)
M4.4
Unit 2 Maintenance Activities on the Incorrect Division of H,O,
Monitoring ... ~......... ~........... ~............
19
M4.5
Conclusion
- Inadequate
Personnel Performance........,
.
~
.
20
M8
Miscellaneous Maintenance
Issues ..........................
20
M8.1
(Closed)
LER 50-410/96-08:
Technical Specification
Violations Caused by Inadequate
Procedure ........... ~...
20
M8.2
(Closed)
LER 50-220/96-06:
Technical Specification Violation
Caused
by Cognitive Error in Calculation Verification ........
21
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23
III. ENGINEERING
E2
Engineering Support of Facilities and Equipment ~.......
~
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E2.1
Unit 2 Secondary
Containment Pressurization
E8
Miscellaneous
Engineering
Issues
E8.'I
(Closed) LERs 50-220/95-05 and 50-220/95-05 Supplement
1:
Building Blowout Panels Outside the Design Basis Because of
Coflstructlotl Error ......,...,...............,......
23
E8.2
Incorrect Safety Limit Identified by General Electric .........
25
E8.3
(Clos~~I LER 50-220/96-05:
Incorrect Safety Limit Caused by
Inadequate
Calculational Procedure ..
~ . ~........... ~....
26
-E8.4
(Closed) LER 50-410/96-06:
Incorrect Safety Limit Caused by
Inadequate
Calculationa( Procedure .....
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26
E8.5
(Closed) LER 50-410/96-06 Supplement
1: Incorrect Safety
Limit Caused
by Inadequate
Calculational Procedure .... ~....
26
IV. PLANTSUPPORT...............................
~...........
~ ..
26
V. MANAGEMENTMEETINGS
X1
Exit Meeting Summary.......
~ ~.......
X3
Management
Meeting Summary
X3.1
SALP Meeting .... ~...........
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ATTACHMENT
Attachment
1 - Partial List of Persons
Contacted
- Inspection Procedures
Used
- Items Opened,
Closed, and Updated
- List of Acronyms Used
REPORT DETAILS
Nine Mile Point Units
1 and 2
50-220/96-1 0 8E 50-41 0/96-1 0
July 28 - September 7, 1996
SUMMARYOF ACTIVITIES
Niagara Mohawk Power Corporation (NMPC) Activities
Unit 1
During this inspection period, Nine Mile Point Unit
1 (Unit 1) operated
at varying
reactor power levels due to mechanical difficulties with the ¹13 shaft-driven
feedwater pump.
On July 29, Unit
1 was shutdown to evaluate
and repair the ¹13
feedwater pump clutch mechanism;
additional activities during the outage included
a drywell entry to repack a main steam isolation valve and repair an inoperable
safety relief valve acoustic monitor and thermocouple.
On August 3, Unit 1 was
restarted, but reactor power was limited to approximately 46% because
the repairs
to ¹13 feedwater pump were unsuccessful.
Unit
1 was again shutdown on August
8 to repair ¹13 feedwater pump, and investigation identified damaged
dental clutch
gear teeth.
Unit
1 was restarted
on August 11, but reactor power was still limited
to 46% while an engineering
evaluation determined
a course of action for repair of
the ¹13 feedwater pump.
On August 17, Unit 1 was shutdown, ¹13 feedwater
pump was repaired successfully,
and the unit was restarted
on August 21,
achieving full power on August 23.
Unit 1 operated
at essentially 100% reactor
power for the remainder of the period.
Unit 2
Nine Mile Point Unit 2 (Unit 2) maintained essentially 100% power throughout the
period, with a short reduction to 85% power on August 14 due to maintenance
on
the control building chilled water system.
Nuclear Regulatory Commission (NRC) Staff Activities
Ins ection Activities
The NRC resident inspectors performed inspections of the licensee's activities
in
the areas of operations,
maintenance
and surveillance, engineering,
and plant
support.
The inspectors conducted their inspections during normal, backshift, and
weekend hours.
There were no specialist inspections conducted
during this period.
The results of the inspection are contained
in this report.
U dated
Final Safet
Anal sis Re ort
UFSAR Reviews
A recent discovery of a licensee operating their facility in a manner contrary to the
UFSAR description highlighted the need for additional verification that licensees
were complying with UFSAR commitments.
While performing the inspections
discussed
in this report, the inspectors reviewed the applicable portions of the
UFSAR related to the areas inspected.
The inspectors verified that the UFSAR
wording was consistent with the observed
plant practices, procedures
and/or
parameters,
with the following exception.
The description of the
Unit 2 emergency
ventilation system does not discuss the interlock associated
with the unit cooler
test damper (see Section E2.1).
I. OPERATIONS
01
Conduct of Operations (71707)
'1.1
General Comments
Using Inspection Procedure 71707, the inspectors conducted frequent reviews of
ongoing plant operations.
In general, the conduct of operations was professional
and safety-conscious;
specific events and noteworthy observations
are detailed in
the sections below.
01.2
Unit
1 Shutdown to Re air the Shaft Driven Feedwater
Pum
a.
Ins ection Sco
e
On July 28, 1996, Unit 1 was shutdown to repair the ¹13 shaft driven feedwater
pump.
The inspectors reviewed plant procedures
prior to the scheduled
shutdown
(N1-OP-43A, "Reactivity Control," and N1-OP-43B, "Balance of Plant Startup and
Shutdown" ), attended the pre-evolution briefing held by the Station Shift Supervisor
(SSS), and observed portions of the shutdown.
Observations
and Findin s
On July 28, 1996, the inspectors monitored Unit
1 control room operations
associated
with the normal plant shutdown to repair the shaft driven feedwater
pump.
Initial reactor power level was approximately 45%.
Plant staff verified
shutdown prerequisites
and established
the desired rod configuration.
The power
reduction and securing of the main turbine occurred without incident.
The reactor
was manually scrammed at low power to complete the reactor shutdown.
The inspectors noted that the operators
had difficulty maintaining reactor vessel
water level with the normal band.
Initially, as a result of the scram, reactor vessel
water level lowered from a normal level of 76 inches to approximately 38 inches.
High pressure
coolant injection (HPCI) initiated at 53 inches, as expected.
By
design,
HPCI is supposed
to secure at 95 inches to automatically maintain reactor
level within a pre-established
band.
However, due to leakage past the feedwater
Topical headings such as 01, M8, etc., are used in accordance with the NRC standardized reactor Inspection report outline.
Individual reports are not expected to address
all outline topics.
The NRC inspection manual procedure
or temporary
instruction that was used as inspection guidance Is listed for each applicable report section.
regulating valves, and excessive flow from the control rod drive (CRD) system,
reactor vessel level continued to rise above the top of the narrow range level
instrumentation.
The operators verified that the reactor was shutdown.
All control rods indicated
fully inserted, except one.
The numeric rod position indication (RPI) for control rod 14-47 did not indicate, the green "full-in"lights for the rod on the full-core display
were not lit, and the process computer identified the rod position as full out.
The
confusion over the position of control rod 14-47 delayed resetting of the scram for
nearly one hour.
This delay exacerbated
the problem with the rising reactor vessel
water level, as full CRD flow continued until the scram was reset.
The SSS
discussed
the problem with the Operations Manager and concluded that procedure
N1-OP-43A allowed the scram to be reset to verity that all control rods were
inserted.
The scram was reset and control rod 14-47 indicated fully inserted.
Subsequently,
a procedure
change was processed
to make it consistent with the
associated
emergency operating procedure
(EOP), N1-EOP-3.1, Rev. 1, which
required the scram to be reset to allow for alternate control rod movement in the
event a rod was stuck.
The inspectors
observed the SSS's pre-evolution brief, which broadly reviewed the
upcoming shutdown
and outage work scope.
But the inspectors noted that there
was little interaction between the SSS and the operating crew relative to potential
problems or past difficulties; such as previous problems with the rod position
indication on shutdowns.
Additionally, delineation of responsibilities and overall
coordination techniques
were not discussed
among the crew.
This lack of
communication and forethought may have contributed to the problems that the
crew experienced
with reactor level, or the confusion as to the proper action when
one control rod was at an unknown position.
The inspectors discussed
the
shutdown with the SSS, who concurred that the shutdown did not go smoothly.
The SSS stated that the crew had not performed
a shutdown recently, and that
training in the simulator would have been beneficial in reviewing plant response
and
clarifying operator roles and responsibilities.
On August 17, the loss of RPI for the same control rod recurred during a
subsequent
shutdown with a scram from =5% power.
During this scram, the full-
core display again failed to identify position for control rod 14-47; however, the
process computer indicated the rod had inserted.
When questioned
by the
inspectors, the system engineer indicated these losses of RPI were due to failures in
the RPI system probe buffer card and the full-in over-travel reed switch.
