ML17333A838
| ML17333A838 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 03/27/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17333A835 | List: |
| References | |
| 50-315-97-02, 50-315-97-2, 50-316-97-02, 50-316-97-2, NUDOCS 9704040147 | |
| Download: ML17333A838 (38) | |
See also: IR 05000315/1997002
Text
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket Nos:
50-315, 50-316,
License Nos:
Report No:
50-31 5/97002; 50-31 6/97002
Licensee:
Indiana Michigan Power Company
Facility:
Donald C. Cook Nuclear Generating Plant
Location:
1 Cook Place
Bridgman, Mi 49106
Dates:
January 6, 1997 - February 15, 1997
Inspectors:
B. L. Bartlett, Senior Resident Inspector
B. J. Fuller, Resident Inspector
J. D. Maynen, Resident Inspector
Approved by:
Bruce L. Burgess. Chief
Reactor Projects Branch 6
9704040i47
970327
ADOCK 050003i5
8
Ex cuiv
mm r
D. C. Cook Units
1 and 2
NRC Inspection Report 50-315/97002, 50-316/97002
This inspection included aspects of licensee operations, maintenance,
engineering, and
plant support.
The report covers a 6-week period of resident inspection and includes the
follow-up to issues identified during previous inspection reports.
~r~in
The procedure revision process required the procedure writer to determine the
appropriate procedure review requirements for evaluating the acceptability of a
procedure change.
The procedure detailing the procedure review process contained
limited guidance to help the writer select one or more methods to ensure
a
procedure change was adequate.
The licensee's attempt to improve a procedure
resulted in an inadvertent entry into TS 3.0.3 when the procedure caused
a loss of
four loop injection capability.
IVI in
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Licensee repairs to 2-MRV-212 and 2-MRV-241 were completed as planneo.
The
licensee expended many hours of preplanning to ensure all aspects of the job were
considered
before entry into a time-limited LCO, and displayed a conservative
decision making philosophy.
The inspectors concluded that mechanical
maintenance
procedures
needed improvement regarding some aspects of
mechanical maintenance
procedure review and parts preparation (Section M1.2).
After an emergent oil leak the licensee's engineering organization identified that the
oil level in the Sl pumps was being maintained at too high a level. While this high
'evel did not adversely affect the operability of the pumps it did reveal a failure to
maintain levels as recommended
by the vendor technical manual.
A non-cited
violation was issued for the failure to have a procedure that adequately reflected
vendor recommendations
or to have an approved alternative level.
(Section M1.3)
The inspectors concluded that a complacent attitude about new fuel receipt existed.
Each group involved in the receipt process carried out tasks to complete the job,
without a team effort to ensure the job was done in accordance with requirements.
Command and control of the new fuel was not the responsibility of a team leader,
but was dispersed
among the workers performing the tasks.
Seven violations and
one deviation were identified during new fuel receipt in preparation for the Unit 1
refueling. (Section M4.1)
The licensee's self-assessment
organizations, including Quality Control, the
maintenance
workers, their supervisor, and the other work groups involved, failed
to identify the significant and pervasive problem with procedural adherence
and
quality.
(Section M4.1)
l
~En ini~rin
During new fuel receipt inspection the inspectors'observed
the reactor engineer
closely inspecting new fuel assemblies.
However, the reactor engineer was not
cognizant of maintenance workers, involved in new fuel receipt inspection, not
following their procedures.
While it was not a procedural requirement that monitor
the job performance of the other work groups it appeared that he was too
complacent.
(Section M4.1)
Pl
o
Routine observations were made by inspectors with no discrepancies
noted.
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Unit 1 main transformer temperature limitations forced operation of the Unit to be between
90 percent to 99 percent power during the inspection period.
Unit 2 entered the inspection period at full power.
On January 10, 1997, reactor power
was reduced to 70 percent as part of testing and repair of the dump valves to the steam
generator stop valves.
On February 7, 1997, power was reduced to approximately 55
percent power to perform repairs of the east main feedwater pump. At the end of the
inspection period the Unit was still at 55 percent holding for the repairs on the feedwater
pump.
1
01
Conduct of Operations
I.~rien
01.1
nrl
mmn
717
7
Using Inspection Procedure 71707, the inspectors conducted frequent reviews of
ongoing plant operations.
The conduct of operational activity that was observed
was generally good.
Specific events and noteworthy observations
are detailed in
the sections below.
03
Operations Procedures and Documentation
03.1
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On January 12, 1997, the safety injection (SI) pump discharge cross-tie valve was
closed before the residual heat removal (RHR) discharge cross-tie valve was opened
in accordance with procedure, ""01 OHP 4021.008.004,
"Adjusting the Level of
Accumulators," Revision 6. As a result, four loop injection requirements were not
met for approximately a one minute period.
The inspectors interviewed the
procedure writer and the procedure writer's supervisor.
In addition, the following
documents were reviewed:
Licensee Condition Report (CR) 97-0151
Licensee Event Report 50-315/95004-00,
"Technical Specification 3.0.3
Entered On Loss of Four Loop Injection Capability Due to Personnel
Error
during Performance of Surveillance"
Licensee Event Report 50-315/97001-00,
"Technical Specification 3.0.3
Entered On Los's of Four Loop Injection Capability Due to Incorrect
Procedural Guidance"
NRC ~nspection Report 50-315/316-95009
NRC Inspection Report 50-315/316-96004
Procedure ""01 OHP 4021.008.004,
"Adjusting the Level of
Accumulators," Revision 6
OPM.002, "Operations Department Procedure Review Manual"
i
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This was the first time Revision 6 of procedure ""01 OHP 4021.008.004,
"Adjusting the Level of Accumulators," was used.
The licensee had revised the
procedure to address operator concerns with filling accumulators with the Sl pump
discharge cross-tie valves open.
