ML17292A770
| ML17292A770 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 03/28/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML17292A768 | List: |
| References | |
| 50-397-97-03, 50-397-97-3, NUDOCS 9704030190 | |
| Download: ML17292A770 (35) | |
See also: IR 05000397/1997003
Text
'ENCLOSURE 2
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket No.:
License No.:
Report No.:
Licensee:
Facility:
Location:
Dates:
Inspectors:
Approved By:
50-397
50-397/97-03
Washington Public Power Supply System
Washington Nuclear Project-2
Richland, Washington
January
19 through March 1, 1997
G. D. Replogle, Acting Senior Resident Inspector
M. Tschiltz, Senior Resident Diablo Canyon
H. J. Wong, Chief, Reactor Project Branch
E
Division of Reactor Projects
Attachment:
Supplemental
Information
9704030l90
970328
ADOCK 05000397
8
EXECUTIVE SUMMARY
r
Washington Nuclear Project-2
NRC Inspection Report 50-397/97-03
This routine, announced
inspection included aspects
of licensee operations,
engineering,
maintenance,
and plant support.
The reports covers
a 6-week period of resident
inspection.
~Oerationa
Operators responded
well to a reactor recirculation control pump trip.
The post accident sampling system was inoperable for about seven weeks due to
scheduling conv'enience,
Operations
and Engineering demonstrated
a poor safety
focus on maintaining the system operable.
Several examples of the failure to follow plant procedures
by operations personnel.
were identified between January
6 and January 20, 1997.
Human performance
was a contributing factor in all of the occurrences.. Licensee corrective actions
initiated on January 23, 1997, appeared
sotnewhat effective in curbing the
performance trend.
Examples of the violation of TS 6.8.1 included:
The failure of control ro'om operators to appropriately reposition
in accordance
with a surveillance procedure.
Thb failure of work planning and operations personnel to identify TS Action
.Staterrients that were required to be entered prior to deenergizing
standby
service water Building A ventilation fan.
Additionally, no risk assessment
of
the out-of-service equipment was performed prior to maintenance.
Equipment operators failed to close, in accordance
with clearance
order
requirements,
a manual valve that was required to assure containmerit
isolation.
~ Maintenance
e
The performance of work and surveillances was generally acceptable
and
technicians generally demonstrated
good work practices.
e
The procedure for a response
time test for the reactor water cleanup system had.
not been revised to reflect a change
in the setpoint pressure.
~
Five human performance related events associated
with maintenance
activities were
identified between January
13 and February'3, 1997.
Licensee corrective actions
initiated on January 23, 1997, appeared
to improve the performance trend, but two
additional problems occurred on February 3 and February 11, 1997.'hree
of the
events w'ere considered
to be examples of a TS 6.8.1 violation.
While two other '
-2-
events were of concern, they did not constitute violations of NRC requirements
(Section M4.1). The events included in the Notice of Violation included:
Contract workers were found contaminated
after failing to implement the
radiological work permit requirements
when entering
a contamination
area
. Maintenance was performed on a safety-related
diesel generator
(DG) room
damper utilizing inappropriate ."minor maintenance"
controls.
The high pressure
core spray (HPCS) diesel tripped during surveillance
testing because
an equipment operator failed to follow procedures
when
=
establishing switch positions.
Other human performance
concerns
included:
A maintenance
worker exhibited poor work practices in utilizing an
uninsulated screwdriver when working above the rod block monitor.
The
screwdriver was inadvertently dropped, shorting out the rod block monitor
power supply.
I
Poor contractor oversight in allowing hands-on work contributed to tripping
~En ineerin
~
One unresolved
item w'as opened
regarding inoperable reactor water cleanup flow
Switches LD-FS-15 and LD-FS-16. -The instruments were inoperable since spring
1995 due to miscalibration.
e
One violatiori of the Emergency
Plan implementing procedures
was identified,
regarding the training of on-shift Health Physics Technicians
(HPT). When concerns
we'e first raised by the licensee's self-assessment
team, corrective measures
were
not prompt and the on-shift HPT positions were not appropriately staffed until
4 days later.
In a conference
call with the NRC on March 3, 1997, the licensee did not provide
sufficient justification that the proposed
training for nonqualified HPTs would,
prepare them for the Emergency
Response
Organization
(ERO) HPT positions.
A June 1996 quality assurance
(QA) audit of the Emergency Preparedness
Program
was ineffective, as issues concerning the number of HPTs on shift were raised but
were inappropriately resolved.
Re ort Details
I
Summar
of Plant Status
The inspection period began on January
19, 1997, with the reactor at 68 percent power,
and in single loop operation.
Power remained at app'roximately 68 percent until
January 30, when power was reduced to 57 percent, due to excess power generation
in
the Northwest (economic dispatch).
On February 7, power was reduced to approximately
30 percent to support recovery of the reactor recirculation control (RRC) Pump A.
~
Operations increased power to 91 percent on February 10, but the RRC Pump A tripped on
February
11 due to'improper troubleshooting
activities and power was again reduced to
65 percent.
Power was maintaine'd at about 65 percent until February 15, when reactor
power was reduced to 30 percent to support recovery of the RRC Pump A. After
successful recovery of the pump, power was increased to 70 percent on February 16, and
remained there until February
1,7 when power was increased to 90 percent.
Between
February 19 and February 23, power was maintained at 70 percent during the day and
reduced to 55 percent at night in a load following mode.
On February 23, the power was
reduced to 30 percent to support recovery of the RRG pump Drive 1A1.
(The pump was
previously operating on only one drive, 1A'2.) On February 24, power.was Increased to
88 percent and was subsequently
increased to 90 percent on February 25.