The buffer
card was replaced,
and the reed switch is scheduled for additional troubleshooting
during the next extended
outage.
Conclusions
The shutdown did not progress smoothly.
Difficulties were noted with respect to
controlling reactor vessel water level, and there was confusion regarding the proper
action when one control rod was at an indeterminate position.
The inspectors
considered the SSS briefing weak, in that it did not include significant detail of the
planned shutdown nor a discussion of past problems.
This may have caused
some
the problems noted by the inspectors.
Unit 1 Startu
Ins ection Sco
e
The inspectors observed control room operations during a plant- startup on August
20, 1996.
Specifically, the inspectors
monitored part of the startup prerequisite
verification, the initial reactor startup, power ascension,
and post-maintenance
testing of the shaft-driven feedwater pump.
Observations
and Findin s
During the reactor startup, the inspectors noted that operations management
was
present to observe the evolution.
Prior to the special evolution (power ascension
and testing of the shaft-driven feedwater pump), the Operations Manager conducted
a Management
Expectations
Briefing with the crew in accordance
with procedure
GAP-SAT-03, "Control of Special Evolutions," Revision 02, Section 3.4.1.
The
discussion included management's
expectations for conduct of operations,
detailed
hardware and operational changes
pertaining to the ¹13 feedwater pump temporary
modification, and addressed
the upcoming schedule of events.
The startup was completed without incident.
The inspectors noted that a quality
assurance
(QA) auditor monitored the power ascension
and the post-maintenance
testing of the ¹13 feedwater pump.
Also, subsequent
to criticality and prior to
placing the unit online, Unit 1 operations management
was present to observe the
conduct of control room operations.
Additionally, the inspectors noted that a Unit 2
senior reactor operator (SRO) monitored Unit 1 control room activities, as an
independent
observer, to identify weaknesses
and ways to develop consistency
between the units.
Conclusions
Management oversight of the reactor startup was good, and the pre-evolution brief
was detailed and safety-focused.
The control room staff demonstrated
a
questioning attitude and the briefing appeared
synergistic.
The presence
of QA and
a Unit 2 SRO in the control room during the startup was a positive attribute.
Operational Status of Facilities and Equipment (71707)
Unit
1 Control Rod Uncou lin s
Ins ection Sco
e
During this inspection period, the licensee identified two potential control rod drive
(CRD) uncouplings
at Unit 1
~ The inspectors discussed
current and previous CRD
uncouplings with plant management
'and staff; reviewed licensee Deviation/Event
Reports (DERs), including potential causes
and proposed/completed
corrective
actions; and reviewed General Electric (GE) Service Information Letter (SIL) No.
052, Supplement
2 (dated July 31, 1974) and Supplement
3 (dated March 17,
1989) relating to CRD anomalies.
Observations
and Findin s
On July 31, 1996, CRD 46-27 was being continuously withdrawn as part of startup
prerequisites.
The plant was shutdown with the mode switch in REFuEL.
During the
rod withdrawal, the over-travel annunciator alarmed, indicating that the rod was
potentially uncoupled.
The rod was fully inserted and probably recoupled.
During a
subsequent
withdrawal, the rod again indicated uncoupled.
The Operations
Manager was concerned that the estimated position for CRD 46-27 during the
upcoming startup would be approximately 12 inches, and uncoupling checks could
not be performed at this rod height.
Therefore, plant management
decided, after
discussion with reactor engineering
personnel, to fully insert the rod, declare the rod
inoperable, valve it out of service, and perform repairs during the upcoming
refueling outage (RFO14) in Spring 1997.
On August 6, 1996, a second
CRD (¹ 18-35) indicated that it was uncoupled during
the weekly uncoupling checks.
The rod was inserted and verified recoupled,
and
returned to the previous position, in accordance
with Procedure
N1-OP-5.
NMPC stated that CRD uncouplings were uncommon at Unit 1; however, in
1991/1992, five CRD uncouplings occurred during that fuel cycle period.
documented
the uncouplings on four DERs.
Four of the five CRD units were
replaced during the next refueling outage,
and the other CRD unit was replaced
during a later forced outage.
Since 1992, no other CRD uncouplings were
documented.
Of the five 1991/1992 CRD uncouplings,
one resulted from separation
of the inner
filter from the stop piston.
During rod withdrawal, the inner filter impacted against
the uncoupling rod with sufficient force to uncouple the drive from the rod.
Inner
filter separation
could be attributable to either improper inner filter installation or
distortion/wear of the inner filter latching spring.
A second uncoupling was
attributed to a bent uncoupling rod in the center spud hole; NMPC assumed
the
most probable cause was that the uncoupling rod was reversed
in the spud base,
permitting the uncoupling rod to move within the spud.
The root causes of the
remaining three CRD uncouplings were not positively determined.
The inspectors'eview
of GE SIL 52 identified that all CRD uncoupling problems
were attributed to internal drive problems.
The probable causes
were:
1) improper
installation and engagement
of the inner filter; 2) improper positioning of the control
rod lock plug due to binding of the lock plug shaft or uncoupling D-handle; 3) crud
buildup on the inner filter; or 4) the wrong uncoupling rod or mispositioning of the
uncoupling rod.
GE also determined
~;at if a drive uncoupled
and was subsequently
recoupled, the drive was considered
operable; however, motion should be restricted
0
to jog only mode of withdrawal operation and the drive should be removed for filter
screen inspection and replacement
during the next scheduled
outage.
Although CRD uncoupling was not a common industry occurrence,
documented
their evaluation of the GE SIL against the potential for this to occur at
Unit 1.
From an accident perspective,
an uncoupled
rod could result in a positive
reactivity excursion due to a dropped rod, which is an analyzed condition.
The
inspectors did not identify any safety concerns.
C.
Conclusions
NMPC's decision to declare CRD 46-27 inoperable due to recurring uncouplings
and
the inability to verify coupling at the projected critical rod height appeared
appropriate
and conservative.
02.2
Unit 2 RCIC Walkdown
The inspectors walked down the accessible
portions of the Unit 2 reactor core
isolation cooling (RCIC) system, and reviewed the recently completed surveillance
tests for the system (N2-OSP-ICS-001) to verify operability.
The material condition
of the components
and the general housekeeping
were acceptable,
with the
exception of a minor packing leak on the steam trap bypass valve.
NMPC was
aware of the steam leak, had scheduled it for repair, and completed the repairs
subsequent
to the end of the reporting period.
08
Miscellaneous Operations Issues (90712, 92700, 92910)
08.1
Closed
Unit 1 S ecial Re ort: ¹12 Dr well Hi h Ran
e Gamma Radiation
Monitorin
S stem Ino erable
On March 25, 1996, with Unit
1 operating at 100% reactor power, NMPC declared
the ¹12 drywell high range gamma radiation monitoring system inoperable to
replace
a resistor.
During the period when ¹12 drywell high range gamma radiation
monitoring system was out of service, the redundant system was operable.
Repairs
were completed on March 26, and NMPC returned the system to service following
post-maintenance
calibration.
NMPC submitted
a special report to the NRC within 14 days, as required by Unit
1
Technical Specifications (TS) 3.6.11-1, Action Statement Table 3.6.11-2 (3a)
~ The
inspectors reviewed the special report and confirmed that all required information
was provided.
08.2
Closed
Unit 1 S ecial Re ort: ¹12 Dr well Hi h Ran
e Gamma Radiation
Monitorin
S stem lno erable
On August 11, 1996, with Unit
1 reactor mode switch in sTARTuP, NMPC removed
the ¹12 drywell high range gamma radiation monitoring system from service due to
a downscale indication.
Instrument and control (ISC) technicians checked the
calibration of the system and found no out-of-tolerance condition.
The IRC
technicians
also performed
a wire integrity check and source check, but noted no
abnormalities.
During the period when ¹12 drywell high range gamma radiation
monitoring system was out of service, the redundant system was operable.
declared the system operable on August 13, after calibration and a 24-hour period
of monitoring.
NMPC submitted
a special report to the NRC within 14 days, as required by Unit 1
TS 3.6.11-1, Action Statement Table 3.6.11-2 (3a).
The inspectors reviewed the
special report and confirmed that all required information was provided.
08.3
Closed
VIO 50-220 95-03-01: 0 erator Actions Contrar
to Procedures
In April 1995, Unit 1 experienced
a reactor scram due to a turbine trip. During the
post-scram review, NMPC identified two cases where procedures
were not properly
implemented:
During the immediate actions following the scram, the Chief Shift Operator
(CSO - a licensed reactor operator) failed to properly position the reactor
mode switch.
After the scram, during troubleshooting
to determine why Power Board ¹11
failed to automatically transfer to the reserve power supply, it was
determined that an operator had not performed an electrical continuity check
of the fast transfer control circuitry after the turbine generator was paralleled
to the grid on the previous startup.
