ML19354D730

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Maint Team Insp Rept 50-458/89-04 on 890918-1017. Violations Noted.Major Areas Inspected:Maint Programs & Performance of Maint Activities,Including Maint & Mgt Support & Overall Plant Performance
ML19354D730
Person / Time
Site: River Bend Entergy icon.png
Issue date: 12/05/1989
From: Cummins J, Gagliardo J
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML19354D726 List:
References
50-458-89-04, 50-458-89-4, NUDOCS 9001020084
Download: ML19354D730 (50)


See also: IR 05000458/1989004

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APPENDIX B

U.S. NVCLEAR REGULATORY COMMISSION

REGION IV

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NRC Inspection Report:

50-458/89-04

Operating License: HPF-47

Docket: 50-458

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Licensee: Gulf States Utilities Company

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P.O. Box 220

St. Francisville, Louisiana 70775

Facility Name: . River Bend Station

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Inspection At: River Bend Station, St. Francisville, Louisiana 70775

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Inspection Conducted: September 18 through October 17, 1989

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Inspectors; m

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. Cummins, Team Leader

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, Reactor Inspector, Operational Programs

Section, Division of Reactor Safety

Team Members:

C. J. Hale, Senior Quality Systems Engineer, Material and Quality

Programs Section, Division of Reactor Safety

W. B. Jones, Resident Inspector, Project Section C, Division of

Reactor Projects

D. L. Kelley, Reactor Inspector, Test Programs Section, Division

of Reactor Safety

T. O. McKernon, Reactor Inspector, Operational Programs Section,

Division of Reactor Safety

F. M. McManus, Consultant

L. T. Ricketson, Health Physics Inspector, facilities Radiological

Protection Section, Division of Radiation Safety and Safeguards

D. H. Schultz, Consultant

R. B. Vickr y, Reactor Inspector, Operational Programs Section,

Di isio of Reactor Safety

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Approved:

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J.iE. Gag Vardo, Chief, Operational Programs

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Section, Division of Reactor Safety, Region IV

Inspection Summary: Special, announced maintenance team inspection conducted

September 18 through October 17, 1989 (Report 50-458/89-04),

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Areas-Incpected: A Nuclear Regulatory Commission (NRC) team inspected

maintenance programs and the performance of maintenance activities

(safety-related and balance of plant), including overall plant performance

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related to maintenance and management support and implementation of

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maintenance. The inspectors used the NRC Maintenance Inspection Guidance,

dated September 1988, and Terporary Instruction 2515/97, dated November 3,

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1988.

Results: The-inspectors concluded that the licensee's maintenance process

consisted of generally well-developed programs with an appropriate level of

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management involvement so that the process functioned to maintain plant

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components available to perform their intended function.

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inspectorsidentifiedanapparentviolation(threeinstancesofafailureto

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follow procedure as discussed in Section 3.1.3) and observed that certain

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clements in the_ licensee's programs and implementation could be strengthened,

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- The following unresolved items were identified and are discussed in this

report: .

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ower oscillations associated with flow control valve

Uncontrolledp(Section2.3.3),and

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Required documentation not available to justify Valve IE12*MOVF024A torque

switchsettingsbelowminimumvalue(Section3.1.3).

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EXECUTIVE SUl W RY

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. A team of Nuclear Rcgulatory Commission (NRC). staff conducted a

performance-based inspection of the maintenance process at River Bend Station

from September 18 through October 17, 1989. The purpose of.this inspection was

to determine whether components, systems, and structures at the River Bend

Station were adequately maintained so that they will perform their intended

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function when required.

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The inspection was conducted in accordance with the guidance provided in

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Temporary Instruction (TI) 2515/97, 'Taintenance Inspection," dated November 3,

1988.

In accordance with the guidance in TI 2515/97, the team color-coded a

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" maintenance inspection tree" that identified for inspection the major elements

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associated with effective maintenance. The tree was used as a visual aid

during the exit meeting to depict the results of the inspection.

The inspectors. evaluated three major areas:

(1)overallplantperformenceas

affected by maintenance, (2) management support of maintenance, and (3)

maintenance implementation.

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The inspectors concluded that River Bend Station had developed a maintenance

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program that implemented the significant attributes of en effective maintenance

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process. However, the team identified the following strengths and weaknesses

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that are documented in the report and were discussed with the licensee during

the exit meeting:

STRENGTHS

'Gooddedicatedmaintenancestaffthatitorkedasateemwithwelldefined

areas of responsibility.

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Strong management' involvement in all phases of the maintenance process

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including corporate managers and supervisors at the work site.

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Communications between corporate and plant management and between

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maintenance organizations onsite was generally good.

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Good effective scheduling of maintenance activities including the

coordination of other activities which could be impacted (i.e.,

surveillancetesting).

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Adequate, well implemented maintenance programs and other programs that

interface with or support maintenance.

Craft personnel were generally skilled, knowledgeable, and competent and

documented maintenance activities well.

Outstanding maintenance facilities.

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Good quality centrol planning and involvement in maintenance activities.

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A strong maintenance enhancement program, which even though it was not

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formalized, appeared to be an enhancement to the overall maintenance

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process.

WEAKNESSES

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Craft not performing all the steps in the maintenance work orders and

marking the steps.not applicable without eny documented justification.

Identified cases in which potential problems were documented in

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naintenance work orders, but no paper trail was provided to ensure that

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the problems were addressed or-corrected.

Two instances in which documentation did not accurately reflect what had

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actually occurred.

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Apparent use of the circuit testing, lifted leads, and jumpers procedure

to isolate equipment in lieu of the protective tagging procedure, which

gave.the >otential of changing component or system status in the field

without t1e control room being knowledgeable of the change.

Inappropriate control of contracted maintenance activities in the field

and review of their completed work packages.

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Personnel entering the radiologically controlled area through entries

other than.the control point, which did not ensure that the control of

radiologically controlled area was maintained.

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Poor training and qualification requirements for system engineers.

Inadequate control of electrical safety equipment and insufficient

training on the use of this safety equipment.

Root cause determination of emergency safety features actuations not being

performed.

Several instances of insufficient instruction guidance in work plans.

Excessive number of quality assurance finding reports (OAFRs) open for

more than a year.

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TABLE OF CONTENTS

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EX ECUT I VE Summa ry . . . . . . . . . . . . . . . . . . . . . . . . . . .

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INSPECTION DETAILS. ... . . . . . . . . . . . . ... . . . . . .-. .

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Overall Plant Performance Related to Maintenance . . . . . ., .

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1.1.. Scope". . . . .-. . . . . . . . . . . . . . . . . . . . . .

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1.3 Findings. . ... . . . . . . . . . . . . . . . . . . . . . .

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1.2 Conclusions . . . . . . . . . . . . . . . . . . . . . . .

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Management Suport-of Maintenance . . .:. . . . . . . . . . . .

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l2.1 Management Commitment and' Involvement . . . . . . . . . .

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Scope .-. . . . . . . . . . . . . . . . . . . .

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2.1.2

Conclusions . . . . . . . . . . . . . . . . . .

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2.1.3'

Findings. . .'

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2.2 Management Organization and Administration. . . . . . . .

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Scope

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2.2.2.

Conclusion. . . . . . . . . .. .-. . . . . . . .

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2.2.3

Findings. . . . . . . . . . ..... . . . . . ...

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12.3. Technical Support . . . . . . . . . . . . . . . . . . . .

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Scope . . . . . . . . . . . . . . . . . . . . .

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Conclusion.

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2.3.3.

Findings. ._. . . . . . . . . . ... . . . . . .

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Maintenance' Implementation . . . . . . . . . . . . . . . . . .

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3.1 Work Control. . . . . . . . . . . . . . . . . . . . . . .

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3.1.1

Scope . . . . .'. . . . . . . . . . . . . . . .

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Conclusion. . . . . . . . . . . . . . . . . . .

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3.1.3

Findings. . . . . . . . . . . . . . . . . . . .

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3.2 Plant Maintenance Organization. . . . . . . . . . . . . .

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3.2.1

Scope . . . . . . . . . . . . . . . . . . . . .

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3.2.2

Conclusion. . . . . . . . . . . . . . . . . . .

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3.2.3

Findings. . . . . . . . . . . . . . . . . . . .

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3.3 Maintenance Facilities and Materials Control. . . . . . .

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Scope . . . . . . . . . . . . . . . . . . . . .

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3.3.2'

Conclusion. . . . . . . . . . . . . . . . . . .

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3.3.3

Findings. . . . . . . . . . . . . . . . . . . .

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3.4 Personnel Control . . . . . . . . . . . ... . . . . . . .

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3.4.1

Scope . . . . . . . . . . . . . . . . . . . . .

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3.4.2

Conclusion. . . . . . . . . . . . . . . . . . .

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3.4.3

Findings. . . . . . . . . . . . . . . . . ... .

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Exit' Interview . . . . . . . . . . . . . . . . . . . . . . . .

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ATTACHMENTS

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'PERS0tlS CONTACTED

B.

ACRONYMS-

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.itAINTENANCE TEAM INSPECTION PRESEllTATION TREE

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INSPECTION DETAILS

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OVERALL PLAtlT pERFORP.ANCE RELATED TO !!AINTENANCE

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1.1 Scope

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The inspectors reviewed River Bend Station's operating history data and

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performed system and plant walkdowns as direct, observable indicators of the

effective implementation of maintenance. These areas were inspected based on

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the premise that overall plant performance with respect to plant operability,

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equipment availability, and general reliability can be related directly to the

effective implementation of maintenance.

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1.2 Conclusions

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The inspectors concluded that the licensee had implemented an effective

maintenance program. However, the inspectors considered the lack of thorough

root-cause identification of emergency safety feature actuations (ESFAs) a

weakness.

It appeared to the inspectors that weekly walkthrough inspections

conducted by plant management personnel could be strengthened if specific area

responsibility for housekeeping and material condition was assigned to

individuals. Although the oil leakage areas were wiped up, the licensee needed

.to implement a concentrated effort to correct the oil leakage problem.

1.3 Findi_ngs

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Data gathered from NUREG-0020, " Licensed Operating Reactors: Status Summary

-Report," licensee monthly operating reports, and licensee operating statistics

for the first 47 months of plant operation showed a decline in the number of

forced-outage hours with a corresponding increase in on-line operating hours

without any unusual operating characteristics. The majority of the

forced-outage hours occurred at the beginning of plant operation.

The work order backlog was not overly large and the work-off rate had

maintained the backlog at a level desired by management. The licensee did not

trend maintenance rework, which made it difficult to assess the effectiveness

of plant maintenance activities.

RiverBendStationhadexperienced33unplannedautomaticshutdowns(scrams)

during its first 47 months of critical operation.

Five additional scrams were

planned as part of plant startup testing. Approximately one-half of the

unplanned scrams occurred from initial criticality (October 31,1985)to

commercial operation (June'6, 1986).

The inspectors reviewed the above data for unplanned scrams through December

1988. The licensee initially identified 336 root causes of these scrans;

however, 286 of these root causes were eliminated. Three additional unplanned

scrams occurred from January 1989 through September 1989. Three(possibly

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four) of all these scrams had a maintenance-related activity identified as one

of the root causes.

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There were 66 ESFAs, or aartial actuations, over the last approximately

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2-1/2 years. However, t1e data base contained only a brief description of the

events. Discussions with licensee personnel revealed that ESTA root-cause

identification and correction did not receive the same level of rigorous

examination as scrams. The examination of the limited data showed that possibly

seven of the actuations nay have had a maintenance-related root cause.

The inspectors selected the normal service water, standby service water, and

residual heat removal systems for system walkdown inspections. The genera)

condition of the components _of these systems was considered satisfactory. The

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major components of these systems were observed to be properly lined up for the

plant operating mode. However, the inspectors noted the following

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deficiencies;

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The standby service water pump shafts and coupling were rusty.

Several valves either had no tags or still had construction tags attached.

Many tags were attached with light-weight wire twisted at the ends instead

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of with small diameter cable and crimps as seen in other areas of the

plant.

(There was a plant-wide labeling effort under way.)

The service water piping and pipe supports, as well as other system piping

and supports, in Tunnels D and E had external rust because preservative

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coatings of paint had not been applied.

(There was a plant-wide painting

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effort under way to correct this situation.)

Of the 10 service water boot seals in Tunnel D, 6 were found with water in

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them, apparently from rain water seepage through deteriorated construction

sealing between buildings.

There were minimal areas of radiological contamination in the auxiliary and

turbine buildings and most areas were accessibic in street clothes, which

demonstrated the licensee's attention to contamination control.

The general condition of the plant areas and equipment was satisfactory

although the inspectors noted the following deficiencies:

The lighting was poor in Tunnels D and E and the residual heat removal

pump rooms.

