ML20043A527

Insp Repts 50-327/90-17 & 50-328/90-17 on 900406-0505. Violations Noted.Major Areas Inspected:Control Room Observations,Sys Lineups,Radiation Protection,Safeguards, Surveillance Testing & Followup to Generic Ltr 88-17

ML20043A527
Person / Time
Site:	Sequoyah
Issue date:	05/16/1990
From:	Brady J, Harmon P, David Loveless, Linda Watson NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II), Office of Nuclear Reactor Regulation
To:
Shared Package
ML20043A521	List: ML20043A520 ML20043A526 ML20043A527
References
50-327-90-17, 50-328-90-17, GL-88-17, NUDOCS 9005220196
Download: ML20043A527 (18)

See also: IR 05000327/1990017

Text

{{#Wiki_filter:v ' , .. l

4 + . , pist UNITED STATES g

,

'o : NUCLEAR REGULATORY COMMISSION q 6 , [ REGION 11 j b.

_ E f.- 101 MARIETTA STREET N.W. i ATLANTA, GEORGI A 30323 'l ) .....,/ l - g ! - , d > Report Nos.: 50-327/90-17 and 50-328/90-17 ' ' " d Licensee: Tennessee Valley Authority- ' 6N 38A Lookout-Place 1101' Market Street' Chattanooga;: TN : 37402-28C' . > 1 , Docket;Nos.: ' 1 50-327 and 50-328. License;Nos.:,~0PR-77 and/DPR-79i l FacilityName:;Scqboyah' Units 1and!2 _ Inspection Conductes April'_6,:1990 - May,:5,;1990' ., 'l'ead Inspector: N /JM h 6/&hf 'F. Hapn,;5eniot' Resident LInspector-

Dete Signed

r Inspectors :- M (t / 4 N i k k /C/k D. Lovelpts, ResidentvInspector .Date Signed j h b l(oNb ~ J. Bradyt( Project Er)91neer.: Datb 51gned- ! . Approved.by: N/w9,4MIC 5[/N/94 L. J..Watspf, Cnief, Project Section 1 Date 71gned ) TVA Projects _ Division Office c,f- Nuclear Reactor Regulation: ! ' SUMMARY- Scope: 1 This announced inspection involved inspection effort byj the Resident Inspectors in the area of operational safety ' verification- includingL control room l observations, operations performance, system lineups, radiation protection. . 1 safeguards, and conditions adverse to quality., Other areas ' inspected included . surveillance testing, maintenance, refueling activities. facility modifications, ., - i followup on Generic Letter 88-17 licensee alf-assessment capability - and. event followup, a Results: 1 One violation was identified which --involved a failure to -follow the i requirements of AI-47 for dispositioning ~of step sequence deviations, paragraph 8.a. 0ne non-cited. vf 01ation_ was identified pertaining to loss of a { 6.9 kv Shutdown Board which involved operator error,;an inadequate surveillance 1 procedure, and clearance problems,-paragraph 8.b. a r 9005220196 900516

PDR ADOCK 03000327 ' i 1 . -Q PDC j _ . , . , 9 _ , f' k i ' .(

- 'd ' . / . , , ' 2 P ~ Three events that' occurred-during the inspection perio'd are described in detail- . in paragraph 8. The events were a reactor? trip,; lossi ofL shutdown board voltage, and;inadvertant start of an.RHR pump.- Weaknesses :were noted in the- L licensee's clearanc'e tagging ' and removal process ' which the licensee has~- j committed to correct. These weaknesses were contributors to' the loss: of - " shutdown board' voltage. event described in paragraph 8.b.- ..; . . The areas of Operation's,-Maintenance, and Surveillance were adequate and fully- capable to support. current; plantLoperations. The l observed; activities of the- ' contro1 room operators were professional and well executed.- i i ~.+: $

t

P

' '! ..! . s [ '. W > i: .; 4 .. 4 Y &

. - . . - . _- < 1: , , ,; > . , .. ,

l . . , ,q l s L 1.

l. ' REPORT DETAILS.- 1 '

1 1 l . , l-

1.

. Persons Contacted' h Licensee Employcas ' , i . . J.(Bynum, Interim Site Director . !

• W. 'Byrd, Project Controls and. Financial- Services: Manager -

M

• C; Vondra, Plant Manager

. . . < l'

• T. Flippo Quality Assurance: Audit Manager

, l R. Beecken,. Maintenance Manager q ll L.: Bush, Maintenance Progrem Manager. 3 L M. Burzynski, Site-Licensing. Manager '

• M. Cooper,' Acting Site Licensing Manager

.. . j L D. Craven, Supervisor, Instrumentationland. Control .) ' '

• J

Gates,. Technical:-Support Manager- ' . J.' Holland,. Corrective Action: Program Manager- 1 W. Lagergr'en, ~ Jr. , Operations; Manager. . M.-Lorek, Operations Superintendent

- R. Lumpkin, Site Quality Manager' d R.:Proffitt,: Acting Compliance Licensing Manager: ' l R. Rogers,: Supervisor, Engineering' Support Section- , ' L M. Sullivani Radiological Controls Manager ,

• S. Spencer, Licensing Engineer

1 l

• P. Trudel, Project Engineer:

.; C. Whittemore, Licensing Engineer ' ! NRC Employees J

• L. J. Watson, Chief, Project Section 1

l ' Attended exit interview

p Acronyms and initialisms used in this report.are-listed (in' ths last j l- paragraph. <4 l 2; Operational Safety Verification (71707) ! L .i a. Control Room Observations 1 r Ji L The inspectors- conducted discussions with' control . room -operators, ' ' verified that proper control rocm staffing was maintained,-verified- 2 that access to the' control room was properly controlled,1and that' 4 operator attentiveness was commensurate with _ the plant configuration , 4 L and plant activities -in progress, . and with on-going ~ control . room' L ope""-'ons. The operators were' observed adhering to appropriate,_ !. " app a procedures, including Emergency Operating Procedures, for the 4 -going activities. Additionally, the inspector: observed uppe'r. .; - managemer;t in the control room on a number of -occasions. n ,, , i .h > i [ {1 I J

, /

v

, .

n

> .

