ML20055B642

From kanterella
Jump to navigation Jump to search
IE Insp Rept 50-293/82-16 on 820510-0613.Noncompliance Noted:Failure to Lock or Control Access to High Radiation Area
ML20055B642
Person / Time
Site: Pilgrim
Issue date: 06/30/1982
From: Eichenholz H, Elasser T, Elsasser T, Jerrica Johnson
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20055B637 List:
References
50-293-82-16, IEB-77-05, IEB-77-05A, IEB-77-06, IEB-77-5, IEB-77-5A, IEB-77-6, IEB-78-01, IEB-78-04, IEB-78-1, IEB-78-10, IEB-78-14, IEB-78-4, NUDOCS 8207220579
Download: ML20055B642 (22)


See also: IR 05000293/1982016

Text

See Next Page for DCS NUMBERS

.

.

U. S. NUCLEAR REGULATORY COMMISSION

REGION I

Report No.

50-293/ 82-16

Docket No.

50-293

License No. DPR-35

Priority

--

Category

C

Licensee:

Boston Edison Company

800 Boylston Street

Boston, Massachusetts 02199

Facility Name:

Pilgrim Nuclear Power Station

Inspection At:

Plymouth, Massachusetts

Inspection Conducted:

May_10 - June 13, 1982

AwR Adw>c,-

6/2. 3 / St

Inspectors:

U

U

J. Johnson, Senior Resident Inspector

date

htW$

SkJ /fs'

'

H. Eichenholz, ResidenFInspector

' datt

date

L. Briggs, Reactor Inspector (May 11-14,

June 1-4, 1982)

Approved by:

~

4 O/fk

T. Elsa

Chief. Reactor Pro.iects

date

'

Section No. 1B, Projects Branch No. 1

Inspection Summary:

Inspection on May 10- June 13, 1982 (Report No. 50-293/82-16)

Areas Inspected:

Routine unannounced safety inspection of plant operations,

including followup of previous inspection findings, an operational safety veri-

fication, followup of plant trips, events, and LER's, a review of surveillance.

and maintenance activities, followup on IE Bulletins and Circulars, and a review

of actions to implement the Performance Improvement Program. The inspection

involved 317 inspector-hours by two resident and one region-based inspectors.

Results: One violation was identified in one area (Failure to lock or control

access to a high radiation area, Paragraph 4.C.(4)).

Region I Form 12

(Rev. February 1982)

820722

0

3

PDR AD

PDR

G

'

'

2.

DCS Numbers Associated with Report 50-293/82-16

50293-810916

50293-810917

50293-810918

50293-810925

50293-811002

50293-811009

50293-811020

50293-811026

50293-811110

j

50293-811116

'

50293-811130

50293-811221

50293-820105

50293-820118

50293-820222

50293-820226

50293-820324

50293- 820331

50293- 820506

50293- 820512

50293- 820513

50293- 820519

50293- 820603

50293- 820611

9

'

_ - _ _ _ _ _ _ - _ _ _

..

e

,

\\

,

3.

'y

.

.

x.-

'

'

DETAILS

i

(

,

s

.'

[

e

i

1.

Persons Contacted

.

.

r

\\

J. Aboltin, Sr. Reactor Engineer

?'%

G. Anderson, Watch Engineer

D

R. Belanger, I&C Engineer

--

-

P. Cafarella, Shift Technical Advisor

~i ]

.

-

A. Caputo, Fire Prevention and Protection Engineer

V

'

<\\

s.

-s"

R. Cook, Instructor

x

.

m ~

R. DeLoach, Group Leader - Operations QC

1

-

-

B. Eldredge, Sr. HP Supervisor

x

'

s.

,

G. Fiedler, Watch Engineer

o

t 'j

3

%

.

.

,

J. Frazer, I&C Supervisor

s

E. Graham, Sr. Plant Engineer

'

. . ,

s

W. Harrington, Sr. Vice President - Nuclear

h

. .

.,~

',

'

>.

R. Kuhn, Sr. ALARA Engineer

N

,

,

G. LaFond, I&E Supervisor

R. Machon, Nuclear Operations Manager (Pilgrim Station)

,' ' '\\

P. Mastrangelo, Watch Engineer

.s

s

C. Mathis, Deputy Nuclear Operations Manager

.( '

~

$

',

'

'

J. McCann, Watch Engineer

ii .N'i

y

y

J. McEachern, Security Supervisor

-

i

T. McLoughlin, Sr. Compliance Engineer

' '

,

~

E. O'Rork, Watch Engineer

.,

L. Oxen, Director - Nuclear Operations Review

'

-

K. Roberts, Chief Maintenance Engineer

R. Sherry, Maintenance Er.gineer

?'

q

-

R. Silva, Staff Engineer - Mechanical

'

ij

-

P. Smith, Chief Technical Engineer

'J' Q, '

, . . ,

R. Smith, Sr. Chemical Engineer

'

.,

K. Taylor, Day Watch Engineer

.

,

R. Titcomb, Q.A. Auditor

s

.

_

R. Trudeau, Chief Radiological Engineer

. ' '

N

,,

G. Whitney, Plant Engineer

s

P. Willard, I&C Engineer

c

_%

.

E. Ziemianski, Management Services Group Leader

~

'

Theinspectoralsointerviewedothermembersofthehealthphysics,.operaElons,

.

i

.x

maintenance, security, and technical staffs.

5

-

2.

Followup on Previous Inspection Findings

I

s

(Closed) Deficiency (50-293/76-31-01).

Failure to report environmental moni-

toring data. The NRC has reviewed environmental monitoring reports No: 10

(1977) and No. 12 (1979) and documented this review in inspection report

No.'s 78-27, and 81-06.

No further recurrence of not reporting required'in-

x

formation has been observed. This item is closed.

'N

s';

s

.

\\

h

'

.

\\

\\

%

_

[% NL'

s

1

.

-Y'

.

N

,

sA

4-

..

,

,i

,

N

(Close' ) Unresolved item (50-293/78-25-05).NSRAC competency detemination.

d

Ly

T4 inspdctor reviewed NSRAC charter dated March 24, 1982 and the associated

competency natrix. Members and alternates collectively satisfy all areas re-

-

qCf red by T.S. 6 5.B.

The NSRAC membership also includes personnel from another

'

-

'

utility and Massachusetts Institute of Technology. This item is closed.

.

