ML17202U895
| ML17202U895 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 12/06/1990 |
| From: | Burgess B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17202U893 | List: |
| References | |
| 50-237-90-23, 50-249-90-23, NUDOCS 9012130323 | |
| Download: ML17202U895 (25) | |
See also: IR 05000237/1990023
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- U :* S. NUCLEAR REGULATORY COMMISSION
. REGION III
Report Nos.
50-237/90023(DRP); 50-249/90023(DRP)
Docket Nos.
50-237* 50;..249
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License Nos.
Licensee:* Common~ealt~fdison tomp~ny
P. 0. Box 767.
Chi c.a*go, IL 60690.
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- FaciHty Name:
Dresden Nuclear Power Station,. Units 2 and *3
JnspeC:tion At:
Dres.denSite, Merri~, lL
. Inspect ion c.o~ducted:
'S.eptemb~r 29 through November 16, 199.0
Inspectors:
.D. E. Hills.
M.* S. Peck
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J. D. Monrii nger*
0; E~ Jones
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J. A. Holmes
Approved sy:m~chi*f ** **
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Projects Section 18
fd/&(1--u.:
Date .
Inspection.Summary
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Inspection during the period of September 29 th~ough November 16, 1990
(Reports No .. 50.:.237 /90023( DRP); 50-249/90023( DRP) ) ..
Areas Inspected:_ Routine unannounced resident inspection of previously
"identified inspection items, licensee event re~orts followup, plant
operati6ns, maintenahc~ and surv~illances, engine~ring and technical support,
safety assessment/quality verification and report review.
Results:
Three violations were identified with numerous examples.* One involved
the failure to follow procedures and instructions and inc~uded fi~e
exam~les. These exampl~s permeated different disciplines and involved
failing t6 utilize or ignoring procedures and instructions or inattention
to detail in implemen~ing these requirements.
Specifics are described in
paragraphs 4.a, 4.c *. 4.e, 5.a.2 and 5.b.l. The second violation involved.
- 9012130323 901207
F*r*R
ADOCK 05000237
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- inadequate corrective actions in regard.to fuel b~ndle ~ispbsitioning
events .with two examp1es *. Specifics are described iri paragraph 7.~. The
third violati~n involved inad~qu~te training to assure adequate knowledge
of ~lant administ~ati~e requirements with two examples.
Specifi~s ~re *
- described-in par~gra~h 2..
One violation was ideritified which toncerne4 an inadequate out of service*.-
checklfst.
However, a Notice of Violation was not issued in accordance_**
with the discretionary enforcement policy described _in*lO CFR 2,
Appendix C~ Sectio~ V.A.
Specific~ are described in p~ragraph 4.b.
- Five ~nreso1ve~-items we~e 1dentifi~d .. An unresolved item invol~irig a
possibly inoperable source range monitor whil_e moving fuel iil that core
quadrant is pending further NRC review of the event (paragraph 4.f.).
An
unresolved item involying the licensee's policy of~not declaring
equipment inoperable and not enteriryg corresponding limiti-rig conditions
for ope~~tion when eq~ipmen~ was p~rposely rehdered inoperable for.
'surveillance testing is periding f~rther tlarificatiori of requi~ement~
(paragraph 4.g).
An unresolved ite*m involving "licensee mai:ntenance
. practices on Appendix R fire protection *emergency lighting is pending
completion of a licensee investigation report (paragraph 5.b.3). *An
unresolved item involv1ng the li.cerisee's discovery that the fil.ter media
in the Unit 3 Reactor Building Ventilation Ai~ P~r~iculate Sa~pler had
._been misall_igned is pending further review by N.RC regional specialists_ ..
(paragraph 5.b.2). *Finally, an unresolved item involving the licensee's_***
- usage of Qua 1 ity Control lrispect ion Feedback Sheets is* pending furthe*r
_NRC review of th~t are~ (paragrap~ 7.c);
Plan~ Operatirins
,* * A number of events occurred during the current Unit 2 reflle*l i ng outage
indicative of personnel performance.problems such as communicatfons arid
inattention to detail.
A 1 though. they were spread across severa 1
discipTines, notew6rt~y events_involving the ~lant operatioris-functibna]
area included two foel bundle mispositioning events, a.reactor cavity
overflow .event, inadvertent draining of a diesel generator fuel oil -day
tank and an inadverteht diesel generator automatic start. Although the
5afety significance in atl cases was minimal, the number of events
. represent an adverse trend.
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- Maintenance/Surveillance
In addition to the events above, *othe~ adverse events occurred in the
Maintenance/Surveillance functional area.
N~teworthy among these were an
inadvertent automatic start of a core spray pump~ disassembly of the
wrong feedwater containment isolation check valve and calibratio~ adjustments
to the wrong torus to reactor building vacuum breaker pre~sure transmitter.
These.were indicative of personnel performance pr6blems such.as*
. communications and attention to detail,
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Engineeriri'g/T~chnical Support
Review o(a modific~tion and associated field work dfd not id_entify any.
problems .. One of the violations described in the report iriv6lved _the
- lack of a formal training program to assure appropriate technical staff
personnel were train~d on applicable admihist~ative requirements .
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Safety Assessment/Quality Verification
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Liceri~ee manage~ent ~e~ognized the adverse,t~~nd in ~he riumber of e~erits~*
i ndi ca ti ve of personnel performance problems.
Management involvement* was** ..
highly evident in the review of these events and-the.dete~mination of:
corrective actions*. **In addition, generiC corrective actions. were* .. _,
implemented as described in paragraph 7.b. *However, one. viol at.ion ..
concerned inadequate corrective actions *;n regard to* fuel bundle
mi spo sit ion i ng events.
Another involved failure of techn"ica i staff
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personnel to.recognize procedural nonadherence as a condition adverse to
quality s~ch that corrective'actfons to address the root cause ~as not
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taken;
This was indicat.ive of a personnel train;:ng defiC.iency .. It must
- be noted however that the inspectors regard *licensee >corrective actions
-.to n_orinally be thorough-and-comprehensive*.
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Persons Contacted
Commonwealth Edisi~n Company
DETAILS
- E. Eenigenburg; Station Manager
- L. Gerner, Technical Superintendent
E. Mantel, Services Dire~tor
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- D. Van felt, Assistant Su~erintendent -
Ma~ntenante
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- J". Kotowski, Production Superintendent .
J. Achterberg; Assisiant Superintendent ~ Work* Planni~g
- G.
Smith~ Assistant:superintende~t-Operations
K. Peterman, Regulatory Assurance Supervisor
M. Korchynsky, Operating Engineer
B. Zank; 'Operating Engineer
J. *williams, Operating Engineer
R. Stobert, Operating En~ineer
- *M: Strait, Technical Staff Supervisor
L. .Johnson, Q.t. Supervisor .
- . J. Mayer; Station Secur1ty Administrator
0. MoreY, ch*emistry Services Supervisor *
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0. Saccom~ndti, Health Phys{cs Serv1ces Su~er~~sor.
- K. Kociuba,:. Q*uality Assurance Superintendent*
- 0~ Wheeler, Ehgineering and Con!truction *
- 8. Viehl, Ehgineerihg.and C6nstructi6n
- G: Kusnik, Quality Control
- K .. Yates, Onsite Nuciear Safety* Group Administrator
The inspector~ also talked with and i*nterviewed several other. licensee
employees, -including m!=!mbers of the, technical and engineering staffs,
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reactor and auxiliary operators, shift engi'neers and_ foremen, electrical,
mechanical and instrument personnel, and contract secur.ity personnel.
- Oehotes th~s~ attending one or more exit int~rviews conducted informally
- at various times ~hroughout the ins~ection period.
- 2.
Previously Identified Inspection Items (92701 and 92702).
(Closed)ViolatioriS0-237/89019-0l(D.RP): *Failure to place isbl_ated
emergency core cooling system (ECCS) level ,switc*h in *tripped condition
resulting in Technical Specification (TS)- violation.
in addition to interim actions taken by the licensee, the inspector
verified that the licensee .had developed and placed in the control room* a
- -Technical Speci(iC:ation Instrumentation .Operability Manual".
.This
provided guidance on t~e prefer~ed method of placing Technical
Specification {nstrumentation in th~ tripped condition and assistance. in
locating the proper controlled*docu_ments to be used in this regard~
Operations Policy Statement N6. 23 was issued on July 31, .1990, to
provide instructions regarding usage of this manual.
The inspector has
no other concerns in -this area.*
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(Closed) Unresolved Item 56~237J90019-0l(DRP): Review shift oper~ii6ns
failu~e to maintain the Control Rod Drive (CRD) Accumulator High
Water/Low Pressure* Alarm Log (AHWLPAL) for the period between .April 1990
and August 30, 1990.