A:, '

~

~ ' ,. " ' - .. , 1 2- < , 1 .t 'The inspector verified that.the.. licensee was operating the plant in a: .; - normall plant configuration as required? by' TS and; when abnormal l ' conditions' existed, that ' the operators were' complying' with the - 1 " ' appropriate' LC0 action statements.- The-inspector .verifiV that' RCS: 1 - leak: rate' calculations were performed and that leakage trates were . < L .within the TS limits. ' . . i

Thelinspectors otnervedLinstrumentatio.nf and - recorder

tracssifor

J abnormalities and verified c the ? status' of ' selected' controliroom: annunciatorsito ensure that' control room operators understood' the status of the plant. Panel '. ind_lca tionsi were c reviewed forr.the ; nuclear. - < h Linstruments, theV emergency power ? sources, the 'shfety Lparameter-- , - display system and! the. radiation monitors; to. e.nsure: operability and j operation within TS limits. ' ' Lj ] Due to'the large number of modifications in: process; on Urit: 1, . N ' ' . critical : drawings have become zincreasingly di.fficult' tocre_ad and- interpret. ECN. clouds combined with " Unit:1 only" or " Unit 2-.only"' markings and overlaps have reduced the clarityTof theLdrawings. This 3 . has reduced the operator's abilityLto expeditiously' read- printsi for, < configuration: control.' Management 1:1dicatedithat provisions exist to ,! allow operations personnel ^to1reques t reissuance' of. prints: theyideem unacceptable. These prints willLtten be issued as. unit specific? prints. ~ The~ licensee stated that a memorandum 1or night order will be issued reinforcing this ' option No violations or deviations were' observed.- ~ ) b. . Control Room Logs j 1 The inspectors observed- control room _operationsi ~and ; reviewed 1 applicable logs including the snift logs.; operating: orders, night- ! order book, clearance hold order 1 book, and ; configuration log to ' obtain information concerning ' operating trendsf and: activities.n lThe , TACF log was.. reviewed to verify that. the' u'se of jumpers t and. lifted L leads causing' equipment -to'.be inoperable < v.as' clearlyAnoted1and ; , l. understood. The licensee iis. actively pursuing : correction lto

L conditions . requiring t TACFs. No. issues _.were identified; with ' these < ' specific logs. Plant secondary side chemistry reports /were reviewed. -The inspector. - ' verified that primary plant chemistry was within TS limits. i In audition, the implementation of the 1icensee's sampling: program I was observed. Plant specific monitt ,- 7 systems' including. seismic, j meteorological. and fire detection ii.dications wera reviewed for- j operability. A review of surveillance _ records 'and-tagout logs.'was -{ - performed to confirm the operability of the RPS. j f No violations or deviations were identified-. J J . -l .+ . , 1 ". , . ' = EN n. . . - . . . .. '

ww ~ - - , , <,;

'{

'

. w' ' .# - .- - j , N:- _ ' 1 , . 3 , L ' l _ i - c. ECCS System Alignment i t The11nspectors walked down "accepible ~ portions; of the ' following [ K safety-related systems: on Units 1;and .2, to. verify operability, flow i h 3athb heatLsink, water supply, oower supply,: and proper valve" and . O J 3reaker alignment: 5 4 RHR: System, Unit l11 t l ETDAFW pump Unit:2- 1- , [ -In' addition, thet inspectors verified that a selected portion of Lthe.. ~ " - L containment isolation lineup lwas correct. No violations or deviations wereTidentified, n. .; L d. P1 ant Tours 'f ' p ,. L Tours of the' diesel generator, auxiliary.econtrol, cohtainment,;and ' ' ! turbine-buildings, and exterior areas:were conducted to obr,erve, plant? equipment conditfons, - potentialL fire hazards, contro1pof. ignitionJ .

a

- sources, fluidileaks',Jexcessive vibrations, missileL hazards and plant - 1 - housekeeping ard cleanliness conditions. . The, plant was'in. adequate! O condition' considering that: Unit I was in= ar major refueling-outage.; - t i Work areasiwereebeing adequately controlled to prevent safety

hazards. The : inspector visually inspe'cted Lthe majorc componentsi J required to be operable per?TS for leakage and any--general" condition J that might preventc. fulfilling their; functionalirequirements. LThes

(

inspector observed ' shift turnovers and determined that necessaryf information concerning the plant systems--status'was-addressed. .) No violations or deviations were identified.;

e. Radiation Protection [ The , inspectors. observed HP- practices and verified the: implementation: 'I of ' radiation protection controls. On a regular basisi RWPs sere

l

reviewed and specific.-work activities were, monitored'to ensure the i activities were being conducted in accordance with the. applicable. t" RWPs. Workers werexobserved. for ' proper frisking upont exiting > , , contaminated areas and the; radiologically controlled area. 1Selec'ted: , radiation. protecimn instruments E were verified cperable and:' j calibr icn fregt.cneies were reviewed. ~ j 2 f. ' Safeguards Inspection- . In the course of .the-monthlyJactivities, the inspectors ? included a i ~ review of the ' licensee's . physical. securityz program. The performance ~ ~' of various shitts cf the' security force was;. observed in thesconduct ' ni of daily activities including: protected 3 and vital ' area access x ~ controls; searching of: personnel and packages;L escortingLof visitors; j x ' badge' issuance and retrieval; and patrols and compensatory posts a . . , l 3 - 4 . MF, [ , , , , j ' ' F '