,

('Closedi Inspector Follow Item (50-293/79-SB-04).

Degraded grid voltage. On

'

,(

December 18, 1981, a meeting was held between the licensee and NRC:NRR to discuss

licensing proposals for degraded grid voltage.

On May 28, 1982, Amendment No. 61

'

to the operating license was issued by NRR which included requirements for under-

s

voltage relays and alarms.

This item is closed.

s

(Closed)' Inspector Follow Item (50-293/79-SC-08).CRD return line containment

isolation valve. The licensee has modified the CRD return line by cutting and

capping. The NRC:NRR has reviewed this change and deleted the return line

'

check valves from the T.S. list of containment isolation valves. This Amend-

ment (No. 57) was issued on March 20, 1982.

This item is closed.

\\

'E

(Closed) Unresolved Item (50-293/79-06-03). Administrative format of T.S.

changes. The inspector made a comparison of the T.S. provided by the licensee

and NRR. Minor typographical differences erist but are not significant. The

inspector has observed that the licensee is now issuing T.S. page changes as

received by NRR following license amendment issuance. This item is closed.

'

(Closed)InspectorFollowItem(50-293/80-26-09).

Core Spray Sparger. Amend-

ment No. 59 to the operating license was issued on March 31, 1982. This change

allows the licensee to take credit for core spray heat transfer action, concurs

that the indications are either not cracks or are not growing, and that in-

tegrity will be verified in accordance with the routine ISI program.

This

item is closed.

(Closed) Unresolved Item (50-293/80-26-06). Mode Switch-to-Shutdown scram

circuit. The licensee has modified the reactor protective system using PDCR

81-27. This change was recommended by G.E. in SIL No. 344 Rev. 1, dated

April,1981, and includes the addition of a set of normally open contacts in

the shutdown scram circuit. The inspector reviewed this change and detemined

L

that the design would correct the original problem identified by the licensee

and described in NRC Information Notice No. 80-45. This item is closed.

(0 pen) Violation (50-293/80-09-01).

Fuel moved without secondary containment

integrity. The inspector reviewed the actions of the licensee during the 1981

refueling outage.

No recurrent violations were identified. The inspector

also reviewed the

corrective actions described by the licensee in a letter

dated August 1, 1980.

Procedure 4.3 has been revised to require the ORC to

approve fuel handling, and to require a special check list (OPER 25) to be

completed prior to moves within the spent fuel pool.

Special training was con-

ducted prior to the last

refueling outage for all personnel involved. This

,'

'

item remains open pending a revision to the training and requalification pro-

grams as described in the licensee's August 1,1980 response.

.

--

..

.-

-=

_

_.

_

- - - - . . .

-

. _ _ -

.

.

1

5.

,

1

l

(Closed) Infraction (50-293/80-09-02).

Electrical system lineup not covered

by procedure. The inspector has observed several temporary /off-normal tests

and system lineups that have been appropriately described by ORC approved

[

temporary procedures.

In addition, the licensee has promulgated special

'

.

instructions to operators via Special Orders which are also approved by the

ORC. This item is closed for record purposes, however, the inspector will

continue to review the licensee's actions to operate the station in accord-

ance with properly approved procedures.

(0 pen) Infraction (50-293/80-09-03). Watch Engineer not notified of fuel

<

'

movement. The inspector reviewed the corrective actions described in the

licensee's responses dated August 1, 1980 and November 19, 1980.

Procedure

4.3 has been revised to require ORC approval for fuel movement and to com-

plete a separate check list (OPER 25) for moves within the spent fuel pool.

Special training was conducted prior to the 1981 refueling outage and the

'

inspector did not identify any recurring problems. However, this item remains

open pending a revision to the training and requalification programs as

i

descrfDcd in the licensee's November 19, 1980 response.

1'

(Closed) Deficiency (50-293/80-09-04).

Events not properly logged. The

licensee's August 1, 1980 response referenced a new station record - the Re-

fueling Supervisor's Log. The licensee revised this response on November 13,

,

1981 by stating that refueling events would be logged in the Station Operations

Log, and that the refueling SR0 would summarize actions in the Station Operations

Log at the end of the shift.

The inspector verified that procedure 4.3 has been

revised accordingly and that these logging requirements were followed during

-

the 1981 outage. This item is closed.

!

(Closed) Violation Level 6(50-293/81-02-02).

Administrative procedures not

followed. The inspector reviewed the actions described in the licensee's

responses dated April 27, 1981 and June 16, 1981. Procedure 1.3.7 was revised

on October 7,1981 deleting the redundant requirement to sumarize the operation

of the plant at the end of the shift.

Procedure No. 2.1.17 was revised to be

,

!

compatible with procedure No. 7.9.2 and to require the Watch Engineer's signature

i

verification of the valve lineup prior to a radwaste discharge. The inspector

has verified proper Watch Engineer signature verification on recent radwaste

discharges. This item is closed.

(Closed) Unresolved Item (50-293/81-31-02). Modify RBCCW heat exchangers.

,

.

The inspector reviewed station records and held discussions with the QC Group

l

leader. The two RBCCW heat exchangers were modified by PDCR 81-55 and main-

i

tenance request No's. 81-30-7, and 81-30-22. New reinforced pass partition

'

plates were added and the channel cover grooves were reconditioned. QC inspection

reports 181-30-7,'and 181-30-22 document satisfactory hydrostatic tests.

A QA

audit accepted the vendor as an acceptable supplier of services and off-site

work was witnessed. This item is closed.

1

i

__

__

_ ___._..-. . . , _ _ . _ _ _ _ _

.

-

. .

.

. .

.

.

6.

(0 pen)InspectorFollowItem(50-293/81-16-02). Replace piping and socket

weld in two inch reactor vessel drain line. The licensee's QA department

identified a problem with the repair weld method which was performed in

November, 1980.

Deficiency Report (DR) No. 690 was issued to resolve this

problem. The licensee committed to replace the pipe and questionable weld

during the 1981 outage. NRC inspection report No. 82-02 documents the com-

pletion of this commitment under maintenance request No. 81-12-52 in January,

1981. The inspector reviewed the QA audit file for DR 690 and noted that the

QA auditor had identified that the replacement piping and coupling was 316L

stainless steel as opposed to the original construction specification

(6498-M-300) of 304 or 304L stainless steel. The Nuclear Engineering Depart-

ment had eveluated this change (memo dated March 18,1982) and detennined

that the substitution was acceptable. However, the inspector noted that the

piping specification (6498-M-300) is referenced in FSAR Figure 1.0.5.