The AHWLPAL wai used to document CRD accumulators
that become degraded due to either a low pressure or high water level
~ondition and facilitated a~ a tracking tool to determin~ tf a particular
accumulator exhibited a'r:ecurring problem.
During the period in
quest ibn, no record of CRD accumul a to.rs degraded by a low pr.es sure or *
high water level condition could be located by the licensee,
The *average
frequency of accumulator alarms was ap~roximately once per shift per
unit.
Dresden Admini ~trati ve* Procedure* (OAP) 7-5, "Operating Logs and Records"~.
Revision 8, ~rbvided detailed instructions for the maintena~ce of records
and logs which were administratively required t6 be maintained f6r the.
life of the.~lant .. Step S.8 of DAP-7-5 required a AHWLPAL to.be
m~intained for each.unit as an ongoing record of CRD*~~cumulat6r alar~s,*.
Addi ti ona lly; the Acc_umul a tor High Water/~ow .. Pressure annunciator *
response procedure, Dre~den Operatiri~ Abriormal.{DOA) 902-5 G-2,
Revision 3, directed the Nucle*ar StatiOn Operator (NSO)" to r.eview past
.~ntries in the AHWLPAL follow~ng a new alar~. and to initiit~ a *.
~airitenance wcirk request if a particula~*acc~mulator was exhibiting a
rec~rring prbblem._ DOA 902-5 G-2 also required the NSO to document the
new accumulator alarms in the AHWLPAL.
The requ{r'ements for the AHWLPAL were transfe.rred into* OAP 7-5 on
December 8, 1989; from the Unit _Operator's Daily -Surveillance Log, .
. Appendix .. A.
The failure of shift per~o*nnel to complete the AHWLPAL
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during the.period between April 1990 and August 30,.1990, was related,~in
part, to inadequate training of operatfons personnel a,t the time of _the
transfer such that some individuals.were.not aware of the administ~attve
require~ent .. Review of the Unit 3 AHWLPAL (the Unit 2*AHWLPAL had been*
lost) indicated _at least'seyen NSOs had followed the CRD loggirig.
requirements until April:l990.
Interviews indicat~d that inadequate
training also contributed to these NSOs ceasing p~rformance of the
logging ~equirements in that they were not aware that this was a
contin~ing official requirement.
However, the source do~ument, OAP 7-5*.
was identified on each AHWLPAL *page .. Additionally, copies of the source
document, sheathed in a clear plastic docti~ent protector and defining the
requirements for the log, were fq4nd at th~ begirining of the log book.
This .is of concern*bec~use plant operations person~el, without proper
di re ct ion from management, stopped the performance of documentation
acti~ities for records. *Inadequate t~aining.of appropriate personnel a~
to admini.strative requirements concerning the AHWLPAL w~s considered to
be* an example of a violation (50-237/90023-0la (DRP)) of 10 CFR 50,
Appendix B, Criterion II.
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.The inspectors found through interview~, that the technical staff CRD
sy~tem engineer knew through independent review of the programmatic
failure to maintain the AHWLPAL, per the administrative requirements of
OAP 7-5 and DOA 902-5 G-2, since approximately May 1990.
The system
engineer was not cognizant of and had not been trained on the
requirements of OAP 9-12, "Procedural Adherence Deficiencies,"
Revisi_on 0, to document failures to meet the procedural intent or* to
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perform steps.and a~tiVities tontain~d ~ithin a procedu~e.* Through*
additional ihterviews, the irisp~ctors found that the ~roblem of
- unfa~iliarity and la~k of training for the documentation of procedur~l
adherence deficiencies was nbt limited to this single individual.
This
was significant in that the use of OAP 9~12.fa~ilitatei the*
ideritificatfon~ ~anagement revie~ of, ~nd resolution tracking including
corrective actions of conditions* adverse to quality associated with
procedural *inadherence.
Although ihe'system engineer knew a change in.
the method of documenting CRD accumulator alarms was planned and, as .
such; was riot concerned,. this did hot corrett the immediate problem nor
did .it address why the NSOs .were not following an administrative
requirement. : Although other plant reporting and corrective action *
mechanisms e~isted th~t ~ould have-also provtd~d these f~nctions, thes~.
- oth~r plant deviat1bn reporting programs were also not used.
Inadequate
training of appropriate personnel in regard t() recognizing and processing
this procedural inadherence as a conditfon adverse to qualjty such that.
adequate*corr'ective action .could be taken is: considered an "exampl~ of a
- violati~~ (50~237/90023~01b (DRP)) of 10 CFR 50~ Appendix S,
Cri teri ori. I I.
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Both of these examples of violations would appe~~ to be indicative of :an
overall .problem *invo~ving personnel knowledge of plant admiilistr:ative
requi~ements ~nd the significance of these requiremen~s. Although some
training on administrative requirements *is given to personnel, there is
an absence of an ove~all program to control and ensure appropri~te
personnel are trained on. administrative requirements that they need to
know to perform their duties.
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( c 1 osed) Un"reso 1 ved I tern 50..;237 /90022-03( DRP); "so.;.249/90022.,-03(DRP). ~
Review licensee's incorporat1on of safety evaluation reports into 'the
Updated Final Safety Arialysis Report (UFSAR).
In an Enf6rcement
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Conference conducted i~ the NRC Regicin III Qffite on October 12, 1990,
th~ licensee d~s~ribed the schedule fbr re~onstitut~on of the UFSAR and
measures to ensure adequate 10 CFR 50.59 evalua:tions*in the interim.* The ...
Enforcement *conference is documented.-in I~spection Report 50-217/90025; *
50-249/90024.
Th~ inspector has no further concerhs in this area.
(Closed) Open Item 50-'249/86012-48:
Observation 2.5.4 from Safety System
Outage Modification Irispection (SSOMI)*.
Concern re~arding use bf
s~licone*grease o~ valve gaskets, seals and seats ver~~s leak t{ghtness.
This item was reviewed in Inspection Report 50-237/89026; 50-249/89025,
in response to the licensee's discovery of grease on the internals of the:*
Unit 3 reactor building to torus vacuum breaker check valves. *It was
concluded that the grease discovered.on the check val~es was applied
prior to the c6rrective actions to prevent greasing of yalve seats* to
pass local leak rate tests. These corrective actions were described i*n.
that report.
The inspector also reviewed the work request package for
feedwater outboard chetk valve 220-628 which contained specific
prohibitions against use of lubricant on-valve seats including a quality
control.hold point to verify this~ *The inspector has no other concerns
in this area.
"(Closed) Allegation AMS No. RIII-90.,.A-0102 (Part B):
Falsification of
Training Records.
An allegati9n was made to th~ ~RC concerning
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falsification of training. records by
11whiting-out
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that training was received prior to performing work.
According to the
alleger, training .was given on grinding and flapping of welds for. generic
use.on October 10, 1990.
The craft workers were told to backdate the
training records to September 20, 1990, to .show that training was given
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prior to starting the.task.
The alleger and two.other workers refused to
backdate the training rec6rd.and entered October 10, 1990.
These three
. entries were
11whi ted-ou:t
11 and* changed to September 20, 1990 ..
The inspector interviewed emplo~ees of Fl~or Contractors Internationil,
foe .. , "(FCII), _and reviewed FCII Site Proc_ed.ure SP-II-02, Revision 0,
11 0ri.~ntatlon, Indoctril'1ation and Training.
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FCIIProcedure SP-II-02
referenced the FCII training matrix for required training.
Grinding and
flapping are craft skills"' that would be performed either by a pipefitter
or b6ilermaker.
The required training for these crafts ~as FCII orientation
and DAPs *1-4. *Only th~ pipefitter and boilermaker foremen were required,
by "the FCII. training matrix, to receive training in job specific procedures.
In order l~ reduce job errors, the.foremen performed a walkdown of the
job arid reviewed the task* to be *performed with the craft prior to
starting the work.
To give the craft a sense of personal responsibility,
. this informal training was dqcumented using -the Training Report Form
fdund in FCII training procedure SP~II-02. This work review ~nd trainiQg
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,documenta.t ion was not procedurally required.
- The inspector. rev.iewed work areas found in *the uou*tage Package Status .
Report. 11
Three* ~reas*were identified that would incl_ude gririding and.
flapping ~s part of th~ work.
These wer~ Inservice 1nspe~tion (ISi),
Erosion/Corrosion, and the Reactor Vessel Level Instrumentation-System
{RVLIS) Modification .. The irispector reviewed th~ trainin~ report record~
associated with the following work packages:
lSI Work Pac~age Nos~ 09334~-1 through 21
Erosion Corrosion Work P~ckage Nos.