+ ,

._ . - _ _ - _ ~ . , , e s

,t 4 8

4 ' _ 4 a ! In addition, the inspectors. observed protected: area lighting, and~ l protected and vital: area ' barrier _ integrity.. Specifically,: thel i Resident Inspectors: 1. . visited central'and secondary alarm stations. 2.- verified onsite/offsite communication capabilities' ,a No violations or' deviations were identified. g.- Conditions Adverse to Qualityi , , . The inspectors ? reviewed selectediitems L to determine!. that the. ' licensee's proMem identificationosystem as HdefinedSin- AI-12;- 1 Part III, Corrective Action, was functioning. CAQR's were routinelyL L! reviewed for adequacy in addressing.a' problem,or event. _ Additionally ? a sample of1 the following ! documents 1 were ; revi_ewed Lfor J adequate - ' , d handling:-- A s 1. " Work Requests- . . M ' 2.- Potentia 12 Reportable. Occurrences , 3. Problem Reporting = Documents: -! 4.- -Correct-on-the-Spot' Documents; d , 5.- Licensee Event Reports < , 4 Of the: items reviewed,2each was;foundEto have been identified by the j licensee with immedit.te correctivetaction_in-place. For those.. issues q that required 1ong term corrective- action;the licensee was making , adequate progress. The : inspector discussed-QA: involvement in plantiactiv'iiiies,4with the' '

Site Quality Surveillance Manager. The inspector reviewed 33 QA 6 surveillance. monitoring reports for Aprili199.0:and found that 8'C0TSs: i were issue:1 as aLresult of these activities. ThetCOTSs were issuedi ' in the~following areas:- ' ' SI Scheduling

Hydrostatic Testing , q' Design Changes f - Maintenance Performance 1 10 CFR 50.59 Evar sti.ons (2) l 4 SI Observation' .:* Frisking , The inspector determined that all . items ' identified in these ~-

c

- activities ' were properly dispositioned as: ~ required-by _ AI-12, Part I' Corrective Action. 4

No vic ions or deviaticas were identified. , x 4 ' i ze t h . x g . . . wx n .- . . . . . . . x

7i s,. , c.I- g i4- - ,e SI ~ No trends werez identified .in' the operationab safety verification area.. General conditions.in the; plant were adequate considering that Unit l'was inEa' major' refueling outage. Work was' adequately _ controlled by the ' operations; staff to ensure that TS requirements were met. 3. Surveillance.0bservation (61726):. ' y a Licenset. activities :wcre" directly observe'd/ reviewed to as'certairL that . Q c surveillance of safety-rela.ted systemsfand components was being, conducted '"j d in accordance with TS requirements. . The: inspectors verifiedithatf testing was1 performed inLaccordance;with adequate procedures;; test instrumentation was calibrated; LCOs were met;: 1 1 s l] '

test results met acceptance criteria and were reviewed by personnel;other

than: the indiv_idual- directing the test;- deficiencies were? identified, ~ asJ appropriate, .and :any deficiencies identified _during the; testing' were: j properly reviewed- and' resolved by management' personnel; and system). 4 restoration > was ' adequate. 'For completed tests, thel inspecto'r 'verifiedi o 1 that= testing - frequencies -were met and tests .were ! performed,byf. qualified d individuals.- ' l u The following: activity was observed with noldeficienciesLidentified:= SI-7.1, Diesel-Generator AC Electrical PcWer Verification- - The area of surveillance scheduling 'and management wasiobserved to be hl- + . 4 adequate. j ' , o 4. MaintenanceObservation(62703). 1 7 . Station maintenance' activities on. safety-related' systems ' and components'1 j ' were observeJ/ reviewed to ascertain that they were conducted in accordance- D with approved procedures, regulatory guides,:indu'stry codes and standards, ~ and in conformance with TS. , , The following items were- considered during this review: lLCOs'were. met- 1 while . components or systems were removed - from service;: redundant. j components'were operable; approvals were obtained prior tolinitiating the , work; anivities were accomplished: using'. approved?proceduresnand ~were 1 inspected as applicable; procedures used were adequate' to controit the, , . activ4ty; troubleshooting activities were contrc!1ed and'theRrepair - records accurately reflected the activities;: functunal: testing and/or: calibrations were performed prior to. returning 'compont.sts or : systems to! J service; - QC records were - mainta~ined; . activities: .were .ac.complished tj 4 qualified persor.nel; parts 'and : materials used were properly certified;'. j radiological controls were implemented; QC hold: points, were . established i + where - requirt d and- were observed; fire ' prevention controls were.

- implemented; outside . contractor 1 force activities 1wersscontrolled fin '

accordance w1th the approved QA program;- and ;nousekeeping. was actively i ! pursued. ' 4 , !

.u ; 2 -l y , , , , , g " > < y . w~- .. , . .