From
February 26 through March 1, power was varied between 55 and 100 percent, depending
on the power needs
in the Northwest.
I. 0 erations
01
Conduct of Operations
01.1 General-Comments
71707
Using Inspection Procedure 71707, the inspectors conducted frequent reviews of
ongoing plant operations.
The conduct'of'operations
was generally professional
and
~ safety-conscious.
01.2
RRC Pum
Tri
a.
Ins ection Sco
e 71707
On February 11, 1997, RRC Pump A tripped'during adjustable
speed drive
troubleshooting
activities.
The inspector reviewed Operations'esponse
to'the
event.
b.
Observations
and Findin s
In response
to the event, operators efficiently and quickly transitioned the plant to
single-loop operation.
The inspectors verified that TS requirements
were met, no
problems were found, and considered
this to be a good response
to the event.
Additional information pertaining to the causes of the event are in Section M4'.1 of
this report.
-2-
c.
Conclusions
Operations'esponse
to a RRC pump trip was considered
good.
02
Operational Status of Facilities and Equipment
02.1
En ineered Safet
Feature
S stem Walkdowns
71707
The inspectors walked down accessible
portions of the following engineered
safety
feature systems:
~ Low Pressure
~ All Safety-Related
Batteries
~ HPCS (semi-annual detailed review)
~
1
~ Residual Heat Removal (RHR) Trains A, B and C
02.2
Equipment operability and material condition were acceptable
in most cases.
The
inspector identified minor housekeeping
concerns during the walkdowns, such as
'unattended
tools lying on equipment and debris in some'areas.
The licensee took
prompt'measures
to restore cleanliness..
During tours of the control room inspectors
observed shift turnovers:being
conducte'd
in a conscientious
manner with control
panel walkdowns.
The inspectors noted that the number of nonoutage
control room
deficiencies had been historically above the goal of 20, but that the deficiencies were
being identified and tracked for resolution.
b.
Ins ection Sco
e 71707
1
\\
The inspector audited the Limite'd Condition for Operation/Inoperable
Equipment log.
'I
F
Observations
and Findin
s
The inspector noted that the liquid'and gaseous
effluent sampling capabilities of the
PASS were inoperable from January
16 through March 7, 1997.
The PASS was
installed as part of actions specified in NUREG 0737, "Clarification of TMI Action
Plan Requirements."
As documented
in the NUREG, essential capabilities of the
PASS included, but were not limited to, taking samples to: '(1) determine core
damage;
and (2) differentiate between cladding failure and fuel melt.
The inspector contacted the system engineer to identify the causes. of the
malfunctions and to determine when the system would be restored to'service.
The
system engineer'indicated
that for both the liquid and gaseous
effluent'sampling
capabilities the valve-open permissive logic was not working 'properly.
The engineer
~
3
suspected
that faulty limit switches were causing the problems and stated that there
were no restrictions on when the repairs could be performed.
However, the work
week leader had scheduled
the work for the week of March 16, 1997, for scheduling
convenience.
The licensee stated that the operational status of the PASS was not a significant
concern.
The primary function of the PASS was to assess
fuel damage during and
following an event and there were two alternative methods that could be utilized to
accomplish this task.
Based on discussions with NRR pe'rsonnel, the inspector concluded that the noted
alternative methods,
although useful when PASS was inoperable for unavoidable
reasons,
were not adequate
replacements
for PASS (as long term actions).
The
alternative methods relied on installed monitors and did not involve taking samples.
Neither of the methods could be utilized to differentiate between cladding failure and
fuel melt.
Plant Procedure
Manual (PPM) 1.11.6, "PASS Program," requires that the PASS be
available to the maximum extent practicable when the reactor is in operational
conditions
1, 2, or 3. While this requirement does not provide definitive guidance,
the seven weeks of inoperability was beyond management
expectations.
c.
Conclusions
Operations
and Engineering demonstrated
a poor safety focus in not restoring
operability of the post-accident
monitoring system for'approximately seven weeks.
04 'perator Know(edge and Performance
04.1 Human Performance
Issues
71707
a.
Ins ection Sco
e 71707
From January,6 to 20, 1997, the licensee identified three events caused
by human
performance
errors in the area of Operations.
The inspectors reviewed these events.
b.
Observations
and Findin s
, Inappropriate'Entry into TS Actions Statements:
On January 6, '1997, operators
de-
energized the standby service water (SSW) Building A ventilation fan (PRA-FN-1A) to
perform bearing lubrication and inspection activities (Work Order DGZ6). Operations
did not recognize that the operability of other TS systems would be affected by the
work. When the fan breaker.was
opened,
control. room alarms alerted operators that
SSW-A and DG1 were rendered
The licensee subsequently
entered the
appropriate
TS Actions statements
until power to the fan w'as restored.
The licensee
initiated Problem Evaluation Request
(PER) 297-0016 to address
this issue.
'4-
Prior to the job, the control room operators
had searched
TS, but did not find a,
requirement directly associated
with Fan PRA-FN-1A.
Based on the absence
of a
direct TS requirement, the control room operators erroneously
assumed that
removing the fan from service would not affect'the operability of other TS systems.
The production scheduling shift manager
(PSSM) subsequently
reviewed and
approved the operators'ssessment.
The licensee determined that the operators should have known that removing the fan
from service would affect the operability of Pump SSW-A and DG1. However, the
control room staff did not appropriately identify all TS Action Statements
that were
affected by the PRA-FN-1A job. As a corrective measure,
the licensee plans to have
the senior reactor operator review these assessments
in the future.