NMPC attributed the cause of both of the above instances to operators not self-
verifying correct completion of all necessary
actions after the conclusion of the
activity.
In addition, the SSS failed to ensure that personnel
on his shift had
referred to the appropriate procedures
to verify implementation,
as written. The
corrective actions included a reinforcement of specific procedural requirements
and
NMPC's expectations
regarding the use and adherence
to procedures
and self-
checking.
The inspectors considered
the corrective actions acceptable.
08.4
Closed
URI 50-220 95-03-02:
Procedures
not Consistent with Technical
S ecifications
During a review of the reactor scram in April 1995 (discussed
in Section 08.3), the
inspectors considered
certain procedures
were not consistent with Unit 1 TSs.
Specifically, the scram procedure
(N1-SOP-01, "Reactor Scram" ) and the EOP for an
anticipated transient without a scram (NMP1-EOP-3, "Failure to Scram" ) allowed the
reactor mode switch to be left in the REFUEL position.
When in the hot shutdown
condition, the Unit
1 TS required the mode switch to be in the sHuToowN position
except for scram recovery operations.
As a result of discussions with the NRC
inspectors,
NMPC initiated DER 1-95-1241.
NMPC determined that the procedures
were acceptable,
as written, but that the
implementation needed clarification.
By placing the mode switch in the REFUEL
position, the operators
are able to manipulate control rods, as necessary,
to insert
any control rods that did not settle at position "00" on the scram; if no rod
movement was being attempted,
the mode switch was to be in the sHuTDowN
position.
The associated
procedures
were changed to reflect the clarifications
discussed
above; i.e., maintaining the mode switch in REFuEL while in the hot
shutdown condition for reasons
other than scram recovery, is not permitted.
The
inspectors considered the corrective actions acceptable.
08.5
Closed
URI 50-220 95-16-01:
Weak Initial 0 erabilit
Determinations
ln September
1995, based on discussions with the SSS and a review of the SSS
log, the NRC identified two instances where initial operability determinations
by
shift supervision were considered
weak.
NMPC initiated a review of the specific
instances
and determined that the SSS had performed an appropriate operability
determination, but had not clearly documented
the basis for the determination
in the
SSS log. The inspectors reviewed the associated
DER and the specific final
and discussed
the concern with NMPC operations
management.
The inspectors
have since observed that the bases for operability
determinations
are better documented.
The inspectors
had no further questions
regarding this item.
II, MAINTENANCE
'VI1
Conduct of Maintenance (61726, 62703, 62707)
Using Inspection Procedures
61726, 62703, and 62707, the inspectors periodically
observed plant maintenance
activities and performance of various surveillance tests.
In general, maintenance
and surveillance activities were conducted
professionally,
with the work orders (WOs) and necessary
procedures
at the work site and in use,
and with the appropriate focus on safety.
Specific activities and noteworthy
observations
are detailed in the sections below.
The inspectors reviewed
procedures
and observed
portions of the following maintenance/surveillance
activities:
~ WO 96-10638-00
~ N2-ISP-MSS-R1 09
~ N2-OSP-CSL-R@002
~ WO 96-1 1 21 9-01
~ WO 96-11219-02
Troubleshooting
of Division II H,/0, Monitor
Main Steam Line High Radiation Monitors Instrument
Channel Calibration
Hydrostatic Leakrate Test for 2CSL" MOV112
Lower Setpoint for Condensing
Water on Chiller
2HVK "CHL-1A
Lower Setpoint for Condensing
Water on Chiller
2HVK"CHL-1 B
Surveillance activities are included under "Maintenance."
For example, a section involving surveillance observations might
be Included as a separate sub.topic under M1, "Conduct of Maintenance."
4 N2-IPM-SWP-R109
0 N2-OPS-GTS-M001
o
N1 ST Q'IB
GAP-OPS-02
4 GAP-PSH-01
NIP-PRO-04
Calibration of the Control Building Service Water Flow
Instrument Channels
Standby Gas Treatment System Functional Test
Core Spray Loop 12,Pumps
and Valves Operability
Control of Hazardous
Energy and Configuration Tagging
Work Control
Procedure
Change Evaluations
Unit 2 Main Steam Line Radiation Monitor Failures
lns ection Sco
e
The inspectors reviewed the troubleshooting,
repair, and post-maintenance
testing
activities associated with repetitive failures of the Unit 2 main steam fine (MSL)
radiation monitor on August 29, and September
3, 1996.
The inspectors
also
reviewed the applicable TS sections,
and discussed
the method used by NMPC to
declared the system operable following the corrective maintenance.
Observations
and Findin s
On August 29, during a walkdown of the control room main control panels, the
oncoming Assistant Station Shift Supervisor (ASSS) observed that the "8" MSL
radiation monitor (2MSS" RT46B) was reading abnormally high.
A review of the
three previous shift checks identified that the indications were normal ~ The
radiation monitor was declared inoperable and TS 3.3.1 was entered.
The TS
action statement
requires placing the inoperable channel in a tripped condition
within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.
This causes
a
~/~ trip signal for the nuclear steam supply shutoff
system (NSSSS) and a
DER 2-96-2054
was written to address
the failure concurrent with initiation of repair activities.
Troubleshooting
identified that the detector was working properly but that the
monitor control panel drawer had a problem.
NMPC replaced the suspect drawer
with a functioning spare drawer.
Subsequent
investigation identified a bad module
in the drawer.
The troubleshooting
and repairs took longer than twelve hours to complete.
Thus,
NMPC took the required actions and inserted the channel trips, as required by the
TS limiting condition for operation (LCO) ~
On August 30, the routine calibration
(N2-ISP-MSS-R109, "Main Steam Line High Radiation Monitors Instrument Channel
Calibration," Revision 1) was being used for post-maintenance
testing to determine
the radiation monitor operability.
During the post-maintenance
testing on August 30, the inspectors observed that the
LCO required trips were cleared in support of testing.
The inspectors questioned
shift management
regarding removal of the trips while the LCO action statement
was still in effect.
The SSS informed the inspectors that the trips had to be cleared
to perform the surveillance test before the channel could be declared operable.
Additionally, the SSS stated that this had been discussed
with operations
10
management;
and referred to the basis section associated
with TS 4.0.3, which
states that surveillance requirements
have to be met to demonstrate
that inoperable
equipment has been restored to operable status.
Not withstanding the above justification, the removal of the LCO-required trips prior
to declaring the MSL radiation monitor operable appears to be a violation of TS 3.3.1
~
NMPC disagrees with this interpretation of the TS and, subsequent
to the
inspection period, issued
a letter to the NRC (dated October 21, 1996), requesting
a
clarification of a "... longstanding
[industry] position that permits the conduct of
certain technical specification surveillance and testing needed to demonstrate that
previously inoperable equipment has been restored to an operable condition."
Pending
an evaluation of this issue by the NRC Office of Reactor Regulation (NRR),
and a review of the NRR response
to NMPC, this item will remain unresolved.
(URI 50-41 0/96-10-01)
On September
3, operators
again observed that radiation monitor 2MSS" RT468
was spiking from 650 mrem/hour to 1450 mrem/hour.
The radiation monitor was
declared inoperable
and troubleshooting
identified a bad connector between the
drawer and the detector.
The connector degradation
was apparently due to heat,
but manipulation of the cable and connector during the August 30~ troubleshooting
and testing may have contributed to connector failure.
Although NMPC has had no indication of problems with the other three channels of
MSL radiation monitoring, they checked the local temperatures
for all of the MSL
radiation monitor connectors
and found them within vendor recommendations.
NMPC also intended to examine the remaining connectors
during the upcoming
refueling outage.
The inspectors considered this action to be appropriate.
NMPC replaced the connector for MSL radiation monitor 2MSS" RT468 and was
able to determine operability of the affected portions of the radiation monitor
without removing the LCO required trips.
The inspectors, through discussions with
the work supervisor,
and review of the repairs and plant drawings, verified that the
post-maintenance
testing was adequate.
Conclusions
Troubleshooting
activities for both MSL radiation monitor failures were methodical
and thorough.
The examination by NMPC for similar connector degradation was
considered
appropriate.
However, removal of the LCO required trips, prior to
declaring the MSL radiation monitor operable,
appeared
to be a violation of TS;
furthermore, the need to remove LCO required trips to complete the testing to
determine operability is not limited to the MSL radiation monitors.
This item is
unresolved
pending further NRC review.
11
M1.2
Unit 2 LPCS Pum
Suction Valve Leak Rate Testin
Ins ection Sco
e
On August 27, 1996, leak rate testing on the Unit 2 low pressure
pump suction valve failed due to the inability to achieve rated test pressure;
subsequent
testing was successful.