-_ _ _ _ . . _ . . . _ . . . . . . ,' .. ,7 6 The.following work request was' reviewed: B261319 Unit ~1 MDAFW Pump Inspection 2 lh < , ~' _ . Theiarea of maintenance was= determined to be-adequate, j 5. Refueling ~ Activities'(60710) 1 TVA. managementiactivities:we're reviewed on 'a. daily basis? by the NRCl _. 1 inspectors during the 'rdueling: outage. . Resident Inspectors observed--that - planning,t scheduling.. work' control and other management' meetings 7were effective.'in controlling ~ plenti activities. First oline' supervisors; were: .: knowledgeable. :involvedlin ,the day-to-day activities of theJNan.t.t anc -1 " wereL being held accountable for their .performancelin relation;to the refueling Loutage activities. . The results of these planning activities were evidenced. by_ the< closeness with which l refueling outage :activ.ities were completed in relation:to.the _ refueling outage schedule milestones. - The ' licensee submitted a TS change, to install the new Vantage Sifuel;in , Unit 1 for thei upcoming 1 cycle.; Thel inspector . observed u refueling 1 l . activities which included fuel movement"in the spent; fuel area, ~ reactor _ i , vesselchead cleaning and-inspection inside containment,'and fuel Inventory 1 control and' documentation- activities in. the contro'l room.; All, observed il activities were performed using the proper'in'structions:and procedures and 1 with proper attention to detail'. . Housekeepingtin the refueling area was _j adequate and staffing met-the TS requirements. j t I 6. FacilityModifications(37701) 1 During the inspection period the _ inspector 1 reviewed LportionsCof ! modifications in ' progress for Eagle 21.- BITJ and UHI system ' removal, 'and. O removal of the RHR Autoclosure interlock. 1 The inspector verified that the drawings. hadibeen revisedifor. Unit.11 to reflect the modifications'referencedk The drawings were noted as becoming increasingly. complex and difficult = to use because. of plant-specific -; markups to delineate -Unit 1 and .2 differences on the' prints, which 'are . ' common to both ~ units. This issue was identified to the licen'see at the. - exit. Procedure' revisias supporting- the modifications wereinot complete at the time of the exit- a r The . Eagle 21 modification was also reviewed by. members of the ADSP J Projects . staff. Operator and maintenance . personnel training 'and post il modification testing were observed with no deficiencies noted.' Details 1 of these reviews will be presented in the'SER. ! 7, TI 2515/103, Loss of Decay Heat Removal (GL 88-17)

1 The inspector reviewed the licensee's response and actions taken to comply 1 with the requirements of: GL 88-17 concernin'g' potential for loss of Decay, d Heat Removal capability during perieds.of reduced level inventory.in the j 'RCS., Both expeditious actions- in response to GL 88-17 and long term ,' 3 ~ ' > w' , i' I ' ,

m 4 < y , , ] ' .,

. c.' ,. , , y 7. 1 1 j corrective actions were inspected. The-li_censee's response 'and _ctions ~ j ~ a . taken; appear to meet 'all requirementsz of GL 88-17. The inspection-

requirements and findings are detailed below.

3 06.02, Instrumentation. a. Level Indications" . . 1 Expeditious actions currently in place (TI ~2515/101): .( Reactor 1 Vessel Level . Indication. System' (RVLIS) on - train A$is - j H ' indicated on a control: room recorder;1 sight" glass with video monitor 1 isLindicated in- the-control' room:for narrow: range of RCS! level while

I

in mid-loop; and. a1 temporary: tygot hose. is ! connected for! periodic j calibration ~and flushing of gauge glass. Programmed Enhancements (Implemented during current outage for - Unit 1,-planned.for next refuel 7g outage for Unit 2): , ; .I Ultrasonic : narrow range . level indication with audible;and visible-

i

.controlL room alarms and liouid level . monitors with -wide and: narrow : j ranges. ! b. ' Temperature Monitoring d Expeditious' actions currently in place:i j ' Two core exit thermocouples monitored.Once per hour by. operations personnel in MCR. ' ' Q Programmed' Enhancements: j Two thermocouples with visible and audible alarms!in MCR. I c. DHR System Monitoring I

Currentlyj have indication of RHR pump flow: rate, motor amps,: pump

discharge pressure and alarm for high; discharge pressure /miniflow conditions. No modifications planned. . }4 06.03, Procedures , 9 a. DHR Operation } S01-74.1, Residual Heat Removal Systems, provides adequate instructions for reduced inventory /mid-loop operations and guidance ' . in case ofL malfunctions or accidents. EmergencyJ procedures . are adequately referenced for loss of' functions,' containment closure,' and- ~ - ' incipient or actual core damage. q -! 1 i

) n , - 1 0 $ I

, 7 . . . - - . . .- . . e .m

, . - ... . . 8

t - b. Containment Closure Control- , ' Containment closure is controlled by- Al-58; Configuration-Control, and SQA-199, Integrated -Schedule 1 and- Work ' Control . .These documents together require cognizance by operators of the status'of containment 'i and . instructions to restore: containment closure.'

1 - c. - Avoidance of. Perturbations W'hilelin' Reduced Inventory ] SQA-199-provides guidance forjcareful consideration of all'evolutionsi 7 while - int reduced inventory. SI-373,1 RCS Level f andE Inventory i" Conditions,'contains adequate precautions?and administrative controls for' timely response to possib1 : loss'of DHR.. 'q d. RCS Draining and Monitoring- of'the Tanks' Receiving Drained sWater) !-r S01-68.1,ReactorCooladtfSystemiand.S01-74.1, Residual'HeatRemoval- O System, provide adequate ~ instructions for... draining .the LRCS,c entry" ! into-and recovery from reduc'ed inventory and.mid-loop. conditions. e. Containment. Closure o Control of_ containment penetrations- iss r'equired by: AI-58 ' SQA-199 . requires a current log of all breaches:and openings duringJreduced inventory conditions. . Assurance :that' containment can ~ be closed expeditious?y Lis provided by trainingL.and procedu.res. A01-14,: Loss . E of DHR, contains guidance: for1 ct ntrol, :of. possible;: hostile _ 'i L environments.. - Equipment hatch emergency? closure _ist contro11edi by ~ ' - MI-6.16, Removal and Installation of Equipment Hatch, usingcal minimum - 1 '/ of -4 bolts, which are. maintained in:a ready condition. . Control- of; ' pressure caused by hydrogen burns during core accidents.is covered by. r SI-673, RCS Level Verification =for Reduced Mid-loop and Partial; Drain l . Condition, and includesL requirements :for/ at l_ east:one -igniterj train? ! availableiduring reduced iinventory. . DHR recovery;and' sources of - ' water. and their use. are ? controlled by . A01-14'.1 This procedure'alsoy