I'he
inspector noted that PPM 1.16.6B, "Voluntary Entry into TS Activities During
'ower Operations,"
Revision 6, requires the PSSM (a licensed senior reactor
operator) to identify TS Action Statements that are required to be entered to perform
requested
work. Additionally,. the PSSM is required to request a'probabilistic safety
assessment
if the TS.entry involves risk-significant TS system's.
(SSW-A and DG1
are identified as risk-significant systems.)
As such, it appeared that the level of
control associated
with this activity was appropriate,
but the reactor operator and
PSSM had failed to identify the TS impacts.
The failure of the PSSM to:
(1) identify TS Action Statements
associated
with the
SSW-A pump and DG1; and (2) request
a probailistic safety assessment
were
considered
examples of a violation of TS 6.8.1, which requires the licensee,
in part,
to implement procedures
governing maintenance
activities.
The violation is
considered to be self-disclosing by the event (VIO 50-397/9703-01).
. Control Rod Positioning Error
On January
17, 1997, during the performance of
PPM 7.4.1.3.1.2, "Control Rod Exercise," Revision 15, the reactor operator identified
that Control Rod 54-19 was out of position.
The control rod was documented
as
being successfully moved to Position 48 (several'steps
earlier), but" was still at
Position 46.
The licensee reviewed computer records of the control rod movements
and found
that the operator had not attempted to reposition the rod to Position 48 earlier in the
surveillance.
Additionally, the shift technical advisor, who was performing the
second verification, had also failed to identify the mistake.
The inspector noted that PPM 7.4.1.3.1.2, Step 5k, states:
"For each control rod that has been exercised satisfactorily... initial the
appropriate location on core map (Attachment 9.2)."
Contrary to the above, the reactor operator had initialed the location on the core map
that corresponded
to Control Rod 54-19, but the rod was not exercised satisfactorily.
-5-
This is an example of a violation of TS 6.8.1.
This TS requires the licensee,
in part,
to implement procedures
covering surveillance and test activities of safety-related
equipment
(VIO 50-397/9703-01).
As corrective measures,
the licensee:
(1) repositioned the control rod using an
approved
procedure;
(2) performed calculations to ensure that an overpower
condition did not occur and no thermal limits were exceeded;
and (3) counselled the
individuals involved.
Failure to Close Valve RHR-V-176B: On January 20, 1997 Valve RHR-V-176B was
required to be closed in accordance
with Clearance
Order 96-12-0074 and
Valve closure was necessary
in order to maintain primary containment
integrity during the performance of maintenance
on Valve RHR-V-134B (the normal
containment isolation valve for the penetration).
On January 23, 1997, when releasing the clearance:order,
manual Valve
RHR-V-'176B was found in the open position.
Upon discovery, the licensee entered
'nto
TS Action Statement 3.6.1.1, whi'ch 'requires restoring primary containment
integrity within
1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> or being in at least HOT SHUTDOWN within the next 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />
and in COLD SHUTDOWN within the following 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Within an hour the licensee
exited the action statement after closing Valve RHR-V-176B.
The licensee determined that two equipment operators
(EO) had tagged and
independently
verified Valve RHR-V-176B to be closed, when the valve was actually
in the open position.
The valve was stuck on its back seat and when the EOs
attempted to turn the valve handwheel
in the closed direction, it did not move.'he
EOs assumed
the valve was already closed.
/
PPM 1.3.8, "Plant Clearance Orders," Revision 30, Section 3.9, specifies that EOs
are responsible for positioning components
in the plant as determined
by. clearance
order.
The failure to properly close Valve RHR-V-'176B is a violation of TS 6.8.1,
which requires the licensee',
in part, to implement procedures, coverirIg equipment
c'ontrol (locking and tagging).
The violation was considered to be self-disclosing by
, the event (VIO 50-397/9703-01).
The inspector considered the following to be contributors to the event:
t
The EO (who initially failed to reposition the valve closed) was not informed
that the valve needed to be repositioned
(rather than verified to be closed).
PPM 1.3.8 does not require that this.information be included on the clearance
order.
The valve is a normally open valve and would have been out of its
normal position if it were found closed.
The licensee stated that information regarding the expected
valve position was
intentionally not required by PPM 1.3.8, to avoid confusion on final component
'-6-
position.
However, the inspector noted that informing the EOs whether
a valve
needed to be repositioned
or just checked would not likely lead to confusion.
The personnel involved with hanging and verifying the danger tag on
Valve RHR-V-176B also failed to use other confirmatory means of determining
the valve's'position that would have brought into question the actual position
of the valve.
't
The significance of the event was mitigated by the subsequent
determination that
Valve RHR-V-134B was closed for all but one minute of the period when the,
clearance
order was in effect.
RHR-V-134B was cycled open momentarily as part of
the stem lubrication procedure
but was otherwise deenergized
clased.
Licensee Corrective Actions:
On January 23, 1997, the licensee initiated
PER 297-0072 to address the apparent trend in human performance
errors.
Licensee
management
additionally:
(1) ordered
a site-wide stand-down,
in which all work was
stopped until workers and management
completed discussions
about the recent
human performance issues and their causes;
(2) required that a face-to-face briefing
be conducted
by supervision prior to the conduct of field work; (3) implemented
a
management/supervisory
oversight program; and (4) reinforced attention-to-detail
concepts with all workers.
Although the increased
management
attention appeared
to reduce the error rate, the
inspectors noted that two additional events occurred on February 3 and 11, 1997,
(after the January 23 plant-wide stand-down)
(See Section M4.1). These events
involved several operations
personnel involved. in plant maintenance
and surveillance
activities.