The inspectors
observed
portions of the retest,
reviewed the test procedure,
and discussed
the test with NMPC staff.
b.
Observations
and Findin s
During performance of procedure
N2-OSP-CSL'-R@002,
"Hydrostatic Leakrate Test
for 2CSL" MOV112," Revision 2, Unit 2 operators were unable to reach the required
test pressure of 50-52 pounds per square inch gage (psig).
While trying to
pressurize the space between motor operated
valve (2CSL" MOV112) and the
manual isolation valve (2CSL "V121), the operators injected approximately 30
gallons of water and only raised pressure
from 5 psig to 17 psig.
The test was
considered
unsatisfactory
and appropriate actions were taken in accordance
with TS
for an inoperable containment isolation valve.
Additionally, a DER was written to
address the test failure.
Based on previous successful
leak rate testing of MOV112, and other MOVs in
similar plant configurations,
NMPC evaluated the test failure and believed that the
manual isolation valve was not completely closed, possibly due to foreign material
on the valve seat.
NMPC cycled open and closed 2CSL"V121, under the
appropriate administrative controls, satisfactorily retested MOV112 without any
'djustments
to the valve, and exited the LCO.
The inspectors reviewed the initial test procedure which was completed
unsatisfactorily, and discussed
the cause of the test failure with the system
engineer,
Based on the discussion
and a review of the DER disposition, the
inspectors considered
the cause reasonable.
C.
Conclusions
The inspectors considered
the analysis to determine the cause of the LPCS pump
suction valve surveillance failure to be good.
Subsequent
retest of the valve was
successful
and timely.
M2
IVlalntenance and Material Condition of Facilities arid Equipment
(61726, 62703)
M2.1
Re airs to Unit
1 Shaft Driven Feedwater
Pum
a.
Ins ection Sco
e
The friction clutch for the Unit
1 ¹13 shaft-driven feedwater pump failed to engage
during a power ascension
on July 22, 1996.
The inspectors reviewed the
associated
troubleshooting,
evaluation,
and repair activities; discussed
the course of
0
12
action with plant staff and management;
attended review meetings,.and
reviewed
applicable DERs,
design document changes,
applicability reviews.
Observations
and Findin s
On July 19, 1996, the ¹13 shaft-driven feedwater pump was secured
as part of a
scheduled
power reduction to inspect and clean the main turbine condenser water
boxes.
On July 21, while attempting to engage the feedwater pump friction clutch
prior to increasing power, the clutch failed to adequately
engage,
resulting in the
inability to achieve required speed.
The licensee determined that failure of the
friction clutch to engage was due to internal binding of an associated
solenoid
operated valve (SOV-29-01 V1A/B), which resulted in insufficient oil pressure to the
friction clutch.
A representative
from the vendor, Philadelphia Gear, noted
discoloration of the valve internals, presumed to be a result of lubricating oil
breakdown,
and concluded that the SOV failed from age-related
wear.
The SOV
was replaced,
and two additional SOVs used under similar operational conditions,
were identified and replaced.
DER 1-96-1696 was written to identify these
deficiencies.
On July 22, following repairs on the shaft-driven feedwater pump, NMPC personnel
cleared the markup to conduct post-maintenance
testing.
However, the SOV was
left in the "engaged" position; and when control power and actuating oil pressure
were restored
as part of the markup clearance, the friction clutch tried to engage
the output shaft which was locked in position with the maintenance
pin. The pin is
designed to prohibit movement of the feed pump output shaft.
This resulted in
damage to the clutch mechanism.
When plant personnel
removed the pin, the shaft
started to rotate.
This could have resulted in serious personal injury and was
considered
a "near-miss" by NMPC. The licensee issued
DER 1-96-1718 to address
this issue and determine the root cause.
Unit 1 was shutdown on July 28 to
perform repairs.
Plant management
conducted
"tail-gate" training with all
maintenance
and operations personnel relative to the personnel
errors described
above.
The training included
a discussion of what happened,
how the activity
should have been performed, and the potential consequences.
Unit 1 was restarted
on August 3, with reactor power limited to approximately
46% because
of the inoperable shaft-driven feedwater pump.
On August 7, during
startup of the ¹13 pump, the dental clutch failed to properly engage.
On August 8,
NMPC took the unit off-line. NMPC identified two possible reasons for why the
dental clutch did not engage:
(1) a gasket was missing on a control oil supply
line spectacle flange, and (2) the constant bleed ports for the friction clutch
had been clogged, but were cleaned
and opened.
The system engineer stated that
the combination of the gasket and the constant bleed ports probably lowered the
friction clutch actuating oil pressure,
allowed slippage of the friction clutch,
and caused dental clutch damage.
The speed mismatch of the feedwater pump
input and output shafts resulted in the damage to the dental clutch.
The plant
was again restarted
on August 11, with the shaft-driven feedwater pump
and operated
at approximately 46% rated thermal power until another
0
13
outage on August 17.
NMPC was informed that repairs to the dental clutch would
take about 15 weeks.
After considering several options, NMPC elected to operate
the pump solely on the friction clutch.
Unit
1 was restarted
on August 22, post-maintenance
testing was completed
satisfactorily, and the unit returned to full power on August 23.
The inspectors
noted that NMPC's technical meetings were thorough and safety-focused,
and the
engineering applicability review per 10 CFR 50.59 was determined to be
appropriate.
C.
Conclusions
Failure to confirm the position of the SOV following maintenance,
and poor
coordination between the ltkC technicians
and operations personnel
during clearing
of the markup, resulted in friction clutch engagement
with the maintenance
pin
installed.
Also, plant personnel who removed the pin could have sustained
serious
personal injury.
The technical review meetings were thorough and safety-focused.
Plant
management
raised numerous technical and operational concerns, that were
subsequently
resolved.
Overall, the inspectors determined that the final repairs
appeared
appropriate
and were technically sound.
However, personnel inattention
resulted in damage to the clutch mechanism,
and could have resulted in a serious
personal injury.
M2.2
Unit 1 Control Rod Scram Solenoid Pilot Valve Dia hra
m Re lacement
In the fall of 1995, industry concerns
regarding slow scram insertion times were
identified.
Particularly, the 5% insertion times were found to be increasing for
scram solenoid pilot valves (SSPVs) equipped with Viton diaphragms.
At Nine Mile,
only Unit 1 was affected, since Unit 2 SSPVs are of a different design.
As
documented
in NRC Inspection Report 50-220/96-02,
NMPC initiated periodic at-
power scram time testing, as recommended
by the Boiling Water Reactor Owner's
Group's (BWROG's) Regulatory Response
Group (RRG), to address the concern.
Since the concern was identified, NMPC had been replacing the Unit
1 Viton
diaphragms with new Buna-N diaphragms.
By August 11, 1996, all Unit 1 SSPV
Viton diaphragms were replaced with the new material and tested satisfactorily.
Subsequently,
NMPC terminated the periodic at-power scram time testing at Unit 1
~
Since February 1996, the inspectors
have periodically monitored the diaphragm
replacements,
discussed
and observed
NMPC's actions to resolve the concern with
the Viton diaphragms,
and noted no concerns.
0
14
M2.3
Unit 2 TS Re uired Shutdown due to Both Divisions of the Control Buildin
Chilled
Water S stem lno erable
Ins ection Sco
e
On August 13, 1996, the Unit 2 SSS initiated a plant shutdown because
both
divisions of the control building chilled water system were inoperable.
The
inspectors monitored portions of the shutdown and the maintenance
activities to
return the systems to service; this included
a review of the maintenance
and
surveillance packages,
the shutdown procedure,
and the administrative procedures
supporting the work.
b.
Observations
and Findin s
When starting the Division 2 emergency
diesel generator
(EDG) for a planned
surveillance test, the Division 2 control building chiller automatically tripped due to
low service water flow. The chiller is part of the control building chilled water
system, which is a subsystem
of the control room outdoor air special filter train
system.
The special filter train system
is an emergency system that ensures
the
control room and remote shutdown rooms are capable of being maintained habitable
during post-accident
modes of plant operation by diverting outside air through
a
charcoal filter. The chillers support the operation of the special filter train by
cooling the outside air.
In accordance
with the Unit 2 TS 3.7.3, the Division 2
control building outdoor air special filter train system needed to be declared
The chiller tripped at 10:26 a.m. on August 13, at which time the SSS declared the
Division 2 chiller inoperable.
With one division of the special filter train system
inoperable, the TS LCO action statement allows 7 days for repairs or the plant must
be shutdown.
NMPC engineering determined that the trip setpoint for the low
service water flow automatic action was set too high, and had been since June
1989, when the low trip setpoint was increased from 215 gallons per minute (gpm)
to 250 gpm.