includes instructions for use of: then SGs; for heati removal after recovery of water level sufficient to use-that-mechanism. Adequate support equipment is assured by' SI-673, data -sheet 3, _which requires , that electrical. power,' component cooling water,_ and essential raw- ' ' cooling water for the' required: injection pumps are available._ The J inspector > will complete: the review of this narea? during the .next inspection period. . ' .

Procedures and instructions exist for each individual. aspect and 1 condition of reduced inventory operations. - The..large number of . , procedures . references andi tiering involved: to locate the -proper. l ! procedure for the different -evolutions and off-normal / abnormal ' processes <1s cumbersome. This concern was identified to the licensee

. during the exit' interview. The licensee' stated that the procedures

would be reviewed to: determine if consolidation or other measures 4 would enhance the ability to use the' procedures.. , .. y n a , >

' t ' *

+ ...w. . . .

,

m _ _ - _ - _ n ' ..* . . 4, .. ,, e '

9, 06.04, Reliable Equipment ] TS changes . 89-18 and 89-02 - addressed - the removale ofithe autoclosui e .- ) ' interlock and prevention of inters," stem LOCA end specific requirements for. lj DHR flow rates ~ for. core cooling, boron mixing : and vortexing. . These:- ' ' changes to . equipment, procedures and" TSs provide assurance' that - ,' inadvertant-isolation and loss of DHR are minimized.. " 06.05, Analysis = Analyses were in place to ensure' thatf flooding: of. the core via gravity - feed is achievable. Vent Tsizes, flow, and backpressure: conditions were l included in'the. analysis. Other' analyses"were performed for assumptions- '{ that-could not be directly verified by test _ or demonstration.- f 06.06. TS Changes y TS charges ' supporting the changes to equipment and procedures, were reviewed in section 06.04 above.. ~ ~ j 06.07, Control of RCS Perturbationst Administrative controls for this' area were discussediin'section 06.03.c. 3 $ TI 2515/103 remains open. 8. EventFollow-up(93702) i . ' a. On April 10,1990 at 1:34 a.m., -Sequoyah : Unit 2 tripped from fulli power. The plant responded as designed with minor exceptions. The " , cause of. the trip was determined; to beitest'ing Lof the1 Reactor l Protection System which was: performed out;of-' sequence by instrument:. r - technicians. '~ The -surveillance test involved, SI-90.82', _ Surv-illance. Testing of thd ' Unit 2- Train B SSPS,- was coordinated frcm the control room by the appropriate' test airector. Technicians,were dispatched to the local ., panels -to establish communication. -The te t director.. began reading f the procedure steps, and performed preliminary steps- through stept 'd 2.2. The tett director then read through steps.3.0, requiring source range monitoring operable. The next step. 4.0, is described:in.thec . ' procedure as being 3erformed at the: Auxiliary instrument panel per: 1 Data Sheet 2, attacled to the procedure. The procedure package'is.

designed to allow the instrument; technician 'to: detach data sheet; 2 ' , and take it with him to the local panel. Data' sheet 2 contains [ instructions for performing steps 4.1 through: 5.5. These steps are to be performed locally with the. coordination of the test. director. ' The test' director read through step 3.0, and steps 4.1 to 4.6. At , ! ! , ' ! , , .i

,.;< . , . . a - _

-- , , , = ,

..

, '- ' C_A_t .5 "" '10;

[

! i step 4.61 the test director is required:to' verify that communications y are established with the technicians at- the11ocal' panels. When1 communications ' were established. _he: resumed g performance . of thei procedure; at step 4.6'.'2. The test director didLnot: realize that . steps ~4.2 through 4.5 had-not:yet been performed byLthe te;t crew as- J . 1 required by procedure. ;Instead,_ steps 4.6.2 andL4.6.3 were-performed prio.r.- to steps: 4.2 L through - 4'.5. Due to this. error, a. reactor; trip. bypass breaker was racked inJand placed in ser_vice (step;4;6.3)J before the Multiplexer Test Selector. Switch wastplaced inithe pro; ara < position (step 4.4).=

, y q 1 Placing Lthe bypass breaker in service -causes a Train'B' Trouble alarmi ' to comelin.: . The' Multiplexer: Test Selector Switch Lpositions -include ) .theiTrainLA' test position.that must be passed through;to go to_ the . Train B test position. ' As the1 switch was moved' through the:. < Train A position,. at Train A Trouble alarm cameLin, indicating that _ Train A was in ' test;at the same time that the Train-B trouble' alarm was ini for.the. bypass breaker.= ~ The= Reactor' Protection System isidesigned to2 - allow only one trainz at' aJtime;;to beLtested,E and will: generate.a reactor trip if both trains are;placed in test'at-the:sameltime. :The a ~ trip occurred'as, designed., j -Investigation into the eventirevealed'that;the' test. personnel becam.e j aware that they were 'out: ofisequence' just, prior fto performance? of J - -step 4.6.5,-but theatest directorcand crew determined that the-test ! could be continued with- no _ impact'.- This determination wasemade without consulting ,or' using the1 guidance of ' Al-47, - Conduct of _ - i 1 Testing. AI-47 section 7.9 requires'that out-of_-sequence steps, when discovered shall be -treated as a . test deficiency. - Further,?the deficiency must be evaluated before - proceeding further, including; ss review of the prerequisites,- previous . steps, and control 11ogic. 1 After determining the , proper ? course , of! action, . the . proposed- i corrective: action must be approved by the' responsible: supervisor and ' the SOS. These requirements were not met and'onlyla cursory review- I ~ was conducted by the' performing crew; j Failure to follow the requirements ofEAI-47 when the out of sequence.