.c..'Conclusions
'Three examples of a human perfoimance related procedural violation were identified
.
between January
6 and February 3, 1997.
Licensee corrective actions initiated on
January 23, 1997, appeared
generally effective in curbing the performance trend, but
two additional problems, involving operations
personnel,
were identified subsequent
to the plant stand-down.
II. lVlaintenance
M1
Conduct of (IIlai'ntenance
'
M1.1'eneral Comments
a.
Ins ection Sco
e 62703
61726
The inspectors observed the following work activities:
-7-
~
Work Order FMY4, Intermediate
Range Monitor A Repairs
~
PPM 7.4.3.3.1.52,
"HPCS Initiation on Water Level 2 (BRD) - Channel
Functional Test/Channel
Check"
~
Operating and Engineering Test Procedure 8.3.351, Revision 2, "Reactor Water
Clean Up (RWCU)-FT-16 Response
Time Testing"
b.
Observations
and Findin s
The performance of the work and surveillances was generally acceptable.
Technicians usually demonstrated
good work practices.
Noteworthy observations
are discussed
in Sections M1.2 and M1;3 below.
M1.2 HPCS Instrumentation Surveillance
PPM 7.4.3.3.1.52
'i
During the performance of the surveillance; the inspector observed that instrument
and control (IRC) technicians
using quick disconnect fittings were not wearing
anticontamination
clothing, although the system they were working on was
. consjdered contaminated..The
licensee had installed sleeves
on the quick disconnect
fittings to provide some measure of contamination protection and this was
considered
an acceptable
practice by the Health Physics
(HP) department;
however,
the inspector noted that, without anticontamination
clothing (e.g., gloves) and the
performance of surveys on completion of the surveillance, there, was an increased
possibilityof spreading contamination.
Surveys of the fitting used during the
~
surveillance revealed
no contamination.
M1.3 RWCU S stem Res
onse Time Testin
The licensee identified that the test procedure was not appropriately updated prior to
the test.
During review of the test results, the. response
time obtained was tho'ught
to-be outside of allowable values.
However, the licensee determined that the latest
procedure, revision failed to account for a change
in the setpoint pressure from
169 inches to 150 inches.
The, licensee utilized information from th'e strip chart.
recorder to verify that appropriate acceptance
criteria were met.
The licensee's
actions were acceptable.
j
c.
Conclusions
on Conduct of Maintenance
!
The performance of work and surveillances was generally acceptable
and technicians
generally demonstr'ated
good work practices.
The failure to appropriately revise a
procedure when a setpoint change was made resulted in the use of inappropriate
acceptance
criteria when testing RWCU instruments.
Corrective measures
were
acceptable.
-8-
M4
Maintenance Staff Knowledge and Performance
M4.1 Human Performance
Issues
62 07
a.
Ins ection Sco
e 71707
Between January
13 and February 3, the licensee identified five events in the area of
maintenance
that were attributable,
in part, to human performance
errors.
The
inspectors reviewed these events.
b.
Observations
and Findin s
Contaminated Workers:
On January 23, 1997, three Raytheon contract workers
were found to be contaminated
when setting off alarms on a PCM while attempting
to exit from the radiologically,controlled area.
Upon further investigation, the'
licensee determined that the workers had inadvertently entered
a contamination
area
(located on scaffolding in the HPCS pump room) without the appropriate
anti-
contamination clothing.
The workers Vvere signed onto Radiological Work
Permit 96000375 00, which required the workers, in part, to don a complete set of
anticontamination
clothing prior to entering the contamination zone.
PPM 1.11,11,
"Entry Into, Conduct in, and Exit from Radiologically Controlled Areas," Revision 11,
dated March 15, 1996, requires,
in part, that per'sons entering
a radiological
controlled area adhere to radiological work permit requirements.
The failure to adhere to PPM 1.11.11
is an example of a violation of TS 6.8.1, which
requires that the licensee adhere to procedures
for the control of radioactivity. The
violation was considered to be self-disclosing through an event
.
(Violation 50-397/9703-02).
The licensee's
investigation identified the following as contributors:
~
The workers 'and the HPT at the control point did not communicate effectively
~
'
regarding the scope and location of the work that was to be performed.
The
workers checked
in with the HPT prior to the job, but no meaningful
discussions
regarding the job and job location were conducted.
It is a
management
expectation that workers communicate the scope and location of
their job with the HPT prior to starting work.
~
The workers did not effectively demonstrate
self-checking practices.
The
contamination
area posting was located at eye level on the scaffold ladder.
The workers failed to read the sign.
~
The layout of the area was not typical for a contamination
zone.
For example,
there was no step-off pad, no dress-out
area, and no clearly identifiable
boundary (such as a roped off, area):
The workers were conditioned to look for
-9-
these indicators, and when they were absent the workers assumed
the area
was not contaminated.
In response
to the event, the I)censee initiated PER 297-0074.
At the close of the
inspection period the licensee had not determined
all of the corrective actions
necessary
to resolve this issue.
Rod Block Monitor Failure:
On January
13, 1997, Rod Block Monitor B failed when
a'echnician
dropped an uninsulated screwdriver across the power supply terminals
which shorted out the power supply.
The technician was performing
PPM 7.4.3.1.1.80,
"Local Power Range Monitor Gain Calibrations," when the event
occurred.
The local power range monitor'djustment screws were locatqd directly
over the rod block monitor power supply.
The licensee initiated PER 297-0039 to
address this event.
The licensee determined that the technician failed to.meet management
expectations
far this job. Technicians were expected to use insulated screwdrivers while in the
proximity of energized circuits; however, this expectation was not documented.