093350~1 through 7
RVLIS Work Packige Nos. 094094-1 through 10
The al~egation wa~ partially substani{ated, .iri ~hat there were training
'report entr'ies where the date had .been altered by writing over the
original date.
Iri one instance,_the trairiing report was .dated
September 21, "1990, and the first three entries were ori gi na lly dated
October 10 or 2~, 1990 and theri written over to reflect
September 20; 1990.
No white-out was used to alter the entry.
However, the training was not procedurally required and the training
record was not a document re qui red by the qua r; ty program.
The contractor
has indic_ated that a new form ITlay be used in the future to document* the
work review*.
No 'further action is. considered necessary in this area.
Duplfcate Items
~he following Unit* 3 items are ~eing closed because they are duplicates
of corresponding Unit 2 items.
These issues are still op~n and being
tracked th~ough the Unit 2 tracking humbers .
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. 50-249/90022.;.01
- 50-2~9/90022-02
.Two examples of a violcltion and no deviations were 1dentified in .this.
area.
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Licensee Event Reports Followup (90712 and 92700)
Through direct .. observations, discussions with licensee.personnel, _and
revi~w of records, the following event report was reviewed to ~etermine.
that reportabil i ty reqLii rements were fulfi 11 ed ;* immediate corrective
- .*action was accomplished; and *correct fve act 1 on to prevent recurrence had
been ~ccom~lished in.~ccordance with Technical Specificationi.
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(Closed) LER 237/90010: Gore Spray Pump 28 Automatic Start.
This.event *
- .i~cluding licensee to~rective acttori~ i~ discussed in paragraph 5.a.1.
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No violations-or deviatio-ns were ide~tified in this area .
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4~ .* Plant Operations (60705, 607io, 71707, i171~. 71714*and 93702)
jhe i~spectori observed control room ope~at~ons, reviewed ~pplic~ble log~
and conducted discussions with cont*rol room operators during this pe.riod.
The inspectors verified the operability of selected emergency systems,
revie~ed tagbut records and verified.~roper returri to service of affected
- component*s;
Tours of Units 2 and 3 reactor buildings and turbine'.
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. buildings were conducted* to observe plant equipment conditions, *incl,uding*.
- potential fire hazards, fluid leaks, and ~xcessive vibr~tions and to
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verify that maintenance reque*sts had been i ni ti ated for equipment in need
of maintenance.
The irispectors'reviewed new procedures and changes to*
. procedures th.at were implemented during t.he fnspection period. *The review-"
-consisted of a verification for accuracy, and correc.tness. These reviews* ..
- and observations were* conducted to verify that faci.lity operations were.in *
conformance'.with the requirement~established.under Technical Specifications~
- 10 CFR, and administrative ~rocedOres~-
Each week during routine activitie.s or tours, the inspector monitored the
. licensee 1 s security program to ensure that observed a~tions were being
. implemented according to their approved seturity ~lan. The inspector
noted ihat persons within the protected area displayed proper .
- ph6t6-identification badge~ and those individuals requiring es~orts were
- properly escorted. * The inspector al so. verified that checked vi ta l areas
were l oc.ked and a 1 arme*d .. Addi ti 6na lly, the inspector al so verified that
observed personnel arid packages ~nteri~g the protected area were searched**
by appropriate eq.ui pment or by hand.
In addition, a ge.neral plant walkthrough inspection was performed by NRC,
Regioh III, Division of Reactor Projects, Branch 2, on October 16, 1990.
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Commeri:ts fq:im that inspection including those concerning radiation*
practices were provided to the. licensee for resol~tion.
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. Unit.2-was sh~tdown for refueling on September 23, 1990. * The i~spectors*
revie~ed the technical adequacy of approved procedures arid establi~hment
. of administrative controls for refueling activitTes through Dresden Fuel
Procedure (DFP) 800-1, "Master Refueling Procedure," and other associated
refueling and operating $Urveillance procedures.
The inspector ~lso
- verified implementation of these administrative controls prior to* and
during. fuel movements by -re.view of appropriate completed checklists, logs* ..
. and s1Jrvei 11 ances, direct observat i ori, personnel interviews, and veri fi catfon
that Techn~cal Specification requirements for refue1ing were met:
Observation of n~w fuel receipt and licensee inspectibn ~as do~umented iri
inspection report 50-231/90017; 50-249/90017~ Activities prior to*fuel.
moveme~t were also ~bserved. including react6r shutdbwn and various aspects
of removal of the shielding blocks, drywell head, reactor vessel *head arid
dryer/separator.
The inspectors verified that key personnel possessed an
- adequate understanding of their indiVi~ual re~ponsibilities ~nd admini- *.
strative requitements through ~irect ~bservatibn and personnel
iritervie~~- .
Adeq~ate staffing for refueling activitie~ and adequate plant cle~nliness:
conditions were also verified by the inspectors.
App.ropriate radiation
. proiection controls w~re verified to have .been im~lemented in conjuriction
with these aciivities.
The ins~ectors also ~erified ~hat steps were
being taken for the fuel handling fore*men to activate their. senior reactor
operator licenses in accordance with 10 CFR 5.5. 5~(f)( 2).
Speci~ic incidenti i~volving fuel.handling a~tivities.are discussed in
paragraph-7.a~
The inspectors p~rfor~ed a detailed walkdown of the a~cessible poftions
. of the Unit 2 high pressure coolant injection (~PCI) system.and the
Unit 3 core*.spray (CS) system.
At the time of the walkdown, the Unit 2
HPCI system wa~ oot o( service for -m~int~nance ~nd mddffication~..
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Several minor deficiencie~ ~egarding the"HPCI and CS
s~stems were noted
by the inspectors which were quickly resolved by the.plant staff to the*
fnspedors' satisfaction. *
The*inspector r~vie~e~ ~he licensee's program and pro~edures relating to
~reventative measures taken for ~xtreme c6ld weather .. In response to
- IE Bulletin 79-24, the licensee sta.ted that 'safety-related process,-.
instrument and sampling lines had not experiented freezing and that the
above ground EGCS lines entering the.Dresden Unit 2/3 contaminated
condensate storage tanks were well insulated, heat traced and cont~ined
in an i~sulated permanent en~los~re. In addition, all tithe~
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safety-related instrument and sampling lines were indoors and n6t exposed
to sub-freezing temperatures.
The inspector verified the material
condition of the insulation ori the ECCS* lines, the. presence of heat
tracing and the adequacy of the insulated enclosure. * The inspector
ve~ified the completion of Dresden Operatirig Surveillance (DOS) 010-9,
Revision 2, which outlined equipment manipulations and inspections to be
performed in preparation for seasonal weather changes.
Thi~ surveillance
s~ecified the seasonal requirements for energiting tank heaters, heat
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tracing and _space heaters, a.nd for inspecting steam heating coil.sand
pipe in~ulation for signs of degradation.
Various oper~tiorial.occurrences were also reviewed as follows:
a.
On October 14, 1990, while Unit 2 was d~fueled, approxi~ately .*
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1;300 gallons of contaminated condensate water were spilled onto the
third and fourth floors oft.he reactor building.* The spill was the
result of overflow of water through .the reactor cavity ventilati.on
duct openings.
The reactor cavity ~as being flooded to support
- *reactor vessel 'iriternal inspection but leve.l should. not have been
raised past- the bottom of the duct openings.
Cavity fill was
atcomplished .with cdndensate flow from the condenser hotwell with
makeO~ from*the condensate storage tank.
The fuel handler~*we~e * *
initia.l ly monitoring cavity level from the refuel floor. but later ..
left, and i~formed the_NSO-of their departute.
The change in level.
from ~.hat last. reported by the- fuel handlers and that later reported
- by an. Equ; pment Attendant (EA) was noted to di ff er from the change
reflected on the control room indication.
In addition, the NSO
. realized that control foom indicated level had risen to where it had
been ma i.ntai ned a week earlier.*. As such, the Shift Engi n~er and
Shift Supervfsor verified level to be belo_w the ducts from the
refuel fl6or:
H6wever, they did hot approach close eno~gh for
.
~ositive ~erification'slnce.this would* have nece~sitated changi~g
.into anti-con:tam1nation clothing.
There.fore; they verified that the-
EA had gotten closer on hiS .earlier check.
Although the EA was ...
later disp*atched to again check lever, the overflow occurred priol'.'
to the EA reaching the refuel floor."
.
.
~ - '
.