There were oil leaks on all three main feedwater pumps, the

electro-hydraulic control pump skid, the generator hydrogen seal oil skid,

and Division I and II diesel generator engines, and, to a lessor extent,

the high-pressure core spray (HPCS) diesel generator engine.

There were large amounts of unused, unsecured scaffolding stored next to

the suppression pool suction valve of the HPCS and in several other

locations on elevation 84' of the auxiliary building.

There was graffiti in several locations, including the north wall of the

Train A room for the standby gas treatnent system.

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There was an unsecured.-.inserv. ice hydrogen bottle in Calibration-

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Rack ICMS-BAK20A. A chain was available but'was not being:used.-

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less-traveled areas of the plant.(i.e, water treatment area; off gas

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refrigeration equipment;--standby service water cooling tower).'

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2.

MANAGEliENT SUPPORT OF 14AINTENANCE

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The objective of this part of the inspection was to assess licensee

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management's support of the maintenance process with respect to the

establishment, implementation, and control of an effective maintenance program.

The major areas evaluated were management's commitnent to and involvement in

the organization and administration, allocation of resources, and technical

support provided to the maintenance process,

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The inspectors' concluded that management at River Bend Station had developed

and implemented adequate programs to provide appropriate support to the

maintenance process and that menagement at all levels was actively and

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appropriately involved in the process,

2.1 Hanagement Commitment and Involvement

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2.1.1 Scope

The inspectors reviewed the licensee's application of industry initiatives.

They evaluated the licensee's programs for reviewing, implementing, and

tracking industry operating experience. The inspectors also reviewed the

licensee's programs for tracking, trending, and evaluating plant performance

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trends, human performance evaluations, and actions-taken with regard to

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motor-operated valves (MOVs) maintenance and diagnostic testing. The

inspectors interviewed selected managers and employees to ascertain whether

these individuals understood their assigned responsibilities.

2.1.2 Conclusions

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The inspectors determined that the licensee's application of the industrialized

initiatives program, which was well documented, was sufficiently proceduralized

and adequately functioning. Management's oversight of plant activities was

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highly visible with responsibilities and authorities clearly defined. However,

the licensee was having difficulty in applying operations experience in the

evaluation of plant events, in trending root causes identified in condition

reports, and in reducing backlogs related to the nuclear plant reliability data

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system (HPRDS).

P.1.3 Findings

Managers attended daily meetings, assigned problem resolution responsibilities,

and frequently visited job sites and performed plant tours.

The licensee participated extensively in the Institute of Nuclear Power

Operations' (INPO) initiatives with regards to maintenance. The inspectors

reviewed selected parts of the documentation related to INPO maintenance

assistance visit, outage management visit, and annual plant evaluation as well

as the documentation for the INPO-assisted self-assessment. The licensee

contributed personnel to assist in maintenance peer evaluation programs at

other facilities and at INP0 workshops.

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'The licensee was using a maintenance enhancement program (MEP) that had not

been formalized. The inspectors discussed the program with licensee personnel

and reviewed the MEP evaluation sheets. The purpose of the MEP was to evaluate

the strengths and weaknesses of the River Bend Station managers, including

maintenance discipline foremen. These evaluations were considered at the time

of each manager's annual appraisal. Although recently implemented, the program

appeared beneficial and established a well-understood basis for managers'.

goal-related efforts and their agreed-upon expectations. The licensee had not

implemented the MEP at the craftsmen-level.

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The licensee established tracking measures for regulatory issuances, nuclear

steam supply system vendor information, equipment vendor information,

10 CFR Part 21 notifications, nucicar plant reliability data system

information, and for issues generated by the Nuclear Management and Resources

Council and the boilir.g-water reactor owners group.

The licensee also was strengthening the significant operating experience

report (50ER) tracking and NPRDS programs as a result of deficiencies

identified in a recent INPO plant evaluation visit. The inspectors found these

corrective actions generally sufficient.

The licensee initiated a diagnostic testing program for MOVs in response to

GenericLetter(GL)89-10,datedJune 28, 1989. This program was a followup to

GL 85-03, which resulted in the testing of 22 high-pressure core spray and

reactor core isolation cooling valves during the second refueling outage. The

licensee's systems engineering group identified 238 MOVs that will require

testing during the next refueling outage (Refueling-3) or 5-year period,

whichever is later. This timetable required testing of 80 to 90 MOVs during

planned outages and 30 to 40 MOVs during the operating cycle; however, it does

not account for test failures, repairs, or retesting. The licensee expected

the baseline MOV signature data by December 1989, which will allow about 1 year

for the initial 30 to 40 MOV tests.

The inspectors noted that the licensee anticipated that field engineering would

lose about 14 contract engineers by December 1990, with 6 requisitioned replace-

ments planned. The inspectors discussed their concerns with the licensee

personnel about staffing levels affecting the implementation of the M0V testing

programs.

The licensee developed and implemented an independent safety engineering group

responsible for trending condition reports and reviewing the reportability

requirements for these condition reports. There were a number of events during

1908 and 1989 that resulted in actuations and, at times, equipment damage.

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Several of these events (i.e., approximately 33 percent) were attributable to

either human error, lack of procedural adherence, inadequate procedures, or

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insufficient job planning. Examples of these types of events include:

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Licensee Event Report (LER)89-003, which resulted in the failure to perform a

Technical Specification surveillance properly because of inadequate procedure

development; LER 89-015, which resulted in a reactor protection system half-scram

actuation and isolation of the residual heat removal shutdown cooling suction

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valve because of inadvertent grounding of a test jumper; and LER-89-027, which

resulted in the automatic initiation of the standby service water pump because

ci an inadequate surveillance test procedure.

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The licensee's program for check valves included 102 check valves that were

greater _than 2.5 inches in diameter and which had failed the design review

criteria. The design review criteria was based on the minimal fluid velocity

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requirements of Appendix X to Stone & Webster Engineering Company's Valve

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Selection Guidelines and the proximity of the installed check valves to areas

of turbulent-induced flow. The licensee did not calculate the minimum velocity

for each valve type as described in the Electrical Power Research Institute

(EPRI) Guidelines.. Valves less than 2.5 inches in diameter were not considered

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because of the historically low frequency of failure.

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09 ting the first refueling outage, the licensee disassembled the check valves

that had been identified for disassembly during the inservice test (IST)

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program (Relief Request 24 for Q-Class I check valves). A sampling of each

group of check valves was disassembled and inspected in accordance with the IST

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plan. Before the second refueling outage, the licensee selected 32 check

valves to be disassembled and inspected.

If a check valve failed the

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inspection, additional check valves of similar design and application were

identified for disassembly and inspection. Of the 32 valves originally

selected, 9 were actually disassembled and inspected.

Because of previously

identified problems or because they failed the local leak rate test 32

additional valves also were disassembled and ins)ected. Of the 41 valves

disassembled,12 involved service water system c1eck valves. As a result of

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this inspection, five additional check valves have been added to the check

valve program. The licensee has not established a program for disassembling

and inspecting check valves less than 2.5 inches in diameter not covered by IST

Relief Request 24.

The licensee was developing an acoustical emission monitor (AEM) program es a

part of the predictive maintenance program for identifying degraded check valve

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performance. This program was expected to be implemented by the first quarter

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of 1990

The licensee was working with EPRI and other utilities to evaluate

degraded check valves in the laboratory, using the AEM program prior to

utilizing the program in the field. Engineering procedures were being

developed to control the AEM program. Any check valves, identified by the AEM

program as degraded or inoperable will be disassembled and inspected during the

next appropriate outage.

The licensee had not established a trending program for the check valve

monitoring program. However, an industry wide trending program was under

development by the Nuclear Industry Check Valve Group. The licensee was

developing maintenance procedures for each type of check valve that would

include a data sheet that could be used to establish positive and negative

trends in check valve performance.

As a member of the Nuclear Industry Check Valve Group, the licensee was

represented on the steering committee. This group was working with different

agencies and organizations to provide a forum for joint discussions and

resolution of generic check valve issues through the exchange of technical

information related to application, testing, and maintenance of check valves.

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2.2 fianagement Organization and Administration

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2.2.1 Scope

The inspectors reviewed maintenance program coverage; policies, goals, and

objectives for maintenance; allocation of resources; definition of maintenance

requirements; performance measurements; the document control system for

naintenance; and the maintenance decision process,

2.2.2 Conclusions

The inspectors concluded that the licensee had developed and implemented

adequate maintenance programs that were reviewed and updated. These programs

,

included provisions to ensure the establishment of a long-range maintenance

plan, appropriate monitoring of performance goals and objectives, clearly

defined responsibilities, and an appropriate allocation of resources. The

licensee's document control system for maintenance was adequate to control and

'f

track documents. Licensee management involvement was demonstrated in the

excellent control over day-to-day maintenance decisions and throughout the

maintenance process.

2.2.3 Findings

Maintenance Program Coverage

The licensee established and implemented the maintenance plan through

Administrative Procedures ADii-0023, " Conduct of Maintenance," and ADM-0028,

" Maintenance Work Order." These procedures were updated on an annual basis and

clearly define the responsibilities of each manager and supervisor. Discussion

with maintenance supervisory personnel revealed that each individual was

cognizant of their responsibility.

The licensee's system outage schedule provided a 3-month look ahead for system

outages to allow adequate time for scheduling of maintenance activities and

intervice testing. Outage work was scheduled in advance for each possible

plant condition. The schedule was periodically updated and distributed to

maintenance supervisory personnel.

Appropriate management personnel attended plan-of-the-day meetings during which

management goals and objectives were clearly stated.

Establishment of Policies, Goals, and Objectives for Maintenance

The licensee esteblished a performance monitoring program through River Bend

Nuclear Procedure RENP-0028, " River Bend Station Performance lionitoring

Program." This program assessed measurable attributes such as unplanned

reactor automatic shutdowns and forced outage rate. Selective elements of this

program were distributed to the Chief Executive Officer on a regular basis.

Licensee management personnel discussed performance trends with the plant staff

and established goals based on trends and objectives.

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The plant manager and assistant plant manager of maintenance were provided with

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maintenance performance graphs on a weekly and monthly basis. This information

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included unscheduled maintenance staffing hours, maintenance work orders

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available for work, and estimated vs. actual maintenance staffing hours and

work completed vs. scheduled work.

The plant manager and assistent plant manager of maintenance held weekly

meetings wit'e supervisory personnel to discuss these performance graphs.

r

Responsibi dty for meeting the established goals and objectives was clearly

i

established.

Allocation of Resources

The inspectors reviewed records and maintenance item backlogs to evalusta the

control of maintenance resources as well as the allocation of field engineering

,

personnel to support naintenance activities.

,

The licensee had maintained the number of maintenance work orders and

preventivemaintenance(PM)tasksattheirestablishedgoalsof650and500

respectively. The licensee used contract craft level maintenance personnel

minimally during nonoutage periods except to support special activities such as

sealing leaking valves.

The inspectors found that contract personnel were being used in the engineering

breas of system engineering, predictive maintenance, PM review, and updating

the NPRDS. The licensee anticipated reducing the number of contract

engineering personnel over the next 15 months, which may adversely affect many

of these maintenance support functions. The work load on the remaining system

t

engineers will increase as they are required to assume the responsibility for

edditional systems.

For example, the adequacy of the PM program was based on

the adequacy of the PM review efforts in which the responsible system engineer

reviewed the maintenance and preventive maintenance tasks for his/her system.

Definition of Maintenance Requirements

The inspectors reviewed the work package for-implementation of the maintenance

program for the penetration valve leakage control system (PVLCS) and the safety

, relief valve system (SVV). The inspector found that preventive and corrective

maintenance, surveillance testing and inservice testing programs were well

implemented for the PVLCS and SVV.

The inspectors observed implementation of the predictive maintenance program.

Field engineering had been required to perform vibration monitoring on a

J

circulating water pump and operations requested vibration monitoring of a

reactor plant component cooling water pump. The ability to trend vibration

!

data for each point monitored on the pump and motor was well illustrated in

each case.

It appeared to the inspectors that revision of the predictive

maintenance program procedure was needed to ensure actual practicet were

accurately reficcted in the procedure.

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' Conduct Performance Measurements

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The licensee implemented a maintenance enhancement program that involved a

quarterly evaluation of maintenance supervisory and foremen personnel. The

program was still under review for craft personnel because of contract

limitations.

Plant management used key plant perfornance indicators to monitor important

P

trends. These performance elements were described in Procedure RBNP-0028,

" River Bend Station Performance Monitoring Program." The trends were discussed

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with plant staff personnel on a weekly basis.

I

It appeared to the inspectors that additional performance monitoring was needed

for maintenance job planning, contractor control, and root-cause analysis.