The
technician indicated that he had loaned his insulated screwdriver to a fellow worker.
As corrective actions, the licensee planned to:
Provide insulated screwdrivers to all of the l&.C Technicians.
Establish
a written policy requiring the use of insulated tools for certain
conditions.
w
RRC System Pump Trip: On February 11, 1997, RRC Pump A tripped during
'adjustable
speed drive troubleshooting.
The licensee was attempting to resolve
problems with RRC Drive 1A1, when a General Electric (GE) engineer used-an
inappropriate oscilloscope probe and shorted
a power supply capacitor to ground;
The short caused the voltage on the uninteruptible power supply grid to drop (the
grid supplied power to the 1A1 and 1A2 drives).
Subsequently,
the 1A2 drive power
supply tripped on under voltage, which deenergized
the pump.
The same
GE engineer was involved with a.previous event at WNP-2. Specifically,
as documented
in NRC Inspection Report 50-397/96-16, the engineer
(a nonlicensed
person) had inadvertently operated the RRC system and affected changes to
reactivity. As a result of that event, the licensee and GE had standing orders that
this individual was prohibited from performing hands-on work at WNP-2. The,
engineer was permitted to act in a consulting'apacity only.
At the time of the event, the system engineer (who was providing contracting
oversight for the evolution) was aware of the standing order, but did not attempt to
stop the individual from working on the system.
-10-
The licensee identified the following additional contributors to the event:
~
The troubleshooting
plan provided weak guidance to the individuals performing
the work. The appropriate equipment for the task was not specified.
~
An l&C technician should have been utilized to take instrument readings on
energized equipment, but was not.
An ISC technician is most familiar with the
teqt equipment and associated
precautions.
~
Contractor oversight was inadequate.
Inappropriate Maintenance on Safety-Related equipment:. On February 3, 1997, the
licensee identified that work on a safety-related
air damper was performed without
the appropriate procedural controls (PER 297-0096).
Background - Each DG room is serviced by heating, ventilation,-arid air
condition (HVAC) system.
Each system consists of a "normal" HVAC unit, which
runs continuously,
and a "standby" unit that automatically starts when the DG starts.
Both HVAC units are safe'ty-related
and are relied upon to maintain the DG operable
when the DG is operating.
In the winter, some loss of cooling capability can be
tolerated.
However, in the summer months, both HVAC units must be operable to
~ ensure
operability.'etails
- On February
1, 1997, during the investigation of a high DG2 room
temperature
(92
F), an EO identified that the outside air damper for the normal room
HVAC unit was closed.
The damper failed closed when a damper linkage became
disconnected
from the linkage assembly.
The shift manager
(SM) contacted the
system engineer and was told that the problem would not affect DG operability.
Due
'to the low winter temperatures,
the standby HVAC unit was capable of maintaining
the room temperature within design limits if the DG were to start.
As a result of the
conversation,
the SM,assumed
the HVAC unit was not safety-related.
The SM authorized work (reconnect the damper linkage) to be performed under the
.
"minor maintenance,"
provisions of PPM 1.3.7G, "Work Implementation,"
Revision 10.
Under minor maintenance
controls, the work and postmaintenance
testing were accomplished
without. the benefits of preplanning
or procedural
guidance.
The work was performed on February 1'nd the HVAC unit was returned
to service.
PPM 1.3.7G prohibited minor maintenance
on safety-related
equipment where the
work could affect the operability of the equipment.
The repairs for the DG air
damper clearly affected the operability of the DG HVAC unit, and if not performed
correctly, could have resulted in operability problems at a later time. The failure to
perform safety-related work on the DG air damper in a'ccordance
with approved
procedures
is an example of a violation of TS 6.8.1, which requires, in part, that
maintenance
with the potential for affecting the performance of safety-related
-1 1-
equipment
be preplanned
and performed in accordance
with written procedures,
documented
instructions, or drawings appropriate to the circumstances
(VIO 50-397/9703-02).
The inspector considered the work that was initially'performed to be loosely
controlled.
During the job a mechanic bent the linkage arm.
He took the arm to the
shop, straightened
it, and then reinstalled it (without engineering involvement or
other oversight).
The mechanic also noted that the pivot arms were very worn and
wrote a work request to correct the problem (but did not inform engineering
until
February 3).
On February-3, as corrective measures,
the licensee reviewed the work that was
accomplished
and 'verified that'the informal post maintenance
testing'was consistent
with other procedural requirements.
The licensee determined that the work was
inappropriate to be. considered
"minor maintenance."
Additionally, the licensee
established
a standing order that all minor maintenance'would
be p'reapproved
by
senior maintenance
mana
ement
ersonnel
~
9
p
On February 6, during a system walkdown, the system engineer identified that the
pivot arm was broken (PER 297-0105), which again rendered the damper linkage
The inspector noted that in January 1996 work was similarly conducted
on the DG2
standby HVAC unit outside air damper without the appropriate
procedural controls
(NRC Inspection Rep'ort 50-397/96-06) and associated
The violation was caused
by the failure of the licensee to appropriately identify the
safety classification of the damper prior to performing work. The inspector identified
two systems which could be used to determine the safety-related classification of the
noted damper.
First, the licensee's
PASSPORT computer program provided easy
access to the subject information. A randomly selected operator was able to quickly
determine the safety classification of the air damper (in less than 2 minutes).
Second, the licensee maintains component classification records for each plant
component.
It took a licensee employee approximately 5 minutes to determine the
damper's safety classification by reviewing those documents.
The operations
and
maintenance
workers involved with oversight of the work failed to use either of these
.
two methods for determining 'the safety'lassification of the damper, bqt relied on
verbal discussions
instead.