performance of SI-90.82 was : discovered is a Violation' of- TS 6.8.1,- ! and is identified as VIO. 327,328/90-17-01, b. During a transfer.of the power supply to the IA-A 6.9' kv Shutdown' ' Board,.the transfer was performed-improperly and caused a loss:.of-the; i shutdown board. As a result of the loss of power _to th_e: shutdown 3 board, all Emergency Diesel' Generators; started,' and the affected shutdown board was'repowered by the-1A~EDG. The bus was, essentially M unloaded at the time due to plant conditions (Mode 6, refueling), so - there was no loss of equipment normally~ powered by the bus. < At 10:04 a.m. on - April _4 the 1AJA 6.9 kv SD board was being transferred from the alternate supply back tn the normal supplyDin 1 accordance with S01-202.4, 6000 Volt Shutdown _ Boards, UnitsD1 andl2. 4 J ' l . . _

_ ' < ~ a . , h- 2,

. j 11 4 The normal supply'to the -1A-A SD board is the 1B. unit l board which ha'd l just'been reenergized after cleaning. ;When the clearance was removed A from the 1B unit board,:the supply breaker to the SD board-was racked ' back?in but wasLnot reclosed by:thet ASOS removing the clearance. ' W1thithei feeder breaker open,:the' transfer back to the' normal: supply by'the control room operator was made' with theilineup incomplate. 1This resulted !n the~ SD board being transferred from' the. alternate supply _ to ' the : normal . supply with the . feeder breaker' to the> normali _ supply still open. When:theialternate feeder breaker. opened. theiSD board Lwas deenergized, causing the blackout relays to start-all 4 EDGs. The: deenergized SD. board wasi repowered= by the 1A EDG After the operators discovered:the?open breaker, the breaker was closed - the EDG 'was . paralleled withi the11B' unit: board,L andithe SD board . ' energized from'the normal 7 feeder. The clicensee. investigation off the event determined th'at the operator - performing the, transfer did not verify that voltage was available from the normal feeder breaker- prior.to attempting the transfer. Thel operator misinterpreted: step ~ B1 of; S01-202.4E which required - the: operator to check for normalJ3-phase- voltage on; the: normal supply: feeder. Instead'he verified 1 voltage on the-1B; unit 1 board instead of. voltage on the: normal. supply ~ feede, breaker. The procedure :was ambiguouszin that step BILdoesinot specifically list;the location of' ~ the appropriateJ voltage - indicators,- and couldTbe \\ interpreted < as- requiring the operator to checkJ voltage - available 'on:the: normal. supply bus. Otherfoperators' questioned knew that the' requirement'to ~ check 3' phase voltage at the feeder implies that the operator'must go- - to the feeder breaker and. select and read'each of the three phases- individually. This can be; verified <only at the breaker itself, and- not from the control room.: : The. operator only: verified that; the .1B: unit board was energized, using indication-available in the control' room. In addition to the procedurala deficiencies and operatorx errors; described above, the -incident revealed a problem in; the' removal of? clearances. AI-3, Clearance: Procedure, containedL the requirements = for the clearance process and Appendix 0-1 of AI-3 containedcthe Clearance sheet .used to process clearances'. ' AI-3 ' discussed the clearance release process ' including'"the removal of- tags: and the restoration of equipment. TheLterm return to normal" was used to: discuss the restoration ..of . equipment ~ after the clearance was ' released. - AI-3 did not' explicitly define -return to normal. The'S0I position was mentionedLas' an-aid: for return to -normal, but was not defined as the normal configuration of equipment. . A block.on the - Clearance Sheet was provided for ' the S0I position. However, the instructions for this. block' referred to the S01 position as an aid for return to normal and did not explicitly require that the block be filled in. > d < .- n 5 s. E

__ ' .. 4 c . j t' , 12I Lg . AI-3- section 7.8; assigned the responsibility fort determining the position the equipment is placedLin- after removal of the' clearance- tags 1to the SOS or his designated representative.- - However, the inspector noted that section- 3.2 ;could be interpreted to mean that'

the .individuali picking up theitags could . determine the position to o l place the equipment >in,"._not the contro1Lroom operatorsispecifically? responsible for control of1thelplant.. In this event - the . ASOS; y - responsible for. clearance . removal didL not communicate to the, unit ' ASOS: that- the breaker was: not being : shut.1 Thefinspector wasL