The maintenance job planners did not observe the maintenance activities that

they had planned. No formal feedback mechanism was established to inform the

applicable job planner of problems encountered by maintenance personnel during

the performance of the maintenance activity.

.

At the time of the inspection, the ISEG had recently started trending condition

reports and assigning failure codes. The lack of a trending program appeared

to have resulted in a number of clearance violations by contractor personnel.

The NPRDS was approximately 10,000 staffing hours from being fully implemented.

The present root-cause component failure analysis methods being used by the

system engineers was labor intensive and susceptible to error by the user.

It

appeared to the inspectors that PH program task reviews will need to be closely

monitored by management personnel as the individual system engineers work load

increases over the next year.

Document control System for Maintenance

The licensee's Administrative Procedure ADM-003, * Development, Control, and Use

of Procedures," established the licensee's administrative controls for

development, revision, approval, control, and use of procedures. The

inspectors verified that changes to procedures received the same icvel of

review as the original document. The inspectors reviewed over 100 work

documents,during this inspection, in all cases the licensee was able to

retrieve the required documents.

Maintenance Decision process

<

The licensee has established guidelines for the scheduling of surveillance

activities. The surveillance schedule identified system outages 3 months in

advance. This schedule was provided to maintenance, operations, and engineering

for comment before final approval. The licensee held weekly planning meetings

to plan the maintenance activities for the following week. The maintenance

activities that required a system outage were planned to correspond to the

surveillance outage, which resulted in a reduction in system outages.

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A plan-of-the-day meeting was held in the morning and evening to plan any urgent

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maintenance work items. All the different plant disciplines attended these

. meetings, which ensured that all departments were aware of the planned activities.

]

2.3 Technical Support

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2.3.1 Scope

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The inspectors reviewed documentation, held discussions with plant engineering

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and management personnel, attended daily management meetings, and examined

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in-progress and completed meintenance activities to ascertain the adequacy of

,

-communication channels.

Interviews with selected managers and employees also

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were conducted to verify that individuals understood their assigned responsibilities.

2.3.2 Conclusions

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-The licensee demonstrated good communications internally at the plant and with

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corporate-level management. Although the licensee's preventive naintenance review

program was effectively established, the implementation of this progran needed

strengthening. The trending process appeared to be improving, but plant

management's reaction to indicated negative trends was weak.

l

The licensee integrated radiological control considerations into the planning

.and scheduling process and implemented radiological control programs that

effectively supported maintenance of the plant and gave appropriate consideration

<

to as low as reasonably achievable (ALARA) concerns. However, ALARA maps used

for maintenance prework briefings did not have adequate detail of the work area

to orient workers unfamiliar with the facility.

The licensee's program to integrate regulatory documents in the maintenance

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process appeared well established and effectively implemented. The licensee

developed and implemented programs that were effectively integrating quality

control and quality assurance into the maintenance process.

However, procedural

adherence was sometimes lacking; preventive maintenance monitoring was not

tracked and trended effectively; and affirmative response actions to negative

trends appeared to be lacking.

2.3.3 Findinos

Communications

The inspectors attended daily plant meetings at the plant management and technical

staff level and at the maintenance discipline foreman / craftsmen level.

In addition,

the team observed weekly outage scheduling / planning meetings ard on one occasion

observed the facility's review committee evaluation of the emergency diesel

generators operability status, which was the result of a questionabic surveillance

test performed during a past outage. The inspectors noted that the meetings

were well orchestrated and displayed excellent internal communications.

_

Discussions with' plant management and a review of documentation indicated that

good plant-to-corporate communications existed. The maintenance departments

communications with technical support appeared adequate although the inspectors

noted some exceptions in the health physics and operations areas.

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Engineering Support

(1) Preventive Maintenance and Inservice Testing Programs

The inspectors examined selected preventive maintenance and IST activities

performed during the last 2 years on the PVLCS and automatic depressurization

system (ADS). The inspectors reviewed applicable vendor manuals to ascertain

the maintenance requirements for each component located in the PVLCS and ADS.

They then compared vendor recommendations to the equipment qualification

maintenance and surveillance requirements for the two systems.

In each case,

'

the licensee had established a preventive maintenance task to maintain the

equipment opereble.

However, the inspectors noted that the licensee had not established PM

requirements for the check valves located in the PVLCS and ADS. These check

valves are all less that 2.5 inches in diameter. As discussed earlier, the

licensee's check valve performance monitoring did not cover valves less than

2.5 inches in diameter.

The inspectors reviewed the IST requirements for the PVLCS and ADS to ensure

that the applicable check valves were being verified operable.

In each case,

the licensee tested the check valves in accordance with IWV-3521 of Section XI

of the American Society of Hechanical Engineers Boiler and Pressure Vessel Code

(ASMECode).

The licensee has developed and implemented an effective predictive maintenance

program in the areas of vibration and oil analysis. These programs were

identified in Plant Engineering Procedures PEP-003, " Vibration Program";

PEP-0039, " Lubricating 011 Analysis Program"; and PEP-0040, " Insulating 011

Analysis Program." The licensee planned to develop predictive maintenance

programs for grease analysis and thermography.

Approximately 300 components that were located in safety and important-to-

reliability systems were being monitored under the vibration program. Spectral

data, wave forms, and trends were taken for each point monitored. Performance

program and testing engineers performed the analysis. Reports of adverse

trends were generated by the computer analysis program and subsequently

distributed to the system engineers and maintenance and operations personnel.

Degraded rotating components including a circulating water pump motor bearing

and an alignment problem with a feedwater pump speed increader, have been

identified through this program since the completion of the second refueling

outage in June 1989.

The oil analysis program monitors lubrication and transformer insulating oil.

The licensee was monitoring 46 components for lubrication oil analysis and 31

transformers for insulating oil integrity. The results were trended and

reports of adverse trends distributed to the appropriate personnel. During the

second refueling outage a dissolved-gas analysis of the preferred "A" station

transformer identified the presence of acetylene in excess of the alert limit,

which indicated that electrical arcing was occurring within the transformer.

The licensee subsequently replaced the transformer during the refueling outage,

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The inspectors reviewed the PM review progren, part of the licensee's PM

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program, and the implementatior of PMs into the maintenance program. The

licensee's FM program was effectively established and was controlled by

Procedure MSP-0003, " Preventive 11aintenance Program;" however, the PM review

e

program, as established in Procedure PEP-0044, " Preventive Maintenance Review,"

had not been well implemented.

The PM review program was esteblished to determine the effectiveness and

adequacy of the PM program on the basis of component maintenance and

operational history. The findings of these reviews were to be used to correct

existing PM procedures or to write new PM procedures, as required. The

licensee had selected 23 significant systems based on their importance to

safety, their reliability, and their associated operating problems. The

licensee was developing an equipment data list for each of the 23 systems. The

licensee planned to use this list to evaluate the importance of each component

to determine if the component should be included in the PM review for the

system. The licensee designated 10 systems for review of rotating equipment

only. The licensee completed review of 7 of the 10 systems designated for the

" quick review." The inspector reviewed the 21 Pli change recommendations that

resulted from the PM review program for the reactor water cleanup and off-gas

systems. The PM change recommendations were sent to the maintenance department

on_ January 24, 1989; as of October 1989, none of the recormended changes had

been implemented into the PM program.

The program for evaluating PMs required the plant performance and test group to

develop an equipment data list for components of each system. The appropriate

system engineer reviewed the equipment data lists and prioritized each

component according to its effect on operation or safety. The maintenance

history of that component was then evaluated to determine if changes to the PM

program for that component were needed. No formalized method existed for the

system engineer to receive feedback on proposed PM changes from maintenance and

operations before the change request was issued. The inspectors also noted that

the PH change forms were not uniquely identified to allow tracking the status

of the PM change request.

'

The licensee had developed a program to identify required PM tasks resulting

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from plant modifications. Engineering Procedure ENG-03-006, " River Bend

Station Design and Modification Request Control Plan," established a

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meintenance checklist that included any necessary revision to the PM program

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for changes made to plant equipment. The maintenance discipline supervisor had

responsibility for determining changes to the PM program; an engineering

evaluation of the maintenance requirements was not performed as with the PM

review program.

The inspectors reviewed modification requests, MR 87-0639 and MR 88-0088, which

authorized the installation of " live-load" packing of approximately 140 valves.

Many of these valves were located in the drywell and steam tunnel.

The

inspectors noted that the maintenance checklist did not identify any new PM

requirements for the live-load packing. The inspectors further noted that the

Bellville washers used to compress the packing tend to relax over several years

and can result in degradation of the packing assembly. The vendor only

guarantees the packing for 5 years.

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(2) Field and Design Engineering Group

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The licensee established two groups within the engineering organization at

River Bend Station: the field engineering group performed long-term projects

such as performance monitoring and system engineering, and the design engineering

group performed short-term projects and provided specialized technical support

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in such areas as system design and environmental qualification. The engineering

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staff consisted of approximately 100 design engineers, including contractor

personnel, and 82 field engineers. The licensee planned to reduce the number

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of contracted engineers over the next 15 months.

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The inspectors observed good engineering support of some maintenance activities,

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for example, planning of work that was to be done in accordance with the ASME

Code end support in the field of the Division I emergency diesel generator

outage on October 3, 1989.

(3)EvaluationofproblemsbyEngineering

The licensee had experienced reactor recirculation flow coolant valve (FCV)

operability problems during the second operating cycle. The inspectors reviewed

two condition reports (Condition Reports 89-0042 (nd 89-0043), dated January 18,

1989, which documented flow centrol problems resulting in single loop operation

to effect repairs to the flow control system. The ISEG conducted a study of

the single loop operations and the two events that occurred (Condition

Reports 89-0042and89-0043) on January 18, 1989. 'lhe results of the study were

documented on July 21, 1989, in Operating Event Report 89-004

The ISEG report

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and the condition reports documented power and flow oscillations resulting from

the malfunctioning flow control system. The oscillations resulted in reactivity

changes that would have produced a reactor scram (flow bias trip) if the

operator had not intervened.

It was decided to conduct a more indepth review

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of these events and, therefore, this issue was classified as an onresolved item

(458/8904-01) pending further HRC review.

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(4) . System Engineers

The inspectors noted indications that there were program and implementation

weaknesses in'the system engineering area.

A majority of the system engineers did not maintain a day-to-day knowledge of

their assigned systems. They were not required to review condition reports or

maintenance work authorizations on their assigned systems, nor to witness

post-maintenance testing or surveillance performed on their assigned systems.

The system engineer did perform the required inservice testing en their assigned

systems. They had not received detailed training on their assigned systems.

The inspectors noted that some component training, such as on the reactor core

isolation cooling system turbine, had been provided from the vendor.

The system engineers were not trained on, or provided with, previous system

experiences that had been identified through NRC bulletins, information notices,

or significant operating experience reports.

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Qualification cards had not been developed for each system engineer position

except for the low-pressure core spray qualification card, which was developed

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but not implemented.

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The' system engineers did not keep maintenance histories on each system current,

which would make the backup system engineer less effective if the primary system

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engineer was not available.

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Role _of Probabilistic Risk Assessment (pRA) in the Maintenance Process

>.

The licensee expected to complete integration of the first level of the PRA for

- River Bend Station into the maintenance process by Jenuary 1990.

Role of Quality Control / Quality Assurance (QC/QA) in_the Maintenance Process

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~ The inspector reviewed selected MWO document packages to verify that they were

in compliance with the licensee's controlling procedures.

Maintenance work orders fell into two classes, corrective and preventive. All

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corrective MW0s were inspected by QC as applicable, but preventive MW0s were

only sampled or monitored according to a predetermined schedule. The QC

inspection coverage for corrective MW0s was appropriate and the monitoring of

preventive MW0s exceeded the number scheduled.

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While these actions showed strong QC involvement in the MWO process, a weakness

was observed in that the preventive HWO monitoring was not being formally tracked

so that management could readily assess its compliance schedule, nor were

monitoring inspection results being assessed to determine if future monitoring

schedules should be adjusted.

QC personnel were required to inspect the MWO document package against a checklist,

contained in procedure 001-3.7, " Quality Control Inspection Planning," Revision 4.

This checklist was required to be completely filled out and any problems resolved

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before release of the package for work by maintenance personnel. However, an

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inspector examined an MWO package (R116231) of work already completed and noted

that it contained a checklist that was only partially complete.

By the time

the inspectors discussed this matter with QC personnel on October 3, 1989, the

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subject document package had received a final QC inspection before turnover to

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permanent plant files and the checklist had been completed.

It was apparent to

the inspectors that the checklist was completed late, but the checklist did not

indicate who made the late entries or when they were made. This issue has been

referred to the licensee for resolution.