A good questioning attitude by the operators was
exhibited when they questioned the operability of the Sl pump during the filling of
the accumulators.
Pending a formal analysis, the licensee had considered the Sl
pump to be inoperable when using it to fillan accumulator.
Revision 6 also
changed the sequence
of valve manipulations used to fillaccumulators using a Sl
pump.
Changing the sequence
resulted in both Sl and RHR discharge cross-tie
valves being shut simultaneously,
a condition outside the design basis of the plant.,
The licensee made a one hour notification to the NRC on January 16, 1997 and
submitted Licensee Event Report 50-315/97001-00 to document this event.
Revisions to operations department procedures
are reviewed using the Operations
Department Procedure Review Manual, OPM.002.
According to this instruction,
the procedure writer was responsible for determining the review requirements,
but
at a minimum, the revision process required an administrative review. Also,
functional reviews were done for revisions of a technical nature.
The procedure
writer for Revision 6 chose both administrative
and functional reviews for
this'evision.
A qualified licensed operator performed the functional review of the
procedure, but the review failed to identify the sequencing
problem.
This failure
occurred even though the functional review checklist, asked "Is the sequence
of
actions correct?"
Licensee corrective actions included discussions with the procedure writers on the
importance of an adequate technical verification of procedures,
training on source
document requirements,
10 CFR 50.59 reviews and functional reviews.
In addition,
operator aids were placed on the control panels to provide guidance on Sl pump
and RHR pump discharge cross-tie valve controls.
C.
g~nl i<jinn,
Procedure OPM.002 contained limited guidance to help the writer determine the
appropriate method for review of a procedure.
Both the writer and procedure
reviewer were narrowly focused during their review to revision 6 to procedure ""01
OHP 4021.008.004.
The inspector's determined that the review process contained
the necessary
controls to adequately review procedure changes,
including having a
system engineer review the procedure or validating the procedure on the plant
simulator, but these methods were not used.
The licensee's attempt to improve a
procedure resulted in an inadvertent entry into TS 3.0.3 when the procedure caused
a loss of four loop injection capability.
This licensee-identified and corrected failure
to adequately review changes to procedures is being treated as a Non-Cited
Violation, (50-315/316-97002-09)
consistent with Section VII.B.1 of the NRC
08
Miscellaneous Operations Issues
08.1
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1
- 4 22- 2: Limiting Condition for Operation
(LCO) Management:
Entry into LCOs to perform maintenance activities was considered an unresolved
item pending further review by the NRC. The inspectors were concerned that the
licensee was entering LCOs to perform maintenance without adequate justification.
The licensee has begun tracking system performance and availability as required by
the NRC maintenance
rule.
Goals and limitations on equipment and system
availability were set by the licensee and tracked for performance.
Those goals and
availabilities, reviewed by the inspectors and by the NRC maintenance
rule
inspection team, were found to be reasonable
and within limits. A recent example
of good LCO management for maintenance
is discussed
below in Section M1.2.
This unresolved item is closed.
08.2
I
LER
0-
1
4-: Main Generator Trip on Main transformer Sudden
Overpressure
Due to Lightning Strike Causes Reactor Trip. At 0049 on September
21, 1996, a reactor trip occurred due to a turbine trip. The cause of the turbine
trip was a spurious main transformer sudden pressure
signal due to a lightning
strike. The plant responded to the trip as designed.
This event was discussed
in
detail in Inspection Report 50-315/316-96011.
The inspectors concluded that
operators responded
promptly and effectively to the unit trip and had no further
concerns.
This LER is closed.
08.3
I
ER
-
1
7
1- 0: Technical Specification 3.0.3 Entered On Loss of
Four Loop Injection Capability Due to Incorrect Procedural Guidance.
This LER is
discussed
in paragraph 03.1, above.
The LER was reviewed as part of inspector's
followup to the loss of four loop injection capability.
No new issues were revealed.
This LER is closed.
M1
Conduct of Maintenance
a.
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n
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The inspectors observed
all or part of the following maintenance
and surveillance
activities:.
C0038395Repair Water Leak on Inlet to. Oil Cooler on Unit 1 Turbine Driven
Auxiliary Feedwater Pump (TDAFWP)
C0039248Change
Oil/Replace Inboard Oiler Pipe Fitting on Unit 1 TDAFWP
C0038858Repair 2-MRV-212, Steam Generator
1 Stop Valve 2-MRV-210 Steam
Cylinder Train 'A'ump Valve
C0038948Repair 2-MRV-241, Steam Generator 4 Stop Valve 2-MRV-240 Steam
Cylinder Train 'B'ump Valve
R0010418Replace
ASCO Solenoid Valve 1-XSO-256, TDAFWP test valve control
solenoid
R006600502-OHP 4021.STP.051N
Revision 6, Unit 2 North Safety Injection Pump
Operability Test
R006600502-OHP 4021.008.007,
"Operation of the Safety Injection Pumps,"
Revision 0
!
!
R006600502-OHP 5030.001.001,
"Operations Plant Tours," Revision 8
R0056617Unit
1 East Motor Driven Auxiliary Feedwater Pump Essential Service
Water Suction Strainer Lubricate Chain Drive
R0056934Unit
1 East Motor Driven Auxiliary Feedwater Pump Change Oil and
Handpack Coupling
""12MHP4050.FDF.001Receipt
and Storage of New Fuel Assembly Shipping
Containers,
Revision 4
""12MHP4050.FDF.002Unloading
of New Fuel Assemblies from Shipping
Containers, Revision 6
""12MHP4050.FDF.005Handling of New Fuel Assemblies for Inspections and
Associated Work, Revision 3
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""12QHP4050.QC.001Recejpt,
Inspection, and Storage of New Fuel Assemblies
and Inserts, Revision 0
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Overall, observed maintenance was performed correctly, with few problems noted;
however, some maintenance activities observed resulted in significant NRC identified
issues.