HPCS DG Trip: As noted in NRC Inspection Report 50-397/96-26, on January
13,
1997, an EO failed to reposition the "droop switch," which was required by
PPM 7.4.8.1.1.2.12,
"HPCS DG3 Monthly Operability Test."
DG3 subsequently
tripped on reverse power.
The licensee had determined that contributors to the
violation included:
(1) poor self-checking on the part of the EO, and (2) the absence
of detailed prejob briefing.
-1 2-
As followup to this issue, the inspectors identified one additional contributor.
Specifically, independent
verification of the switch position could have prevented the
event.
Independent
verification of the EO's activities (switch repositioning'teps)
appeared
warranted
in that:
(1) the EO had not performed the surveillance within the
past year; (2) the EO did not understand
the function of the droop switch; and
(3) the EO was performing the steps alone, without the assistance
of other
knowledgeable
individuals.
The EO's failure to place the DG3 droop switch in the correct position as required by
Step 17a of PPM 7.4.8.1.1.2
~ 12 is an example of a violation of TS 6.8.1, which
requires, in part, that written procedures
for surveillance and test activities of
safety-related
equipment
be implemented.
The violation was considered,to
be self-
disclosing by the event (VIO 50-397/9703-02).
c.
Conclusions
Several human performance related examples of procedural violations associated
with
maintenance
activities were identified between January
1'3 and February 3, 1997.
Licensee corrective actions initiated on January 23, 1997, appeared
generally
effective in curbing the performance trend, but two additional human peiformance
related events occurred on February 3 and 11, 1997.
Several of the issues involved
both maintenance'and
operations
personnel.
M8
Miscellaneous Mainte'nance Issues
M8.1
Closed
Unresolved Item 50-397 9626-02:
DG3 reverse power trip. This item
is discussed
in Se'ction M4.1..
E2
Engineering Support of Facilities and Equipment
E2.2 Review of Facilit
and
E ui ment Conformance to Final Safet
Anal sis
Re ort
Descri tion
A previous discovery of a licensee, operating their facility in a manner contrary to the
FSAR description highlighted the need for a special focused review that compares
plant practices, procedures,
and/or parameters
to the FSAR description.
While
performing the inspection discussed
in this report, the inspectors reviewed
the'pplicable
portions of the FSAR that related to the areas inspected.
No problems
were identified.
'Il
-13-
E8
Miscellaneous Engineering Issues
E8.1
Ino erable RWCU S stem Isolation Instrumentation
On February 11, 1997, the licensee identified that RWCU flow Switches LF-FS-15
and LD-FS-16 (division
I and II) were inoperable since initial calibration in Spring
1995.
The problem was determined to be due to an error calculating the
instruments'rip setpoint:
The setpoint was found to be 276.5 gpm, while
TS 3.2.2-1(3.k) specified
a maximum setting of 271.7 gpm.
'he
instruments
are used to initiate the RWCU system blowdown flow - high
actuation circuitry. This function is provided to detect and automatically isolate a
postulated
high energy line break at the piping connection to the RWCU system
blowdown flow control valve (RWCU-FCV-33). This blowdown line is utilized during
startup and shutdown evolutions to help maintain reactor water level within
specifications.
However, while at power the line is normally isolated.
As required by TS 3.3.2, the licensee isolated the blowdown line by closirig manual
Valve RWCU-V.-32 within.1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> of discovery.
The inspectors verified that TS
.requirements
were met.
This is considered
an unresolved
item pending further NRC
review of this issue (URI 50-397/9703-03).
A
IV. Plant 'Su
ort
P3
Emerge'ncy Preparedness
Proce'dures
and Documentation
a.
Ins ection Sco
e
82701
'On February 6, 1996, a self-assessment
team identified that the staffing
requirements
identified in PPM 1.3.1, "Department Policies, Programs and.Practices,."
Revision 28, for on-shift HPTs was inconsistent with the requirements of the
Emergency
Plan (EP).
The inspector reviewed licensing documents
and conducted
discussions with the licensee
as followup to this issue.
A
b.
Observations
and Findin s
Background:
The licensee ha'd required that three qualified HPTs be on-shift while in
Operational Modes 1, 2, and 3 ~ However, in June 1996, as part of their downsizing
efforts, the license changed the on-shift staffing requirements to only two qualified
HPTs and the on-shift Chemistry Technician (CT) would also, serve as the third HPT.
The EP, Revision 18, dated October" 1996, contains,
in part, the following
requirements for on-shift HPTs during operational Modes.1, 2, and 3.
~
One HPT fbr surveys
-14-
~
Two additional HPTs for protective'actions.
The EP permitted these HPTs
positions to be filled by other individuals, provided that they had the expertise
to perform the specified duties.
NUREG 0654, provides guidance
on the actions an on-shift protective actions HPT
could be required to perform and includes:
~
Access Control
~
HP Coverage for Repair, Corrective actions, Search and Rescue,
First-aid 5. Fire
Fighting
~
Personnel
Monitoring, and
~
Dosimetry
PPM 13.14.5 "ERO and Training," provides the requirements for staffing and training
of'individuals filling ERO positions.
PPM.1.3.1 specifies the minimum'staffing requirements
at,WNP-2.
This procedure
is
not considered to be an EP implementing procedure, 'but it is utilized in lieu of
PPM 13;14.5 to ensure that on-shift ERO positions are manned.
PPM 1.3.1 was
written to capture the-applicable requirements
stated in PPM 13.14.5.