The trending process and the trend reports, which were issued every 6 months,

showed a constant improvement over each preceding trend period. While this

aspect of the licensee's trend program may be viewed as a strength, plant

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management's reaction to indicated negative trends was weak. For example, a

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negative trend for design engineering during the last 6 months of 1988 continued

to worsen during the first 6 months of 1989 and the first apparent engineering

management reaction to this negative trend did not occur until mid-1989,

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Integration of Radiological Controls Into the Maintenance Process

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Thelicensee!slevelofintegrationofhealthphysics(HP)intotheplanningand

scheduling' process appeared to be adequhte, but according to licensee represen-

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tatives, communications and' relationships between HP and maintenance personsci

4

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were not good in the past, but had improved with tim and were now satisfactory.

The inspectors discussed this with maintenance personal and learned that main-

tenance personnel felt that HP personnel should be involved in work preparation

earlier. HP personnel told the inspectors that typically there was little or

no delay in preparing radiation work permits (RWPs) and that, under the current

4

procedures, they could not initiate RWPs for maintenance work. HP personnel

felt that potential delays could be avoided with earlier submission of RWP

requests with complete and accurate information.

'A

The inspectors reviewed selected training records of licensee personnel and found

i theseworkerswerecurrentinGeneralEmployeeTraining(GET)Iand11,which.

included training for radiation workers, and GET III, for respiratory protection.

Some workers had been given miscellbneous radiation protection training and

GET IV, which emphasized the problems of radioactive contemination. Licensee

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representatives stated that all mechanical maintenance personnel were intended

to receive GET IV. One of two maintenance planners and schedulers, whose records

were reviewed, had also been give specific ALARA training in which mockups of

valves and. piping eere used in the practical portion of the training and-in

preparatien for outage work.

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Radiologichi training was accredited and satisfied the commitments contained

in the USAR and-the requirements of Technical Specifications 6.3.1'and 6.4.

Plant personnel could enter the radiologically controlled area (RCA) with an

access radiation permit for the purpose of touring the area. They were

required only to check with HP before entering the area; there was no sign-in

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procedure. The inspectors noted numerous ways of entering and exiting the RCA

without passing through the main access point. Although the potential exists

for workers to exit through these alternate routes and bypass contamination

monitors, the. inspectors did not observe specific instances of such. Work

performed in the RCA was donc 00 under either standing RWPs or RWPs written

specifically for a particular job, depending on the assessment performed by HP.

The inspectors attended a prejob briefing given to two contractors in

preparation for sealing leaking valves in a steam-affected high radiation area.

The briefing was given by the ALARA technician and an HP technician and

included expected radiation levels, precautions to reduce radiation dese,

allowed staying time, clothing requirements, dosimetry requirements, pathways

to be followed, and general orientation to the area.

Survey maps were used by

HP personnel for prejob briefings.

However, these ALARA maps lecked the detail

necessary to be helpful to a person unfamiliar with the area in which work was

to be done.

The licensee had developed and implemented good ALARA programs and HP personnel

apoeared to have a good personal rapport with maintenance planners and

schedulers.

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Worker awareness of the ALAP,A~ concept and involvement'in maintaining low

radiation doses appeared good as was evidenced by the submission of 25 ALARA

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suggestions in 1988.

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The radiation exposure history is provided below.

RADIATION HISTORY IN MAN-REM

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HAINTENANCE

TOTAL STATION

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YEAR

ALARA-GOAL

ACTUAL

ALARA G0AL

ACTUAL

1986:

50

82.367

26.7

46.610

'

1987

285

378.000

197.27-

193,529

l

1988

100

99'.360

35.00

38.54

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Safety-Review of Maintenance Activities'

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During September 18 through 22, 1989, the inspector informed the licensee that

-high-voltage gloves, which were stored in operations equipment lockers, were

not consistently being stored inside their protective canvas bags when not in

u se'.

The licensee subsequently posted the equipment lockers with instructions

to verify test / inspection date is current, inspect and air test rubber gloves,

-ensure leather protectors are on gloves, restore the gloves in bags, return the

equipment to the locker, and lock the locker.

During the week of ~0ctober 26, 1989, the inspector observed that two lockers

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were unlocked when not in use. One locker was empty and. the other had all the

safety equipment properly stored. While o)erators were racking circuit-

breakers out of high-voltage switchgear, tie inspector observed that the

~ operators.did.not seem familiar with the posted instructions nor the recognized

method of inspecting and air-testing of rubber gloves. The inspectors'

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discussion with the-operators revealed that, although the operators had been

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specifically' trained in the mechanics of breaker removal /reinsta11ation and

informed of the need'to use the safety equipment, the operators had not been

specifically trained in its inspection, storage, and care--other than required

,

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reading of the. licensee's-safety manual. The licensee agreed that the

conditions observed by the inspector were unsafe work practices.

-and Health Act (OSHA) practices appeared to be contrary to Occupational Safety

The above unsafe work

requirements of 29 CFR, Chapter XVII, Section 1926.951,

" Tools and Protective Equipment " Paragraph (a),"ProtectiveEquipment,"

(1)(ii)(1)(iii),"Inaddition,anairtestshallbeperformedforrubbergloves

" Rubber protective equipment shall be visually inspected prior to

use."

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prior to.use.'"' This issue has been referred to the licensee in accordance.

with NRC Information Notice 88-100, " Memorandum of Understanding Between NRC

and OSHA' Relating to NRC-Licensed Facilities," and HRC Inspection Manual,

4

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LChapter 1007, " Interfacing Activities Between Regional Offices of NRC and

OSHA."

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Integration of Regulatory Documents into the Maintenance Process

The licensee had established and implemented programs and procedures to control

the receipt, logging, and tracking of regulatory documents. The licensing

group assigned responsibilities for tracking as well as routing the documents

to.the applicable disciplines for review, Regulatory documents that required

licensee action were submitted to a work scope committee for scheduling,

planning, and analysis. Regulatory documents that required proceduralizing

were sent through the administrative support group assigned to the applicable

discipline for procedure revision.

The inspectors reviewed the licensee's actions in response to Generic Letter (GL) 85-03, " Motor Operated Valves (MOVs)"; GL 89-10, "MOV Diagnostic

Testing Program"; and GL 88-75, "Antipumping Circuitry on Safety-Related

Circuit Breakers." The licensee had performed adequate reviews, assigned

action responsibilities, appropriately tracked items, responded in a timely

manner, and, where applicable, incorporated appropriate activities into plant

that the utility was timely with licensee event report (LER) porting indicated

prograns/ procedures. A further review of operating event re

submittals.

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MAINTEllAllCE IMPLEMENTATION

The objective of this part of the inspection was to determine the extent of

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control of (1) maintenance work; (2) plant maintenance organization programs;

(3) maintenance facilities, equipment, and material; and (4) personnel,

in these

areas the inspectors observed maintenance jobs in progress, reviewed programs, and

_

work packages, interviewed personnel, and observed activities that support

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maintenance (i.e., material and personnel control).

The inspectors concluded the licensee had developed and implemented appropriate

work control programs for maintenance. The facilities and work spaces were very

-good and conducive to the effective performance of maintenance activities. The

licensee had developed and implemented effective personnel control programs

and routinely reviewed staffing to ensure that requirements were being met.

The licensee's training and qualification programs for maintenance personnel

.

were adequate. More specific conclusions are discussed under each area.

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3.1 Work Control

3.1.1

Scope

-The inspectors assessed the work control process by reviewing maintenance in

progress, including work orders, post-maintenance testing, and adherence to

procedures; equipment records and history; work prioritization and backlog

controls; and completed work control documents.

3.1.2 Conclusions

The inspectors concluded that work control programs were adequate. Craft and

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first-line supervision were good in the electrical and instrument and control (I&C)

disciplines, but-lacked procedural control in the mechanical discipline. The

implementation of training for work planners was weak.

Equipment history was

well maintained and retrievable although there were disparities in recordkeeping

and tracking of specific components. The inspectors considered the licensee's

scheduling and control of the work backlog to be a strength, but believed the

process for prioritizing work could be improved. The post-maintenance test

program was adequate, but the licensee's MWO review program needed strengthening.

3.1.3 Findings

$intenanceinProgress

The inspectors were concerned about the weaknesses in the licensee's process

for controlling lifted leads. Licensee employees expressed concern that the

absence of a formal program for controlling lifted leads made it difficult for

the shift supervisors and shift foremen to adequately know the condition of the

plant and its safety systems. The inspectors learned that Procedure ADM-031,

which was in effect during initial plant startup, had effectively controlled

~

lifted leads.

However, the procedure was cancelled after the plant went into

commercial operations. On September 28, 1989 (during the inspection), a

technician lifted a lead during maintenance on a solenoid control valve for a

ventilation damper. The technician was not aware that the lifted lead also

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powered otherfsolenoid' valves. When the-lead was lifted, five additional

solenoid. valves were deenergized and their associated air dampers unexpectedly

,

changed position. More effective controls on lifted leads would have prevented

-this event.

The inspectors'also were concerned that the licensee did not have an effective

process for the shift-to-shift oversight of clearances, tags, and lifted leads.

Shift 4urnover did not always result in an effective turnover or review of the

outstanding clearance tags and' lifted leads as was observed during the performance

w

of Maintenance Work Order Request (MWOR) 130425. Maintenance was initiated on

penetration valve in the main steam isolation valve leakage control system (PVLCS)

The Crew B foreman (night shift) had accepted a clearance

onOctober4,)1989.to isolate the compressor check valve being worked on. A badly

(RB-1-89-2483

eroded disc had caused the-improper compressor output pressure, and work was stopped

by the Crew 8 foreman until the work plan could be revised and replacement parts

obtained. The day shift foreman received the revised work plan and conducted a

crew briefing. However, the inspector noted that the clearance sheet had not been

signed in the " Checked and Accepted By:" block (Block F) by the day shift foreman.

The inspector questioned the day shift foreman about his responsibilities concerning

acceptance of the clearance from the night shift foreman and was advised that the

day; shift foreman did not have to accept the clearance from the night shif t foreman.

Although the day shift crew had started work, work had tn be stopped because

isolation could not be obtained and water was leaking into the check valve.

Later in the day, the inspector noted that the clearance document had been

changed to reficct that the day shift forenan had " accepted" the clearance on

the morning of October 4, 1989. However, after reviewing the card reader

access records, the inspector concluded that the dey shift maintenance foreman

had not " accepted" the clearance in accordance with Procedure ADM-0027,

Revision 7,'" Protective Tagging," before releasing his crew to perform system

maintenance. The day shift foreman later admitted to the inspector that he had

tance of the clearance until the afternoon. This is an

notsignedforaccep(458/8904-02).

apparent violation

The licensae initiated a condition report to

further investigate this problem of Procedure ACM-0027.

The inspectors reviewed the clearance:, that were active at the time of the

inspection and noted that many clearances had been issued to organizations-

rather than persons. A review of Procedure ADM-0027, " Protective Tagging,"

paragraph 3.6, indicated that, "A requester may also be by title (i.e., Shift

Supervisnr, Control Operator Foreman, Maintenance Foreman, etc.) as long as

they comply with Step F.1 of Attachment 7 of this procedure." However, several

instances were noted in the active log of clearances in which organizations

rather than persons wera indicated. The inspectors considered this practice

inconsistent with the intent of Procedure ADM-0027, paragraph E.1., Attachment

7, which stated, " CLEARANCE ISSUED TO - The name of the Forenan the Clearance

is issued to will appear in this block.

In the absence of the Foreman, a

Clearance can be' issued to an individual designated by the Foreman or

supervisor to be in charge of the work." The team concluded that the practice

of. issuing clearances to organizations 'r nead of individuals was a weakness in

the clearance program.

Another type of clearance problem was noted during the review of closed work

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plans. The MWOR 1200?2 stated that "FWS-FV104 does not operate.

Found water

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- in air system. Trouble shoot and repair." Th'e inspectors found no evidence of

a clearance being set to perform the investigation described in the MWOR was

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available, thus the system had been breached without a proper clearance. The

licensee's failure to follow the requirements of Procedure ADM-0027 was an

apparent weakness in procedural adherence.

The licensee converted MWOR 120022 to MWO R120022 in accordance with

Procedure ADM-0028, " Maintenance Work Order." The work plan called for trouble-

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shooting the failed air-operated valve FWS-FV104. Although Step B and Step R of

the work plan provided itstructions for authorization and equipment modification

visor authorized the work.e was specified for the planned work. The shift super-

requirements, no clearanc

,

release without specifying a clearance be set. The

technicians that performed the maintenance set isolation conditions of the instru-

ment air supply to the solenoid operator and power supply to the solenoid operator

by using Procedure GMP-0042, Attachment 2, "Lifud Lead and Jumper Tag Sheet,"

rather than the Protection Tagging Procedure ADM-0027.