Specifically, the receipt of new fuel assemblies was a work evolution poorly
handled by licensee personnel
~ The items identified by the inspectors revealed the
existence of fundamental weaknesses
in the licensee's maintenance
organization. (Section
M4.1) Other jobs reviewed by the inspectors revealed challenges to the maintenance
organization.
This included the repairs to 2-MRV-212 and 2-MRV-241 which received
extensive advanced
planning due to the complex nature of the conditions required to
complete the work. (Section M1.2) Additionally, during the Unit 2 North Safety Injection
Pump operability test, an oil leak on the pump outboard bearing resulted in remaining in an
LCO longer than planned. (Section M1.3)
M1.2
n-Lin
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V Iv
MRV-212
n
MRV-241
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On December 3 and 4, 1996, the licensee identified that two valves, 2-MRV-212, Steam
Generator
1 Stop Valve 2-MRV-210 Steam Cylinder Train 'A'ump Valve, and 2-MRV-
241, Steam Generator 4 Stop Valve 2-MRV-240 Steam Cylinder Train 'B'ump Valve,
had seat leakage.
On January 11, 1997, on-line repairs and testing of both valves were
completed.
The inspectors observed job planning and peiformed continuous observation
of maintenance activities including post maintenance testing.
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Significant preplanning was involved in this job before the work was allowed to begin, due
in part to a previous plant trip during on-line repairs to 2-MRV-241 and the attendant entry
into a very short duration limiting condition for operation (LCO). On-line repairs and testing
of valves 2-MRV-212 and 2-MRV-241 required two separate entries into the Technical
Specification (T.S.) action statement 3.7.1.5.
T.S. 3.7.1.5 required restoration of the
main steam stops within eight hours.
Additionally, if both 2-MRV-212 and 2-MRV-241
leaked excessively, then the plant would have been in an unanalyzed condition requiring
entry into TS 3.0.3.
However, pressure decay leak testing of both 2-MRV-212 and 2-
MRV-241 showed that both valves had less than 10 percent of the allowable leakage (200
gpm); therefore, the main steam stop valves were operable and the safety significance of
the leakage was small.
All work observed was done with the work package present and in active use.
The
inspectors observed continuous coverage by Mechanical and Instrumentation and Controls
(l&C) supervisors and the Main Steam system engineer.
As the work progressed,
a
number of discrepancies
were noted:
A peer inspector, performing a parts receipt inspection as required by the work
package, rejected a valve disc that had been receipt inspected before commencing
the job.
Rejection of the part showed good attentiveness to the inspector's duties.
However, the fact that this part was not thoroughly inspected until the workers
were at the job site on an LCO time-limited repair showed a lack of attention to
detail when preplanning this job.
~
A discrepancy was discovered between what parts were installed internal to the
valve and what the procedure drawing showed.
A "typical" valve configuration
was reflected on the drawing, not the valve as installed in this application.
This
procedure had been used for prior repairs of the dump valves, but the discrepancy
had not been identified. A revision to the procedure was required delaying
completion of the work by more than one hour.
The inspectors observed that the
licensee had started planning this LCO time-limited job at least three weeks prior to
commencement
but still did not do a thorough procedure review.
While reassembling
the actuator for 2-MRV-212 to the valve body, the sequence
of
limitswitch parts (jam nut, indicator disc, adjusting nut, limitswitch arm) on the
valve stem was questioned.
The mechanical maintenance
procedure did not
contain any reference drawing for the stack-up of these parts and inspection of the
throe adjacent actuators showed a different arrangement
on each installation.
Valve actuator reassembly was based on the memory of the ISC technician as to
the as found configuration.
A reference drawing was found after the actuator
reassembly and confirmed that the as left configuration was correct.
Actuator
configuration on 2-MRV-241 was changed to match the reference drawing during
maintenance
on that valve.
The licensee planned to reconfigure the actuators on
the other dump valves during later maintenance.
Repairs to 2-MRV-241 had few problems, and the only delays were due to
correcting material condition deficiencies identified during the procedure.
Correcting minor material condition deficiencies was within the work scope, and the
delays did not challenge the operators or maintenance staff. Condition Reports
were written to document these problems.
Shortly after the repair, 2-MRV-241 began leaking past the seat again.
The licensee
speculated that the leak may have started following cycling the valve for the post-
maintenance
operability surveillance. Valve 2-MRV-241 remained operable since the
leakage was determined to be less than the as found leakage by visual observation.
A
Condition Report was written to document the leak.
Licensee repairs to 2-MRV-212 and 2-MRV-241 were done as planned.
The licensee
expended many hours of preplanning to ensure all aspects of the job were considered prior
to entry into a time-limited LCO, and displayed a conservative decision making philosophy.
The inspectors observed that an area for improvement existed in some aspects of
mechanical maintenance
procedure review'and parts preparation.
M1.3
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172
On January 22, the inspectors observed the performance of Operations Procedure, 02-
OHP 4030.STP.051N,
"North Safety Injection Pump System Test," Revision 6, which was
performed following maintenance
on the pump.
During the surveillance test, the auxiliary
equipment operators (AEOs) noticed an oil leak on the outboard bearing of the Unit 2 North
Safety Injection (Sl) pump.
The inspectors followed up on the licensee's resolution of the
oil leak. The following documents were reviewed:
02-OHP 4021.008.007,
"Operation of the Safety Injection Pumps," Revision 0
02-OHP 4030.STP.051M, "Unit 2 North Safety Injection Pump Operability Test,"
Revision 6
02-OHP 5030.001.001,
"Operations Plant Tours," Revision 8
Condition Report 97-0218
Condition Report 97-0219
Pacific Pumps Vendor Technical Manual VTM-PACP-0002.
b.
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The inspectors attended the pre-job brief given by the reactor operator (RO) and observed
the AEOs perform the test.