Further review.indicated that a precaution in Dresden Operat1ng
Pro_cedure (DOP) 1900-3, "Reactor Cavity-Dryer* Separator* Storage* Pit
Fill and Operation of the Fu'el Pool Cooling and Cleanup' System
- .During Refueling,
11 Revision 8, required.constant communication*
between the reftieling floor and the co~trol room ~hil~ filling th~
reactor vessel to prevent overflow into the. ventilation ducting ..
- However, neither bf the two operating crews involved in the vessel.*
filling actually utilized the procedure .nor was the precaution:
followed.* Failure to maintain constant communication between the
refueling ~lb~r and control room while filling the reactor vessel in
accordance with DOP 1900-3, is considered to be an example of a
violation {50~237/90023-02a* (DRP)) of 10 CFR 50, Appendix B,
Criterion V.
The operating crews were counselled in the
significance of* the event, the need.for attention to detail ahd
procedural adherence.
All Operating En~ineer~ were instructed to_
reference procedures when possible in Daily Orders.
(The Dail~*
Orders which prescribed filling the reactor vessel had not done*
this.) In addition, a misleading operator aid being used iri the
control room Was revised as to ventilation opening level .. Th~~Shift
Engineers were also instructed to ensure procedures were out and
adhered to for all complex, uniq~e or infrequent evo)utions. *
Further torrective actiohs to addre~~ general concerns about events
during the refueling outage*are disc~ssed in paragraph 7.b.
10
. .
.~
.* *.
.*
Additional longer term event specific corrective ~ctions were biing
developed by the licensee.*
- b.
On Octbber 27, 1990; the Swing Unit 2/3 Diesel Generator (DG)
received an unplanned auto~atic start and tied to Unit 2 ESF
Bus 23-1.
At the time of the event, Unit 2 was in a refueling
outage and Unit 3 was in power operation.
The event occurred while
removing Busses 23 and 23-1 from service in accordance with
out-of-s~rvice (OOS) reque~t II-1549 to facilit~te breaker and
cubicle preventative maintenance work.* The intent was to remove
these buses from se~vice while st51.l allowing the swing DG t~ supply
Unit 3 if required. *Further review ihdic~ted that attion~ were
accomplished with OOS II-1549; however, the*oos was *inctirrect .. The
- individual wh6.wrote ~he OOS, who held ari {nactive Sen~or Reactor
Operator(SRO) license, correctly summarized by'reviewing the_
.
applicabl~ electrical schem~tic drawing that four knife switthes had
to be operied to atcomplish, the d~sired attion:
As this individual *
believed the drawing to be unclear as to the pretise designati6~ and
l oca.t ion of the knife switches s.uch as to mak~ i dent ificat i.on of t_he
-actual corresponding switches in the plant difficult, Dresden
Operating Surveillance (DOS) 6600-6,* 0 Bus UndervoltagE!and-.Emergency.
Core Cool fog System Test. for ~he Unit 2/3 DG
11 was referred to for
clarification.
Unfortunately, one of the switches in lhe procedure
~as not the same as to* what that i~dividual th6ught was .the
corresponding switch on the drawing.
While 'the correct switch*
designated on the drawihg .was:~~tually located ori Bus 23-1, the one
in the procedure _was located on .a small panel about 3 feet behind *
Bus 23-1.
It was incorrect tb use the procedure in this respect
.sinte:it was designed for a different function*.
(In fact, in this
test, the diesel. generator was supposed.,to start.) .
DOP 6500*')1,. .
11 De-energizing 4KV Bus 23-1 for *Maintenance,.
11 referenced the proper.
knife switches but was al so not *utilized in preparing the OOS.
The
OOS w~s.reviewed in accordan~e with the l~tensee's admi~istrative
- program by a Shift Foreman (SF) with an active SRO licen.se.
The
.
first* iridividual had attathed a copy of the ~elevant page from the
procedure to the OOS which keyed the SF into ~sing .it in his review.
lherefore, the OOS was incorrett due to ~eferencing of inappropriate
documents fo~ cl~rification of the electrical schematics during its
preparat~on;
A~ ~uch~ the OOS was not.appropriate to the
circumstances in violation* (50-237/90023-03 (DRP.)) of 10 CFR 50,
Appendix B', Criterion V.
The inspectors reviewed a recent previous violation invol~ing
inc6rrect OOS che~klists with three examples and determined the.root*
causes to be sufficiently dissimilar.
Therefore, this event could
not have reasonably been expected to have been prevented by the.
licensee's corrective action for the previous violation.
The
licensee initiat'ed improvements to the undervoltage 'knife sw1tches
for_all the Unit 2 and Unit 3 4 KV busses which had the potential
for an unplanned .DG start. The licensee also planned to develop
s~~cific procedur~s for de-energization of all Unit 2 and Unit 3'
4 kv bus combinations which have the potential for an unplanned OG
start. Additional plans were initiated for issuance of a policy
statement clarifying types of situations in which Operations should
-. ;
~" J..
.. ~ - ...
- request assistance from ot,her departments during ODS preparation and*
verific~tion. As this was considered to be an
i~olated occurrence
and appropriate ~orrective actions were initi~ted, a Ncitice of
Violation is no~ being issued in accor~ance ~ith 10 CFR 2,
Appendi~ C,Section V.A.
Safety significance was also minimal since
all*loads had afready been removed from Bus* 23~1. Opening of the.
incorrect switch defeated some interlocks for ECCS equipment that
were already GOS for the outage.
On October 20, 1990, a*fuel oil spill .occurred in the Unit 2 diesel
generator room. * This. was discovered by two memb.ers of. the Techn*i cal
Staff abou~ the sam~ time Unit 2 DG fuel oil day tank le~el alarm
- .was received* in the. control .room.
Diesel fuel oil day tank drain
valve 2~5~12-SOQ w~s found partially operi and wa5 immediately
closed.
A ftre watch was posted until 'the spill ~as cleaned up.
Appro~imately 500 gallon~ -0f fuel was spilled to the.oil. separator
.
tank with seine drain funnel overflow onto the Unit 2 DG rooni floor. ; .
Safety signifitance was mini~al since .the DG wa~ OOS:for ~aintenance
at the time.
Further review indicated that this valve and diesel*
foel oi 1 transfer pump .. suctton *valve 2:-52018-500 were checked to be
- shut by a non-1.icensed Operations Supervisor on October 8, 1990, in
preparatior:i for cle9ning the main fuel oil storage tank.
1100 Not
_.Operate" tags supplied by the cle,aning vendor were p,laced on .the .
valves.
However, no Dre*sden ODS was written for this activity.* On
_October 20, 1990; the Operations Supervisor opened both. these V!'llVes
to restore,them to what he belie~ed to be their pr~vious positions
and, thereby creating the drain path.
The* Operatio*ns Supervisor was*
- aware of GOS admi~ist~ative re~uirements but failed to foll~w them
to expedite tbe* ~rocess'. These administrative requirements*
contained .in OAP* 3.:._s; "Out-of-Service and Personnel Protection
Cards,
11 prescribe specific prac.tices for removing and returning
eq~ipme~t to and from ser~ice including preparation, review~.
approval, documentation and independent verification me~hod6l-0gies .. *
Failing to*foll-0w OAP 3-5 in regards to ODS requirements is.
_ considered to be an examp_le of a violatfon (50-237/90023-02b (DRP))
.. ~f 10 CFR 50,* Appendix s; ~riterion V~ The Opera~ion~ S~pervisor.
- was counseled as to the.importance of interacting with Operati,ons-
Department shift personnel and the necessity of following ODS *
administrative requirements~ In addition, the day tank valves on
all emergency DGs were locked ihut.
.
d.
. Dur,ing obser.vation *of the repair of the Unit _2 diesel gene.rator
service water (DG SW) -Deturik three-way valves (2-3905-525 and
2-3931-525) per Work Requests 090498 and 090499, the inspectors
developed concerns *regarding previous b~erations of the DG.
In
February, 1990, both valve stems were found sheered-through at the
bonnet separating the valve operators from the plugs.
The valves are
used for flow reversal through t~e DG cooling water heat exchangers
(HX).
If either one of the two valve positions were changed without
the other, then cooling water flow would completely bypass the DG
cooling HX.
When the Shift Supervisor (SS) ~as notified of the degraded DG SW
valves on February 9, 1990 a determination of the Unit 2 DG
12
.
~. ' -..
"
operability was appropriate.
Although it was not clear through*
interviews with associated indi~iduals what the licensee considered*.
in the operability determination, through review of additional
documentation the inspectors agree that the DG was operable.
However, as th~ determination of operability was not easily
discernible, the ins~ectors ~ere co~cerned that the justification
for the operability determination was not documented.