conce rned ' that - equipment configuration - could L be- changedLwithout - the : - cognizance of the responsible control' room operators which could result in personnel or> equipment hazards, lhe 11censee's investigation? of this event iderctified' ac numbere of . causes' and corrective actions which will;be documented in an LER.':In addition,: the licensee committed to correct _ the1 procedural: 1 inadequacies'in.AI-3. .The failure to; establish adequate 1 procedures i for : S01-202.41 and - Al-3, and tox implement those ; procedures ---is a- violation (NCV 327,328/90-17-02).- The-violation was # ediin- this' instance because the criteriatspecified-in Section . af the< Enforcement Policy of 10 CFE 2 were satisfied. NCV 327,a a/90-17-02- 0) - is considered closed. ~ ] c. RHR Pump Start Due To Operator Error On April 9,1990, an - AU0 was dispatched, to the Unit 1 RHR pump: J _ suction valve 1-FCV-74-3 Eto--stroke- the valve closed. Unit 1 was 1 - defueled at the time of the-event. The AU0 proceeded to the Unit 2- i RHR pump room:instead,.and' began closing the?2-FCV-74-3~ valve. .His instructions.were to close the valva to approximately.75% closed, and then to manually stroke the' valve the Nst_of the;way closed. After. stroking the valve. partially closed by the. motor operator,Lhe' stopped the valve 1 travel and= walked around the: partition to check the actual- position'of.the-valve. He noted_that the valve had been stroked-less- than 75% closed and proceeded back to the valve motor panelito stroke ! the valve further. When he got back to the panel,'he:inadvertantly 3 pushed. the; 2A RHR pump start pushbutton.- Hearing the pump start, he j realized: he: had pushed the ' pump , start button instead of the valve-

close pushbutton. He immediately: stopped the: pump, and then closed 1 the valve-by the valve pushbutton.- By: this time the Unit 2 control; 1 room. operator had received a low flow-alarm on the 2ARHR pump and. 1 had dispatched another AVO to- investigate. When the- AU0 got(to the- ~! pump room, he stopped the first: AVO from further action. .At that l ' point,i the first !AVO rulized that 'not only had .he pushed the ' wrong 1 switch,' but he was also a the wrong' unit. The event investigation ! revealed that the. AVO was oncerned more with .his' instructions to j partially stroke' the valve tc 3 than -with making sure .he had -gone o to the correct unit. The- error n pushing the _ wrong button' was _ , attributed to inattention to detaii, since the pump start button _ and valve close button are on the same pnel.- ' ]" , .> iM j ' ' _ -

. . - - . .. -. . . - . -. , ". ~ } y -131 q The: inspector ' reviewed- the event report Land interviiwAd personnel l associated with- this event. . The; event report was; thorough, and . appropriate. corrective. actions were identified. -The inspector had noL furtherJquestions.= The three events identified above had; comonality in' that attention- to detail 1was ' not exhibitediand each resulted tin. events which could have been -prevented. ' , Plant: management' agreed. to review the. three events ' ' collectively L to " evaluate any trends - or- common root. causes -for the' - personnel errors 1.in~each. < ~ . 9. Evaluation of LicenseeJSelf-Assessment- Capability;(40500)- d 1 Ths licensee's NuclearL SafetyLRevidw Board x(NSRB); uses subdomitteesLt'o - conduct detailed investigations; and< interviews: pertaining to; particular. l 4 topics of' interest. :Four subcomittee meetings were conducted on-.May 2, ' 1990. These included QA, Operations / Maintenance / Modifications,; Rad' Chem,. o and Engineering. ~ The inspectors attended portionsc of the subcomittee meetings fo'r topics which included steam generator chemistry relatingsto the inspections conducted - during1the' refuelings outage, presentations 1 ~ , detailing the. events-described in-paragraph 8 of this report, QA overviews 1 of the refueling . outage . wor _k, and QA = audits' of COTSs.

During . those t

9 meetings and briefingst the1 inspector observed that .thecsubcomitteeL 3 members _ aggressively . questioned site personnel on ' details of root causes - i and management ' responses - to the issues.. In addition, the inspector 1 discussed the current NSRB areas of interest with the: NSRB: chairman.s ]a L 10. - ExitInterview(30703) I The inspection- scope--andL findings-:were'sumarized on May. 4',1990, with e those persons indicated in paragraph:1. The1 Senior: Resident Inspector described the -areas -inspected and -discussed .in detail the inspection findings listed below. The' licensee acknowledged:theLinspection findings and did not11dentify as ' proprietary any of- the. material ' reviewed by: the, . . inspectors during- the inspectioni 1The t- three eventsWidentified in

paragraph -8 had' commonality in that attention'to' detail;'was not exhibited ~ - and each t resulted in. events - which could have been prevented. The _ .! licensee' agreed to provide. additionallinformation 'on the root causes and ' corrective. actions for these. events. 1A concern was, expressed in-relation to control room drawing clarity due to the significant scope and number:of modifications ' being: performed- on Unit:1 - during- the current refueling , outage. . Management' stated that information relative to drawing updates: 1 . ~ and reissuance would: be promulgated to operations personnel. ~ A concern j was expressed in relation to the fragmented procedure approach to-mid-loop i operation. Management' stated that a' review of this concern would be ! conducted.- ! ! ! . 1 ' ll: ' ' " - ft ,

y, - . -. - . - , , , " , ^ ^ , ! .. 4'. I. [:: .