The brief was thorough, and all operator responsibilities were
clearly defined.
The inspectors noted good operator self-checking and communications
during the test.
Operating Procedure 02-OHP 4030.STP.051N was in hand and in use
throughout the test, and the AEOs followed the procedure.
No problems were noted with
the performance of the surveillance test; however, while thb pump was running, the
operators noticed oil leaking past the outboard pump bearing and misting onto the splash
guard.
Due to the oil leak, the Unit Supervisor did not want to declare the pump operable
until Plant Engineering had assessed
the severity of the oil leak.
Operations Procedure
(OHP) 5030.001.001,
"Operations Plant Tours," required, in part,
that the operators check running equipment oil system sump level for a minimum level of
one-quarter of the range of the sight glass and a maximum level within the indicating range
of the sight glass.
The oil level in the Unit 2 North Sl pump was approximately seven-
eighths of the range of the sight glass, or about one inch below the top of the sump, while
the pump was running.
The idle level was higher, but still within the indicating range of
the sight glass; therefore, the operators signed off the test procedure showing that the oil
level of the Sl pump was within the normal operating range.
10
The licensee's engineering staff evaluated the oil leak and determined that it was too large
to declare the pump operable.
Emergent maintenance was done on the outboard pump"
bearing to clean the oil vent and drain lines, replace the bearing housing gasket, and RTV
the bearing housing.
The subsequent
operability test of the Unit 2 North SI pump again
resulted in oil leaking along the shaft through the labyrinth seal.
Further evaluation pointed to excessive
oil level in the oil reservoir as the cause of the leak.
The Pacific Pumps Vendor Technical Manual, VTM-PACP-0002, showed normal Sl pump
oil level as 3.5 inches below the top of the reservoir and the maximum oil level as 2.5
inches below the top of the reservoir; however, the "as found" oil level was approximately
one inch below the top of the reservoir.
The oil level was drained to within the vendor
technical manual limits, and the operability test was run again.
The Unit 2 North Sl pump
passed the operability test, and no oil leakage was evident.
The pump was declared
operable at on January 23, 1997.
Oil levels in the Unit 2 South SI pump oil reservoir and both'of the Unit 1 Sl pump oil
reservoirs were found to be above the vendor technical manual limits, so those oil
reservoirs were also drained.
The safety significance of this event was small because the
pumps would have remained operable if required.
The licensee's analysis showed that the
oil leak would continue until the level drained to within the vendor manual limits and then
stopped.
Operator aids were attached to the oil reservoirs on all four Sl pumps indicating the
acceptable vendor manual band for oil level. Additionally, the licensee planned to review
the vendor technical manuals for all other safety-related pumps and place operator aids on
all safety-related pumps to show what level range was acceptable for oil level.
C.
After an emergent oil leak the licensee's engineering organization identified that the oil
level in the Sl pumps was being maintained at too high a level. While this high level did
not adversely affect the operability of the pumps it did reveal a failure to maintain levels as
recommended
by the vendor technical manual
~ The failure to have a procedure that
adequately controlled Safety Injection pump oil level constituted
a violation of minor
significance and is being treated as a'Non-Cited Violation, (50-315/316-97002-10)
consistent with Section IV of the NRC Enforcement Policy.
M4
Maintenance Staff Knowledge and Performance
M41 NwF
IR
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a.
Licensee preparation for the planned Unit 1 refueling outage was observed by the
inspectors.
This inspection primarily focused on the control of and movement of new fuel
during receipt inspection.
Receipt, storage and handling of the new fuel were safely
performed, but failures to meet NRC requirements and a lack of ownership over new fuel
were noted by the inspectors.
The following documents were reviewed:
11
""12MHP4050.FDF.001Receipt
and Storage of New Fuel Assembly Shipping
Containers
'"12MHP4050.FDF.002Unloading
of New Fuel Assemblies from Shipping
Containers
""12MHP4050.FDF.005Handling of New Fuel Assemblies for Inspections and
Associated Work
""12QHP4050.QC.001Receipt,
Inspection, and Storage of New Fuel Assemblies
and Inserts
ANSI B30.9-1971Slings
PMI-2011Procedure
Use and Adherence
MHI-4053Control of Heavy Loads
Regulatory Guide (RG) 1.33Quality Assurance Program Requirements
(Operation)
b.
I n
During routine inspection activities, the residents identified programmatic problems
concerning the licensee's receipt of new fuel assemblies,
including:
,procedural adherence,
maintenance of procedures,
command and control of new fuel receipt activities,
foreign material exclusion control, and
self assessment
of the new fuel receipt program.
1.
Procedural Adherence
Plant Manager's Instruction (PMI)-2011, Procedure
Use and Adherence, required that "in-
hand" procedures
(designated
by "" in the procedure number) to be at the job site, and in
use.
~
The inspectors identified that on January 28, 1997 the procedures for unloading
shipping containers from the truck (Procedure ""12MHP4050.FDF.001, "Receipt
and Storage of New Fuel Shipping Containers" ) and for unloading assemblies
from
the shipping containers (Procedure ""12MHP4050.FDF.002, "Unloading of New
Fuel Assemblies From Shipping Containers" ) were not being used "in-hand" for the
performance of the work.
In fact, the procedures were located outside the foreign
material exclusion zone (FMEZ) and were not being referenced.
12
Plant Manager's Instruction (PMI) 2011, "Procedure Use and Adherence," required that,
unless the procedure specifically allowed a different sequence,
procedure performance
shall be:
e
Read the step,
Perform the steo,
Document completion of the step,
Proceed to the next step.
On January 28, 1997, the inspectors identified that the unloading of new fuel
shipping containers was not performed in a step by step manner.
Procedure
"'12MHP4050.FDF.001, Receipt and Storage of New Fuel Shipping
Containers,'tep
6.7 attached rigging to the shipping container before lifting. Step 6.12
,established
a work loop back to step 6.8 to liftanother container. Step 6.8 did not
attach rigging, only a tag line. The procedure was not worked in a step by step
manner as required by PMI-2011.