This

item remains open pending review of a safety evaluation performed pursuant to

10 CFR 50.59 for this material change.

(0 pen)ViolationLevel 5(50-293/81-12-01).

Procedures inadequate - seven

examples. The inspector verified that the corrective actions as described in

the licensee's September 8, 1981 response were adequate in five of the seven

areas. These are described below:

(item numbers refer to the original Notice

ofViolation)

(1) Procedure No. 2.2.87 has been revised to prohibit valving out'a control

rod not fully inserted without the Reactor Engineer's concurrence that the

shutdown margin is maintained.

(2) Procedure 1.3.34 specifies the logging the run time of each train of SGTS

filters.

(5) Procedures 8.5.2.1 and 8.7.4.3 have been revised to specify the correct

valve timing.

(6) Procedure 8.7.1.8 has been retired.

(7) Procedure 8.7.1.5 has been revised to include new up-to-date sketches

showing proper instruction for venting and draining.

Two, areas have either uncorrected or recurring problems:

(3) Procedure 1.3.8 was revised to add requirements for control of procedures

posted in the plant.

However, the inspector identified 12 locations in

the plant that had procedures posted that were not specified in procedure

1.3.8.

Moreover, the licensee's response dated September 8, 1981, stated that

copies of the retired 5.3.1 procedure had been removed but two copies

were still posted in the ' eactor building (instrument rack 2206 51' eleva-

r

tion, and MCC B20 23' elevation).

.

.

7.

These items were imediately corrected by the licensee following identi-

fication by the inspector. This area remains open pending a review of

the licensee's latest proposed revision to procedure 1.3.8 and verifica-

tion of implementation.

(4) The licensee's resporse dated September 8, 1981, stated that procedures

2.2.85 and 2.2.86 were being revised to include coverage of the normal

position of the RHR-Fuel Pool spectacle flanges and that full compliance

would be achieved by September 30, 1981. The inspector reviewed the current

revisions of these procedures (2.2.85 " Fuel Pool Cooling and Filtration

System", Rev. 13) and determined that the stated revisions had not been

made.

Procedure 2.2.86 Section VII.E. mentions repositioning the spectacle flanges

but only describes a particular evolution during which the RHR system is

inoperable

(RHR system cooling of the spent fuel pool). The procedural

sections that should have been revised and which were the subject of this

item included specifying the normal position of the RHR-Fuel Pool spectacle

flanges, and procedural steps for change over during specific evolutions

such as torus cleanup (2.2.85 Section K) and lowering torus level (2.2.85

SectionJ).

The licensee acknowledged these comments and initiated immediate action to re-

vise these procedures. This area remains open pending a review of the licensee's

proposed revision to procedures 2.2.85 and 2.2.86.

(0 pen) Violation Level 6 (50-293/81-02-03).

Document control. Seven quality

assurance program related procedures were not approved by the QA Manager.

Radwaste procedures were out of date.

The licensee's response dated April 27,

1981 stated that full compliance would be achieved with respect to the QA

Managers approval by June 1,1981, and that full compliance had been achieved for

the radwaste procedures. The licensee revised this response in a letter dated

June 16, 1981 and stated that the QA Manager's review and approval was expected

-

by July 15, 1981.

The inspector reviewed the status of these items and detennined

that all actions were either not complete or uncorrected. One quality assurance

proe a related procedure (1.4.6 " Housekeeping", Rev. 5) has not yet been

appre ind by the QA Manager. One radwaste control room procedure was out of

date ' 7.9.2 " Liquid Radioactive Waste Discharge", Rev.13 in place - Rev.15

effective) . The licensee immediately corrected this out of date radwaste

pro'cedure after identification by the inspector.

This item remains open pending review of the QA Manager's approval of the subject

procedure.

.

.

8.

3..

Operational Safety Verification

A.

Scope and Acceptance Criteria

The inspector observed control room operations, reviewed selected logs

and records, and held discussions with control room operators. The in-

spector reviewed the operability (including valve positions) of the

Core Spray (operability test witness) and High Pressure Coolant Injection

(systemwalkdown) systems. Tours of the turbine building, intake structure,

reactor building, radwaste area, station yard, switchgear rooms, cable

spreading room, emergency diesel generator rooms, auxilliary bay, CAS, SAS,

and control room (daily) were conducted. The inspectors observations in-

cluded a review of equipment conditions, control room annunciators,

potential fire hazards, physical security, housekeeping, radiological con-

trols, equipment control (tagging), and gaseous release rates from the

station.

The inspector reviewed records of a radioactive liquid discharge, sampling

of the Standby Liquid Control System baron concentration, and residual

chlorine analysis.

These reviews were performed in order to verify conformance with the

facility Technical Specifications and the licensee's procedures.

B.

Findinas

'

(1) On May 10, 1982, the inspector noted two radiation monitoring instru-

ments that were out of calibration. A portable area radiation moni-

toring instrument in the Turbine Building truck lock (RM-16 SN 534)

was due for calibration on April 1,1982. The licensee stated that

it had only been used for trending purposes to detect any highly

radioactive drums brought into the area and had not been used for

any required survey, and immediately removed it from service. A

neutron monitoring instrument at the entrance to the drywell (PRS-2

SN 272) was due for calibration on May 3,1982. The licensee stated

that it also had not been used for any required survey since the cali-

bration due date, and removed it from the reactor building.

No violations were identified however, the inspector will continue

to review radiation survey instrument operability during future routine

'

inspecticns.

(2) On May 24, 1982, the inspector observed a security watchman posted as

a fire watch in the Auxiliary Boiler room who's level of attention

was questionable. The Deputy Nuclear Operations Manager observed

this situatidh and took immeidate action to counsel the individual.

The individual was reprimanded and in addition, a memo was issued to

all security force members reinforcing correct performance of duties.

The inspector had no further questions in this area at this time.

No

violations were identified.

.

,

.-

-

T

.

.

9.

(3) On May 26, 1982 the inspector identified posted procedures in the plant

that were out of date.

Details concerning this observation are des-

cribed in Paragraph 2 under followup of previously identified items

81-12-01 and 81-02-03.

