ML20059A689
| ML20059A689 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/10/1990 |
| From: | Knop R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20059A687 | List: |
| References | |
| 50-346-90-09, 50-346-90-9, NUDOCS 9008230171 | |
| Download: ML20059A689 (16) | |
See also: IR 05000346/1990009
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U.S. N)CiEAR REGULATORY COMMISSION
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REGION III
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Report No. 50-346/90009(DRP)
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Docket No. 50-346
Operating License No NPF-3-
Licensee: Toledo Edison Company
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Edison Plaza, 300 Madison Avenue
Toledo, OH 43652
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Facility Name: Davis-Besse 1
Inspection At: Oak Harbor, Ohio
Inspection Conducted:- April 17 through July 17, 1990
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Inspectors:
P. M. Byron
D. C. Kosloff
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R. K. Walton
P. L. Hiland
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Approved By
R.' V K
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Reactor Projects Branch 3
Date
Inspection Summary
Inspection on April 17 through July 17,1990(ReportNo.'50346/90009(DRP))
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Areas Inspected: A routine safety inspection by resident inspectors of
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licensee actions on previous inspection findings, licensee event reports,
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plant operations, refueling, radiological controls, maintenance / surveillance,-
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emergency preparedness, security, engineering and technical support, and
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safety assessment / quality verification was performed.
Results: Seven events occurred during the inspection period (Paragraphs 4,
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7,10 and 11), collectively these events demonstrated a weakness in task
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management, planning and control of plant activities.
The NRC is considering
this weakness for enforcement action.
In addition, a non-cited violation was
identified for failing to implement a Technical Specification requirement .
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(Paragraph 3) and another non-cited violation was identified for failing to
adequately im
'(Paragraph 7)plement a Technical Specification surveillance requirements
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9008230171 900813
ADOCK 0500
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DETAILS
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Persons Contacted
a.
Toledo Edison Company
D. Shelton, Vice President, Nuclear
- G. Gibbs, Director, Quality Assurance
- L. Stort, Plant Manager
H.-Heffley, Maintenance Manager
- R.Brandt,-PlantOperationsManager(Acting)
- H. Bezilla, Superintendent,-Operations
E. Salowitz, Director, Planning and Support
- S. 'Jain, Director, DB Engineering.
- K. Prasad,- Nuclear Engineering Manager (Acting)
'G. Grime, Industrial Security Director
D. Timms, Systems Engineering Manager.-
- R. Uebbing, Maintenance Coordinator
J. Polyak, Radiological Control Manager
- R. Coad, Radiological Protection Supervisor
J. Lash, Independent Safety Engineering Manager
- H. Stevens,-Indeper. dent Safety Engineering
R. Schrauder, Nuclear: Licensing Manager
- G. Honma, Compliance Supervisor
- R. Gaston, Licensing. Technologist
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- R. Seba, Licensing Engineer-
b.
USNRC-
'*P. Byron, Senior Resident. Inspector
- D. Kosloff, Resident Inspec/or
- R. Walton', Resident' Inspector
P. Hiland. Senior Resident Inspector, Perry
- Denotes those personnel attending the. June-4 1990, exit meeting.
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' Denotes those personnel attending the July 17, 1990, exit meeting.
2.
Licensee Action on Previous Inspection Findings (92701)'
.(Closed)OpenItem(346/86032-13(DRP)):
Completion of.a plan' for
repairing and maintaining fire and ventilation boundary' doors and
balancing ventilation air flow. Completion of this item was related
to the. licensee's completion of plant modifications required to comply
with 10 CFR 50, Appendix R requirements.
The inspectors' have observed
numerous work and engineering activities related:to this item..
Inspections related to Appendix P have also' reviewed activities related
to'this item. lThe licensee-is continuing work in this-~ area;and it
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. appears that appropriate effort'is being expended to maintain doors.
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The inspectors will continue to' monitor the status of doors.- This' item
is . closed.-
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_(Closed)OpenItem(346/87022-01(DRP)): Determine if the licensee's
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method of operability determination for the Component Cooling Water
(CCW) Systems is appropriate during-inoperability of'CCW room ventilation.
After this item was identified, the NRC provided guidance to its staff
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on reviewing licensee operability decisions.
Based on that guidance,
the inspectors determined that the licensee's practice was appropriate.