It was determined that the Division
1 chiller was also affected, and
the SSS declared that chiller inoperable at 5:11 p.m. With both divisions of the
special filter train system inoperable, TS 3.7.3 is not applicable.
TS 3.0.3 states
that when an LCO cannot be met, place the plant in an operational condition where
the TS does not apply.
In this case, the plant was required to be shutdown within
12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.
Power reduction was started at 5:45 p.m.
Coincident with shutdown activities,
engineering
reviewed the design of the service water system in conjunction with the
anticipated demands
on the system during accident conditions.
They determined
that the low flow setpoint could be adjusted from the current 250 gpm to 210 gpm.
Maintenance work orders were initiated to adjust the trip setpoints
(WO 96-11219-
01 and WO 96-11219-02, Lower Setpoint for Condensing
Water on Chillers
2HVK"CHL-1A and 2HVK"CHL-1B, respectively).
The Division
1 chiller was
declared operable after the flow setpoint had been adjusted
and satisfactorily
0
15
tested.
At 8:11 p.m., power reduction was stopped at 85% and Unit 2 exited TS 3.0.3.
Power was returned to 100% the same day.
NMPC's preliminary determination of the cause for the low setpoint for the service
water flow trip was inadequate
design.
Pending completion of the engineering
evaluation by NMPC and NRC review, this item will remain unresolved.
(URI 50-41 0/96-1 0-02)
The inspectors reviewed the work orders and monitored part of the trip setpoint
adjustment.
The work orders were technically correct and the adjustments
were
performed correctly and without incident.
During the review of the change to the
surveillance procedure for the calibration of the chiller service water flow
instruments that was used for the post maintenance
test, the inspectors identified
that the procedure
change evaluation
(PCE) form was incorrectly completed.
Specifically, the preparer of the PCE and the responsible
procedure owner (RPO)
were the same person.
Per NMPC Procedure
NIP-PRO-04, "Procedure
Change
Evaluations," Paragraph 3.3.1.a, the RPO must be an individual other than the
preparer.
Another qualified RPO reviewed and approved the PCE before work
continued;
and the original RPO generated
a deviation/event report (DER 2-96-1906)
to document the problem and initiate corrective actions to prevent recurrence.
The
failure to properly complete the PCE form is a violation of TS 6.8.1.
Based on the
immediate corrective actions and low safety consequence,
this NRC identified
violation is being treated as a Non-Cited Violation, consistent with Section IV of the
C.
Conclusion
The SSS recognized the effect of the chiller tripping during the test of the EDG and
took the appropriate actions related to one inoperable division of the control building
outdoor air special filter system.
When the second division was also deemed
inoperable, the actions required by TS 3.0.3 were initiated coincident with
adjustments to the flow switches.
NMPC's preliminary determination of the cause
for the service water flow trip low setpoint was inadequate
design.
M3
Maintenance Procedures
and Documentation (61726, 62703, 62707)
M3.1
Procedure
Chan
es Not in Accordance with TS Re uirements
Ins ection Sco
e
During the review of the procedure
change evaluation
(PCE) forms associated
with
the repairs of the control building chillers discussed
in Section M2.3 of this report,
the inspectors noted that the procedure was not consistent with the requirements of
Unit 2 TSs.
16
Observations
and Findin s
TS 6.8.3 requires temporary changes
to procedures
be approved by two members
of the unit management
staff, at least one of whom holds an SRO license on the
affected unit.
NIP-PRO-04, "Procedure Change Evaluations," paragraph 3.3.3.c,
does not require an SRO approval; only an RPO approval is needed for editorial
corrections.
NMPC site-common procedure
NIP-PRO-04 has defined
a type of procedure
change
called an "editorial correction."
Editorial corrections included enhancing existing
information already in the procedure that was not technical, correcting obvious non-
technical errors to existing information, updating reference numbers to other
documents
or correcting misspellings,
and other administrative type of correction.
This practice is not uncommon
in the nuclear industry.
However, NIP-PRO-04 also
allowed design changes to be considered
as "editorial corrections."
Editorial
correction Criterion 3, allowed one-for-one changes to existing information to
incorporate changes to controlled design documents.
The changes
needed to be
entirely supported
by the reviews and approvals for the design document.
The
design document shall be referenced
on the PCE and may include EDC [Engineering
Design.Change]/DCRs
[Document Change Requests],
specifications,
or approved
calculations (such as setpoints by EDCs).
To revise the chiller service water low flow setpoint,
a PCE was generated
for
surveillance Procedure
N2-IPM-SWP-R109, "Calibration of the Control Building
Service Water Flow Instrument Channels."
The PCE was classified as an editorial
correction, with RPO approval only. A change to the acceptance
criteria should be
considered
a technical change,
and SRO approval is required.
The failure to obtain
SRO approval of the temporary change prior to implementation
is a violation of
Unit 2 TS 6.8.3.
(VIO 60-410/96-10-03)
Conclusion
A shrong procedure review and approval process
should have identified that the
PCE procedure was not consistent with the requirements of the Technical
Specifications.
This is another example where the NRC has recently identified a
programmatic procedure that departs from the requirements
of the license.
A past
example was discussed
in NRC Inspection Report 96-01, and related to the
implementation of temporary modifications prior to the completion of the required
safety evaluations.
Maintenance Staff Knowledge and Performance (61726, 62703, 62707)
Personnel
Performance
The inspectors reviewed the below three maintenance-related
issues,
all associated
with personnel performance
errors.
The review included applicable portions of the
SSS and CSO logs, plant procedures,
Licensee Event Reports (LERs), DERs, the
17
UFSARs and TSs.
Also, the inspectors
held discussions
with plant personnel
and
management
regarding these events.
Unit
1 - inadvertent scram of the wrong control rod;
Unit 1 - calculation error not identified during core spray surveillance; and
Unit 2-- maintenance
on the wrong division of H,/0, monitoring.
The details associated
with these issues are provided in the following three
sections, with an overall conclusion provided in Section M4.5 of this report.
Unit 1 Inadvertent Scram of a Sin le Control Rod
On July 26, 1996, with Unit 1 operating at approximately 45% power, control rod 18-31 had been fully inserted and removed from service to support maintenance
activities on the associated
hydraulic control unit (HCU). During the application of
the markup for HCU 18-31, the operator applying the markup removed the fuses for
the wrong control rod (38-31), causing rod 38-31 to scram from the fully
withdrawn position.
(A markup is a component tagging process
used to provide
protection for personnel
and/or equipment during operation, maintenance
and
modification activities. Within the industry, this is commonly referred to as a
tagout.)
The control room operators identified the error, instructed the operator to
replace the fuses for control rod 38-31, and complete the markup of HCU 18-31.
The SSS conferred with Reactor engineering,
and control rod 38-31 was restored to
the fully withdrawn position.
NMPC reactor engineering
informed the inspectors that the!mpact of the
inadvertent rod scram on the plant was minimal, due to the low power level at the
time of the event.
The inspectors considered
NMPC's immediate actions to recover
from the event to be appropriate.
As noted on the associated
DER, the apparent
cause was that the operator failed to
verify the correct component prior to removing the fuses.
NMPC also determined
that a contributing factor was the operator's self-imposed schedular pressure to
prepare for shift turnover.
As a result of this event, the individual involved was counseled
and Unit 1
operations management
generated
a night order to emphasize
their expectation of
concurrent verification during the application of markups associated
with HCU
maintenance.
Concurrent verification was defined as a second checker positively
identifying the correct component
and intended action before any actions are taken.
NMPC's expectation regarding the use of concurrent verification was already
provided in the Unit 1 Operations
Reference
Manual
~ Through discussions
with
Unit 1 personnel,
the inspectors ascertained
that prior to this event, HCU markups
were completed using independent
verification and not the more conservative
concurrent verification.
Until recently, HCU maintenance
was not routinely
completed at power.
The inspectors considered
these corrective actions appropriate
to address this particular event.
18
The inspectors reviewed Procedure
GAP-OPS-02, "Control of Hazardous
Energy and
Configuration Tagging," Revision 6, which required the operator applying the
markup to place all necessary
devices in the required position and then apply the
completed tag.
The failure to remove the correct fuses,
as per the markup order, is
considered
an example of a procedural violation.
The violation is described
in
Section M4.5.of this report.
Calculation Error Durin
Unit 1 Core S
ra
Surveillance
On July 17, 1996, Unit 1 plant management
determined that the unit had been
operated
in a condition prohibited by TS since June 6, 1996.
Specifically, a
calculational error, during the performance of surveillance test procedure
N1-ST-
Q1B, "Core Spray Loop 12 Pumps and Valves Operability," was identified for core
spray topping pump 121 (CSTP-121) differential pressure
(dp).