OAP 7-9, *_:
Malfunction of Safety Related Equip_ment
11 disc.ussed logging in *the
Shift Supervisor's Log significant information surrounding the.
circumstances so that a* reasonable judgement can b~ made* of th,
cause of the problem and its significance.* However, OAP 7-9 was
ambiguous as to the threshold f.or safety-related equipment problems.*
for'which this would apply.
Review of the ~hift Supervisor's log..
., .
. and interviews with licensee personn~l .indicated that do~umen~ation ...
.of the justif1cation for operability calls was not a current**
- practice at *Dresden. -As a result**of a Co_rporate Nuclear"Operations
.Dire~tfve issued prior to the inspector's concetn, the licensee
already had plans to address this as part of an equipment
~operability program.
Specifically; the licensee planned to have a
procedure that would prescribe do!=umentat ion by December. 31, 1990 .
. The inspector has no further concerns in this area.
.
A review of *p~st performances of. Dresden Operating Survei 11 ance.
(DOS) 6600-2, "Reversal of Emergency Diesel Generator Cooling Water
. Flow" subsequent tci the February 9, 1990 discovery of .the* degraded .
.. reversa 1 on* February 25, 1990 ..
Due to the degraded .condition, * _
tu~ning of the valve handwheel *durin~ the surveillance would nbi.
have ~esult~d in actual val~e position change although the plug *
'position* inqicator would have shown *a change;
As a result, the
failure to achieve' actual flow reversal went unre'cognized .and. the
licensee's commitment to .IE Bulletin 81-03,
11 Flow BlOckage *of
.
Cooling Water to Safety System Components b,YCorbicula andMytilus"
was not. fulfilled.
However, the safety* significance of not
- performing the flow reversa.1 in this case was minimal.since theDG
surveillance indicated adequate HX differential pressure a~d DG
cooling.
~ince the intent was to perform the flow re~ersal, the
Jic-ensee's surveillance program accounted for .the commitment, and
the safety significance in thfs *case ~as minimal_, this failure t6
.
~chieve the actual flow teversil .is not being tonsidered a deviation
ftom the NRC tommitment: . Of more coricern to the NRC is the fact
that these valves were known to be de~raded *such that the handwheel
could not be used to change Valve position and yet the licensee did
not ensure.this knowledge was applied to the subsequent surveillance
1
performance.
These valves were not repaired until over eight months
. after discovery .. In addition, if only one of the two DG SW valves
had been degraded, the action by the operator on February 25, 1990,
would have resulted in the isolation of cooling water to the DG.
However, this cdnditioh would have been identified by step 9 of
DOS 6600-2, which required the operator to stand by at the DG to .
confirm proper SW cooling f1ow during the monthly DG -0perating
survei 1.1 ance test run conducted on February 25, 1990*..
In this case,
the licensee 1s administrative .programs were i.neffective in assuri~g
. 13
. .
~*
- .. ::" ..
......
..
that the status and ramifications of degraded equipment was made
known to appro~riate personnel ahd reflected in decisions regarding
.sub~eq~ent activities.
e.
OAP 7-14, "Control and Criteria For Locked Equipment and .Va_lves,
11
described the criteria for the selection of valves which.were to be
locked .in position.
Included in DAP 7-14 were manual valves which;
0
Maintain or could comprpmise the operability of ~n Emergency
Core Cooling.System*(ECCS); Step 2~a (2)
.
. . .
. .
- .
.
.
- .*
.
0
Are in the. flowpath of systems which are required for safe
~lant shutdown during post-accident siiuations. Step 2.a (3)
The inspectors ob~e~ved that the DG S~ Dezurik th~ee-way ~~lves 6n
- each ~f the three DGs wer~ maintain~d iri an. unlo~ked conditi-0n;
These valves were .. not listed in DOP 040-M3, *"Locked Valve List:
Acces'sible During Operations,_" Revision *13.
The mispositioning of
either one of the two DG S~valves wo~]d result in the isolation of
the DG from cooling water flow.
The DGs provided the emergency
electrical power source for the'ECCS systems.
Baseef 6n the
- Technical S~ecification definitiori*of operability, the status of the
DG could tompromi-se the functionality of the ECCS. _Additionally,
1he DG,
a~ defined in the UFSAR, was required for safe shutdown *
during design bases events,*which included the simultaneous Joss of
off site power..
Al though either.manual valves were chrrect ly locked*
in the pG system, an exception had been made in this case due to the
design of the~e ~arti~ular valves which make them more difficult to
operate.
However, the intent of lo2king ~alves was to provide ~
. *positive barrier to personnel to signify the importance o.f that'.
pa~ticular.v~i~e
1 s positi~n.
In this c~se, th~t ba~rier was not
provided and th~ l~censee
1 ~ adm1nistritiv~ procedure did not allow
for that excepti-0n.
The iMspectors noted that the manual containment isolation valves on
the drywell manifold sample systems were also unlocked on both
units .. These valv~s were alsonot included in DOP 040-M3.
The issue of locked manual containm*ent isolation valves was
addressed in the systematic eva.luation program (SEP).
As indicated
in a Safety Evaluation Report dated September 24, 1982, the NRC
position .was that manual containment isolation. valves should be
administratively controlled ~~d locked. in a closed position such
that.the valves were not ioadvertently opened during per~ods when.
- containment integrity was required.
This staff position on manual
- containment.isolation valv~s at Dresden has been consistent with NRC
10 CFR 50, Appendix A, General Design .Criteria, 55, 56, and 57. *As
part of the SEP process, CECo ~ommitted, per corres~ondence on .
~ovember 18, 1982, from T. J. Rausch to P. O'Connor, to changirig the
appropriate procedures to implement administrative controls ensuring
manual containment.isolation valves would be locked closed.
The *
licensee's administrative procedures were consistent with this
commitment.
14
- ... :.
. *
- ,.
manifold sample system manual containment iso.lation v_alves in .a
locked condition in accordance with OAP 7-14 is. considered an
example _of a violation (50-237/90023.,.02c (DRP)) of 10 CFR 50,
Appendix B, Criterion V. *
f.
During'f~~l loading on Novemb~~ 12, 1990, fu~l loading was suspend~d
when abnormal indications were recognized on Source Range Monitor
(SRM) 23.
While inv_estigating the cause of these indications from
under the reactor vessel, instrument maintenance technicians noted
. that SRM 22- had_ dropped from its fully inserted position.
g .
- Subsequently, SRM 22 fa Hed a response test such that it appeared
SRM 22 ~ay not have been operable and responding for a short period
while loading fuel i'n its corresponding core quadrant.
This is
considere~ an uriresolved ttem (50-237/900~3-04 (DRP)} pending
_furthe_r review' of the eXterit and cause of this problem.
- The i~spector~ noted that the licensee~s policy ~as not to declare
Technical.Specification (TS) equip'ment inoperable and officially
enter associated TS limitin~ conditions f6r operation when the
..
equipment was purposely r~ndered inoperable for the purpose-of TS*
surveillance testing.
Examples included the standby liquid control
,sy~tem test in which the injection path was manua)ly isolated, the
diesel .generator surveillance in which *manual loading of :*the d_iesel *
~enerator rendered the l~ad shedding feature-inoperable, HPCI and
.isolation condenser isolation instrument surveillance in which an
installed.jumper prevented automatic isolation and a torus to*
reattqr buildi~g vacuum breaker instrumentation survei*llance in
- which ihe differential ~~essure.tran~mitter was valved-
. out-of,..service. * _In addition; the inspectors noted that upon a
control rod -accu~ul~tor high water/low pr~ssure alarm which
indicated possible inoperability of the accumulator, the practice
was to allow up to an entif~ shift prior to investigating the alarm.
This permit~ a long delay *during which_ the accumulator may be in6perable
and action not take'n. to restore the accumulator to operability.
These practices in regard to Technical Specification operability are
considered a~ unres6lved item.(50-237/90023-05 (DRP)) pending f~rther *
clarification of .requirements.
Three examples of a violation*, one example of a non-cited violation, and
--~o deviations were identif1ed in this area.
5.
Maintenance and Survetllances (~2703, 61726, and 93702)
a.
Maintenance Activities
. Station maintenanc~ activities of systems and components l~sted
below were observed or reviewed to ascertain that they were
conducted in a~cordanc_e with approved proce9ures, regulatory guides
and industry codes or. standards and in conformance with Technical
Specifications.
The follow{ng items were considered during this review:
15
- .
The Limiting Conditions for Operation (LCO) were met while
- components or.systems wer~ removed from service; approval~ were
obtained prior t6 initiating the work; activities ~ere at~omplished
usin~ approved proced~res and were inspected as -appli~able; .