This item is closed.
(Closed) Violation-(346/88014-02(DRP)): During a previous refueling
operation, an operator demonstrated a lack of sufficient knowledge to-
operate refueling equipment. A review of training records revealed
that the operator had not received hands-on training in the previous
four years. The licensee has since changed refueling
ensure that operators are trained prior to refueling. procedures. to
Training consists
of classrocm studies and operations with a dumnly assembly. The' operations
superintendent provides.a list of qualified personnel which is included-
in the Fuel Handling Directors log.
The inspectors have observed
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defueling and refueling operations. The operators were knowledgeable
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of their equipment and procedures.
This item is closed..
No violations or deviations were identified in this area.
3.
Licensee Event Reports followup (92700)
Through direct observation, discussions with licensee personnel,.
and review of records, the following licensee event reports (LERs)
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were reviewed to determine that reportability rcquirements were fulfilled,
that immediate corrective actions to prevent recurrence was accomplished
inaccordancewithTechnicalSpecifications(TS). The LERs listed below
are considered closed:
(Closed)LER90006:
Inadvertent Safety Features Actuation System (SFAS)
Actuation While T)efueled When Dreaker Switch HAAE2 Was Bumped Open.
This event was discussed in Inspection Report 50-346/90005. This LER
is closed.
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(Closed)LER90007:
Inadvertent Inconsequential Safety-Features Actuation
'5FstemActuationWhileDefueled.
Three SFAS actuations were reported in
this LER. This LER describes random spiking observed in containment
radiation monitor' RE 2005. The licensee has not yet-identified the cause
of these spikes.
The inspectors will continue to moniu r the licensee's
efforts to identify the cause of these spikes.
These SFAS actuations
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were discussed in Inspection Report No. 50-346/90005.- This LER is
closed.
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(Closedl LtR 0008:
Unnecessary Safety Features Actuation System Level 1
Acto:.tTon DurinfUore Support Assembly (CSA) flove. This SFAS actuation
wu caused by two SFAS radiation monitors being exposed to radiation from
the CSA. All fuel was removed from the reactor when this actuation
(ccurred. All equipment functioned as expected and the SFAS actuation
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had no safety significance. The radiation levels in containment during
the CSA move were higher than expected. The CSA move was discussed in
Inspection Report No. 50-346/90012.
This LER is closed.
(Closed) LER 90009: Source Check of Station Vent Radiation Monitors
Did Not Satisfy Technical Specification (TS) 3.3.3.10.
On March 16,
1979, the licensee submitted a license amendment request to include the
Radioactive Effluent Technical Specifications (RETS) in the Appendix A
TS. This request was supplemented by_the licensee with five letters
dated between December 23, 1982 and. November 1, 1984. On July 2, 1985,
in response to the license amenoment request, Amendment 86 was issued
(effectiveOctober 30,1985), incorporating definition 1.29, " Source
Check," which states that a source check uses a radioactive source,-
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and Table 4.3-16 which' requires that the ststion vent monitors be-
given a monthly source check,
in 1982, the licensee had installed the station vent monitors that
became the subject of Amendment 66
The licensee required that the
vendor supply the monitors with an installed radioactive check source.
The vendor, apparently unknown to the licensee, sup) lied monitors which
used an installed light emitting diode (LED) as a c1eck source instead
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of a radioactive source.
To detect a radioactive release, the detector
uses a detector crystal which emits light when struck by ionizing
radiation, the light is detected by a photomultiplier tube. The LED
checked th' detector by activatin
activatin, the detector crystal. g the photomultiplier tube without
The licensee also performed an 18-month
calibration of the detectors using a radioactive source.
On April 26,.1990, a licensee system engineer determined that the LED
check was not a source check. The licensee declared the detectors-
inoperable and complied with the TS action statement.- The inspecto?
verified that on April 27, 1990, the monthly source check procedures,
DB-SC-03229 and DB-SC-03230, were revised to require use of a radioactive
source. The inspectors reviewed the procedures and verified that the use
of a radioactive source is now required.
The detectors were successfully
checked with a radioactive source on April 28, 1990.
The licensee
concluded that the root cause of the event was a failure to. conduct an
adequate review of installed equipment relative to the:TS requirement.
The licensee did not propose any corrective action for-this root cause
because there have been extensive improvements in the conduct of
activities since this inadequate review occurred.