Licensee Identified Concern:. Members of the licensee's
self-assessment
team
identified that PPM 1.3.1 only required that two HPTs be on-shift, versus the three
HPTs specified by the EP.
In respon'se to the finding the licensee initiated
PER 297-0110, dated February 6, 1997.
Inspector Followup:. The inspector reviewed PER 297-0110 on Februar'y 10, 1997,
and noted that the licensee had not increased the number of on-shift HPTs to be
consistent with the EP (4 days after the issue was identified).
The inspector raised
the concern to licensee management
and the licensee subsequently
took immediate
actions to ensure that at least three qualified HPTs were on shift at all times.
During subsequent
discussions
with the Corporate Emergency Preparedness
Safety
and Health Officer (EP Officer), the inspector was advised that the licensee believed
that the CTs were appropriately trained to assume the responsibilities of the on-shift
- HPTs.
As such, the issue identified in PER 297-0110 was administrati've in nature
and would be resolved by a few clarifying procedural changes.
The inspector disagreed with the licensee's
assessment
of the issue for the following
reasons:
~
The CTs had not completed the ERO training that was required for HPTs.
The'P
stated that training responsibilities were located in the EP implementing
t
I
-15-
procedures.
Additionally, the EP stated that individuals identified to function in
these
ERO positions will receive specialized initial training in the duties and
responsibilities of the position and the applicable procedures.
I
PPM 13.14.5 required that training for individuals selected for ERO participation
be successfully completed priar to ERO position assignment.
The required
training was identified in the Emergency Position Training Matrix located in the
Training Course Catalog," Revision 2.
One course
exclusive to HPTs,'which was not completed by most of the CTs, was "HP
Emergency Functions."
In some instances,
the CTs were not trained to perform the tasks specified by
NUREG 0654:
HPTs normally received training for the above tasks as part of
the HPT qualification program.
This training was not required by the CT
training program. 'Furthermore, training normally provided to the CTs would not
be sufficient to perform the NUREG 0654 tasks at WNP-2..
The on-shift CTs were not informed by any, means that they'were to assume
the responsibilities of the on'-shift HPTs.
Per'PPM 13.14.5, all individuals filling
~ ERO positions were to be informed of these responsibilities via a "letter of
assignment."
The SMs (the emergency director during the initial stages of an event) were not
informed that the on-shift CTs would be assuming the HPT ERO
responsibilities.
The licensee provided
a list of qualified ERO individuals to the
SMs for reference,
but the CTs were not identified as being qualified to fillthe
HPT positions.'
The failure to adhere to PPM 13.34.5 to
(1) ensure that the CTs completed the
training specified by the Emergency Preparedness
Training Course Catalog; and
(2) document the assignments
of the CTs to the ERO HPT positions via a "letter of
assignment,"
is considered
a violation of TS 6.8.1.f.
This TS requires that the
licensee follow procedures
covering EP implementation
(VIO 50-397/9703-04).
'he licensee agreed that:
(.1) the CTs involved were not appropriately informed of,
their responsibilities;
(2) the'SMs were not informed that the CTs were providing on-
shift HPT coverage
(for ERO purposes);
and (3) the CTs had not completed the ERO
training specified in the Emergency Preparedness
Training Course Catalog.
The licensee disagreed,
however, with the inspectors'ssessment
that some of the
CTs were not appropriately trained to perform the tasks specified in NUREG 0654.
On February 13, 1997, the licensee issued Revision 29 to PPM 1.3.1, which requires
that three HPTs be on-shift.
However, the requirement was followed by a footnote,
which states:
-1 6-
"One HP position is required to be a qualified full-time HP Technician.
The
other two positions may be filled by anyone on shift, with one of the two,
positions normally being filled by the on-shift CT."
The inspectors considered
the above position to be a further reduction in the training
requirements for the ERO HPTs.
The licensee had not yet implemented the reduced
requirements
and continued to maintain three HPTs on-shift (pending final resolutiop
of the issue with the NRC).
The licensee and NRC personnel
(including Region IV and NRR personnel)
participated
in a conference
call on March 3, 1997, to discuss the issues.
During the call, the
licensee described the minimum qualifications for the three on-shift HPTs.
The
~ licensee claimed that one HPT would be fully qualified, one would be a CT (with
radworker training and an additional course entitled "HP for CTs and the third HPT
would receive rad-worker training and a series of introductory HP courses.
0
Based'on the discussions
during the call, the NRC participants concluded that the
proposed training did not appear adequate
to prepare the non-HP qualified
'echnicians
for the ERO HPT positions for the following reasons:
The radworker training was an elementary course 'which was intended to
provide maintenance
workers with,sufficient skills to understand
the risks of
radiation, follow the directions contained
in RPWs, don anticontamination
garments,
understand
radiation area and contamination
area postings, obtain,
dosimetry; and perform'self-frisking activities utilizing the station portal
monitors.
However, the training was insufficient to perform the advanced
. tasks detailed in NUREG 0654.
'
The "HP for CT" lesson overview states,
in part:
"This lesson is not intended to qualify CT to perform HP duties.
Its
purpose
is to allow CT to perform self-monitoring functions while
obtaining, transporting,
and storing radioactive samples."
The introductory training for the third HP was not sufficient to perform HP:
functions at WNP-2.
For example,
a substantial amount of advanced
training
was required before an i'ndividual would be permitted to perform HP coverage
for repair, the fire brigade, search and rescue,
and first-aid.
~,
10 CFR 50.120, requires the licensee to establish
a training program, in part, for
HPTs.
The training program is required to incorporate the instructional
requirements
necessary
to ensure that th'e facility is operated
in a safe manner.