A similar circumstance of using GMP-0042 to set isolation conditions was noted

during performance of MM0 R134876. The work was authorized to be performed

without a clearance being set; the maintenance technicians used a " lifted lead"

tag (GMP-0042) to isolate the 110 psig air supply to the ASCO solenoid valve.

This is another example of the apparent violation (458/8904-02) for failure to

follow the provisions of Procedure ADM-0027.

It appeared to the inspectors that Procedure GMP-0042 was intended to support

instrument and electrical circuitry testing or alignments, not mechanical

maintenance activitiet such as cleaning air lines.

Contrary to the manner in

which the technicians used Procedure GMP-0D42, Procedure ADM-0027 clearly

stated in paragraph 5.21 that " fluid or gas systems that operate with

- temperatures greater than 200 F or pressures greater than 50 psig should be

isolated from the work area by two closed valves in series, with a tell-talu

vent or drain open between the isolation valves." These clearance conditions

were.not set for MWO R134876. The inspectors considered performance of

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maintenance on components without setting a protective tagging clearance in

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accordance with Procedure ADM-0027 a weakness in the licensee's program for

setting clearances.

On several occasions, the inspectors noted that maintenance technicians

arbitrarily did not perform a work plan step; they simply marked the step as

"N/A" with no explanation, nor did they note this action in the appropriate

section of the work order for subsequent approval by reviewing personnel.

Because of significantly increased lower bearing temperatures, MWO R122471 was

initiated to remove the normal service water pump motor (1SWP-PIC) so that the

vendor could overhaul it. The inspectors observed a mechanic mark one step

"N/A" without providing an explanation. The mechanic simply did not follow the

work plan. There was a sequence of steps in this work order that was critical

to the success of the maintenance activity; however, the maintenance

technicians failed to observe the protocol of signifying completion of each

step by initials before proceeding. The team was particularly concerned

because numerous hours had passed since the activities had been completed and a

different crew was' performing the succeeding evolutions. The inspectors also

noted that Procedure ADM-0028, " Maintenance Work Order," paragraph 5.12.24,

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stated to " follow the job plan in detail (not necessarily in sequential order

unless specified)'and initial the items as they are performed and reperformed."

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This provision was in conflict with Procedure ADM-0003, " Development, Control,

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.and Use of Procedures," paragraph 6.5.1, which stated that "unless otherwise

specified, steps in a-procedure shall be performed sequentially."

During conduct of-the electrical portion of the work plan, electricians failed

to follow the work plan with regard to refilling both bearing reservoirs with

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fresh 011 because it was not availabic.

Furthermore, when the electricians

,

found an alternative source of oil, they failed to sample uncontrolled oil before

adding itlto the motor reservoirs. Thus, licensee personnel did not follow the

requirements of paragraph 5.2.1 of Procedure ADM-0023, which stated that

- maintenance personnel shall adhere to instructions of approved work' documents."

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' The work' alan did not include the necessary torque data sheet for the motor

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mounting bolts or coupling bolts.

Furthermore, no instructions were provided

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in the work plan for a jacking device that would permit turning the very large

service water pump / motor assembly while performing run-out checks. During the

conduct of MWO R131564, which started on October 2, 1989, the work had to be

stopped because the coupling on Sump Pump DFT-P1B was sheared. The licensee

advised the inspectors that the planner--after receiving MWO R131564 on

August-16,1989--had inspected the turbine building floor drain sump pumps

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before writing the job plan on August 21, 1989. There had been no evidence of

a pump coupling problem at that time. This indicated that if enough time

elapsed between planning and accomplishment, the circumstances under which the

original planning occurred could change.

Procedure ADM-0028, " Maintenance Work

Order," paragraph 5.2, indicated that "the Discipline Supervisor shall review

the MWOR and when necessary inspect the problem (s), to validate the request."

r

There were no specific instructions.about a job-site walkdown before planning

the work or consideration about what to do if considerable time elapses before

the job plan is worked.

i

The inspectors reviewed the training received by the planners in an effort to

determine potential causes for some of these problems. The licensee considered

three courses fundamental to the qualification of a planner. However, none of

the nine planners had completed all three courses, which indicated that

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implementation of the training was inadequate.

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The NRC inspectors observed 180 technicians performing a semi-annual

surveillance (STP 503-4205) of the control rod block source range monitor. The

procedure defined the purpose, plant mode, applicability, and frequency;

required equipment; precautions and limitations, and prerequisites. The

procedure was easy to follow and the technicians demonstrated an understanding

and familiarity with the contents of the procedure and the system.

Communications between the two technicians, using a reader / performer technique,

were excellent. All measuring and test equipment (M&TE) was in calibration and

in good condition. One minor procedure deficiency and one technique deficiency

were noted. One procedure step was duplicated and appeared unnecessary. The

technicians submitted a comment sheet to remcve one of the duplicate

steps (7.1.83.5 or 7.1.83.11). The technicians used a homemade device to hold

the push-button down to disarm an alarm.

Use of an unauthorized device without

appropriate procedural controls was considered a weakness.

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The inspectors observed 1&C technicians perform selected portions of

MW0s R134933 and R124038.- Both MW0s were to evaluate and troubleshoot area

high temperature alarms associated with the TAMARIS temperature monitoring

system to determine that the indications and alarms were consistent with the

ambient temperatures at the sensor locations. Troubleshooting by I&C personnel

was-performed with assistance from field engineering. During the pre-work

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review of the work plan ILC technicians and the field engineer noted that the

incorrect loop calibration report was listed, and the work plan limited the

o

ability to perform actual troubleshooting. An incorrect assumption that work

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was to be doni-in the iodine filter room resulted in the involvement of a

health physics technician. Although the technician properly hung the lifted

A,

lead tags to the thermocouple wires and disconnected the leads, he proceeded

with the work for several minutes before the second technician required him to

document the lifted leads on the lifted iced tag sheet. The inspector

_ concluded that'the failure to document lifted leads in a timely manner was a

poor work practice.

Field engineering and health physics support of these

maintenance activities was good.

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-The conduct of these MW0s, collectively, showed a weakness in the licensee's

program for maintenance personnel to follow procedure; a weakness in the job

planning because the planner failed to specify the necessity for step

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sequencing, failed to include the necessary data, and made incorrect

assumptions; and a program weakness because Procedure ADM-00P8 provided an

alternative to compliance with necessary procedural 4 tail when it should not

and when-it is in conflict with Procedure ADM-0003.

In addition,

implementation of training for planners was inadequate.

Maintenance of Equipment Records and History' Area

4

-Although the licensee had a computerized and sortable record of equiament.

history, it was difficult to use without a master equipment list. T1e system

utilized a " mark" number to identify the ap111 cable system designation.

Several components were listed under more tian one mark number. The data base

appeared to be updated on a regular basis and centained sufficient data to

produce useful information, however, there was no evidence of the inclusion of

repair time. The inspector determined from discussions with licensee personnel

that there was an effort under way to generate a master equipment list, but

because of the fiscal restraints, it-was a low priority item.

The inspectors reviewed the equipment history for several components in the

'

standby service water (SSW) system and the residual heat removal system. Two

motor-operated valves in the SSW system had no equipment history records,

several components had entries under more than one mark number, and the RHR

pump entries were not under the mark number shown on the flow diagrams or in

the operating procedure. The inspectors learned that there were three

numbering systems in use; there was no independent verification of the

equipment history data; and there was no cross-reference of like component

identifiers between systems. Because each system had its own identification

prefix, component failure trending would be difficult, and unless the multiple

mark number entries were known, trending of system components would be

difficult. Thus, without correction of these problems, the equipment history

data was of limited value.

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-Work Prioritization Area and Backloo Controls

The work prioritization listing was maintained in a computerized data base with

. items separated in two categories, operating and outage. These categories were

then prioritized one through five (one being the highest priority).

The work priority method appeared to encompass all outstanding work requests.

The

multiple work request entries would suggest that periodic screening of entries

was in order. 'Although PRA is not used in assigning priorities, the priorities

were assigned.in an order that indicated safety and effect of balance of plant

items on safety were considered.

Although the start date for priority two items generally exceeded the recommended

start time of 7 days, there were no safety issues identified with the delayed

start times. The prioritization of work was satisfactory but could be improved.

The inspectors examined the backlog data, which indicated between 800 to 1000

items in the_ backlogimost of which were low priority. The mechanical and

electrical work orders had decreased over the last year, and the number of

overdue MW0s had been significantly redt.ced in the last year. Licensee

management indicated that the present backlog and work-off rate were at a

desirable level. The team considered the licensee's control of the maintenance

backlog a defined strength _in the maintenance process.

Completed Work Control Documents

An adequate program was in place for the review of completed work that had been

documented, but the' inspectors identified discrepancies that had been

overlooked during the licensee's review process.

Hydrostatic testing of-the unit cooler following weld repair of the header was

required in accordance with MWO R112280.

However, the hydrostatic test was not

. performed before returning the unit cooler to service; instead, specific steps

in the job plan were marked "H/A" by maintenance personnel.

The condition was first identified by the field engineering codes and standards

group during a review of the closed MWO and was subsequently documented in

Condition Report 88-0757. After an investigation, the licensee concluded that

a hydrostatic test that meets ASME Code requirements had been performed.

Ncnetheless, the intpectors were concerned that because the codes and standards

group did not review MW0s until after they were closed out, a failure to

perform a required step, such as the weld repair hydrostatic test, could remain

undetected for months.

Closed work plan documents, such as MWO R118513, often contained steps that had

not been performed, but no explanatory coments were provided, nor were

approved changes made to the document.

In addition, Step BB of MWO R118513

required operations to be notified of completed maintenance to ensure that any

limiting conditions for operation (LCO) associated with these MWO were closed.

The step was marked "M/A" although LC0 TR89-010 was distinctly stamped on the

front of the MWO as effective and applicable. MWO R123150 and hWO R05633 also

hed discrepancies with regard to the LC0 stamp.

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An inspection and retorque of yoke and bonnet bolts on the residual heat

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removal (RHR) ,"A" test return valve (IE12*MOVF024A), was required in accordance

withMWO56253(PromptMMO).

The MWO functional / operability testing section and Step 6 of the work plan

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required a check for a bent valve stem during stroke testing of the valve; an

entry was made that the step was "not performed." No explanation was provided

for not accomplishing the step.

Failing to follow the work plan was another

example of the apparent violation (458/8904-02) of the licensee's adherence to

procedures.

In addition, the inspectors noted that paragraph 5.14.2 of Procedure ADM-0028,

" Maintenance Work Order," required the maintenance supervisor or designee

during his post-naintenance review to " ensure all fields of the MWO are

e

correctly filled out and that all blanks have been N/A'd." The team perceived

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this instruction as counter-productive to the intent of the review. Revising

this instruction would ensure the intended review action was accomplished.

Closed work plan documents often-contained indications of abnormal problems

that were encountered during the maintenance activity. However, no evidence of

an evaluation of the abnormality existed, and apparently the licensee took no

,

further action on the described problem.

MWO R118513, MWO R120022, and MWO R118194 have examples of craft technicians

not recording problems that were encountered during maintenance activities in

the proper location of the work sheet. To be-consistent with the procedural

requirements of Procedure ADM-0028, the problems encountered are recorded and

that action is-initiated to resolve the problems.

. Inasmuch as craft technicians failed to comply with these requirements, the

inspectors considered this to be a weakness in the licensee's program.

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Closed work plan documents sometimes contained indications of improper work

practices by craft technicians in which the quality of the installed components

was not. maintained, production was adversely affected, and rework was.

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increased.

During performance of MWO R123150, the valve actuator was removed to permit

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extensive rework of the valve stem, seat, and packing. However, the actuator

was-damaged during valve repair and the actuator ceuld not be used during

reassembly. The inspectors noted that the subject of component protection

during maintenance activities was not addressed in the maintenance procedure.

s

This was considered a program weakness.

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During performance of MWO R133582, the shaft assembly was installed in the

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pump housing and the housing bolts were tightened, leaving the steps to

set impeller clearance and to make final adjustments of gland and seal to

another shift. However. while attempting to set the impeller clearance,

the subsequent shift noted that the impeller was loose on the shaft even

though the assembly steps had been signed off by the previous shift. The

pump had to be disassembled and the impeller tightened on the pump shaft

before the remaining steps could be completed.