Because the licensee had not performed the source check as required by
the TS, a violation of TS 3.3.3.10 (346/90009-01(DRP)) extsted at various
times from October 30, 1985 until April 28, 1990.
This 'icensee-identified
violation is not being cited because the criteria speci(ied in Sr.ction V.G.
of the Enforcement Policy were satisfied.
No other violations or deviations were identified.
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Plant Operations (71707, 71710, 64100, 93702)
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Operational Safety Verification
Inspections were routinely performed to ensure that the: licensee
conducts activities at the facility safely and in conformance:
with regulatory requirements. The inspections focused on the<
implementation and overall effe ,civeness of the licensee's- control
of operating activities, and on the performance;of licensed and
non-licensed operators and shift managers,
The inspections included
direct observation of activities, tours oi the facility. -intryiews
and Uscussions with licensee personnel, independent verification of
saf'n o stem status and limitin
revUn of facility procedures; _ g conditions of operation (LCO), a' d<
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records,'and reports. _The following.
items were corsidered during these-inspections:
' Adequacy c plant staffing and supervision.
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Control room professionalism,; including procedure adherence,-
op'erator attentiveness, and response to alarms, events, and
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off-normal conditions,
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Operability of selected safety-related systems, including;
attendant alarms, instrumentation, and controls.-
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Maintenance of quality records and reports.
The inspectors observed that control room shift supervisors,
shift managers, and operators were attentive to plant conditions,
performed frequent panel walk-downs and were responsive to-
off-normal alarms and conditions,
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On May 1,1990, the licensee drained the reactor' vessel about
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18 inches lower then' planned while draining the refueling-canal.
Prompt operator action
The reactor
vessel was refilled by. prevented further-draindown.
gravity drain from _the Borated Water Storage
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Tank (BWST). The reactor vessel internals indexing fixture was in
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place above the reactor vessel during the operation and the draindown
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occurred because there is very little flow from the canal to the-
vessel once the canal level drops to the . top of the indexing fixture. .
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Initially the operators thought that the indexing fixture was ;1ocated:
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elsewhere. The canal draining procedure did_not provide any guidance
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regarding the location or effects of the indexing fixture. This
event -is described in'more detail in Inspection- Report
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No.50-346/90012(DRSS), As stated in the report, the refueling'
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canal draining was accomplished utilizing procedure'DB-0P-06023,
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" Fill, Drain, and Purification of. Refueling Canal,". Revision 00,
dated February 14, 1990. Section 3.6 addresses' lowering the water
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level using a decay heat pump (DHP).
The inspectors reviewed
DB-0P-06023 and determined that the. procedure was not appropriate to
the circumstances in that it does -not address the indexing fixture nor
does it contain precautions about the loss of decay heat cooling
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from a partially filled reactor coolant system'as-described in
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Generic Letter 87-12. This is a violation of.10 CFR 50, Appendix B,
Criterion Y, which requires that activities effecting quality shall
beappropriatetothecircumstances(346/90012-03).
Conduct of Operations Procedures DB-0P-00000,- Revision 01, dated.
April 2 1990,-Section 6.7.6 requires that prior to the performance
of critical, complicated, unusual, or infrequent.. operations, a
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procedure review shall' be performed, and briefings: shall be
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conducted by the individual in charge of_the evolution. The
licensee has determined that no: formal briefing was held nor was a'
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pre-evolution walkdown performed. The shift supervisor briefed
individuals separately, but did not identify' equipment which was
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involved as required by 6.7.6.c.
Since the draining of the refueling
canal is normally performed during refueling outages it meets the-
criteria of-infrequent operations. These are examples-of violations-
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of Technical Specification 6.8.1 (346/90012-04) which requires.that
procedures be adhered to.-
On May 18, 1990, a Safety Features' Activation System (SFAS)
initidion occurred as a result of maintenance being performed on
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one SFAS channel and a concurrent loss of power.to ansecond SFAS
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channel. The loss of. power occurred when an operator assumed that
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essential bus'Y3 was powered by an alternate power supply which
had been disconnected earlier in the day. The licensee was
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performing the' prerequisites for DB-SC-04053, "4160. System Transfer
and Lockout Test Buses;C1 and C2," Revision 00, dated May 3,1989. -
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Step 4.2.10, as changed by Temporary Approval, TA 90-3109, dated
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tiay 15,1990, requires that regulated rectifiers YRF1 and YRF3 be
israted and the' verification step references procedure DB-0P-06319,
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at' AC System Procedure." The o)erator went to the wrong.