- *
functional testing and/or calibrations were performed prior to
returning components or systems to service;* quality control records
- .were maintained;_ activities were accomplished by qualified
personnel; parts and materials used were properly certified;
radiological control~ were implemented; ~nd, fire prevention
controls were implemented.* Work requests were reviewed to determine
-status of outstanding job~ and to assur~ that priority is assigned
to* safety-related equipment maintenance which may affect system*-
performance. *
. The inspectors witnessed or reviewed. portions of the fol~ owing
activities: . *
Rebuild o~ the 2A2 Diesel Generator Air Start Relief Valve
Welding of the
11C
11
R~circulation System RiSer Overlays
Uni~ 2 Die~el Gerterato~. Service Water Three~way Valve Repair
- Control Rod Drive Replacement *
Recirc~l~tion Pump 2A~ucti6n Valve Repaii
Unit 2 Diesel Generator Air Start Re~ulator Replacem~nt
- Various occ~rrences were also reviewed as follows:
(I;) On Octobe~ 3, 1990, while the* reactor wa~being d~fueTed, core
spray (CS) pump 2B*a~tomaticall~ started.
At the time, .all low
pressure coolant ihjection (lPCI) pump~ were out of service and
both CS pumps were op~rable. * During refuel ccinditions,
Techn~cal Specific~tio~s pnly require-~perability bf two CS
pumps, two ~PCI pumps, or a combination of one LPCI and one CS
p~mp. Only one diesel generator was operable for.Unit 2 *in
accordance with Techn~ca1 Specifications for refuel conditions.
This was the swing 2/3 diesel generator which supplied*
emergency powe~ to CS pump 2A.
Electrical maintenance *personnel were performing a preventive.*
work package on the Unit 2. diesel generator output breaker.
Jhis invalved removal of the breaker from the cubicle; ~leaning
of the c~bi~le and r~placement of a tontact ~witch inside the
- cubicle.
This switch, in ser1~s with the CS pump actuation
'circuitry, was to provide information *to the ci.rcui try on
whether the. diesel generator* output* bre*aker was op.en.
The CS
circuitry upstream of the switch was de-energized since an
actual initiation signal was not present.* Changi~g out the
switch did not render the pump inoperable si~ce it was still
capable of automatic start through the load Sequence pbrtion of
the circuitry.
This would have just resulted in a ten second
start delay.
lf an actuation signal occurred, this portion of
- the circuitry picked up in parallel .to the immediate start
circuitry regardless of whether an undervoltage condition*
existed. *
16
... ,*
..
.. ,.
- .*.
The mbst likely cause of *the automatit start wa~ that while
changing out the switch a lead may have inadvertently been
.grounded*allowing enough voltage from.the downstream drcuitry
to pick up the pump stari. rel a~. After erisuring that an
initi~tion signal was not present or needed, the operators took.
the* pump control .switch to pull-to-lock.
No other portion of
- the :system actuated except for the pump minimum flow* valve.
The CS pump was considered inoperable at that point and .the
appropriate action statement entered.
Electri~al technicians ~ere aware.that although the breaker was
out-of-service'.and *removed from the cubicle, the circuitry
involving the switc~_was not out~of~service. Therefore, the*
- ~
instrument technicians*were aware that adverse actions could
- occur with this activity and, therefore, took precautions .1n'
.. accordance with *the work package including utilization of a .
. rubber mat:
The work package *was discussed with Operatibns
.*~ersonriel ~rior to receiving permission to beg~n the work.
This included review of ~ssoci~ted drawings that' indicated the
existence of core spray interlocks.
However, it was not
entirely clear fro~ the work pack~ge and the reviewed drawings
- as to wh~t the interlocks accbmplished.
As such, the licensee
be 1 i eved that if. Ope rat ibns personnel were aware of the nature
oL these interlocks* they may have halted the work .activity for.*
a few days until *the C~ pump wa~ schedul~d t6.be temoved lrom
service. *As ~uch, the licensee's corrective action was to
require listjng in the work package of ~ossible specific
interactions for any equipment that may have interlocks:that
- affect other systems or contacts.that may energize or
. de-e.nergi ze equipment or re 1 ated ci rcufts.
In this way,
Operations* reviewers would have more information on which _to
base deci~ions as tQ whether to let work begin.
It must be.
noted however, that this type 6f decision is dependent on thi
individual and the circumstances such that pe~mission to
.
proceed may be given.anyway.
Therefore,*'this corrective action
may not be sufficient t~ preclude repetition.
However; iri this
case, the inspectbrs *believed the ro'ot cause to be difficult to
address since reasonable precautions were t~ken in ch~nging out
the switch.
In add it i ori, * arriving at this root cause was by
process of elimination* of any other causes but ~as still. not
contlusi~e beyond any doubt.
Further* corrective action to
address general concerns ab6ut events during the refueling
outage is discussed in paragraph 7.b. *
(2.) On October 15, *1990, Unit 2 outboard containment isolation
feedwater.check valve 220-62A was ~istakenly disassembled
instead of the to~responding tf~in B valve.
Due to leakage
problems, both the A and B valves ~e~e to be worked on sometime
during.the refueling outage.
The B train had be~n correctly
taken out-of-ser~ice in accordance with OOS II-1279 on October 6,
1990 .. The Mechanical Maintenance Foreman (MMF) responsible for
the job~ walked down the OOS on the correct train on October lli ..
.1990.
However, the MMF later mistakenly directed work to be
17
.. **
. ~ ..
.. '.
...
performed on the .A val ye. *Work package 081758 clearly designated
the B.valve.
In addJtion, sufficient id~ntification tagging
existed on the A train such that the problem would have been
apparent if the tags had been che~ked~ Quality coritrol hold
. points existed in the work p'ackage but were c:in later instructions
in~olving re-assembly of the valve,
In additio~, Technical.
.
Staff engineers responsi~le for local leak rate testing examined*
the val~e after the valve cov~r was removed.
These individuals
~lso failed ~o recognize.that this was not the B valve.
The
Techni ca 1 Staff system engineer was aware .of the. work but did *
not personally.~jew the valve since other Technical Staff
personnel were performing that functfo~. As i~chL the. lack of
- attention to detail on the ~art of the MMF, coupled with the .
unquestioning ~elian~e.of -~ther p~rsonnel that th~ MMF.was ..
. correct, caused ihe'wrong valve to be disassembled and not
- .discovered until October.9, 1990.
OAP 15-6; "P.reparation and
.C.ontrol of. Work Requests," Revision 0, required.work to* be
performed _per repair inanual(-s), *traveler/procedure, or work*
i~str~ctions ptov~ded in the work package:
Failure*to disassemble.
the correct'valve,in accordance with the work package i~ considered
. to be an example of ~ violation (50-237/90023-02d (DRP)) of.
10 CFR 50, App~ndix B, Cfiterion V;
.
.
..
On *that date* radiation protection personne 1 noted that dos*es to
,_workers on that job were' much less than. expected since the
~ valve was known to be more highly cont~min~ted thah the
A valve.
A check as a result of this informat.ion identified
the erro~. * It must be noted that the disassembly attually :
occurred* .prior to the generfo attention to deta i 1 corrective
- actions discJssed in paragraph *7.b.
It was fortunate that *
. *safety significance in thfs case was minimal.
The A line *had
been used approximately .two days earlier for filling the Unit 2
reactor. vessel cavity ... Therefore, if .the valve 'had been in a
disassembled state Just two days earlier, the X-area*(steam
tunnel) would .have been flooded~ In addition; if the inboard
containment isolation feedwater check valve hadn't held, the*
reactor vessel cavity could have*~artially drained back through
, this line:
The licensee was _still developihg ev~nt*specific
corrective actions at *the end of the inspection period.
(3.) On October 19, 1990, the inspectors identified six Appendix
11R
11
eme~gency lights (required for safe shutdown in the event of a
disabling lire) with the electrolyt~ level below the add line~
The inspector observed electrolyte level varying from just
_below the add lineto one inch below the add line. -.
The Emergency Lighting Monthly Inspection~ Dresden Electrical
Surveillance (DES) 4153-02, stated that "Electrolyte level
shall be at the full 1 i ne".
However, contrary to the
.
established procedure, the licensee indicated that a practice
- 18
- .. *
..
. ,
b.
had been followed such th~t th~ emergency light~ need 6nl~ be
fi.lled when the electrolyte level was at.or below the add line.
The licensee further indicated that al so *contrary to the
established procedure*, the de.termination to add distilled .water
was at the di~cretion 6f the mainten~nce personriel.
- conversaticins ~ith the emerge~cy light vendor a~d review of the
vendor technical manual indicated that allowing the electrolyta *
level to fall below the add line could cause damage t6 the *
. battery.