(4) On June 4,

1982, the inspector performed an operational safety veri-

fication of the High Pressure Coolant Injection (HPCI) system that

included a system walkdown in the HPCI Quadrant on the -17' elevation

of the Reactor Building. The inspector verified by visual observation,

that accessible valves in the flow path were correctly positioned and

controlled as specified in station procedures and drawings. The inspect-

or observed significant steam leakage from reponents in the steam

supply line to the HPCI turbine, and was conc.crned that the resultant

high humidity and temperature might reduce reliability of the system.

Subsequently, the inspector verified that maintenance requests had

already been issued covering the components in question. The inspector

discussed plans for the performance of maintenance to correct this

condition with senior station management personnel and was informed

that maintenance was scheduled.

Furthermore, due to the inspector's

concerns associated with high humidity, the licensee advanced the

schedule so that on June 8,1982 repairs were initiated.

Further

details of these maintenance activities are discussed in Paragraph 6

of this report.

No violations were identified.

(5) Fire Brigade Shift Assignments

On May 19, 1982, the inspector reviewed implementation of the Security

Plan requirements and observed shift manning practices including assign-

ment of fire brigade duty by security force personnel. The inspector

noted that the selection of fire brigade response personnel was not

consistent with the guidance established by the NRC's Review Guideline

No. 19, Manpower Sharing for Operating Reactors. This fact was brought

to the attention of cognizant station personnel as an item of concern

by the inspector, since it appeared that assignments were being made

for fire brigade duty without due regard for imediate response capa-

bility of the personnel.

'

Subsequent to discussions with the licensee's Security Supervisor, a

written directive was issued to the duty security supervisors instructing

them of appropriate assignment of fire brigade duty concurrent with

security duties.

Based on this directive and review of it's implementa-

tion, the inspector was satisfied that established criteria was being

met and had no further questions at this time.

No violations were identified during this operational safety verification.

,

.

.

10.

4.

Followup on LER's, Events / Plant Trips, and Periodic Reports

A.

Review of Licensee Event Reports (LER's)

(1) LER's submitted to NRC:RI were reviewed to verify that the details

were clearly reported, including accuracy of the discription of the

cause and addeuqacy of corrective action. The inspector determined

whether further information was required from the licensee, whether

generic implications were indicated, and whether the event warranted

onsite followup. The following LER's were reviewed:

LER No.

Subject

  • 81-50

Ground on 125v inverter - RCIC System

  • 81-51

Broken test connection - primary boundary

81-52

Torus temperature above T.S. limit

  • 81-54

Masonary wall failures

  • 81-57

Limitorque operator mounting bolts loose

  • 81-58

Fixed CO2 system failed discharge test

  • 81-59

Secondary containment leak rate test failure

  • 81-60

APRM bypass switch design

  • 81-61

Gouges in torus wall

  • 81-62

Target rock SRV failures

81-63

Anomalous measurement

  • 81-64

'C' RHR pump operation without suction path

82-01

Sliding fire door not functional

82-02

Sensing line frozen for pressure switch

  • 82-04

Type 'B' LLRT flanges

82-05 CRD insert / withdraw line pipe supports

  • 82-07

HPCI, RCIC excess steam flow setpoints

  • 82-08

Torque switch jumpers not installed

  • 82-14

Sliding fire door inoperable

(2) For the LER's selected for onsite review (denoted by asterisks above),

the inspector verified that appropriate corrective action was taken

or responsibility assigned and that continued operation of the facility

was conducted in accordance with the T.S.

Report accuracy, compliance

with current reporting requirements and applicability to other site

systems and components were also reviewed.

,

-- 81-50; Ground on 125v system. This LER was issued because of a

violation of the T.S. requirements for the RCIC containment isola-

tion valve instrumentation. This event was reviewed in NRC inspec-

tion reports No. 81-19 and 81-22. This LER is closed.

81-51; Broken test connection.

Followup of this event is described

--

in NRC inspection report 81-19.

This LER is closed.

-

- _ ..

. .

._

.

. - .

. . __

_

._

_

_

-

-

-

.

.

,

t

11.

}

81-54; Masonary wall failures.

Followup of this event is described

--

in NRC inspection reports 81-19 and 81-31. Moreover, an additional.

-

NRC inspection, No. 82-07, was performed to review the licensee's

actions with regard to IEB 80-11 and masonary wall problems. This

LER is closed,

i

I

l

-- 81-57; Limitorque operator mounting bolts loose. The affected hold

down bolts were repaired. An engineering investigation is in pro-

.

t

gress to evaluate the cause of the loose and broken bolts and the

!

relationship (if any) between this event and other component failures

in the RHR system. This LER remains open pending a review of this

analysis and an updated LER.

,

i

81-58;

Fixed CO2 system.

A_ test of the CO2 system on October 26,

--

l

1981 revealed that the system was unable.to deliver the_ required

concentrations within a specified time. The system has been made

-

j

inoperable because of possible low temperature damage to electrical

,

i

components. BECo. letter to NRC:NRR dated April 26, 1982 describes

'

the licensee's plans for adding a total flooding Halon 1301 system.

A fire watch has been patrolling the area as required by T.S.13.12.D.

This LER remains open pending a review of an updated LER describing

an. engineering evaluation.

81-59; Secondary containment leak rate test failure. NRC. inspection

-

--

reports No. 81-35, and 82-10 describe followup of actions taken with

respect to secondary containment leak rate testing. The licensee

,

has also submitted additional reports (dated February 16, 1982 and-

'

May 27, 1982) required by T.S. 6.9.C.3 describing results of

satisfactory testing. This LER is considered closed.

3

81-60; APRM bypass switch design. NRC inspection report No. 81-31

--

describes initial review of this event. The inspector verified that

,

l

caution tags are in place on the APRM and IRM bypass switches. The

licensee plans either. design modifications or T.S. changes. This

LER is closed.

I

81-61; Gouges in torus wall. NRC inspection. reports No. 81-24,

[

--

81-35, and 82-01 document close out of this event.

t

,

81-62; Safety-Relief Valve (SRV) failures.

NRC inspection

I

'

--

reports No. 81-24, 81-35, and 82-10 document review of this event.

Performance of SRV's has been incorporated into the T.S.

This LER

is closed.

,

81-64;

'C' RHR pump operation. NRC inspection report No. 81-24

--

documents review of this event. The inspector will continue to

'

review operations for attention to detail.

This LER is closed.