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in DB-0P-06319 and isolated both tie rectifiers and associated
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inw ters rather than only the rectifiers. A11~four levels of
SFAS were #.itiated from the-loss of: power which resulted in--
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1000 gallons of water being injected 1nto the reactor ~
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ig of the emergency diesel generators, and the closure
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at isolation valves (refer-to paragraph 7.b for more.
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che 'icensee revealed that a temporary restricted change,
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.o0 to De-0P-06319 which related to alternate power supply-
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(YAM !.ad not beu cancelled nor' had maintenance work order (MWO) -
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2-86-0272-23 whici connected a new regulated alternate supply '(XY3)
and disconnected Y LR had not been closed out though the work was
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comCated. The paperwork indicated that YAR was still; connected.
In 4; tion, drawings for the-modification.had been' posted before
the work was completed and is documented in -PCAQR 90-0402, dated
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May 11, 1990. The operators, with the available information,
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assumed that TA 90-3109 had also been issued prematurely and
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performed step 4.2.10 as written prior to the temporary change which
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required both the rectifiers and associated inverters be isolated.'
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A review of the event.by the inspectors revealed that the event-
could have been prevented if the operators had followed DB-SC-04053,
step 4.2.10 as written. The inspectors also concluded;that the
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licensee inadequately controlled the NWO process and the temporary
arocedure- change process. This resulted in the operators not
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seing aware of plant configurations.
The failure to follow
procedures .is a violation of Technical Specification 6.8.1 which
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requires that written p ecedures be implemented.for electrical
systeens.which is listed in A
ndix- A, Section 3.5 of Regulatory
Gu W M 3 (346/90009-02(DRP
tiF4))22,1990,
at about 8:00 p.m. while lining up Decay Heat Remeval
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(04 Pump No. I to m lrculate to-the Borated Water Storage Tank
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(BWST , approximately 15O ga71ons of reactor coolant was inadvertently-
discharged into the BWST from the pressurizer. .The licensee found
that the suctions of both Decay Heat (Dli) systees (DH-32 and DH-33)
were open. These' inlet valves;from the makeup an purification
system cross connected both decay heat loops. When the discharge
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isolation valve to the BWST (DH-66) was opened, reactor coolant
flowed from operating DHR Loop No. 21through: the make-up 'and;
purification system. through DHR' Loop. No. I and into the, BWST. LThe
licensee has documented this event in Potential Condition Adverse to
Quality (PCAQ) 90-0437.
Review-of the event reveals that affected;
procedures could be more clear in giving direction.:
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Section 14 of Procedure DB-0P-06012 " Decay Heat and Low: Pressure
Injection Operating Procedure", is used to lineu(DH Pump 1-1 to the-
BWST.
Section 14.1.1 has a caution to'be sure t1at DH pump suction
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valves are closed before opening test flow valves ~to ensure that
water cannot be forced from the reactor coolant'-system (RCS) to:the -
BWST.
Section 14.2.3 requires the operator to perform valve:
verification ~ list B-l'unless otherwise directed by the' Shift
Supervisor.
Vertification list B-1 lists valve ~DH-33 to be in the
closed position. The assistant shift: supervisor decided that this
step was not applicable as he believed.the valve. lineup to be as
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described in verification. list B-1.
However, both DH-32 and:32 were
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found open. This is an apparent violation'since the operators did
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not follow the procedure as req'uired by' Technical Specification 6.8.1 in that they did not verify the' pos' tion of
DH32and33(346/90009-03).
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On May 27, 1990, at about 00:03 a.m. , while. setting up to perform an-
Integrated Safety Features Actuation System (SFAS) test; operators
were again lining up DHR Loop No. 1 in a recirculation mode in
accordance with procedure DB-0P-03136, " Decay Heat Pump #1 Quarterly
Pump and Valve Test.". Section 5.1.1'.d requires DH66 to be opened-
,and section 5.1.1.b requires DH 68 to be opened.
When DH 68-was opened,
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pressurizer level dropped approximately 65 inches (1600. gallons)
before DH-66 was closed.