The surveillance
test involved throttling core spray system flow to meet prescribed procedural
guidance values and obtain flow data.
The control room operators
used this data to
perform additional calculations to determine pump differential pressure.
The operator who performed the initial calculations omitted a pressure
correction
factor8or gauge elevation.
During the same shift, the ASSS discovered the error
and corrected
a portion of the calculation, the result of which was to be carried
forward to subsequent
steps.
However, the ASSS failed to carry the corrections
through the remainder of the calculations.
The following day, the inservice testing
(IST) supervisor also failed to identify the error during his review.
The error was
finally discovered
six weeks later, July 17, during a final supervisory review. When
the error was discovered,
the licensee determined that the pump dp was higher than
the acceptance
criteria. Although the pump remained available, the pump was
declared inoperable because
the dp was outside of the acceptable
range and,
therefore, the surveillance test was unsatisfactory.
A differential pressure
higher
than expected
is normally considered
good.
However, since this was an IST
examination, the acceptable
range is determined
by the pump curves defined by the
American Society of Mechanical Engineers
(ASME) manual.
The surveillance was
reperformed
on July 17, the dp was acceptable,
and CSTP-121 was declared
The licensee's root cause was cognitive personnel
error due to inadequate
self-
checking of'calculations; also, the failure of more than one individual to identify the
error is significant.
The calculation error in performance of surveillance test N1-ST-
Q1B, and the failure to perform adequate
supervisory reviews, are additional
examples of procedural violations,
The violation is described
in Section M4.5 of this
report.
Subsequently,
NMPC issued
LER 50-220/96-06, describing this event.
The review
of the LER is contained
in Section M8.2 of this report.
19
M4.4
On July 25, 1996, while Unit 2 was operating at 100% reactor power, I&C
technicians performed troubleshooting
on the wrong division of the
hydrogen/oxygen
(H,/0,) monitoring system.
At the time of the event, the Division
2 H,/0, monitor was inoperable due to the indicated H, concentration
(1.6%) being
inconsistent with actual chemistry samples (0%).
During troubleshooting
activities
performed under WO 96-10638-00, technicians lifted leads for the Division
1 H,/0,
When the Division
alarmed in the control room, the
operators contacted the technicians
and work was immediately stopped.
Upon
investigation, the crew determined that the steps in the WO were for lifting the
leads for Division
1 instead of Division 2.
The Division
1 lifted leads
were reconnected,
and a DER was written to evaluate the event.
Subsequently,
the
Division 2 H,/0, indication was repaired and declared operable on July 26.
Through discussions
with maintenance
and operations
personnel,
the inspectors
ascertained that the lifted leads did not impact the operability of the Division
1 H,/0,
monitor.
The inspectors verified this information by a review of applicable plant
drawings and the Unit 2 UFSAR.
The apparent cause of the event, as described
in DER 2-96-1754, was inadequate
self-checking by the l&C Supervisor.
Specifically, during performance of the WO,
the l&C Foreman
and Supervisor determined that the annunciator should be
defeated
(i.e., lifting the leads) to minimize disruptions of control room operations.
To accomplish this, a WO change was made to incorporate steps from a previously
approved procedure
(N2-ISP-CMS-0110).
When incorporating the steps into the
work order, the l&C Supervisor inadvertently copied the portion pertaining to the
wrong division.
To assess
the quality of NMPC's root cause and corrective actions, the inspectors
reviewed the applicable WO, surveillance procedure,
and DER, and discussed
the
event with the NMPC I&C Supervisor.
The inspectors
also reviewed the associated
administrative procedure,
GAP-PSH-01, "Work Control," Revision 15
~
GAP-PSH-01
states that if a change to an in-progress work order would adversely affect the
scope or plant impact statement,
the work must be stopped until the WO has been
updated or another WO generated.
Although the intended change would not have
affected the original scope or plant impact; the implementation of the change did, in
fact, adversely affect the scope
and the plant impact statement.
Therefore, the
change was not made in accordance
with GAP-PSH-01, Section 3.11
~ 1, and is
considered
an example of a failure to properly implement the procedure.
The
violation is described
in Section M4.5 of this report.
Although procedure
GAP-PSH-01 allows minor WO changes to be completed by the
supervisor without independent
review, the inspectors considered
the lack of
independent
review for determining whether a WO change
is considered
minor, and
for determining the adequacy of the minor WO changes
themselves,
to be a
vulnerability.
The inspectors were also concerned that the technicians
had possible
opportunities to identify that the WO was directing work on the wrong division of
0,
20
H,/0, monitoring.
In particular, the cabinet containing the annunciator leads was
clearly marked Division 1, and should have prompted the technicians to question
whether the step text of the work order was correct.
This sort of questioning
attitude is promoted by NMPC's "STAAR" (sToP, THINK, AsK, AGT, REYIEw) policy.
M4.5
Conclusion
- Inade
uate Personnel
Performance
In sections M4.2 through M4.4, the inspectors described three maintenance
related
issues associated
with poor personnel
performance.
These are:
(1) a Unit 1
operator pulled the wrong fuses during the application of a markup, resulting in the
inadvertent scram of a control rod; (2) a Unit
1 operator made a calculational error
during completion of a core spray topping pump surveillance, resulting in a six week
delay in identifying that pump differential pressure
was higher than acceptance
criteria; and (3) a Unit 2 IKC Supervisor made
a minor change to a WO, but
incorporated work steps for the wrong division of H,/0, monitoring, resulting in
maintenance
on the wrong division.
In each case, procedural requirements
were
violated as a result of personnel
errors; and each is an example of a violation of TS 6.8.1, which requires procedures
be properly implemented.
(VIO 50-220/96-10-04
8c 50-41 0/96-10-04)
In addition, relative to working on the wrong division of H,/0 the inspectors
considered the lack of independent
review for a WO change to be a vulnerability.
Also, the failure of the technicians to identify that the WO was directing work on
the wrong division to be indicative of poor questioning attitude.
Relative to the
calculational error, supervisory reviews by the ASSS or the IST supervisor were
inadequate
in that they failed to identify that the core spray topping pump did not
meet the surveillance test acceptance
criteria.
M8
Miscellaneous Maintenance Issues (90712, 92700)
M8.1
Closed
LER 50-410 96-08:
Technical S ecification Violations Caused
b
Inade
uate Procedure
During preparations for RF05, scheduled to begin September
28, 1996, Unit 2
personnel identified that the downscale
rod block function of the source range
monitors (SRM) had been inoperable during portions of the first four refueling
outages.
During core offload in the previous outages,
as each SRM channel
indicated downscale
(i.e., less than 3 counts per second
[CPS)), the rod block
function relay was removed and jumpers were installed.
This allowed removal of
NMPC Unit 2 TS Table 3.3.6-1, note (f), permits the function to
be inoperable during refueling, if the associated
SRM channel is downscale.
During
the subsequent
channel functional test prior to reload, the downscale
rod block
function was not tested.
As fuel was loaded into the core, and the SRM channel
came on scale, the rod block relay was installed in the affected channel.
Per TS 3.3.6., the downscale
rod block function was required to be operable prior to the
SRM channel exceeding
3 cps.
0,
21
The apparent
cause of the missed surveillances was a misinterpretation of the TS
requirement for the SRM downscale
rod block function.
No corrective actions were
required since the event was discovered prior to the beginning of the RFO5, and the
necessary
changes
were incorporated into the refueling procedures.
This licensee
identified violation is being treated
as a Non-Cited Violation, consistent with Section
VII.B.1 of the.NRC Enforcement Policy.
M8.2
Closed
LER 50-220 96-06:
Technical S ecification Violation Caused
b
Co nitive
Error in Calculation Verification
The inspectors reviewed LER 50-220/96-06 and determined that it satisfactorily
described the event, the root cause evaluation, and corrective actions to prevent
similar occurrences.
As discussed
in Section M4.3 of this report, a calculational
error during a surveillance test resulted in the failure to identify.that Core Spray
Topping Pump 121 failed to meet the test procedure acceptance
criteria,
Specifically, the pump had high differential pressure
(dp).
However, the procedure violation discussed
in section M4.5, also caused
NMPC to
violate Unit 1 technical specifications since the pump should have been declared
TS 3.1.4.b states that if one pump is inoperable, the redundant
component must be verified operable daily until the pump is returned to service, and
the pump must be returned to service within 7 days.
If the pump is not restored to
an operable condition within seven days, TS 3.1.4.d requires the reactor be
shutdown within one hour, and in a cold shutdown condition within the next ten
hours.
The failure to declare the pump inoperable when the results of the
surveillance test were unacceptable
is a violation of TS 3.1.4.
The inspectors noted
the high dp indicated the pump was performing in excess of the value required and
the surveillance test was successfully performed once the calculational error was
identified.