4

,

l

j

.

l

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

_ - . , . _ . _ . -_

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

, _ . - , - . - _ -

. , . - - - -

-m_.

. - . ,

c-

,.,_ _ . - _ ,

---

.

.

12.

82-04; Type 'B' LLRT flanges. NRC inspection report No. 82-01

--

documents initial review of this event. The licensee reviewed the

design of similar components which should have been in-

cluded in the type

'B' LLRT program. The inspector reviewed the

test results of these additional components and verified that pro-

cedure No. 8.7.1.3 was revised appropriately. The inspector also

verified that responsibilities had been assi5ned and that an

associated change to procedure No. 8.7.15 was being tracked. This

LER is clo' sed.

-- 82-07; HPCI, RCIC high steam flow setpoints. The licensee made

setpoint changes to the high flow trip instruments and has revised

the appropriate calibration procedures. This action was taken

following discussions between the inspector and the licensee con-

cerning recent problems at another operating BWR.

Subsequent to

the licensee's actions, the NRC issued Infonr.ation Notice No. 82-16

dated May 28, 1982 to all reactor facilities.

IN 82-16 also cautions

about consideration of spurious trips and TMI TAP item II.K.3.15.

The inspector noted that the licensee has taken this issue into

consideration and has already installed a 3 sec. (nominal) time

delay in. the HPCI and RCIC high steam flow isolation circuits in

order to avoid spurious trips. This LER is considered closed.

-- 82-08; Torque switch jumpers not installed.

NRC inspection report

No. 82-10 describes initial followup of this event. The licensee

prepared a list of all safety related valves, reviewed the wiring

diagram for each, and visually inspected each to ensure that the

wiring was as designed.

Of 104 valves reviewed, 57 were identified

as requiring ju:.1pers across the torque switch.

Of these 57, 9 jumpers

did not exist and were corrected.

This LER remains open pending a

review of an updated LER summarizing these actions.

The inspector expressed concern that the examination of valves

for the jumpers required many systems to be removed from service

with the plant operating.

Information had previously been sent

to the licensee in 1981 describing the problem of missing torque

switch jumpers (G.E. SIL No. 235 Supplement 1 dated June 1981, and

NRC IEC 81-13 dated September 25,1981).

The plant was shutdown

between September,1981 and March,1982 for a refueling outage.

It was not until March 31, 1982 during startup testing that an

-

inoperable HPCI injection valve triggered a generic review for

possible missing jumpers. As a result of TMI TAP Item No. I.C.5

Feedback of Operating Experience, the licensee has established

procedures to followup on external information. The inspector

stated that further followup of the licensee's system for feedback

of operating experience will be performed during a future inspection.

(50-293/82-16-01).

.

13.

82-14;

Inoperable sliding fire door. The inspector held discussions

--

with senior station management and detennined that a roving fire

patrol had been in existence for an unrelated CO, tank inoperability

and that the T.S. action statement had been follbwed.

No violations were identified during this review.

B.

Review of Periodic Monthly Reports

Upon receipt, periodic reports submitted pursuant to Technical Specification 6.9 were reviewed to determine whether the required information was included

and planned corrective action was adequate, whether any infonnation should

be classified as an abnormal occurrence, and the validity of the infonnation.

The following reports were reviewed:

March,1982 Operational Status Report dated April 13, 1982

--

April,1982 Operational status report dated May 14, 1982

--

The inspector questioned the licensee concerning two areas: 1) the March

report, section of Major Safety Related Maintenance, did not describe

corrective actions to prevent recurrence, and 2) the March report, section

of Summary of Operations describing Safety / Relief Valve challenges, did not

include two lifts of SRV's following 0-ring inspections.

The licensee stated that more attention to item 1) would be given in future

reports and that item 2) would be corrected as applicable during a future

report.

The inspector had no further questions, no violations were identified.

C.

Followup of Events / Plant Trips

(1)

Inadvertent Anticipated Transient Without Scram (ATWS), Alternate

Rod Insertion (ARI) and Recirculation Pump Trip (RPT)_

During the performance of routine functional testing of ATWS equip-

ment on May 12, 1982, an inadvertent ATWS, RPT and ARI occurred at

2:05 pm with the reactor at 98% power. The operators observed rapid

core flow decrease and control rod insertion, recognized the ATWS trip,

and initiated actions for a reactor trip (manually securing reactor

"

feed pumps resulting in an automatic low level scram). All other

plant equipment responded normally.

The inspector reviewed control room logs, strip chart records, and

discussed the event with licensee personnel. The cause of the trip

was attributed to an undetected relay failure (in the tripped posi-

tion) at the same time a second channel was being tested. Shutdown and

recovery procedures were followed and a reactor startup began at 3:20 am

on May 13, 1982, with the failed relay in the tripped position.

.

.

14.

At 9:13 am on May 13, 1982, a second ATWS trip occurred prior to

criticality.

The operators again took action for a reactor trip.

This second ATWS trip was caused by I&C technician error (removing

the wrong module) while attempting to locate part number information

for replacement parts.

Procedure 8.M.1-29, "ATWS Functional and Trip Unit Calibration Test",

Rev. 5, requires verification that the logic has returned to nomal

t

after each channel functional test. The licensee stated that technicians

had been using the trip light on each module for this verification

because of the difficulty in observing the actual position of the relays.

The inspector noted that these trip lights were not the appropriate

indication to observe and that additional trip channel indications

(neon lights) were available to aid in the detection of trip logic

status to help preclude inadvertent trips.

The licensee stated that

procedure 8.M.1-29 would be revised to reflect improved testing methods

and appropriate use of available indication to minimize inadvertent

system actuation.

The inspector verified through discussions with the Senior Radio-

chemistry Supervisor that no abnormal off gas indications were evident

that may have resulted from the ARI trip.

The licensee's actions to revise procedure 8.M.1-29 will be folicwed

during a future inspection (50-293/82-16-02).

(2)

'E' Salt Service Water Pump (SSW)

On May 13, 1982 at 9:30 am, the licensee observed the 'E'

SSW pump

motor running with the shaft stopped.

Investigation revealed that

the shaft coupling had been damaged by a small piece of wood found

stuck in the impeller. Redundant equipment testing was initiated and

repairs to the pump were comenced.

The SSW system has 5 pumps ('A' through 'E').

The T.S. requires two

SSW pumps to be operable in each of two containment cooling loops.