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During performance of tiWO R134408, the as-found torque switch settings

-were 1.5 for the opened and closed positions. The recommended torque

switchsettings_(CMP-1253,AppendixA,TabulationofM0VData)were

1.75 minimum /2 maximum. The inspectors noted in Procedure CHP-1253,

Section 8.5.3, that the torque switch setting could be set-below the

.

recomended minimum value if (1) actual valve stem thrust data is

available that indicates the need to lower the torque switch setting, and

(2) design / field engineering has reviewed the thrust data'and approves the

lesser torque switch setting. The inspectors reviewed previous work

packages for the 1E12*MOVF024A valve where electrical vork may have caused

such an adjustment and approval to occur; no documented evidence was

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available to indicate that the lower-than-recommended setting had been

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. approved in accordance with the CMP-1253 procedure. This is an unresolved

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issue pending further licensee and NRC investigation and resolution

(458/8904-03). The inspectors also considered it to be a program weakness

that there was no ready method available to indicate when such adjustments

may:have been appropriate in previous maintenance actions.

During its review of closed work packages that preceded the above

described problem with the torque switch, the inspectors were unable to

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determine when, how, or why previous closecut inspections performed in

accordance with Procedure CMP-1253 failed to detect the potential problem.

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The licensee issued MWO R122427 to investigate and repair mechanical

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deficiencies noted under 11W0 R134408. The inspectors reviewed the

referenced procedure CMP-9190, " Valve Lapping," and noted that

Section 8.0, " Procedure," required steps-to be performed that were

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'different from those recorded by the mechanic. Failure of the mechanic ~to

follow the method clearly specified in the procedure was considered a

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program weakness.

Closed work plan documents sometimes contained incorrect or incomplete data

entries that the inspectors observed were inconsistent with the requirements of

Procedure ADM-0028.

For example the PM task sheet for MWO P533993 had the

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wrong component mark number, thus the clearance request for setting isolation

conditions generated confusion and delayed the commencement of the maintenance

activity. _ The computer data base from which the PM task sheet was prepared had

the incorrect mark number. The inspectors noted that the HPCS standard

operating procedure also contained an-incorrect mark number.

In addition,

MWO R134408 carried an incorrect mark nunber because the MWOR was prepared with

the wrong component mark number.

Inconsistencies in component nark numbers

appeared to be the result of the licensee not having a complete master

equipment list, which was considered a progran weakness. Such errors could

clso contribute to poor naintenance history if left uncorrected.

Closed work plan documents were often noted to lack sufficient, specific work

plan steps that would permit the craft technicians to explicitly accomplish

their work:

No procedures or vendur technical manuals were referenced by 11WO 56253 to

assist with the accomplishment of certain steps.

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The installation of Oatis Signature test equipment was called for by

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MWO R134408. However, wiring diagrams were neither referenced nor included.

Although MWO R123150 referenced procedures and the vendor's manual, it was

not specific. The vendor's manual contained many sections that were not

directly applicable to the task, and applicable sections of referenced

procedures were seldom specified in any of the work plans.

In general,

the level of detail was poor.

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The practice of not referencing specific sections of technical manuals or

procedures and the= lack of a definitive program was inconsistent with the

requirements of ANSI N18.7-1976, " Administrative Controls and Quality Assurance

for the Operational Phase of Nuclear Power Plants," Section 5.3.5 (4),

" Supporting Maintenance Documents." This poor practice was considered a weakness.

.

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.The inspectors reviewed selected liW0s that contained LCO-related conditions.

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Most of these NW0s included work plan steps that required the maintenance

foreman to-ensure that the LC0 was cleared when the work completed (for example,

MWO R123150, Step T, and MWO R117861, Step 5).

However, the inspectors found

this incongruous because the maintenance technicians cannot ensure the LC0 is

cleared when work is complete; therefore, they should not be tasked with the

responsibility.

It appeared to the inspectors that at the time the shift

supervisor / control operator foreman completes his review of the MWO, following)the

he should be:specifically tasked with the review of outstanding LCOs against the

MWO and take proper; administrative action.

The following example illustrates a conflict between two procedures, which

could have led _to the shift supervisor not being aware of plant status. The

licensee performed MWO R134856 to install a filter'in the air supply line to

ASCO Solenoid Valve IHVR* SOY 10B. 'To deenergized the solenoid for overhaul,

the technicians used the loop calibration report diagram (1.THVR.038) to

determine the point at which the power leads should have lifted and decided to

lift leads in the control room termination cabinet. When one of these leads

was lifted, five additional air dampers unexpectedly changed position (CR 89-1058).

When the NRC inspector reviewed the MW0, he found that the " problems encounter /

remarks" section of the work performed section was inappropriately narked N/A

and the shift supervisor approval block was marked N/A by the field engineer.

Procedure ENG 3-006, " Modification Request Control Plan," Section 6.9.5,

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rovided the field engineer authority to sign the MWO for the shift supervisor

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p(for MW0s initiated to perform work under a modification request).

Procedure ADM 0028 for control of Sections 5.16.1 and 5.16.2 of the MWO required

the shift supervisor / control operator foreman to review MW0s to insure applicable

retests were performed and to complete applicable portions of the sign off

section of the NW0.

!

On September 30, 1989, while conducting Procedure STP 051-0201, "RPS-Main Steam

'

Line Isolation Valve Closure Monthly ChFunct," an unexpected reactor scram

occurred. The licensee's investigation (CR 89-1070) showed that the contacts

on Test Switch C71-56D, Channel D, were open rather than in their normally closed

position. This test switch, General Electric (GE) Model CR 2940, is a three-

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position key-operated switch, the key can only be removed when the switch is in

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Lthe normal position. The key was removed and the switch-appeared to be in the

! normal position; however, the switch was actually about 1/32 of an inch off the

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normal position and the contacts were open. The last known operation of the

Channel D test switch occurred on September 2, 1989, during the previous monthly

check of Procedure STP 051-0201. The Channel D test switch was replaced and the

plant returned to power operations.- At least one switch from spares exhibited

the same fault:

the key could be removed before the contacts were in the desired

position. On October 3, 1989, all spare GE CR 2940 switches were evaluated, and

8 of 23 failed. The licensee's root-cause cvaluation of the switch failure was

in progress at the end of this inspection. Condition Report 89-1079, dated

October 3, 1989, identified 24 GE Model CR 2940 type switches installed in the

control room. The licensee's engineering staff verified that the switch contact

of interest (three and four) for all 24 installed switches were in the proper

position. The facility review committee authorized restert, in part, on the basis

of GE design philosophy that includes a light or an annunciator when switches

are used for bypass. The inspectors were concerned that this decision was based

F

on a design philosophy rather than rigorous engineering evaluation.

During the troubleshooting efforts of the reactor scram of September 30, 1989, a

field engineer noted two schematic diagrams for the reactor protection system

(508 series) were missing from the control room set of control prints.

He

informed the shift supervisor at that time. On October 2, 1989, the two schematics

were.still missing. Discussion with the shift supervisor revealed that he had

audited the 508 series of diagrams and that the missing prints were being replaced

that afternoon. Procedure ADM 0005, " Station Document Control," Section 4.5,

assigns responsibilities for maintaining control over documents within their

respective satellite station to satellite station custodians. The compliance

department committed to a 100 percent audit of the control room prints.

3.2- plant Maintenance Organization

3.2.1 Scope

The objective of this part of the inspection was to determine the effectiveness

and extent of control exercised by the plant maintenance organization for

maintenance activities in the mechanical, electrical, and instrumentation and

control areas. Management oversight and control of contracted maintenance and

handling of deficiency identification and control methads also were evaluated,

as were maintenance trending and support interfaces.

3.2.2 Conclusions

Although the licensee had good programs in place and was achieving good results

'in' implementing the programs in the electrical and I&C disciplines, some

improvement in the mechanical area was required. The deficiency reporting

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program was readily available and used by plant personnel in an adequate

manner. Maintenance trer: ding programs were not developed and implemented.

Support interfaces were adequate, but required some improvement'in some areas.

While contracted maintenance appeared limited (almost exclusively to personnel

services) the licensee's controls appeared adequate for ensuring that contract

personnel were properly trained and supervised while working on site.

However,

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management attention was needed to ensure that contract work was adequately

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controlled and documented. The lack of an objective verification of education

and experience claims by contracted personnel was considered a weakness.

The . licensee's system for identification and control of deficiencies was well

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documented and the tracking and accountability of the deficiencies were effective.

The program was availabic to, and frequently used by, plant-personnel. However,

the length of time some quality assurance finding reports have remained open

a1peared to be excessive and was considered a weakness in the implementation of

'tle program..

Support for direct maintenance activities by engineering, quality control,

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. operations, safety, health physics, and supply departments was demonstrated to

be~ adequate.

3.2.3 Findings

Electrical Maintenance Organization

The inspector considered the technical ability, attitude, and conscious commitment

of the electrical maintenance organization personnel a strength. They did an

excellent job of following procedures and documenting the results.

The inspector observed that the electrical maintenance organization adhered to an

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orderly process of identifying electrical maintenance needs. Work order priority

was recognized and progressed accordingly. Supervisors were kept informed of-

progress and any unusual delays or problems. ~ Craft personnel. documented and

instituted action to correct deficiencies noted.during their performance of work

activities. -The work orders contained detailed descriptions of work performed,

.

documentation of deficiencies, corrective actions instituted, and other actions

important to the work activity.

System integrity was maintained through proceduralized tagging of lifted leads,

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jumpers, and removed equipment during maintenance activities.

Electrical foremen

interfaced with the craft on the job site and monitored maintenance activities.

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z(he inspector reviewed the work package to upgrade power line conditionsISCI-XRC1

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The work package contained QC. hold points to verify qualified parts were

controlled. The testing was done with a marked-up copy of.a startup procedure.

Although this procedure was narked up extensively, it did not provide the

S

require acceptance criteria for upgrade.

.

Qualif.ication status was maintained current through the training department and

job assignments were made according to each individual's qualifications and needs.

The work order briefing sheets contained the signature of the craft employees

assigned along with that of the foreman, who assures that the employees assigned

to perform.the work are properly qualified. This provides an auditable system

to detect qualification discrepancies during maintenance activities. Procedures

used with work activities are checked out to an individual and dated, which provides

an auditable trail to ensure that the correct revision of the procedure is used.

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When H&TE personnel issued maintenance tools, they checked to see that they

were calibrated and noted this in the work documents.

The inspector observed several controls and work practices to ensure that

maintenance activities returned the systems to their normal operating

configurations. The electrical group adhered closely to work order instructions,

which required the proper tagging of components. They exhibited excellent

,,

housekeeping work practices during and at the completion of work activities.

The work activities were well documented to provide accountability of work

_

' performance. Work documents were promptly and adequately reviewed to ensure

all requirements of the work activity had been properly accomplished and

acceptable, or that exceptions were properly identified. All four electrical

maintenance crews and associated foremen exhibited excellent work practices and

demonstrated knowledge in the areas observed. Although not always equipped

with modern equipment, such as breaker lifting and testing devices, the quality

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of-their work was not affected. The electrical maintenance group communicated

well with other organizational groups to coordinate their work activities.

Mechanical Maintenance Organization

Station procedures and policies controlled the maintenance activities of the

mechanical discipline and provided a generally adequate methodology. However,

as discussed in Section 3.1.3, specific areas required further licensee

attention. Although the mechanical group seemed well aware of requirements

affecting the performance of their trade, errors in performance did occur.

Nonetheless, the mechanical group demonstrated a strict adherence to safe

practices in the operation of vehicles and a good knowledge of special chemical

(ontrol permits. They were able to reference appropriate guidance to clarify

questions. Craft-personnel. demonstrated a clear understanding of what to do

when work plans could not be complied with. The correct use of spare parts was

clearly understood. The mechanical technicians appeared to be highly motivated

toward performing their tasks correctly and showed a willingness to adhere to

procedure.

In contrast, however, on one occasion, the torque wrench that would

be used to tighten cap nuts on a check valve was dropped with no apparent

regard for the possible upset in wrench calibration.

(It was not able to be

determined whether the wrench would have been subsequently used since the

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maintenance was interrupted.)

First line supervisory attention was readily apparent on the job, with craft

level knowledge noted to be very good.

Supervisors routinely demonstrated

their responsibilities to assign properly qualified personnel and to conduct

proper prejob briefings.- However, as noted elsewhere in this report, attention

to critical administrative detail was noted to be lacking. A peer evaluation

-progran for the mechanical discipline was implemented during the inspection

period to increase monitoring activities of craft performance.

If improved

performance does not result from this v:tivity, the licensee should consider a

higher level of management involvement in on-the-job site evaluation.

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Instrumentation and Control (I&C) Maintenance

The I&C maintenance activities were controlled by station procedures and

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policies. The MWORs were documented and processed for corrective maintenance

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work'

Approved MWOPs were routed to the work planning department for development

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of an MWO package. The MWO was routed to the I&C supervisor who assigned a foreman

to accomplish the work. The foreman assigned the work on the basis of the training

~ and experience levels of their crews.