After the inspector ideritifi~d ~he lo~ elettr6lyte level in the
emerg~ncy 1ighting units~ the license~ initiated immediate
. corrective. actions*~~ich consisted of:
- (l.) .rn.spected and *provided maintenance on Unit 3 emergency
lights requi~ing servicing (for.ex~mple adding distilled
water.to a*battery w.ith low eJectrolY,te-leve.l.)
Unit 2
wa~ defueled at the time~
.. *
(2.) Review of .the emergency 1 i ght i ng maintenance procedure.
(3:) Conduct of an investigatio~: *
On November 14; 1990; the lfce~see indica~ed_that an inv~sti~ation
report was being developed and would include an event* summary,
root caGse(s) and corrective action(s) *~hich would also be
.
implemented for Unit 2.
In addition, the Jicensee would document
the emergency lights in the as~fo~nd condi~ion on*eme~gehcy
~lighting drawings.* The licensee also indicated the irivestigati~~
rep6rt and:the marked u~ drawings'for *Un~t*3 will be tentatively
completed by Decem.ber 14, 19.90. *T.his i*s considere.d an u*11resolved
item (50-2-37/90023-:06 (DRP)) pending review of the licensee's
submittal.
Surveillance Activities*
The inspectcirs observed surveill~nce testing, i~cludin~ required
Technical Specification su~~eill~nce testing, and verified for
actual act1vities observed that tes.fing was performed in. accordance
with adequate procedures.
The inspettors also verified.that test
instrumentation was calibrated, that Limiting Condition~ for ..
Operation were met, that remova 1 a11d restoration of t.he affected
.. :components ~~re accomplished and that test results conformed with.
Technical Specifitation and procedure requirements.
Additionally~
the inspectors ensured that t,he. test results were revi_ewed by
personnel other than the individual directing the test, and that any
deficiencies ideritifie~ durin~ the testing were pro~erly reviewed
and resolved by appropriate management personnel.
- The inspectors witnessed or reviewed portions of the following test
activities:
Unit 3 Rod Swapping
Emergency Light Eight Hour Discharge Test
.
Radwaste River. Discharge SP ING. Ca 1 i bra.ti on/S.etpoi nt Adjustment
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Unit .2 250 VDC Battery Discharge Test
Source Range Monitor Che~klist
The following occurrences were also reviewe*d: *
(1.) On August 8, 1990, while calibrating the Unit 3 Torus to
Reactor Building Vacuum Breaker A Pressure Transmitter;
DPT-1622A, the instrument technician ,inadvertently adjusted
DPT-1622B causing Vacuum Bre~ker B to open.
DPT-l622A
calibration was being checked per Dresderi Instrument**
Surveillance (DIS) 1600-20, "Torus to Reactor Building
- Differential Pre~~ure Transmitter 1622A and B Calibration and
Ma1nteriance I~spection
11 in accordance ~ith W~rk Request 094439.
This and other prescribed testing was to collect data for a
- non-detectable failure evaluation of _Rosemont (Model 1153) *
~r~n~mitter~. During*the check DPT-1S22A was val~ed .
out-of~service in accordance with the proced~re and was, .*
therefore, inoperable.
When. the as-fou.nd readings were
- discovered to be outside the tolerance range des.cribed in the
pro~edure, the instr~ment technician was to perform a
re~calibration to *correct the ~roblem. The two transmitters .
. were located approximately eight inche's apart and access to the
calibration adjustments ~ere on the underside of the
. transmitt.ers .. Each of the transmitters were laoelled with a
-small
lab~l under the transmitter.
To adjust the calibrat~on
setting, _the instrument technician _had to turn backwards to
where he was previ9usly sta~ding performin~ th~ calibratioh
check in order to look up* at the transmitter from belo~.
Therefore, the transmitter that had previously been on the
technician's-left for the calibration check was ~hen on the
- right for the adjustment.
As~such;*the technician mistakehly'
adjusted the wrong :transmitter.
D_AP iS-6; "Preparation and
Control of Wor~ Req~ests*, Revision-0, required work to be
- performed.per repair m~nual(s), traveler/procedure; or work
'instructions provided in .. the work package.* -Failing to fol.low
the work reque~t-by adju~ting the wron~ transmitter is
co~sider~d to be an e~ample of a ~iolaticin (50-237/90023-02e
(DRP)) of 10**cFR 50, Appendix *B, Criterion V.
However, safety
significance .is.considered to be minimal in this case since
adj~stments were made
i~ a direction that were conservative to *
Tectini ca 1 Sp'ecHi cations and, therefore, . Va.cu um* Breaker B was .
. never inoperable as to.its relief function during the event.
In addition~**although the va~uum brea~er was open for a brief
time and therefore unable to perform a containment isolation
function, its corresponding check valve remained closed.
The
vacuum breaker was immediately restored. *The licensee
counseled the instrument technicia~ on the rieed for total job
awareness especially ~hen working in congested.areas such as
this.
This event was also tailgated to inst~ument department
per~onnel. The licensee also enhanced the labeling of both the
Unit 2 and 3 transmitters and planned to rotate the
transmitters such-that the adjustment strews could be viewed
from the top.
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6.
(2.).0n November)4, 1990,*the licensee discove*r.ed that. the filter
media in the Unit 3 Reactor Building Ve~tilation Air
Particulate Sampler had bee~ misaligned in the filter h6ld~r.
This allowed a portion of the sample.flow to bypass the filter.
This i.s considered to be an uriresolved item
(50-237/90023~07 (ORP)) ~~nding furth~r review for the cause
~nd significance of* this event.
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Two examples of a violation and no deviations were identified in this
area.
Engineeting and Techhicai Support (37828)
The inspectors rev{ewed the m6dification package to alter ~he diesel
generator air start system (M-12-2-98-06).
The modification was the
result of a des~gh ~eakness id~ntified as a res~lt of the Safety System
FunCtional InspectiOn conducted in 1988 by the licensee.
The inspectors
obse~ved the physical work' of the resupport of the ai~ receiver drain
piping and verified the work was performed by qualified workers' and in_
accordante with approved.instructions and drawings contained in the work*
package.
Add~tionally, wel~er qualification records fo~ those*
individuals welding the hanger supports were verified ..
No violations or deviations. were identi*fied in thfs area.
- 7 .. Safety Assessm~nt/Quality Veri'flcatio~ (35502 and 40500)
.a.
Oh. October. l, 1990, whi.le Unit 2 was shutdown for a refueling outage
~
and fuel was being moved from the v~ssel to the spent fuel pool, the
- licensee discovered that the fuel movement was. 6~t of seq~ence.
Fuel moves were designated by the Nuclear Material Transfer.
Checklist (NMTC) in accordance with Dresden Technical Surveillance
(DTS) 8471, "General Procedu_.re For Fuel Transfers Involvlng the*-
Reactor.
11
Step 581 of the NMTC*indfcated that fuel assembly X28067'.
at core location 45-46 was to be transferred to Spent*Fuel Storage .
. Pool (SFSP) location F2.,.A7.
Instead, fuel assembly X2C113 at core
.location 43-46 was moved to that SFSP location during NMTc*st.ep* 58L
The error was noticed prior to* movement of any other.fuel .assembJies
and all fuel movement was halted.
Safety significance was minimal
- ~ince ~i this was offloading of fuel, a criticality concern did not
exis~ .. Further review indicated that poo~. communications and
inattention to ~etail contributed to the event.
The fuel assembly
to be moved was the last fuel assembly in the control cell. - The
foll6wing step, 582, involved a transfer from a different core
region.
The f~el Handlin~ Supervi~or went bnto the fuel g~apple tri
~aution the fuel handling crew of this fact;_ The indep~ndent
.
verifier and grapple operator were scheduled to swap duties starting
with step 582.
Therefore, following the caution just received about
that step, the independent verifier was studying a core map in
regard to step -582 instead of independently verifying step 581.
The
fuel handling error ~as discussed with the curr~nt and later the
oncoming crew to emphasize the importance of attention to detail an
proper independent verification.
The independent verifiers were
instructed to communicate to the grapple operator whether or not the*
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proper fuel assembly was* grappled prior to moving the assembly.
(Before the event, positive communication was necessary orily if the
- wrong assembly was l'atched.) . Increased supervision to confirm .the
effective~ess of the independent verification was initiated.
In.
additibni*the litensee decide~ ~o expedite repairs to the co~e
.
. posfti6n indication sy~tem (CPIS) on the gr~pple which would have
aided the fuel handlers to identify the correct assembly had it been
entirely 6perabl~.