Based on the corrective actions and low safety consequence,
this
licensee identified violation is being treated as a Non-Cited Violation, consistent
with Section VII.B.1 of the NRC Enforcement Policy.
III. ENGINEERING
E2
Engineering Support of Facilities and Equipment (37551, 40500, 93702)
E2.1
Unit 2 Secondar
Containment Pressurization
a.
Ins ection Sco
e
On August 28, 1996, while at 95% power, Unit 2 operators entered the emergency
operating procedures
(EOPs) for "secondary containment control," due to positive
pressure
in the reactor building.
The inspectors reviewed the description of the
operators'ctions
as contained
in the SSS logs, and reviewed the applicable
EOP.
The inspectors discussed
the event, inr luding the cause of the event, with shift
personnel, the system engineer,
and plant management.
The inspectors
also
0,
22
reviewed the applicable TSs, UFSAR sections,
DER, and plant drawings to assess
the adequacy of the related plant design.
Observations
and Findin s
On August 27-, 1996, Unit 2 operators declared the "A" train of the standby gas
treatment system (GTS) and emergency recirculation ventilation unit cooler 413A
(2HVR"UV413A) inoperable for the performance of the GTS functional surveillance
test (N2-OSP-GTS-M001).
This surveillance procedure
required the unit cooler to be
operated
in the test mode.
At 1:17 a.m. on August 28, the control room operators
received
a reactor building normal ventilation alarm, indicating reactor building
pressure
at +1.25" water gauge.
Operators entered the EOPs for secondary
containment control and TS 3.6.5.1 for secondary containment integrity as
required.
Initial indications were that the unit cooler test damper closed and the
normal inlet damper opened.
At 1:48 a.m. control room operators secured
normal
reactor ventilation and pressure
returned to normal, allowing the operators to exit
the EOPs and TS 3.6.5.1.
Through a review of the SSSs logs, EOPs and TS, and
discussions with the SSS, the inspectors determined the operators'esponse
to the
event to be appropriate.
As documented
in DER 2-96-2038, the cause of the secondary
containment
pressurization
was the shift in unit cooler 413A from the test mode to the
emergency
mode.
In the emergency mode, the unit cooler was connected to the
main exhaust duct for the "below refueling floor" exhaust subsystem.
This placed
the emergency ventilation system in parallel operation with the normal ventilation
exhaust fan.
Since the emergency system was recirculating air within the reactor
building, less air was available for removal by the normal ventilation exhaust fan.
This resulted in positive pressure within the secondary containment.
The inspectors
reviewed the applicable plant drawings, discussed
the issue with the on-watch
ASSS and the system engineer,
and determined the cause to be reasonable.
Through discussions
with the ASSS, the inspectors ascertained
that the emergency
ventilation unit coolers contained
an interlock that caused the GTS inlet damper to
open if the test damper closed while the system was running.
The inspectors
reviewed the applicable drawings with the ASSS and verified the circuitry
associated
with this interlock; based
on this review, the inspectors determined that
the emergency ventilation system responded
as designed to the test damper failure.
However, the inspectors review of the UFSAR, Section 9.4.2.5.3, noted that this
particular interlock was not included in the description of the test damper
operations.
NMPC performed troubleshooting
and functional testing of the test damper and the
associated
circuitry under WO 96-12209-00.
No problems were identified and
failure could not be reproduced.
The surveillance test was reperformed with no
problems.
Engineering provided the operators with an analysis supporting the
operability of the emergency ventilation system.
Subsequently,
the emergency
ventilation system and GTS were returned to an operable status, with the test
damper in the closed position.
23
The inspectors reviewed the supporting analysis and determined it adequate
for
normal operations.
However, the inspectors were concerned that the design of the
test damper interlock allowed secondary
containment pressure to become positive
upon failure of the test damper during the performance of the surveillance test.
According to DER 2-96-2038,
a review to possibly change the procedure was
requested
as part of the supporting analysis.
Therefore, until NMPC completes their
analysis, and the NRC has reviewed the results, the adequa "y of the surveillance
procedure with regards to the potential for a failure of the test damper to result in a
challenge to secondary containment integrity will remain an unresolved
item.
(URI 50-41 0/96-1 0-05)
C.
Conclusions
The operators responded
appropriately to the reactor building pressure transient that
occurred
as a result of the emergency ventilation unit cooler test damper failing shut
during GTS surveillance testing.
Review of plant drawings indicated that the
emergency ventilation system responded
as designed.
supporting analysis was determined to be adequate
for normal operations;
however,
the adequacy of the surveillance procedure with regards to the potential for a failure
of the test damper to result in a challenge to secondary containment integrity is
unresolved.
E8
Miscellaneous Engineering Issues (90712, 92700)
E8.1
Closed
LERs 50-220 95-05 and 50-220 95-05 Su
lement 1:
Buildin
Blowout
Panels Outside the Desi
n Basis Because of Construction Error
a.
Ins ection Sco
e
LER 50-220/95-05 was originally reviewed in NRC Inspection Report 50-220/96-05.
The LER accurately described the fact that oversized bolts were installed in the
reactor and turbine building blowout panels; however, the following weaknesses
were identified:
the LER did not adequately
address the failure to report the condition in
October 1993, or in March 1995;
the LER did not provide sufficient details regarding the 1993 calculational
error to allow for an adequate
assessment
of the licensee's corrective
actions to prevent recurrence;
and
the LER did not address
the potential for, and the significance of, a reactor
building failure.
The inspectors reviewed LER 50-220/95-05, Supplement
1, to determine if the
above items were adequately
addressed.
b.
Observations
and Findin s
Supplement
1 to LER 50-220/95-05 provided additional details regarding the missed
reportability requirements
and the calculational error.
NMPC's bases for not
completing the required reportability notifications, and the technical details
regarding the calculational error provided in the LER supplement,
were consistent
with those contained
in Special Inspection Report 50-220/96-05.
Additionally, the
corrective actions included in the LER supplement
appear comprehensive,
in that the
engineering,
reportability, and configuration control aspects
related to the issue
were adequately
addressed.
The inspectors determined that Supplement
1 to LER
50-220/95-05 adequately addressed
the reportability and calculational weakness
identified during review of the original LER.
As described
in the LER Supplement,
NMPC reanalyzed the building failure pressures
to determine the potential for, and the significance of, a reactor building failure.
These analyses
determined that the actual failure of the reactor and turbine
buildings would not occur below an internal pressure
of 143 pounds per square foot
(psf) and 135 psf, respectively.
Additionally, NMPC recalculated the upper
bounding values for the blowout panels for both the original and currently installed
confic~rations, using an elliptical methodology.
The elliptical methodology is more
appropriate for design of blowout panels, where a conservative
upper-bound
failure
point must be established.
Results of the calculations for original installation indicated the panel blowout
point could have been as high as 128 psf and 122 psf for the reactor and
turbine buildings, respectively.
For the current installation, the calculations indicated the blowout points are
a maximum of 65 psf and 62 psf for the reactor and turbine buildings,
respectively.
These calculations were assessed
by members of the NRR staff in August 1996,
and determined to be acceptable.
The results of the assessment
were sent to
NMPC in a letter, dated October 7, 1996.
Based on the results of the analyses,
NMPC determined that had a transient occurred, the blowout panels would still have
functioned to relieve internal pressure
before the calculated failure point of the
reactor and turbine building superstructures.
C.
Conclusions
The inspectors determined that the Supplement to LER 50-220/95-05 adequately
addressed
the weaknesses
identified in the original submittal.
Therefore,
LER 50-
220/95-05 and Supplement
1 to the LER are closed.
0
25
E8.2
Incorrect Safet
Limit Identified b
a.
Ins ection Sco
e
On April 9, 1996, General Electric (GE) informed NMPC that the cycle specific
safety limit minimum.critical power ratio (SLMCPR), for both units, may be more
limiting than determined by previously performed generic calculations.
The
inspectors
assessed
NMPC's actions in response
to the GE information, including a
review of applicable DERs, LERs, the TS, the 10 CFR Part 21 notification, and core
operating limits reports (COLRs). Additionally, the inspectors discussed
the issue
with the plant managers,
and engineers from NMPC's reactor engineering
and fuels
and analysis engineering departments.
b.
Observations
and Findin s
On April 9, 1996, GE informed NMPC that cycle specific SLMCPR, for both units,
may be more limiting than previously calculated.
On April 10, NMPC contacted
to discuss the information and ascertained
that non-conservatism
in the SLMCPR
had been identified at several plants; NMPC determined that it definitely applied to
Unit 2but Unit 1 was not expected to be impacted.
Furthermore,
GE would be
performing cycle specific calculations for both units.
GE recommended
that Unit 2
implement administrative controls to ensure compensation
for the non-conservatism
until the cycle specific calculations were completed.