On January 28, 1997, the inspectors also identified that work was not performed in
a step by step manner for unloading new fuel. The work was being done in parallel
on three shipping containers, by breaking procedure ""12MHP4050.FDF.002 into
loops of steps:
remove container cover for three containers,
position lock tubes for three containers,
upright support frames for three containers,
remove assemblies from support frames for three containers.
The loops of steps were not specified by the procedure.
No allowance existed in the
procedures for parallel operations on more than one container.
The procedure was not
worked in a step by step manner as required by PMI-2011.
After procedure adherence
problems were pointed out by the NRC, the licensee
identified a procedure sequence
error on January 28, 1997.
Procedure
""12MHP4050.FDF.005, Handling of New Fuel Assemblies for Inspections and
Associated Work, step 6.17, required replacement of the NFSV plug after storage
of a new fuel assembly.
Before identifying the error, on January 25, 1997, the
licensee had performed ""12MHP4050.FDF.005 for twelve fuel assemblies without
replacing the floor plug in the new fuel storage vault after seating each fuel
assembly as required by the procedure.
The procedure was not worked in a step
by step manner as required by PMI-2011.
13
pt
0
,'P
II
1
Maintenance Head Instruction (MHI) 4053, "Control of Heavy Loads," requires in Section
3.6, that guidelines set forth in ANSI B30.9-1971, Slings, be followed. ANSI B30,9-1971,
Slings, Section 9-1.9, Safe Operating Practices, step 9-1.9.1b requires that the sling shall
have suitable characteristics
and rated capacity for the load and environment.
The inspectors identified that on February 3, 1997, the licensee lifted a load of
approximately 6,325 pounds using a lifting sling rated at only 6,000 pounds.
This
lifting sling was designated
as the tool to be used for this operation.
The date of
designation could not be recalled by the licensee, but was believed to have been
many years ago.
The licensee did not follow the requirements of MHI-4053 for
sizing slings.
Several violations of NRC requirements were identified in procedure use and adherence.
The failure to use the ""12MHP4050.FDF.001, "Receipt and Storage of New Fuel
Assembly Shipping Containers," and ""12MHP4050.FDF.002, "Unloading of New Fuel
Assemblies from Shipping Containers," in-hand were two examples of a violation of PMI-
2011 (50-315/97002-01a,b
(DRP)). Three examples of a violation of PMI-2011 were
identified in that ""12MHP4050.FDF.001, ""12MHP4050.FDF.002, and
""12MHP4050.FDF.005, "Handling of New Fuel Assembiies for Inspections and
Associated Work," were not followed step-by -.'.ep (50-315/97002-02a,b,c
(DRP)). A
violation of Maintenance Head Instruction 4053, "Control of Heavy Loads," was identified
for using an improperly rated sling (50-315/97002-03
(DRP)).
2.
Maintenance of Procedures
The inspectors identified that previous review and use of the new fuel receipt procedures
had not identified deficiencies with the procedures.
These procedures
had been used since
1991 with only minor changes in 1996. After the lack of procedural adherence was
pointed out by the inspectors, the licensee identified that procedure
""12MHP4050.FDF.005 would not work as written.
Changes to ""12MHP4050.FDF.002 were required to allow parallel operations on three
shipping containers after a lack of such instructions was identified by the inspectors.
This
parallel mode had been the licensee's method of unloading for many years.
Similar
changes were required in ""12MHP4050.FDF.001 to correct sequencing
errors.
Many additional changes to the procedures were made to correct work sequencing,
practices, command
and control issues and rigging problems which were identified on
January 28 and February 3, 1997.
Some changes were licensee initiated enhancements
after the initial problems were identified by the NRC.
~
""12MHP4050.FDF.001 two change sheets since January 28, 1997
~
""12MHP4050.FDF.002 five change sheets since January 28, 1997
~
""12MHP4050.FDF.005 four change sheets since January 28, 1997
14
0
MHI-4053 Control of Heavy Loads, step 3.2.2 stated in part, "No load greater than 5 tons
should be traveled at a height greater than 7 feet above the floor except when clearing
obstacles
or installing or removing equipment from its storage location." This procedure
was inadequate
in that it did not fully implement a licensee commitment documented
in
AEP:NRC:0514F which stated, "Allloads of five tons or less listed in Table 2.1.3.C.1 of
our letter No. AEP:NRC:0514C will be moved as close to the floor as practical, but in no
case higher than 7 feet above the floor." On February 3, 1997, the inspectors observed
three new fuel shipping containers, each weighing approximately 4 tons, moved at a
height greater than 7 feet above the 650'evel floor.
The new fuel handling procedures were inadequate
in that they had errors in work step
sequencing;
lacked foreign material exclusion practices; and contained no detail on rigging
requirements and control of heavy loads requirements.
50-315/97002-06(DRP).
MHI-,
4053 step 3.2.2 constituted
a deviation from an NRC commitment. 50-315/97002-
08(DRP)
3.
Command and Control of New Fuel Receipt
While pursuing the issue of procedural adherence,
the inspectors interviewed the Reactor
Engineering representative.
The reactor engineer told the inspector that the procedure in
question (" "12MHP4050.FDF.002) was not an "in-hard" procedure, so it did not need to
be used step by step.
After the inspectors pointed out that it was an "in-<<~nd" procedure,
the inspectors were referred to the first line maintenance
supervisor, as it was a
maintenance
procedure that was in question.
The reactor engineer did not get involved in
resolving the issue, even though it concerned the handling of fuel.
The first line maintenance
supervisor also informed the inspector that the procedure was
not required to be used step by step and that it was there as a reference for the
mechanics.