Each foreman briefed the work crew and

documented the briefing in the work package. The crew assembled the necessary

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. tools, spare parts, and test equipment, obtained the required clearances and work

_

release, and performed the work in accordance with the MWO. Procedure ADM 0028,

' Maintenance Work Order," details the responsibilities and processing requirement

>

for"the accomplishment of maintenance activities. Most of the I&C work packages

contained reference to a vendor manual and a loop calibration report (LCR),

N . , ';

Vendor technical documents and information were maintained current by the

engineering department, in accordance with the requirements of Procedure EDP-AA-65,

" Review and Processing of Vendor Technical Information" and RBNP 032, " Processing

of Vendor Technical-Information." These procedures require all vendor technical

information received to be routed to the engineering department for review and

approval before being used during maintenance activities. LCRs were prepared by

the design engineering department. Use of LCRs by I&C technicians was governed

by Procedure liCP-4001, " Loop Calibration." Configuration controls were detailed

in Procedure GMP-0042, " Circuit Testing and Lifted Leads and Jumpers."

'

The IAC technicians demonstrated the knowledge and understanding of procedures,

willingness to adhere to procedures, and the skills necessary to accomplish

maintenance and repair at the station. The inspectors noted that I&C foremen

routinely went into the field to check the progress of_ work crews. The work

crew documented its work in the MWO. This description of work consistently was

detailed and complete. The inspectors considered the work performed section of

the MW0s a strength.

.The program and implementation process of controlling maintenance activities in

the I&C department was adequate. As noted in the previous section, the inspectors

were concerned about tile errors contained in some work plans. The inspectors

learned from I&C planners that a recent loss of one planner had placed an excessive

burden on the remaining planners.

Contracted Maintenance

During the review of completed MWO P530212 to perforn Procedure PMP 1245,

" Preventive Maintenance of the Emergency Diesel Generators EGIA and EG18," the

inspector questioned the licensee as to whether certain data met the accQi.ance

criteria of Procedure PMP-1245 for Diesel Generator EG1B. The licensee

subsequently reviewed the data and declared the diesel generator inoperable and

entered the actions of Technical Specification 3.8.1.1.

The data reviewed for

Procedure PMP 1245 had been transferred from other documents and procedures

~

that the licensee had performed under contract work. The licensee subsequently

decided that the acceptance criteria of Procedure PMP 1245 required changes.

.The licensee's failure to review properly the completed Procedure PHP 1245 data

and correct the unacceptable data reflects a failure to control work activities.

Essentially all contracted maintenance was subject to, and worked in accordance

with, the licensee's program, as opposed to working under the contractor's

program approved by the licensee. Most contracted personnel were used to

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augment the existing plant staff during outages or major modifications. One

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recent exception was a contract with Cooper-Industries for maintenance on the

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emergency diesel generators. - The contract specified the scope of work, the

qualifications of the personnel, and the required experience,

m

Procedure MSP-0028. " Qualification of Contract Maintenance Personnel,"

.

Revision 2, was one of several procedures that provided requirements for

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training and control of contracted personnel. This procedure specified minimum

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experience and education levels. The Cooper Industries contract contained

!

these procedural requirements, which included site-specific training structured

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to-the discipline involved.

In addition to general site access training,

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contracted _ personnel and their work was monitored by licensee management, and

all work performed was under direct supervision or done with qualified

!

personnel.

While the- control'and training of contracted personnel af ter they arrived on

'

site was adequately addressed, the preemployment or preaward verification of-

!

personnel appeared to be lacking. Even though there were procedural and

4

contractua.1 requirements concerning education and experience of personnel,

there were no procedural requirements or evidence that objective _ verification

,i

of education and experience was being acconplished.

'The inspectors reviewed the control of contract personnel during the secnnd

refueling outage. . Several examples were identified by the licensee and/or NRC

inspectors that indicated that control over contract personnel was not adequate

to prevent significant violations of the clearance program or to control the

performance of maintenance activities.

Deficiency Identification und Control Area Methods

There were four methods of documenting deficiencies:

the condition report, the

quality assurance findings report (QAFR), corrective action report, and stop-work

_i

order. _ Each of these methods was trended and each deficiency was subjected to

a root-cause analysis. Other less formal means of documenting problems would

.

be the internal " audit concerns," which were tracked and closed but not

trended.

The most frequently used methods for documenting deficiencies were the

condition report ind the QAFR. The QAFR was the principal method used to

document internal audit findings related to programnatic deficiencies or other

p oblems not related to hardware. The condition report was used to document

all hardware deficiencies and programmatic or software problems (in some cases).

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The system for accountability.and the tracking of condition reports and 0AFRs

appeared well established and effectively implemented. Since condition reports

related primarily to hardware, their closure was often dependent on maintenance

and outage schedules. -On the other hand, QAFRs, which related to programmatic

issues, should have been closed promptly; however, as of October 4,1989, there were

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69 0AFRs that were open. Ore of these QAFRs had been open 1140 days and six

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others had been open more than a year. The inspectors considered this a

program weakness.

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Support Interfaces

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On-the basis of direct observation and discussion with shop supervisors and

craft personnel, the inspectors determined that support of direct maintenance

activities was fully implemented. Support engineers and personnel willingly

assisted in maintenance and troubleshooting efforts. Support personnel demon-

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strated an excellent attitude and commitment to the maintenance of plant

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systems and equipment.

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One good example of support personnel involvement was during the QC coverage

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provided for MWO R134876. During the work on this MW0, the QC inspector noted

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the need for additional QC coverage for other work in progress for the

1A diesel generator. He arranged for the needed coverage and work proceeded

with very-little delay.

In. addition, the electrical system engineers provided

full inspection coverage and assistance during the 1A diesel generator system

outage,

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Another was I&C's implementation of a program to support the chemistry depart-

ment. One technician is assigned to provide. direct interface with the

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chemistry department ~ to improve the reliability of analytic instrumentation.

!

3.3 Maintenance Facilities and Materials Contro_1

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3.3.1- Scope

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The objective of this part of the inspection was to assess the maintenance

facilities and controls over equipment, tools, and materials accessibility to

determine how well these elements support plant maintenance and repair work.

Implementation of these controls was not inspected.

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3.3.2 Conclusions

f

The licensee's maintenance facilities were of excellent quality and located so

that they were easily accessible.for the support of maintenance. The program-

"

for material control was found to be well documented, covering all aspects of

receiving, handling, and storage of material. Although the measuring and. test

equipment programs and implementation were considered adequate, an inventory

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control system was needed to strengthen the maintenance tool and equipment

4

area, as well as a method to enhance the experience icvel of issue room

attendants.

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3.3.3

Findings

Maintenance Facilities and Equipment

The inspectors found the arrangement and location of the work shops adequate to

,

support maintenance and repair work. The primary work shops, for example,

machine, I&C, and electrical, were located in the service building. The

inspectors found that the. cold and hot machine shops were particularly well

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equipped to support any conceivable task the licensee would choose to perform

in-house. Contaminated equipment awaiting shipment in the hot machine shop

appeared minimal.

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The array of machinery far exceeded the machinist staffing available to take

advantage of the equipment. The areas were well maintained with adequate laydown

areas for larger components, and an area for personal tools was available to each

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mechanic. 'A highly motivating benefit for each maintenance technician was the

company policy of providing a complete set of personal tools to the technician,

with lost or damaged tools being provided from company stock.

Maintenance manager and supervisor offices were situated close to the shop areas,

providing reedy access to the work spaces for management and supervisory personnel.

The' tool and M&TE issue room was located in the T-tunnei between the turbine

building,and switchgear room.

Contaminated equipment was separated by a cyclone -

fence within the issue facility. The issue facility location supported outage

work when access to the plant was through the T-tunnel; however, this location

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was somewhat inconvenient during routine operations when access to the-plant

through'the T-tunnel was restricted by the health physics department.

Materials Control

The 13 naterials handling procedures provided well-documented controls and

direction for all aspects of receiving, storage, handling, and control of materials.

These procedures were supplemented by Procedure GitP-0041, " Storage and Maintenance

of Material / Equipment," Revision 4; Procedure RBNP-045, " Materials flanagement,"

Revision 0; and Procedure QCI-3.0, " Receiving-Inspection," Revision 10.

The site had three warehouses. The principal warehouse, from which all site

material was received and distributed, was designated "B."

Warehouse "A" was

basically a long-term storage facility. A third facility, designated "RB2,"

was'*n i.he protected area and was primarily used to store and issue consumables

and as a staging area for long-ter:n activities.

The inspector observed that Warehouse "B" was clean and orderly and had a

temperature-and-humidity-controlled area for storing sensitive components and

material. Nonconforming material (i.e., material with inadequate

documentation,= or material awaiting disposition) was segregated in a locked,

fenced area.

Maintenance Tool and Eauipment Control

The issue room attendants controlled the tools and ecuipment necessary to

support maintenance activities (other than normal hand tools). Each issue was

logged by unique identification number, date checked out, and date returned;

checkout was limited to one shift unless specifically authorized by maintenance

supervisors. Personnel checking out tools or equipment were required to be on

a list of approved personnel.

Issue room attendants were classified as utility workers and were entry level

workers who were normally promoted (by seniority), if qualified, to an

appropriate open position as they became available. The result of such

promotions kept the experience level of issue attendants low--currently less

than one year in the job. The licensee had recognized the low experience level

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of' issue room ~ attendants as a program weakness and was negotiating with union

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representatives to establish a permanent position for an issue room attendant.

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The' inspectors believed the low-experience level of the issue room attendants

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could have contributed to the improper issue of M&TE dial indicator, DIN 130A,

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on September 17, 1989.

C1

The issue room supervisor had implemented a program to improve performance of

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the issue room attendants. The attendants demonstrated an understanding of

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issue control pro edures and a conscientious attitude toward properly

>

implementing procedures.

The. team inspected the tool issue and storage facilities and found them to be

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very clean and well maintained. Three locations were used in addition to the

_.

main'issuepointforstorageofbackupsuppliesofseldom-useditems(suchas

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refueling only items)..

.o

Although current inventories were available for the storage locations, no

current, correct inventory was available for the main storage / issue point for

non-M&TE items. The inspector noted that an approximate 10 percent

'..

nonavailability rate was being recorded by the licensee on non-M&TE issue

requests, most'of which were common items. The inspectors noted that in

addition _ to-not having.an inventory of. items, the licensee had not established

a system of minimum / maximum quantities of items, nor defined a system to

reorder when reaching some predetermined quantity of an item.

Inventory

control of non-M&TE tools was mostly reactive to requests for tools that could

not be fulfilled, rather than proactive in the sense of determining tool needs

for tasks expected to be accomplished in the future.

Nonetheless, inspectors

did observe proactive thinking with regard to a major work item to be undertaken

in a forthcoming outage--special tools were being identified and procured well

-in advance of the planned maintenance activity.

In addition, the MATE supervisor

.had implemented a survey of issue room transactions to determine the adequacy

of the quantity and quality of tools and equipment. Although this program was

not formalized,-the inspectors considered it a strength to improve the material

,

and equipment control system.

Control and Calibration of Measuring and Test Eouipment

Procedure ADM 0029, " Control of Measuring and Test Equipment," established the

facilities M&TE program. The procedure details the issue, recall, storage, and

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segregation of special- or limited-use M&TE. This procedure provided

instructions for placing damaged equipment out of service and for resolving the

use of out-of-tolerance equipment in the field.

Each piece of M&TE had a "use card" that was used to record the date out, name

of person checking out, department head authorization, date checked in, name of

person checking in, tracking card used, initials of the clerk checking in the

device, the device identification number, and the calibration due date.

Tracking cards were filled out by the equipment user for identification of

usage in case an out-of-tolerance condition was detected.

Recall of M&TE

approaching the calibration duc date was controlled by computer sort and manual

review of use cards by issue room attendants; this process was conducted twice

weekly.

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Procedure ADM 0029 permited issue room attendants to replace missing or defaced

M&TE calibration labels after verifying by document review that the device was

< in calibration. The M&TE supervisor indicated that this weakness may have

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contributed to the improper issuance of.a piece of test equipment, DIM 130A

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.(discussed below), and that the strengthening of the procedure in this area

would be accomplished;

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The M&TE storage was~consid"ernd adequate. However, out-of-calibration and

out-of-service M&TE items were not. physically separated for storage from the

ready-for-issue racks and, labeling did not clearly identify the segregated

storage racks.

In addition to the inappropriate storage of a dial indicator in

,

a zip-lock storage bag (discussed in some detail below), some items of test

equipment (notably, circuit extender cards) were stored in a jumbled mess.

Damage to an extender card would probably not be detected until used for-

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troubleshooting-or equipment calibration, in which case it would then delay

work.