'C' pump is a designed spare but does not have the capability to be

controlled from the Alternate Shutdown Panels which were installed

for fire protection reasons in early 1980.

On May 14, 1982, the

licensee contacted NRC:NRR and received verification that the 'C'

,

pump can be considered to meet the T.S. containment cooling require-

ments. The inspector verified that the other four pumps (' A' through

'D') were available and had no further questions at this time.

l

At 5:45 pm on May 15, 1982, the 'E' SSW pump had been repaired and

demonstrated operable following a satisfactory surveillance test.

No violations were identified.

i

(

.

.

15

l

(3) Reactor Trip

At 11:54 a.m. on May 19,1982, an automatic high flux reactor scram

occurred as a result of a turbine run back condition from full power.

The run back resulted from a high stator cooling water temperature

condition. Subsequent investigation by the licensee revealed high

stator winding temperature recorder indications, and identification

of a failed stator cooling water high temperature switch. Additionally,

the licensee was conducting testing on the Reactor Building Clcsed Cooling

Water System in a manner that may have influenced Turbine Building Closed

Cooling Water System which could possibly have caused the increasing

stator coolant temperature.

The inspector verified that station procedures were followed and the

requirements of the Technical Specifications were met during the

transient. No ECCS systems were actuated.

Repairs to the temperature switch required issuance of temporary

modification 82-037 that utilizes an alternate switch to effect

turbine run back until a replacement part can be obtained and installed.

On May 20, 1982, the nomal power operations were resumed following

resolution of an unrelated problem with the main turbine generator

voltage regulator.

No violations were identified.

(4) Stuck Traversing In-Core Probe (TIP)

At about 3:00 p.m. on June 3,1982, a technician observed by remove

indication that a TIP had retracted beyond its nomal storage location.

Shift supervision and health physics personnel were notified and the

drive mechanism area on the 23' elevation of the Reactor Building was

surveyed. The area was declared a high radiation area-(50-90 R/hr

on contact,15 R/hr at 10 feet, 2 R/hr at 15 feet and 350 mr/.hr at

-

l

20 feet) and the area guarded and barricaded.

l

The Watch Engineer declared an Alert status at about 3:20:p.m. following

i

a review of emergency plan implementing procedures and nomal radiation

l

1evels in the area. Local, state and federal agencies were notified

and the licensee's emergency facilities manned.

Following surveys

performed to ensure that radiation levels were localized and decreasing

the licensee teminated the Alert at 5:11 p.m. on June 3,1982.

The inspectors observed the licensee's actions during this event,

reviewed records, held discussions with personnel, and toured various

!

areas throughout the station. The cause of the probe not stopping

l

in the shield was a faulty limit switch and traveling tube slot align-

i

ment. This has been repaired. No inadequacies were identified with

the licensee's imediate response to this event. However, two follow

i

items and one violation are discussed below:

j

.

..

.

.

-.

_ _ _ , _ _

.

.

16.

The inspector noted that during the initial stages of this event,

-

the Area Radiation Monitor (ARM) for the TIP machine area (No. 8)

was not in alam when it should have been. This was imediately

investigated, a faulty cable connection identified, and repaired.

Following review of station health physics procedures and discussions

with licensee personnel, the inspector detemined that the ARM is

calibrated every six months but the calibration procedure (No.

6.5.160, " Calibration of the Area Monitoring System", Rev. 1) does

not require a functional check with a source after calibration

and reinstallation of the detector. The licensee stated that a

procedure change would be made to require a source check after re-

installation of the detectors.

The inspector will follow this pro-

posed procedure (s) change in a future inspection (50-293/82-16-03).

-

The licensee's immediate actions to identify the retracted probe,

shut off the drive mechanism, notify health physics personnel and

provide control of the area were in accordance with station pro-

cedures. Although the procedure in use at the time of the event

(9.5, "LPRM Calibration", Rev. 10) includes a precaution describing

observations to make and actions to take if a probe fails to stop

at it's chamber shield limit, a procedure change has been initiated

to strengthen this precaution statement in all procedures related

to TIP operation. The inspector will follow these proposed changes

to procedures 9.5, 9.6, 9.7, and 9.20 during a future inspection

(50-293/82-16-04).

-

Following the termination of the Alert on June 3, 1982, the licensee

continued the assignment of a health physics technician as an access

control point at the posted entrance to the TIP machine high radia-

tion area because of the inability to lock the area. At 5:50 am on

June 4, 1982, the inspector toured the area and observed the health

physics technician lying on the floor. The inspector immediately

contacted the Watch Engineer who took action to ensure that an

adequate control point would be maintained.

The inspector discussed this event with the licensee's management

and determined the following:

the technician in question had an

injured back, had taken medication for the back pain, had laid

down on the floor to relieve the pain and subsequently fell asleep.

The licensee's Senior Health Physics Supervisor immediately counselled

his staff concerning this event, proper aspects of supervision and

personnel condition. The Nuclear Operations Manager stated that

'

additional review of the incident would be perfomed relating to

medical department policy and practices.

Radiation survey data indicated that contact dose rates with the

TIP drive mechanism were 20 R/hr, 2 R/hr, and 1.8 R/hr at 9 pm en

June 3, 1982, 6:30 am on June 4, 1982 and 8:30 am on June 4, 1982,

respectively. Technical Specification (T.S.) 6.13.2 requires each

high radiation area greater than 1000 mrem /hr be locked.

T.S. 6.11

requires radiation protection procedures be adhered to.

Station

a

_

.

.

17

procedure No. 6.1-012. " Access to High Radiation Areas", Rev. 8,

requires that if a Health Physics control point is established that

he will be responsible to ensure the area is locked and access is

otherwise controlled.

The failure of the health physics technician (assigned as control

point) to control access to the TIP drive mechanism high radiation

area is a violation (50-293/82-16-05).

In addition to the improvements described above, the licensee stated

that a review would be perfomed to detennine whether the criteria

for initiating the Emergency Plan is in need of revision, and whether

modifications (such as proximity switches) are necessary for use in

the control circuitry.

(5) Release of Spent Resin

At about 1:00 p.m. on June 11,1982, the licensee identified spent resin

fines on the ground near the Turbine Building. Subsequent surveys

identified contamination on the roofs of the Turbine, Off-Gas, Re-Tube,

and Administration Buildings. Contamination was also found on the ground

within the site controlled areas.