The supervisor added that the procedure would be impossible to work in a
step by step fashion as written and that the mechanics were handling the fuel in
accordance with longstanding licensee practice.
The mechanical supervisor had been
observing the new fuel receipt, but not actively directing the sequence;
however, the work
appeared to be performed safely.
The inspectors then contacted the Maintenance
Mechanical Production Supervisor who agreed that the procedure was intended for "in-
hand" use.
The new fuel receipt was stopped until the maintenance
personnel were
briefed on procedure adherence.
The inspectors questioned
licensee management
team about the position designated
as
"Fuel Handling Supervisor".
The licensee's consensus
was that clear delineation of
responsibility during fuel handling was not evident. After meeting to discuss the
inspectors'oncerns,
licensee management
formally designated the maintenance
supervisor assigned for new fuel receipt as the Fuel Handling Supervisor and revised the
procedures to reflect the designation.
No violations of NRC requirements were identified; however, the inspectors noted that
command and control of the new fuel receipt was not established.
15
t
4.
Foreign Material Exclusion (FME) Control
The inspectors identified a significant amount of small pieces of foreign material around
the opening of the new fuel storage vault (NFSV) on the ledge where the plug had been
removed.
This debris was identified after the insertion of one fuel assembly into the vault,
The NFSV opening was within an established foreign material exclusion zone (FMEZ).
Specific findings are detailed below:
Plant Manager's Procedure,
12 PMP 2220.001.001,
required that if the work evaluation results in an FMEZ designation of FMEZ-1 or
FMEZ-2,'then the work group supervisor shall complete a Foreign Material Exclusion
Requirement/Work Practices Determination, Attachment 2, to determine appropriate
FME requirements, work practices, and post-job inspections.
Additionally, the
procedure required that a copy of the completed Attachment 2 should be included
in the work package and should be used in the pre-job brief. However, Attachment
2 to 12 PMP 2220.001.001
was not completed for work performed in an FMEZ on
January 28, 1997, was not included in the work package,
and was not used in the
pre-job brief, although the supervisor stated that he covered FME practices in the
brief.
Procedure
12 PMP 2220.001.001
also required that while working within the
FMEZ,
clean-as-you-go" work practice shall be maintained to minimize the,
potential for introduction of foreign material into any equipment or system.
Licensee personnel failed to comply with the requirements regarding maintaining
cleanliness of new fuel.
Plant Manager's Instruction 2220, "Foreign Material Exclusion," Step 6.2 assigns
responsibility to the line supervisor for monitoring work and ensuring FME controls
are adequate
and being carried out. The mechanical supervisor assigned
responsibility for this job activity did not monitor the work and failed to recognize
that inspection and "clean-as-you-go" work practices were not implemented.
This
allowed foreign material to exist on the ledge, with the potential to enter the NFSV
with new fuel stored inside.
Procedure
""12MHP4050,FDF.005, "Handling of New Fuel Assemblies for
Inspections and Associated Work," which removed the plug from the vault,
contained no instructions to inspect and clean the opening of the vault.
Two violations of procedure 12 PMP 2220.001.001
were identified by the NRC inspectors
during the new fuel receipt.
First, Attachment 2, "Foreign Material Exclusion
Requirement/Work Practices Determination," was not completed and used in the pre-job
brief. (50-315/97002-07(DRP)).
Second, the "clean-as-you-go" work practices were not
used to prevent foreign material from entering the NFSV (50-315/97002-05
(DRP)).
One
violation of PMI 2220 was identified in that the mechanical supervisor assigned the
responsibility for monitoring the work did not ensure that the "clean-as-you-go"work
practices were implemented (50-315/97002-04
(DRP)).
Finally a violation of 10 CFR 50
Appendix B, Criterion V, "Instructions, Procedures,
and Drawings," was identified in that
procedure ""12MHP4050.FDF.005, "Handling of New Fuel Assemblies for Inspections and
Associated Work," contained no instructions to inspect and clean the opening of the vault
(50-31 5/97002-06(DRP))
~
5.
Self Assessments
of the Program
Plant Performance Assurance
(QC) personnel were tasked with performing new fuel
inspections and were present during all work periods where NRC inspectors identified
concerns with the licensee's performance.
QC personnel did not develop any independent
findings concerning the evolutions cited above.
Reactor Engineering and Maintenance
Mechanical personnel present at the job site or involved with the project also failed to
identify problems associated with new fuel receipt.
The inspectors also reviewed the licensee's response to NRC Bulletin 96-02, "Movement
of Heavy Loads Over Spent Fuel, Over Fuel In The Reactor Core, Or Over Safety-Related
Equipment."
Bulletin 96-02 requested the licensee to review plans and capabilities for the
handling of heavy loads.
The licensee's responded
on May 10, 1996, (AEP:NRC:0514Z)
and committed to initiate a self assessment
of their commitments to NUREG 0612.
The
licensee completed the self assessment
on December 27, 1996 (licensee report number
ENSP-96-01).
Guideline number 5, item number 3 of the licensee's assessment
plan
looked specifically at the commitment regarding 5 <on loads being handled as close to the
floor as possible.
Unfortunately, the licensee's assessment
plan did not verify the
commitment but instead venfied the same inadequate
procedural requirements that had
been included in the maintenance
procedures.
Specifically, the assessment
plan verified
that loads greater than 5 tons would be handled as close to the floor as possible and failed
to verify that loads less than 5 ton would not be handled at heights greater than 7 feet.
One deviation (50-315/316-97002-08
(DRP)) to a commitment was identified. On
February 3, 1997, the inspectors identified that the licensee moved new fuel shipping
containers, containing new fuel assemblies,
and weighing approximately four tons, higher
than 7 feet above the floor'when moving the containers to a location to be unloaded.
c.
g~nl i~in~;
The inspectors identified a total of seven violations and one deviation during new fuel
receipt handling and inspection.