> 14- . . ! i Inspection. Findings:- J J One violation and one non-cited violation were identified.. j - L VIO-327, 328/90-17-01, Failure To Follow Test Director: Requirements - ! Caused. Reactor Trip l e NCV 327', 328/90-17-02, Sh'utdown1 Board:.Vol.tage Lost D0e To' 0perator. h l5 ' - __ drror. -. Inadequate Procedure, and Clearance! Problems. ! ' !: L During the . reporting period . freque.nt discussions werel held, with the: - , Interim Site' Director, Plant Manager and other . managers z. concerning : inspection findings. ' ' ' , L L 11. List- of. Acronyms- and Initialisms - < .a -ABGTS- Auxiliary B'uilding Gas Treatment System ' Auxiliary Building l Isolation' .ABI - p ' ABSCE - Auxiliary Building-Secondary Containment Enclosure j; .. Auxiliary Feedwatery l AFW - L AI- Administrative Instruction' - y" l. ,A01 ' Abnormal--Operating Instruction - L AUD Auxiliary Unit Operator- - ~ASOS-- Assistant Shift Operating Supervisor. . ! l- ASTM - American Society!of . Testing and Materials' ! BIT Boron Injection Tank . i ' - L -BFN Browns Ferry Nuclear Plant ' - - C&A Control and Auxiliary l Buildings , - 'CAQR -- Conditions Adverse ~to' Quality Report l' CCS -Component Cool _ing Water. System - - CCP Centrifugal Charging Pump - CCTS - Corporate Commitment. Tracking System ~ , CFR Code of' Federal Regulations' _ > - , COPS - . Cold Overpressure: Protection System ' o COTS Correct-on-the Spot. L CS Containment Spray - CSSC - Critical Structures, Systems and Components CVCS-- Chemical and Volume Control System 1 CVI Containment Ventilation Isolation - DC Direct Current - -1 Design Change Notice ! DCN - DG Diesel. Generator - 1 DHR Decay Heat Removal ? - -DNE Division ~of Nuclear Engineering 4 - ECN . Engineering Change Notice - n ECCS - Emergency Core Cooling System J EDG Emergency Diesel' Generator - EI -Emergency Instructions ! - ENS Emergency _ Notification System q - E0P Emergercy Operating Procedure. 1 - < EO Emergency Operating Instruction j - ERCW - Essential Raw Cooling Water 1 ESF . Engineered' Safety Feature - < FCV. - Flow Control Valve d . Y N, l '-

, ui- , , . . , . , , , _ . - -

- > . , ' kl ' 9 t 1 g f ' g- . ,. - 15'- . . . o , i -FSAR - ~ Final: Safety Analysis Report s GDC - General Design Criteria , General-Operating Instruction,

G01 -- , Generic-Letter-- . GL-

. HVAC -' Heating Ventilation,and Air Conditioning' Hand-oper'ated: Indicating. Controller HIC - H0 Hold Order ! - "

HP

J- LHealth' Physics . . Instruction' Change Form. ICF - IDI = Independent Design, Inspection 0

- NRC'Information' Notice- ,l IN- -- IFI -- . Inspector: Followup Item- IM Instrument Maintenance . .

-- IMIi - ' Instrument; Maintenance-Instruction IR- , Inspection Report - KVA . Kilovolt-Amp. - KWl ' Kilowatt - KV Kilovolt ' - , LER - . Licensee-Event Report' LCO Limiting Condition for 0peration - LIV - . Licensee Identified Violation. n LOCA-- Loss of Coolant Accident- ' MCR' - Main Control Room, MI Maintenance Instruction

- 'MR Maintenance' Report; . , - MSIV - Main Steamilsolation Valve. NB- NRC' Bulletin ' - NOV Notice of Violation: . > - NQAM - Nuclear Quality Assurance' Manual-

NRC Nuclear-Regulatory Commission'. - ' OSLA - Operations Section Letter - Administrative . 1 OSLT - ' Operations Section Letter - Training.

OSP ~ - Office:of SpecialnProjects- - , , L PLS'- Precautions Limitations, and-Setpoints 1 L PM Preventive-Maintenance- - L PPM Parts'Per Million, - PMT -Post Modification Test - PORC - Plant Operations Review Committee ! P0RS - Plant Operation Review Staff- ' PRD Problem Reporting Document- 2 - PR0 Potentially_ Reportable Occurrence - ' QA' Quality Assurance - - -QC- Quality Control a - RCA Radiation Control Area - RCDT - Reactor Coolant Drain-Tank RCP Reactor: Coolant Pump - RCS Reactor Coolant. System- - RG Regulatory Guide

- l. RHR Residual Heat Removal - RM Radiation Monitor - l . '/ l: 3

a . . . .. . . .- . . . .

,_ ._ .- . 1 f _ ,;l T - . w . .t . . . 16 ' R0 . Reactor Operator' -- RPI Rod Position Indication: - RPM - Revolutions Per Minute ' RTD - Resistivity Tempenture Device' Detector RWP Radiation Work; Permit - RWST - Refueling Water Storage Tank SD - . Shutdown- SER' Safety Evaluation' Report SG Steam Generator. ' - SI Surveillance = Instruction. - SMI Special-Maintenance-Instructfon -- S0I System. Operating Instructions; - SOS Shift Operating Supervisor - SQM - - - Sequoyah-Standard Practice Maintenance- SQRT -- Seismic Qualification Review Team h SR Surveillance Requirements ~ - .SRO SeniorL Reactor Operator - SS0MI- Safety Systems Outage Modification Inspection q SSQE - Safety System' Quality Evaluation- 1 SSPS - Solid State Protection System i STA Shift lechnical Advisor - STI Special Test Instructio'n. . -- TACF - Temporary Alteration Control Form TAVE - Average Reactor Coolant Temperature TDAFW- Turbine Driven ~ Auxiliary Feedwater- , TI Technical-Instruction t - TREF - Reference Temperature l TROI -- Tracking Open Items

l

TS- Technical Specifications - TVA Tennessee Valley Authority - UHI Upper Head Injection - U0 Unit Operator - , URI Unresolved. Item j - USQD - Unreviewed Safety Question Determination VDC Volts Direct Current d - VAC Volts. Alternating Current j - WCG Work-Control Group ' - WP Work Plan -

1

WR Work Reque::t i - > i. i l l l j }}