Surveys of the entire site within the protected area, the parking lots,

shorefront and security access areas were completed within 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> of

identification.

Initial airborne surveys and liquid samples of stonn

drain discharge indicated that no release to unrestricted areas had

taken place.

The inspector reviewed the licensee's actions during this event.

Additional NRC: Region I specialist inspectors arrived on site to review

and evaluate the licensee's actions.

Initial investigation revealed that the source of the spent resin was

via the Reactor Building (R.B.) Vent, the R.B. Contaminated Exhaust

System and the Condensate Demineralizer - Resin Regeneration System

during backwashing evolutions.

At the end of this reporting period, the licensee suspended resin

backwashing evolutions, and had initiated the following programs:

cleanup of all contaminated areas, inspection of the ventilation system,

and additional environmental surveys / sampling.

At 5:15 p.m. on June 11,1982, the licensee declared the 'A' train of

Standby Gas Treatment System (SGTS) inoperable because of inadequate

flow and plugged filters. The resin was cleared and the 'A' train

demonstrated operable by a satisfactory test at 00:15 a.m. on June 12,

1982.

Further cleaning of resins in the inlet plenum to both trains

of the SGTS and other ventilation systems was continuing at the end

of this report period.

_ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ .

.

.

18.

The licensee also initiated reviews to prepare procedure changes and

system modifications to preclude recurrence of this event.

The licensee's actions, commitments, and the NRC's findings relevant

to this event will be described in a future separate inspection report.

5.

Surveillance Activities

A.

Scope and Acceptance Criteria

The inspector reviewed the licensee's actions associated with surveillance

testing in order to verify that the testing was performed in accordance with

approved station procedures and the facility Technical Specifications (T.S.).

Portions of the following tests were reviewed:

routine residual chlorine analysis sampling of the discharge canal on

-

May 18, 1982

- routine EDG loading test on May 20, 1982

- routine EDG start testing via RHR logic signals on May 20, 1982

routine jet pump operability test on May 28, 1982

-

alternative testing required prior to removing the 'E' Salt Service

-

Water pump from service for a support reinstallation on May 24, 1982

routine Core Sprav system operability and flow rate test on June 1,1982

-

- redundant equipment testing required prior to removal of the High

Pressure Coolant Injection (HPCI) System from service for maintenance on

June 7, 1982, and

post maintenance operability tests of the HPCI system on June 8 and 9,

-

1982.

No violations were identified.

6.

Maintenance Activities

The inspector reviewed the licensee's actions associated with maintenance

activities in order to verify that they are conducted in accordance with

station procedures and the facility Technical Specifications. The inspector

verified for selected items that the activity was properly authorized and that

the appropriate radiological controls, equipment control tagging, and fire pro-

tection were being implemented.

The" items / documents reviewed included the following:

- Maintenance Request (MR) 82-1336, Electrical Fire pump

- MR 82-13-39; 'E' Salt Service Water (SSW) pump (vibration problem)

- MR 82-1361; 'B' Condensate pump repair

- MR 82-1366; Control Rod Drive solenoid valve repair

MR 82-23-19; HPCI rpm indicator repair

-

MR 82-23-10; HPCI system steam leak on Y strainer

-

MR 82-23-11; HPCI valve (2301-5) packing steam leak

-

- MR 82-23-12; FPCI valve (2301-3) packing steam leak

No violations were identified during this review.

s

__

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _

.

.

19.

7.

Followup on I.E. Bulletins and Circulars

The inspector reviewed the licensee's actions in response to the I.E. Bulletins

and Circulars listed below to verify that the actions adequately addressed the

concerns identified.

- IEB 77-05 and 77-05A, Electrical Connector Assemblies

The inspector reviewed the licensee's responses dated December 15, 1977

(letter 77-166) and January 17, 1978 (letter 78-9). The January 17, 1978

response contained a listing of valves and components inside the drywell that

were considered necessary to mitigate an accident. The inspector compared

this list with the Technical Specification Section 3.7 and found it to be

complete. The response also stated that the affected power connectors would

'

be removed and the cables would be butt spliced and covered with Raychem

Themofit WCSF-N which is qualified per IEEE 383-1974. The low voltage

control power connectors would be butt spliced as described above or the

Bendix connectors would be qualified by Wyle Laboratories. The licensee

decided to butt splice all affected connectors.

The inspector reviewed the following Plant Design Change Requests (PDCR)

which replaced Bendix connectors with butt splices inside and outside the

listed containment penetrations.

PDCR

Penetration (s)

78-04

Q101B, Q105A, Q105B

78-07

Q102A

78-09

Q102B

78-10

Q106B

78-11

Q103A

No unacceptable conditions were identified. This Bulletin is closed.

- IEB 77-06, Potential Problems with Containment Penetration Assemblies

This Bulletin required the licensee to provide information regarding

electrical penetration operating experience. The requested infomation

was provided in the licensee's response dated December 5, 1977 (letter 77-

158). This response stated that penetrations installed at Pilgrim were

not the type discussed in the Bulletin and that no similar electrical pro-

blems had been experienced.

No unacceptable conditions were identified. This Bulletin is closed.

- IEB 78-01, Flamable Contact-Am Retainers in GE CR120A Relays

The inspector reviewed the licensee's response (BEco. letter 78-30) dated

February 21, 1978. The response stated that CR120A relays (179 total)

were used in safety and non-safety related systems and that all identified

relay contact am retainers would be replaced after receipt of replacement

parts. A review of Maintenance Request 080-4099, completed on February 4,

1980, indicated that all CR120A relays had been modified per the licensee's

response and G.E. SIL 229.

No unacceptable conditions were identified. This Bulletin is closed.

- __

_

_

__

,

,

4

20.

,

-

IEB 78-04, Environmental Qualification of Certain Stem Mounted Limit

Switches lisTcTe'~~keactor Containment

s

The licensee's original response (BECo. Letter 78-49) da'.ed March 21,

1978 and their supplemental response (BECo. Letter 78-?O) dated April 25,

1978, stated that Main Steam Isolation Valve (MSIV) position (4 inside

+

containment and 4 outside) was the only use of the subject switches at the

facility. The letters also stated that no further action would be taken

since redundance of function was accomplished by the 4 MSIV's outside

containment. The licensee subsequently decided to replace the subject

switches. A review of MR 080-30 and MR 080-13 through 20, completed

during the period of February - May,1980, indicated that all Model 2400X

switches were replaced with Namco Model EA 740 nuclear qualified switches.