On April 10, NMPC initiated a DER, common to both units, regarding the concern,
and implemented administrative limits at both units until completion of the GE cycle
specific analysis.
Subsequently,
the GE analysis determined that new SLMCPRs
were needed for Unit 2, and Unit 1 as well. Both units updated the core monitoring
computer to reflect the change
in the SLMCPR, and the previous administrative
limits were removed.
On May 24, 1996, GE notified the NRC, via letter, that the nonconservatism
in the
generic SLMCPR, when applied to some actual core and fuel designs, was
reportable under 10 CFR Part 21
~ The inspectors reviewed the notification and
verified that the actions taken at both units was appropriate.
Therefore, the GE
10 CFR Part 21, "Reportable Condition, Safety Limit MPCR [minimum critical power
ratio] Evaluation," for both units is closed.
As stated in the applicable LERs, NMPC evaluated the core performance for the
current operating cycle.
They determined that the operating limit, as adjusted to
compensate
for the error, was never exceeded,
and that the safety limit would not
have been exceeded
for any analyzed plant transient.
The inspectors discussed
the
evaluations with NMPC personnel
and considered
them appropriate.
The Unit 1 COLR will be updated
by NMPC upon receipt of the revised supplemental
licensing report from GE. The Unit 2 COLR revision incorporated the new limits,
and appeaied to be appropriate,
containing the required reviews and approvals.
Furthermore, the SLMCPR value specified in the Unit 2 TS, Section 2.1.2, will be
26
updated following restart from RFO5, scheduled for late October 1996.
Until the
revision is complete, the SLMCPR will be controlled administratively and limited by
the core monitoring computer.
c.
Conclusions
The inspectors observed the actions taken by both units in response
to the
nonconservative
SLMCPR calculations provided by GE, and determined the actions
were appropriate.
Additionally, the inclusion of an administrative limit at Unit 1,
even though GE initially indicated the Unit 1 was not expected to be impacted by
the calculation error, indicated an appropriate safety focus.
E8.3
Closed
LER 50-220 96-05:
Incorrect Safet
Limit Caused
b
Inade
uate
Calculational Procedure
The inspectors reviewed the subject LER and determined that it satisfactorily
described the event, the root cause evaluation, and corrective actions.
A detailed
review of the issues associated
with this LER is contained
in Section E8.2.
E8.4
Closed
LER 50-410 96-06:
Incorrect Safet
Limit Caused
b
Inade
uate
Calculational Procedure
The inspectors reviewed the subject LER and determined that it satisfactorily
described the event, the root cause evaluation, and corrective actions.
A detailed
review of the issues associated
with this LER is contained
in Section E8.2.
E8.5
Closed
LER 50-410 96-06 Su
lement 1: Incorrect Safet
Limit Caused
b
Inade
uate Calculational Procedure
The inspectors reviewed the supplement to the subject LER and noted that the
changes
were editorial only.
IV. PLANT SUPPORT
The resident inspectors routinely monitored the performance of activities related to
the areas of radiological controls, chemistry, emergency
preparedness,
security, and
fire protection.
No significant observations
were identified during this period.
V. MANAGEMENTMEETINGS
X1
Exit IVleeting Summary
At periodic intervals, and at the conclusion of the inspection period, meetings were
held with senior station management
to discuss the scope and findings of this
inspection.
The final exit meeting occurred on October 18, 1996.
27
Based on the NRC Region
I review of this report, and discussions
with NMPC
representatives,
it was determined that this report does not contain safeguards
or
proprietary information.
X3
Management Meeting Summary
On August 8, 1996, a meeting between the NRC and NMPC management
was held
at the Joint New Center to discuss the results of Systematic Assessment
of
Licensee Performance
(SALP), Report Numbers 50-220/96-99 and 50-410/96-99 for
Nine Mile Point Units
1 and 2. This meeting was open to the public.
ATTACHMENT 1
PARTIAL LIST OF PERSONS CONTACTED
Nia ara Mohawk Power Cor oration
R. Abbott, Vice President,
Nuclear Generation
J. Aldrich, Maintenance
Manager, Unit
1
M. Balduzzi, Operations
Manager, Unit 1
C. Beckham, Manager, Quality Assurance
J. Burton, Director, ISEG
J. Conway, Operations
Manager, Unit 2
K. Dahlberg, General Manager, Projects
R. Dean, Manager, Unit 2 Technical Support
M. McCormick, Vice President,
Nuclear Safety Assessment 5 Support
L. Pisano, Maintenance
Manager, Unit 2
N. Rademacher,
Plant Manager, Unit
1
R. Smith, Operations
Manager, Unit 2
K. Sweet, Technical Manager, Unit
1
K. Ward, Technical Manager, Unit 2
D. Wolniak, Licensing Manager
W. Yaeger, Manager, Engineering,
Unit 1
INSPECTION PROCEDURES USED
IP 37551:
IP 40500:
IP 60605:
IP 61726:
IP 62703:
IP 62707:
IP 71707:
IP 71750:
IP 90712:
IP 92700:
IP 93702:
IP 92901:
On-Site Engineering
Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing
Problems
Preparations
for Refueling
Surveillance Observations
Maintenance
Observation
Maintenance
Observation
Plant Operations
Plant Support
In-Office Review of Written Reports of Nonroutine Events at Power Reactor
Facilities
Onsite Followup of Written Reports of Nonroutine Events at Power Reactor
Facilities
Prompt Onsite Response
to Events at Operating Power Reactors
Followup - Operations
ITEMS OPENED, CLOSED, AND UPDATED
OPENED
50-41 0/96-1 0-01
50-41 0/96-1 0-02
50-41 0/96-1 0-03
50-220
S.
50-41 0/96-1 0-04
50-410/96-1 0-05
CLOSED
50-220/95-03-01
50-220/95-03-02
50-220/95-1 6-01
50-41 0/96-08
50-220/96-06
Standby gas treatment system interlock caused the
containment to experience
a positive pressure
Failure to follow procedures
Procedures
not consistent with TS
Weak initial operability determinations
LER
TS violations caused
by inadequate
procedure
LER
TS violation caused
by cognitive error in calculational
verification
Main steam line radiation monitor returned to service prior
to being declared operable
Service water design not fully analyzed for all accident
conditions and service water header combinations
PCE procedure not consistent with the requirements of
TS
Multiple examples of failure to follow procedures
50-220/95-05
50-220/95-05-01
50-220/96-05
50-410/96-06
50-41 0/96-06-01
LER
LER
LER
LER
LER
Building blowout panels outside the design basis because
of construction error
Building blowout panels outside the design basis because
of construction error
Incorrect safety limit caused
by inadequate
calculational
procedure
Incorrect safety limit caused
by inadequate
calculational
procedure
Incorrect safety limit caused
by inadequate
calculational
procedure
UPDATED
NONE
Reportable condition, safety limit MPCR evaluation
0
LIST OF ACRONYMS USED
ASSS
CFR
cps
CSL
CSO
DER
dp
gpfn
GTS
IN
IR
LCO
LER
NRC
NSSSS
psf
psia
pslg
Assistant Station Shift Supervisor
Boiling Water Reactor
Boiling Water Reactor Owners Group
Code of Federal Regulations
Containment Insolation Valve
Core Operating Limits Report
counts per second
Control Rod Drive
Low Pressure
Chief Shift Operator
Document Change
Request
Deviation/Event Report
differential pressure
Emergency
Core Cooling System
Emergency
Diesel Generator
Emergency Operating Procedure
Engineered
Safety Feature
-Final Safety Analysis Report
gallons per minute
Hydraulic Control Unit
High Pressure
Coolant Injection
Instrument and Controls
Information Notice
Inspection Report
In-service Testing
Limiting Condition of Operation
Licensee Event Report
Minimum Critical Power Ratio
Motor Operated Valve
Non-Cited Violation
Niagara Mohawk Power Corporation
Nuclear Regulatory Commission
Office of Nuclear Reactor Regulation
Nuclear Steam Supply Shutoff System
Procedure
Change Evaluation
pounds per square foot
pounds per square inch absolute
pounds per square inch gage
Quality Assurance
Reactor Core Isolation Cooling
Refueling Outage
Rod Position Indication
RRG
SORC
SRAB
STAAR
TS
WG
Responsible
Procedure
Owner
Regulatory Response
Group
Service Information Letter
Safety Limit Minimum Critical Power Ratio
Station Operations Review Committee
Solenoid Operated Valve
Safety Review and Audit Board
Source range Monitor
Scram Solenoid Pilot Valve
Station Shift Supervisor
Shift Technical Assistant
Stop, Think, Ask, Act, Review
Technical Specification
Update Final Safety Analysis Report
Unresolved Item
Violation
Water Gauge
Work Order