The inspectors identified numerous examples of failure to
use fuel handling procedures in-hand, failure to follow procedures step by step, failure to
follow foreign material exclusion procedures,
failure to comply with requirements
and
commitments in weight handling procedures,
and numerous examples of inadequate
procedures.
The inspectors concluded that a complacent attitude about new fuel receipt existed.
The
job was considered routine, and as a result little effort had gone into identifying problems
or preparing for the job. Additionally, each group involved in the receipt process carried
out tasks to complete the job, without a team effort to ensure the job was done in
accordance with requirements.
Command and control of the new fuel was not the
responsibility of a team leader, but was dispersed among the workers performing the
tasks.
17
4
0
I
0
IVIS
MIscellaneous Maintenance Issues
M8.1
I
Vi
I
i n
1
14-
2
- 2: Unit 1 West CCP inoperable due to
a miscalibrated overcurrent relay and Unit 1 East CCP inoperable for planned
maintenance.
This was one of three violations issued as part of EA 96-020.
Violation 315/95014-01
was closed in Inspection Report 50-315/316-96010.
This
violation was a consequence
of the CCP being inoperable for an extended period
due to the relay being out of calibration.
This violation will be addressed
as a part
of the closeout of violation 315/95014-03 discussed
below. This violation is
closed.
M82
I
Vi
I
1
-
E -: Calibration procedure inappropriate
to the circumstance for an overcurrent relay to the Unit 1 West CCP.
This was one
of three violations issued as part of EA 96-020.
Violation 315/95014-01
was
closed in Inspection Report 50-315/316/96010.
A miscalibrated overcurrent relay
would have rendered the 1W CCP inoperable during a loss of coolant accident.
The
cause of the miscalibrated relay was inexperienced
IRC technicians using a
procedure with an inadequate amount of d'etail.
The NRC inspectors interviewed personnel, reviewed procedures,
evaluated relay and test
equipment, reviewed licensee corrective actions, and verified Implementation of selected
portions of the corrective actions.
The NRC inspectors agreed with the licensee's root
cause analysis that a combination of inexperienced technicians and a weak calibration
procedure lead to the miscalibration of the relay.
In addition, a weak review of the
completed data failed to identify the miscalibrated relay immediately following the
surveillance.
Licensee corrective actions included:
Recalibrating the 1W CCP relay and testing 14 other safety related relays that had
not been operated under the most limiting conditions.
Retraining all lhC technicians on the correct calibration techniques,
as well as
enhancing the relay training program.
Enhancing the relay calibration procedure to add detail on the calibration of the
relay.
The procedure was also modified to add the requirement to record as found
data.
This data was to be used to help trend the reliability of the relays.
Additional training on reporting requirements of 10 CFR Part 50.72 was given to
Nuclear Safety, Licensing, and Fuel Division personnel to address the initial delay in
reporting this issue.
In response to a specific NRC request the licensee also evaluated the potential of
other maintenance activities being conducted, using technicians who had not
maintained their proficiency by requalification training, or on the job performance of
specialized procedures.
The licensee's evaluation determined that this event was
an isolated occurrence.
The NRC inspectors reviewed other procedures,
observed
18
4f
l
technicians performing the other procedures and did not identify any other
examples.
As stated above, all of the corrective actions listed above were sampled by the NRC
inspectors to ensure that the corrective had been implemented.
This violation is closed.
M8.3
I
i
F
II w-
I
m
1
-
24- 2: Review of future core
inspections to assess
effectiveness of the licensee actions to prevent foreign
material intrusion in the core.
During a previous inspection (IR 315/316-
95010(DRP), the inspectors had identified numerous examples of poor FME control
around the fuel handling areas (e.g., spent fuel pool, reactor vessel, refueling
cavity, etc.).
During previous inspection periods the licensee was noted to be
making improvements in the control of foreign material around fuel handling areas.
However, as noted in section M4.1, above, the licensee still has improvement items
to implement.
This inspection follow-up item is still open.
M8.4
I
LER
-
1 -: Reactor Protection System Actuation Results from
Personnel
Error During Calibration of Intermediate Range Nuclear Instrumentation.
On September 26, 1996, a reactor trip signal was generated
by Instrumentation
and Controls technicians when intermediato r~nge nuclear instrument power fuses
were removed without the Level Trip switcn being placed in the bypass position.
The reactor was shutdown in Mode 5 at the time of this event, and no actual
control rod movement occurred.
This event was the subject of a non-cited
violation'n
Inspection Report 50-315/316-96011,
and the inspectors had no further
concerns.
This LER is closed.
III
~Ein(~i
E1
Conduct of Engineering
During the resident inspection activities, routine observations were conducted in the areas
of engineering using Inspection Procedure 37551.
No discrepancies
were noted.
Engineering involvement in the auxiliary feedwater pump oiler issues discussed
in Section
M1.2 was noted to be prompt, thorough, and timely.
IVliscellaneous Engineering Issues
E8.1
r
Iv
I
m
-
1
1
-
7-: Operability of the essential
"
service water system (ESW) with inoperable pump discharge strainers (both units).
Pending additional information from the licensee the issue of whether the ESW
pump discharge strainers were required to be operable in order to support the
operability of the ESW system remained an unresolved item. The licensee supplied
the inspectors with the additional information but the information did add any
substantive data to the issue.
This unresolved item will remain open pending the
response to a task interface agreement
being sent to the office of NRR.
19
0
t
R1
Radiological Protection and Chemistry Controls (71750)
During the resident inspection activities, routine observations were conducted in the areas
of radiological protection and chemistry controls using Inspection Procedure 71750.
No
discrepancies
were noted.
S1
Conduct of Security and Safeguards Activities (71750)
During normal resident inspection activities, routine observations were conducted in the
areas of security and safeguards activities using Inspection Procedure 71750.
No
discrepancies
were noted.