.

No unacceptable conditions were identified. This Bulletin is closed.

-

IEB 78-14, Deterioration of BUNA-N Components in Asco Solenoids

The inspector reviewed the licensee's response, dated February 2,1979

(BECo. Letter 79-33) and procedure 3.M.2.-16, " Scram Pilot Valve Main-

tenance", Revision 1.

-The inspector verified that all BUNA-N components

were replaced during March and May 1979, including the spare hydraulic

'

control unit in the warehouse.

In addition, the licensee intends to re-

build a number of scram pilot valves each outage so that BUNA-N components

will be replaced on a 5 year basis.

No unacceptable conditions were identified. This Bulletin is closed.

.

-

IEB 78-10, Bergen-Paterson Hydraulic Shock Suppressor Accumulator Spring

Coils

The inspector reviewed the licensee's responses dated August 9, 1978 (BECo.

Letter 78-148) and the supplemental response dated October 29, 1979.

Both

responses state that carbon steel accumulator springs will be replaced

when snubbers are functionally tested during refueling outages.

Discussions

with the licensee indicated that 23 snubbers were removed during the last

outage (September,1981 - March,1982); however, spare snubbers were installed

which had been previously rebuilt using carbon steel springs, vice stainless

steel springs. When questioned, the licensee stated that they had obtained

stainless steel springs but were notified by Bergen-Paterson via an Advisory

Letter, dated March 12, 1979, that the 131-000 series stainless steel springs

were not acceptable for installation. The letter also stated that original

carbon steel springs should be used until new stainless steel springs could

be supplied to licensee.

The licensee stated that they now have qualified stainless steel springs

and agreed to purge all carbon steel springs from their spare parts supply

and to rebuild all snubbers removed during the last outage with stainless

steel springs. The licensee also stated that all future hydraulic snubber

replacements would be with snubbers that had stainless steel accumulator

springs.

As of June 3,1982, all carbon steel springs were removed from the

rebuild area and the warehouse.

No unacceptable conditions were identified. This Bulleting is closed.

. -

-- _

. _ _ .

--

s

.

21.

IEC 78-12, HPCI Turbine Control Valve Lift Rod Bending

-

'The inspector reviewed the following documents to verify licensee com-

pletion of the recommended modification.

Chief Maintenance Engineers Memo, 78-57, dated August 16, 1978;

-

PDCR 79-29, dated April 18, 1978, completed March 11, 1980;

-

- Terry Corporation Field Design Improvement, DI #5, Revision 2,1977;

- General Electric (GE) Field Disposition Instruction, GE FDI #164/78003,

Revision 0, December 27, 1977;

GE Product Quality Certification for GE FDI #164/78003, Revision 0;

-

- GE SIL #274;

- BECo. Safety Evaluation #557, April 25,1978; and

- Job Order #80-1563

This Circular is closed.

IEC 78-14, HPCI Turbine Reversing Chamber Hold Down Bolting

-

Reversing chamber hold down bolting was conducted under MR 080-1563

(Refer to IEC 78-12) in accordance with the Circular Instructions.

This Circular is closed.

No violations were identified during this review.

8.

Response to Order for Modification of License / Performance Improvement Program

Boston Edison Company responded to the NRC's Order (dated January 18, 1982

and revised on February 16,1982) by submitting a Performance Improvement

Program dated March 18, 1982, which describes an 18-24 month program for im-

provements in management and oversight. The NRC: Region I tentative acceptance

of this program is described in a letter from the NRC to BECo. dated April 23,

1982.

The inspector met with senior licensee management to review the status of

selected milestones plar.ned for completion in May, 1982. These items are

described below:

Item numbers refer to those described in the licensee's

Performance Improvement Program dated March 18, 1982.

I.1

Develop Action Plan; The licensee has reviewed the results of the

-

Management Analysis Company (MAC) diagnostic evaluation and developed

approximately eighty-eight (88) recommendations for action. These

action items have been reviewed and assignments made for individual

implementation responsibilities. The licensee expected the formal

"

integrating Action Plan to be published by June 18, 1982.

I.2

Peer Review Group Final Review and Comments on the MAC Report; The

Peer Review Group has performed the review of the MAC diagnostic evalu-

ation, provided their written comments to MAC and the licensee, and

met with MAC to discuss these comments.

- - .

.

,

,

.

22.

II.1

Develop Preliminary Program for On-Site Oversight and Review Staffing;

The licensee has developed a preliminary program describing the duties

and responsibilities of the on-site corporate representative. This

individual (Director-Nuclear Operations Review DNOR) will be responsible

for the following functions:

a daily audit of plant operations

-

overview of plant safety related activities

-

review of industry operating experience

-

feedback to corporate management

-

The DNOR will report to the Senior Vice President - Nuclear, and will

have reporting to him the current On-site Safety and Performance group

(Shift Technical Advisors and Performance Engineers).

III.l.B Regulatory Change and Compliance; The feedback from the MAC diagnostic

evaluation has been received and is integrated into the licensee's

program.

III.l.D Complete the Evaluation of Correspondence Review; The licensee has

reviewed all changes to the regulations (10 CFR 50) since issuance

of the operating license in 1972, and all BECo. correspondence to the

'

NRC relating to these changes. The licensee has identified eleven _(ll)

major areas for which verification is being performed to document the

bases for, and accuracy of, compliance with the associated regulation

changes. The inspector reviewed documentation provided concerning two

of these eleven areas (ECCS analysis, Emergency Planning). The licensee

stated that personnel were additionally performing a similar accuracy

verification with respect to the TMI TAP NUREG 0737 items in parallel

with this effort. The licensee stated that this item is about 80-90

percent complete.

IV.1

Improved Traininc Program; The feedback from the MAC diagnostic has

been reviewed anc evaluated.

The inspector determined that the licensee had met the May, 1982 milestones

in four areas and for the other two areas

(I.1, and III.1.D) had essentially

completed the actions and was progressing towards the next group of milestones.

The inspector had no further questions in this area.

9.

Unresolved Items

,

Areas for which more information is required to determine acceptability are

considered unresolved. Unresolved items are discussed in Paragraph 2.

10.

Exit Interview

At periodic intervals during the course of the inspection, meetings were held

with senior facility management to discuss the inspection scope and findings.

. -

.-

.