Th'e MWO 122471 for service water motor overhaul and pump repack contained

information on the details continuation sheet dated September 17, 1989, that

M&TE Dial Indicator DIM 130A was issued for field use after its calibration due

date. The licensee did recheck the dimensions with DIM 121A; which was in

. calibration. During inspection of the 11&TE issue room on September 20, 1989,

the inspectors found DIM 130A located in the ready-for-issue section of the

M&TE room. Dial Indicator DIM 130A was stored in a plastic zip-lock bag, a

calibration label attached to the bag indicated the date of calibration was

-April 26, 1989, and the due date was July-26, 1989. This did not correspond

with the M&TE master list update, which stated that the dial indicator was

received and calibrated by the calibration facility on April 12, 1989. A

calibration due date of October 12, 1989,- was assigned and the dial indicator

was returned to the M&TE issue facility on April 17, 1989. The M&TE use log

indicated DIM 130A was used several times during April and May 1989, and,the

tracking' card, dated May 5, 1989, indicated the calibration due date for

. DIM 130A was July 26, 1989. This date conflicts with the master list and the

M&TE use log.

In addition, tb.e M&TE use log indicated that on September 17,

1989, DIM 130A was issued to mechanical maintenance on two occasions.

The inspectors concluded DIN 130A was issued on September 17, 1989, in

violation of Procedure ADM 0029, " Control of Measuring and Test Equipment,"

because the calibration due date was not verified. Additionally, the return of

DIM 130A to the ready-to-issue section of the issue room was considered a poor

practice. Procedure ADM 0029 required the issue room attendant to check

returned H&TE items for missing or defaced calibration labels. During this

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check the attendant should have noted the expired calibration due date and

implemented an out-of-service report. The storage of sensitive M&TE items in

unprotected zip-lock' bags was considered inappropriate.

Twenty M&TE items scheduled for calibration were checked by the inspector to

make sure they were properly removed from service and segregated.

Ho

discrepancies were noted. During conduct of activities in the calibration

laboratory, the inspectors noted that all equipment in use was in calibration,

personnel appeared knowledgeable of procedures, and the facility temperature

cnd humidity were properly controlled and monitored.

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3;4, Personnel Control

.3.4.1

Scope

The objective of this part of the inspection was to determine the extent to

which personnel are trained and qualified to perform maintenance activities,

~ including staffing, training, and current personnel control status.

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'3.4.2

, Conclusions

,

The licensee's human resources policies had been implemented and established

effective staffing controls.- However, the inspectors noted that projected

-staffing-levels could negatively affect both maintenance and the technical

support areas..

The licensee's supervisor / worker ratics appeared sufficient to effectively

maintain control and coordination of work activities although supervision of

maintenance personnel with regard to procedural adherence needed improvement,

w

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sThe licensee, with few exceptions, pursued an aggressive training and qualification

program with its maintenance personnel.. Additional attention by management is

.'

needed to ensure the maintenance planners are adequately trained to produce quality

work packages. Furthermore, systems engineers needed specific dedicated systems
training.

- 3.4.3' Findings

The licensee's training and qualification program had been INP0 accredited and

appeared well documented. The licensee has initiated formalized training for

plant management.

However, it was noted that not all maintenance planners have-

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received the basic boiling-water reactor series training and, in some instances,

had not- received maintenance _ work order administr6 f on training. Furthermore,

the systems engineers have not received specific dedicated systems training.

.

The facility's organization chart was current.

Plant management monitored

staffing levels and trended relevant data, including reasons for terminations.

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Plant staffing levels for 1989 were about 100 persons below the' full plant

staffing complement. Plant performance data showed that attrition rates in the

.I&C, radiological protection, chemistry, and mechanical maintenance disciplines

-had exceeded the plant's desired goals. Furthermore, the engineering staff will

1

be reduced by 14 persons by December 1990 with only 6 planned requisitions.

The. inspectors were concerned about the potential impact of the reduction in

the systems engineers' workloads and the effectiveness of recently initiated

-programs.

_

Procedure MSP-0009, " Qualification of Maintenance Personnel," governed the

qualification of craft maintenance personnel. This procedure provided for a

two-part training program for specific skills in each of the disciplines. A

computerized training matrix was maintained to indicate each maintenance

technician's status of completion of skill requirements in the classroom and on

the job. This matrix was the supervisors' tool for determining job assignments

for individuals', and foremen used it in job assignments to ensure that persons

were qualified. However, the inspectors learned that foremen were not always

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careful about making sure thatLjob assignments maximized on-the-job training

opportunities for unqualified personnel and that completed on-the-job training

was preperly recorded'to assure maintenance technicians were qualified in as

many skills as:possible, as quickly as possible.

Increased management attention

had shown improvement in this area.

Maintenance training needs were established in 1983 and had not been reviewed

or revised since that~ time. Training personnel agreed that additional training

needs had been identified and needed to be incorporated into the program. The

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inspectors found that approximately half of the maintenance foremen and

supervisors had received very little technical training,

s

Discipline' supervisors indicated that the training department was generally

. responsive to training reeds. Maintenance craftsmen appeared well trained,

knowledgeable of the plant, and cognizant of safety hazards associated with the

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work site. However, supervisory training in administrative responsibilities

was not very effective and,-in some cases, hindered the maintenance process as

discussed in other sections of this report. This condition was exacerbeted in

the mechanical area,by the current shortage of staff (approximately 10 percent

,

under allowance) and the apparently high rate of turnover (approximately

10 percent per annum). The licensee should consider modifications in personnel

programs.that will increase technician retention and broaden the experience

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base.

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lThe inspectors 1found the licensee's perconnel control methods sufficient

although future review by plant / corporate management was encouraged. The

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licensee had established and inplemented a drug screening program and has had

success in screening potential hirees. The training and qualification program

appeared adequate at the craft level but needed further attention by management

,

in the area of planners and system engineers. The plant staffing levels

$

appeared adequate to maintain the plant and keep work order levels and

backlog-to-workoff rates within acceptable ranges.

However, I&C planners were

understaffed and system engineers could t,e affected by projected terminations.

The inspectors were concerned about the financial health of the corporate

entity and resultant budgetary constraints affecting maintenance activities and

staffing.

Plc.nt performance indicators relative to plant expenditures showed

that the licensee expended large amounts of funds in preparation for and during

the second refueling outage.

In contrast, post-outage expenditures were

significantly.below projected norms. The inspectors informed the plant manager

that the future balance between funds, staffing, and enhancement programs

relative to maintaining a healthy and effective maintenance program will

require close and vigilant monitoring,

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EXIT IllTERVIEW

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The inspectors met with Mr. T. Plunkett and other members of the licensee's

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staff at the end of this inspection on October 6,1989. The inspectors-

sunearized the scope of the inspection and presented the inspection findings.

The licensee did not identify- as proprietary any of the materials provided to,

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or reviewed by, the inspectors during this inspection.

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0n October 17, 1989, Mr. J. Jaudon, Mr. J. Gagliardo, and Mr. J. Cummins held

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an exit interview with Mr. J. Deddens and other members of the licensee's staff

and discussed the scope and findings of the inspection.

Persons contacted by

the team and attendees at the exit meeting are identified in Attachment A.

The color-coded presentation tree (Attachment C) was used as a visual aid

during the exit meeting to depict the results of the inspection.

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ATTACHMENT A

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PERSONS CONTACTED

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The team also contacted'other members of the licensee's staff during the

inspection to discuss' identified issues ~.

Those persons with an asterisk preceding their name were in attendance at the

exit meeting held on October 17, 1989.

A

Licensee Personnel

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A. Abella, Field Engineer

R. Adamc, Issue Room Attendant

F. Allison, I&C Planner

J. Amburgey, Senior Nuclear Engineer

T. Anthony, Supervisor, Performance Program and Testing

R. Backen, Operations Quality Assurance

G. Baranek, Senior Planning and Scheduling Specialist

R. Barnes, Supervisor, Codes and Standards

W. Beck, Supervisor, Balance of Plant Design

M. Bissell, 18C Technician

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_B. Blose, Supervisor, Electrical Maintenance

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  • J. Booker, Manager'- Oversight

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_M. Bourgeois, Issue Room Attendant

' W. .Bushall, Jr. , Nuclear Training Coordinator-- Maintenance

G. Bysfield, Supervisor, Control Systems

'G. Canfield, Measuring and Test Supervisor

  • E._Cargill, Director, Radiological Programs

N. Carver, Director Employee Relations

D.,Chustz, Maintenance Support Supervisor

  • J.; Cook, Lead Environmental Analyst

R. Cooke, I&C Technician

R. Coppo, NPRDS Data Section

  • T. Crouse, Manager Quality Assurance

.

L. Cununings, Senior Planning and Scheduling Specialist

K. Dawson, Field Engineer-

  • J. Deddens, Senior Vice President.
  • D. Derbonne, Assistant Plant Manager-Maintenance
  • L.'Dietrich, Supervisor, Nuclear Licensing

P. Dinecola, I&C' Technician

C. Edwards, As Low As Reasonably Achievable Technician

M. Feltner, Engineer, Licensing

C. Foster, Tool Issue Foreman

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J. Fulkerton, I&C Technician

J. Galloway, I&C Technician

R. Gaylor, Co.mputer Systems - Field Engineering

E. Glass, I&C Supervisor (Acting)y Engineering

K. Giadrosich, Supervisor, Qualit

  • P. Graten, Executive Assistant

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J. Hamilton, Director, Design Engineering

W. Hardy, Supervisor, Radiation Protection

R. Hebert, Supervisor Inventory Management

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  • L. Johnson, Site Representative.

A. Kugler, Supervisor, System Supervisor -

  • G. Kime11, Director, Quality Services

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W. Leib, Mechanical Staff Assistant

  • J. Levines, Director Field Engineering

D. Lorfino, Senior Licensing Engineer

R.-McCartney, Mechanical Maintenance Foreman

  • D. Metcalf,-Quality Assurance Engineer

J. Morgan,-System Engineer

-

"J. Mullin,- Mechanical Maintenance Foreman

  • V. Normand, Supervisor of Maintenance Services

G. Hunnery, IAC Technician

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  • W. Odell, Manager, Administration

F. Odom, Calibration Laboratory Supervisor

J. Oliver, Mechanical Maintenance Foreman

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  • T. Plunkett, Plant Manager

F. Prudhomme. I&C Foreman

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R. Redmond, Quality Assurance Engineer

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D. Reynolds, Administrative Support Supervisor

S. -Rima, Nuclear Training Representative

B.' Rogers, QC Inspector

A. Roshto, I&C Technician-

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J.' Salmon, Systems Engineer

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M. Sankovich, Manager, Engineering

  • J. Schippert, Assistant Plant Manager -

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J. Simpson,' Nuclear Maintenance Planning Supervisor

A. Smith, I&C Technician

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B. Smith, Senior._ Planning and Scheduling Specialist

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A.-Soni,: Supervisor, Specifications and Qualifications

A. Speeg, I&C.; Staff Assistant-(Acting)

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'G. Stout, I&C Technician

'T. Su, Field Engineer

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  • K. Suhre, Manager Pros Maintenance

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L. Thompson, Senior Planning and Support Specialist

B; Trude11, Shift Supervisor

H. Uorthrop, Supervisor Warehouse Operations

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R. Yachon, Compliance Department

M. Vierra,'As-Low As Reasonably Achievable Technician

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  • C. Walker, Supervisor, Quality Control

C. ' Walling, Senior Mechanical Engineer

  • R. West, Assistant Plant Manager, Technical Services

R. Whitley, Quality Control Inspector

F. Wilson, Senior Planning and Scheduling Specialist

D. Zemel, Mechanical Maintenance Supervisor

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  • J. E. Cumins, Reactor Inspector, Operational Programs Section, Region IV
  • E. Ford, Senior Resident Inspector, Region IV-

. J. E., Gagliardo, Chief, Operational Programs Section, Region IV

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  • F. Hordon, Director, Project Directorate IV, Office of . Nuclear Reactor

Regulation, NRC Headquarters

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  • W. B. Jones, Resident Inspector, Region IV
  • W. Paulson, Office.of Nuclear Reactor Regulation, NRC Headquarters

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American Society of Mechanical Engineers

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Electrical. Power Research Institute

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general employee. training

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health physics

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high-pressure core spray-

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loop' calibration' report

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clicensee event. report

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linear variable differential transformer

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maintenance. enhancement program

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maintenance team inspection

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maintenance work order-

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maintenance work order request

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nuclear plant reliability data systems

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OccupationalfSafety:and Health Act

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preventive maintenance-

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probabilistic' risk assessment

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.penetrat' ion valve leakage control system

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quality assurance

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reactor core isolation cooling

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residual heat removal

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significant operating experience report

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