The licensee
had established
several tr'aining courses for HPTs that enabled
'them to accomplish the tasks specified in NUREG 0654.
(Note:
The training
was not developed to meet NUREG 0654 requirements
specifically.)
The
-17-
training proposed for non-HP qualified ERO HPT positions did not incorporate
this HPT task specific training.
As a result of the call, the NRC staff had significant concerns
related to the
implementation of the proposed
changes to the training requirements.
The licensee stated that PPM 1:3:7.b, "Emergency Maintenance," permitted the SM
to assign any individual the responsibility of providing HP coverage during a plant
emergency.
However, the inspector reviewed the procedure
and determined that
Step 5.1.6 of the procedure
requires the shift manager/control
room supervisor to
'nsure
HP coverage
is obtained,
as required."In addition, the licensee described that
the procedures
allowed shift managers to assign responsibilities
in emergencies.
The
NRC does permit licensee's to deviate from TS requirements
and other license
conditions in some emergency situations when deemed
necessary
(see
~
Nonetheless,
'the inspector considered
inappropriate,
and beyond
the intent of the 10 CFR 50,54(x), to use this provision as justification for reduced
qualifications.
The licensee continues to evaluate the HPT position training
requirements.
The inspectors will perform additional followup to-the noted concerns
as part of the
closure inspection for the previou'sly noted Notice of Violation.
Quality Assurance (QA) Performance:
The inspectors noted that a similar issue was
identified in Quality Department Surveillance Report 296-054, dated July 3, 1996.
This report identified discrepancies
between the EP, PPM 1.3;1, Revision 25, and
PPM 13.14.5, "Emergency Response
Organization and Training," Revision 17. The
report states,
in part, that PPM 1.3.1 required that three HPTs be on-shift, which
was inconsistent with the licensee's
plans for downsizing.
The report further stated
~ 'that the licensee took immediate corrective action to revise PPMs 1.3.1 and-13.1'4.5
to reduce the number of HPTs on shift to two. Acceptance of the change was based
on the licensee's
position that the on-shift CT.could act as one of the protective
actions HPTs.
The inspector considered
th'e performance of QA in this instance to be ineffective.
QA personnel
made no attempt to'verify that the CTs were properly trained for the
ERO HPT positions and assumed that proper trainin'g had occurred.
'Additionally, QA
did not ensure that the CTs were appropriately notified of their new responsibilities.
's noted previously, the licensee had failed to meet these requirements
of
'PM
13.14.5,
In summary, the QA personnel
did not critically challenge the position that the CTs
could perform the HPT duties.
Further, QA management.did
not provide support in
resolving the issue.
Further, QA personnel were distracted by a nontechnical matter
in the effective resolution of the issue.
0
c.
Conclusions
'-1 8-
One violation of the EP implementing procedures
was identified regarding the training
of on-shift HPTs.
When concerns were first raised by the licensee's
self-assessment
team, corrective measures
were not prompt and the on-shift HPT positions were not
appropriately staffed until 4 days later.
During a conference
call, the licensee. failed
to provide sufficient justification that training provided to nonqualified HPTs would be
sufficient to prepare them for the ERO HPT positions.
Additionally, a June 1996 QA
audit of the EP program was ineffective, in that issues concerning the number of
HPTs on shift were raised, but inappropriately resolved.
V. Mana ement Meetin s
X1
Exit Meeting Summary
The inspectors presented
the inspection results to members of licensee. management
after
the conclusion of the inspection'on March 19, 1997.
The licensee acknowledged
the
findings presented.
F
The inspectors asked the licensee whether any materials examined during the inspection
should be considered
proprietary.
No proprietary information was identified.
~
E
ATTACHMENT
Supplemental
Information
PARTIAL LIST OF PERSONS CONTACTED
Licensee
P. Bemis, Vice President for Nuclear Ope'rations
L. Fernandez,
Licensing Manager
M. Monopoli, Operations Manager
J.,Muth, Quality Support Supervisor
B. Pfitzer, Licensing Engineer
G. Reed, Corporate Emergency Preparedness
Safety'and
Health Officer
G. Smith, Plant General Manager
J. Swailes, Engineering Director
D. Swank, Regulatory Affairs Manager
R. Webring, Vice President Operations Support
'I
INSPECTION PROCEDURES USED
IP 37551:.
IP 61726:
IP 62703:
IP 71707:
IP 82701:
IP 92902:
Onsite, Engineering
Surveillance Observations
Maintenance
Observations
'Plant Operations
Followup - Maintenance
ITEMS OPENED AND CLOSED
~Oened
50-397/9703-01
50-397/9703-02
50-397/9703-03
50-397/9703-04
Three examples of TS 6.8.1 vrolations in Operations.
Three examples of TS 6.8.1 violations in Maintenance.
~ Inoperable RWCU isolation instruments
Failure to follow Emergency
Plan implementing procedures
Closed
50-397/9626-02'URI
Failure to adhere to DG3 surveillance procedure.
-2-
LIST OF ACRONYMS USED
gpm
HPT
IS.C
NRC
PER.
PSSM
~ 'TS
WNP-2
chemistry technician
diesel generator
equipment operator
emergency
plan
emergency
response
organization
Final Safety Analysis Report
gallons per minute
Health Physics
high pressure
health physics technician
heating ventilation and air conditionihg
instrument and controls
U.S. Nuclear Regulatory Commission
Office of Nuclear Reactor Regulation
postaccident sampling system
problem evaluation
request'lant
procedure
manual
production scheduling shift manager
Quality Assurance
reactor recirculation control
shift manager
standby service water
Technical Specification
unresolved
item
Washington Nuclear Project-2
violation