F1
Control of Fire Protection Activities (71760)
During normal resident inspection activities, routine observations were conducted in the
area of fire protection activities using Inspection Procerlure 71750.
No discrepancies
were
noted.
X1
Exit Meeting
The inspectors presented the inspection results to members of the licensee management at
the conclusion of the inspection on February 14, 1997.
The licensee acknowledged the
findings presented.
20
i
PARTIALLIST OF PERSONS CONTACTED
~LI
n~~
¹J. Allard, Maintenance Superintendent
¹M. Ackerman, Manager Nuclear Licensing
¹R. Anderson,
¹G. Arent, Operations Procedure Supervisor
¹P. Barrett, Director Performance Assurance
¹A. Blind, Site Vice President
¹K. Baker, Manager Production Engineering
¹J. Kobyra, Manager Nuclear Engineering
¹M. Finissi, Supervisor Electrical Systems
M. Horvath, Plant Performance Assurance
¹D. Hafer, Manager Plant Engineering
¹S. Hodge, Manager Work Control
¹D. Rice, Mechanical Maintenance Supervisor
¹P. Leonard, Outage Management Team
¹A. Lotfi, Performance
Engineer
¹P. McCarty, Maintenance Procedures
¹D. Morey, Chemistry Superintendent
¹J. Moran, Plant Engineering
¹D. Noble, Radiation Protection Superintendent
¹T. Postlewait, Site Engineering Support Manage
¹D. Rodriguez, Maintenance
¹P. Russell, Plant Protection Superintendent
¹J. Sampson,
Plant Manager
¹P. Schoepf, Manager Safety-Related Systems
¹M. Schwartzwalder, Plant Engineering
¹D. Seipel, Ops Training
¹L. Smart, Nuclear Licensing
¹M. Stark, Supervisor Performance Testing
¹T. Quaka, Supervisor Project Management and
¹G. Tollas, Acting Operations Superintendent
¹J. Wiebe, Manager Engineering and Analysis
¹L. Van Ginhoven, Materials Management Dept.
¹A. Verteramo, Supervisor
Reactor Engineering
¹T. Walsh, Maintenance
¹S. Wolf, Performance Assurance
¹W. Zemo, Supervisor Preventive Maintenance
Installation Services
¹Denotes those present at the February 14, 1997 exit meeting.
21
INSPECTION PROCEDURES USED
IP 375510n-site Engineering
IP 61726Surveillance
Observations
IP 62703Maintenance
Observation
IP 71707Plant Operations
IP 71750Plant Support Activities
IP 60705Refueling Activities
ITEMS OPENED and CLOSED
Qggi~n
50-315/97002-01(DRP)VIOFailure to use procedures
in hand
50-315/97002-02(DRP)VIOFailure to follow procedures step by step
50-315/97002-03(DRP)VIOFailure to follow procedure (undersized sling)
50-315/97002-04(DRP)VIOFailure to follow pr;educe (supervisor monitoring of FMEZ)
50-315/97002-05(DRP)VIOFailure to follow procedure
(FMEZ work practices)
50-315/97002-06(DRP)VIOInadequate
procedures
(Step sequence,
FMEZ practices, rigging
requirements)
50-315/97002-07(DRP)VIOFailure to follow procedure
(FME briefings)
50-315/97002-08(DRP)DEVLifting heavy loads higher than 7 feet
50-315/97002-09(DRP)NCVFailure
to adequately review changes to operations procedures
50-315/316-97002-10(DRP)NCVFailure
to have a proceoure that adequately controlled
Safety Injection pump oil level
Ghmk
50-315/97002-09(DRP)NCVFailure
to adequately review changes to operations procedures
50-315/316-97002-10(DRP)NCVFailure
to have a procedure that adequately controlled
Safety Injection pump oil level
50-315/316-94022-02(DRP)URILimiting Condition for Operation Management:
50-315/97-001(DRP)LERTechnical
Specification 3.0.3 Entered On Loss of Four Loop
Injection Capability Due to Incorrect Procedural Guidance.
22
50-315/96-004(DRP)LERIVlain Generator Trip on Main transformer Sudden Overpressure
Due to Lightning Strike Causes Reactor Trip.
50-315/95014-02(DRP)NOVUnit
1 West CCP inoperable due to a miscalibrated
overcurrent relay and Unit 1 East CCP inoperable for planned maintenance.
50-315/95014-03(DRP)
NOVCalibration procedure inappropriate to the circumstance for
an overcurrent relay to the Unit 1 West CCP.
50-315/96-005(DRP)LERReactor
Protection System Actuation Results from Personnel
Error
During Calibration of Intermediate Range Nuclear Instrumentation
50-315/316-94024-02(DRP)IFIReview
of future core inspections to assess
effectiveness
of the licensee actions to prevent foreign material intrusion in the core.
50-315/316-96007-03(DRP)URIOperability
of the essential service water system with
inoperable pump discharge strainers.
23
List of Acronyms
AEO
CFR
CR
FMEZ
LCO
LER
NFSV
NRC
OHP
PMI
TS
VTM
Auxiliary Equipment Operator
Centrifugal Charging Pump
Code of Federal Regulations
Condition Report
Diesel Generator
Division of Reactor Projects
Enforcement Action
Essential Service Water System
Foreign Material Exclusion Zone
Heating, Ventilation, and.Air Conditioning
Instrumentation and Controls
Large Break Loss of Coolant Accident
Limiting Condition for Operation
Licensee Event Report
Maintenance Head Instruction
Motor Driven Auxiliary Feedwater Pump
New Fuel Storage Vault
Nuclear Regulatory Commission
Operations Head Procedure
Operations Department Procedure Review Manual,
Plant Manager's Instruction
Plant Manager's Procedure
Process Computer Room
Public Document Room
Quality Control
Regulatory Guide
Safety Injection
Technical Specification
Vendor Technical Manual
24
t