On October 2, 1990, despite the previous cor_rective actfons, another
fuel ~ssembly mispositioning event occutred.
An Electrical
.
.
Ma.inter;iance Supervisor (EMS) was on the 'fuel grapple to observe the
- operation-~f the CPIS in preparation for repairs as discussed abcive.
The independent verifier was discussing its operation with the EMS,
Step l2 of Revision 2 of.Part] of the NMTC prescribed movement of
- fuel assembly X2C160 at core location 25-28 to SFSP. locatio-n F2-El.
The grap~le ciperatqr instead moved fuel assembly.A2Dl09 in core
. location 21-28.
The independent verifier* gave a cursory.inspection.
- of the core loc*atibn and *latched: condition, while engaging in.
con~ersati~n ~ith the EMS, and gave verbal permission to move the
fuel assembly.
The error was noted.when moving _the grapple to the
' ne~t 'fuel. assembly ~o be relq~ated and fuel loading was again
.halted .. This event was again related. to inattention to detail and*
lack of self-checkfng.
A discussion* involving management and the
fuel handlers the~selv~s was conducted to determine the best method
of independent verification. It was determined that confosion still
existed regarding the process thi independent verifier followed
- during fuel moves including communications and the process was
inadequately defined in approp~iate procedures~ In additi-0n,
- *externil distractions were not adeq~ately controlled on the grapple
.during foel movement.
A meeting was held .. between .licensee
management arid all fuel handlers* to stress the importance of*
attention to detail, independent verifi~ation and good
communications.
A temporary change was ~issued to OAP 7-7, "Conduct
bf Refueling Operations" to _restrict gr-apple access during fuel
movement.* The CPIS was also repaired prior to resuming fuel
movement.
The lic~nsee also planned to revise fuel handling
. procedures prior to the next refueling outage on Un it 3, curr*ent ly
scheduled for April 1991, _to,clarify the duti'es and responsibilities
of the independent verifier and to 'establish compensatory measures
when the CPIS is inoperable.
Further corrective act1ons to address*
general concerns about events during the outage is discussed is
paragraph 7.b.
Further ~eview of past events, found two* previous and similar fuel
loading errors on January 10 and 12, 1989 during the last Unit 2 .
refueling o~tage. The licensee had determiried .the root cause of
these events to be fuel handler inattention to detail.
As a result,
a memor~ndum had been issued.to ensur~ an independent verifier
.
visually verified the c6rrect storage and core locations in addition
to verifying fuel assembly latching. It als6 emphasized ciear and
concise communication.
It wa~ evident that this corrective action
- was insufficient to prevent *the later October 1, 1990 event.-
Furthermore, the corrective actions from the October 1, 1990 event:
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. were also.fnsuff.icient to prevent still another event *on
October 2, 1990.
Inadequate corrective.actions in response.to the
January 10 and 12, 1989 and October 1, 1990 fuel assembly
mis~ositioning events is considered to be a violation
(50-237/90023-08 (DRP)) of 10 CFR SO, Appendix B, Criterion XVI.
The remaining unloading .of fuel* and the reloading of fuel during the
corrent refueling butage following additional t6rrectiVe actibns did.
not result in any fuel .assembly mispositioning errors.
b.
- As described elsewhere in this report, a.number of events.occurred*
- d~ring the Unit 2 refueling outage ~hich were indicative of personnel
performance problems such as poor communications and inattehtion to
- detail. These included two fuel bundle mispositioning .eve.nts, an
inadvertent BUtci~atic start.of~ core spray pump,* a reactor cavity
overflow event, disassembly of the wrong feedwater i_solation check*
valve; i!'ladvertentdraining of a diesei generator fuer oil d~y tank,
- ' inadvertent diesel generator start and loading and several other
- events which are either covered in other i'nspection reports or were
not related.to ieactor ~r radiation safety; 'It appears that the
frequency of th.ese types of problems inc"rea.sed dramatically during
"the Unit 2 refueling outage as compared to the* last Unit 3 refueling
. outage .. This wasnot a contractor control problem since the majority*
of events in~olved station pers6nnel across several organizational
boundarie~.
~icens~e management recognized the adverse trend and
- instituted specific acdon to address. personnel performanc*e problems
. on a generic.basis .. These generic actions included special meetings
t~ erriphasfs these e~en~s and management expectations of prioritie~*tb
.
workers.
Outage wo~k activities were te~porarily reduted (substantially
- on Sundays) to ensure wor~ers were well
re~ted and to emphasize
- attention-to'detail over schedule.* 1n ~ddition, ~ self~check ~rogram,
recently implemented for operations personnel in response to a
previous violation, was expanded to the entire site. *A third party
review team was requested to review pa~t event~ for any new in~ight~~
The in~pectors observed substantial management in~oJvement to addre~s
.the problems. *
c.
While observing performante of* a qualit.Y control. (QC) hold point in
work request 95491, the inspector noted 'that the*Q.C. inspector.
identified that the step was being performed inco.rrectly.
The.work
reque~t .inVolved repairing of the air receiver tank relief valve 2A2
_for the Unit 2 diesel generator.
The particulai QC hold point was
on a step for bench ~etpoint adjtistment of the relief valve.
The
- mechanics had set the relief valve to "pop" fully open within the
set.pressure band delineated in the procedure .. However, .a relief_
val~e will initially open part way in order to relieve pressure
back to.atceptabl~ system* pressure.
If system ~res~ure continues to
rise the valve will fully ope~ or pop.
As it was set; the val~e would
have relieved below the specified tolerance band. *The QC inspector
explained this to the mechanics who then correctly adjusted the
setpoint.
Followup to this problem was provided by completion of a
QC Inspection Feedback Sheet by the QC.inspector.
This document is
sent to the involved department to inform departmental supervision of
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d.
the probl~m so that any ~tti~ns they feel appropriate ~an be taken. *
. However, this methodology did not provide a tracking me*chanism. to
ensure t_hat the root cause is identified and appropriate corrective
action is take~:
The.l~censee sta~ed ihat this mechanis~ was instituted
to address lesser problems th~t would not be important enou~h to .
. identify through other *available probl_em reporting programs such as
deviation reports.
This is considered to b~ an unresolved item* ..
(50-237/90023~09 (DRP)) pendi~g further revie~ of the administrative
guidance re~arding these :feedback sheets, types of problems identified
i~ these feedback sheets, threshold criteria fo~ other deviation
r_eporting_ methods and the adequacy of actions taken by various
departments in response t~ these feedback sheets.
~h~ in~pector obs~~ved the s~ram/enginee~ed ~afety features (ESF)
actuation reduction main committee meeting held on November 2, 1990.
The committee reviewed the status of corrective actions that were
.. being instituted in ~esponse to previoGs scrami and ESF ~ctuaiio~s-
. to prevent f~rther occurrences,
In ~ddition, a review and
discussion of-recent events was*perfor~ed during the meetin~ to
ensure.adequacy of planned corrective actions from a scram/ESF
. reduction standpoint.
Th.e stat'us cif BWR Owners Group Scram
- Frequency Reduction Recommendation Tracking System items and a
- recent Owners Gr6up ~onference repo~t were also discussed.
This was
viewed by the inspectors as a genu1ne effort to incorporate lessons*
learned from other facilities to prevent adverse occurrehc~s. The.**
inspectors regarded the licensee's scram/ESF reduction ac~ivities to
be beneficial in light. of the -smaller number bf scrain/ESF ac_tuations
occurring in 1990 compared to the previous year.
One violation and do dev{ations were identified in this area.
Re~ort Re~iew (90713)
During the inspection peribd, the tnspe~tor reviewed. the licensee's-
_Monthly Operating Report for September 1990. lhe inspector c6nfirmed
that the information provided met the requir.em~nts of Tech.nical
Specification 6.6.A.3 ,and Regulatory.Guide 1.16.
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9.
~nresolved items
Unresoived items are-~atters about which mor~ i~*ormation is required in
order to ascertain~.whether it is an acceptable item, an open item, a
deviation -or~ violati~n.
Un~esolved items disclosed during th~s
inspection are discuss~d in paragraphs 4.f, 4.g, S~a:3; 5.b.2 and 7.c.
10.
Exit Interview
The inspectors .met with licensee ~epresentatives (denoted in Paragraph i)
- .on November 16, 1990, and informally throughout the inspection ~eriod,
and summarized the scope and*find1ngs of the inspection activities.
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The inspectors also discussed the likely informational co.nte.nt of the
_inspection.report with regard to documents or processes reviewed by the*
inspector during the inspection.
The licensee did not identify any _such
documents/processes as proprietary .. The licensee acknowledged the
findings of the inspection.
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