In this' event, theLDH loop 1 suction
valve (DH1517) to the reactor coolant system (RCS) was open when the
operator opened DH-68 (this valve is in series with DH-66).
With
RCS pressure at.approximately 45 psig and the BWST'at atmospheric
pressure, a flow path existed from the RCS through DH loop 1 piping
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to the BWST via the open DH' loop-1 suction valve from the RCS.
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operator closed the discharge valve-to the-BWST and the pressurizer-
was refilled.
The root = cause of loss of pressurizer level appears
to be that the procedure was inadequate because it required DH-66 and
DH-68 to be opened with the DH loop 1 suction valve to the RCS open.
However, in preparing for this evolution the operators had an opportunity
to review the lineup and identify this procedural weakness. The
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procedures in use have a precaution regarding the potential for cross
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connecting the BWST with the RCS. An adequate review of the lineup
and precautions in the procedure could have prevented this event.
The licensee documented the event in PCAQ 90-0437. This is an
a] parent violation of Technical Specification 6.8.1 which requires.
t1at written procedures shall be implemented covering operation 'of -
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safety-related systems (346/90009-04).
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On May 30, 1990, at about 5:30 a.m., equipment operators started the
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motor driven feedwater pump to perform feedwater system clean up and
oxygen reraoval. The control- room operator raised hotwell level
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several times, -indicating that water was -leaving the system.
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the shift. supervisor requested that the system be checked for leakage,
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the equipment operators found water issuing from'the condensate
storage tank (CST) vent line and draining to the floor drain. A
minimum recirculation line on the discharge of the motor driven feed
pump, by procedure, was directed to both the deareator storage tank
and the CST.
A minimum flow rate of 180 gpm passed through the line
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for at least 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> before pumping operations were secured at about
1:40 p.m.
The licensee estimates that approximately 30,000 gallons
of water issued from the CST into the floor drains and into the
training building pond.
No detectable' radioactivity was; discharged
into the pond, but the water was chemically contaminated with-
approximately 3 ppm hydrazine. The. licensee informed the Environ-
mental Protection Agency (EPA)- of the chemical. release- to the pond.
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Seven events occurred between April 25 and May 29,-1990, which have-
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caused the inspectors to be concerned. The' events were:
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a.
CoreSupportAssembly(Paragraph 4)..liftradiationexposure-(Paragraph
b.
Reactor vessel drain
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Safety Features Actuation System actuation (Paragraph 4 and 7).
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Twopressurizerleveldecreases(Paragraph 4).
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Steamgeneratoroverfill(Paragraph 10),
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Condensate storage tank overfill (Paragraph 4).
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Collectively these events indicate weaknesses in task management
and planning. They also indicate operational and procedural
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weaknesses.. The inspectors' concluded that most were caused by
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inattention to detail and by making assumptions without
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verification. The inspectors have concluded that for several of
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the events the responsibility must be shared by more than one.
organization (i.e., operations, maintenance,outageplanning).
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inspectors' concerns were elevated after.five events occurred in
a 12-day period. Collectively, these events total 5 ap)arent
violations relating to a management breakdown and will ae reviewed
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regarding enforcement' action,
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On May 30, 1990,- the Plant Manager stopped'all work affecting plant
operations.. Work could only be-implemented after review by the
shift supervisor or shift managera
It was planned that work effort
would increase' gradually to give. j! operatorsian opportunity to
regain control.
Operations management met with all crews and each
crew met separately to discuss recent events and possible actions to
prevent recurrence.
The inspectors observed that operations
managers emphasized that successful operation required-all operators.
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to maintain a constant high level of vigilance and-personal
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responsibility for the proper conduct of all plant activities. On
June 1, 1990, the licensee discussed these events-and its: corrective:
actions with-Region III staff.'
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The inspectors will provide augmented coverage during restart _to.
observe and evaluate licensee performance.
Restart is expected.to.
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occur during the next inspection period,
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b.
Off-shift Inspection of Control Rooms
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The inspectors performed routine inspections of the control. room
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during off-shift and weekend periods; these included inspections 7
between the hours of 10:00 p.m. and 5:00 a.m. _ The: inspections were
conducted to assess overall crew performance and, specifically,
control room operator attentiveness during night shifts.
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The inspectors determined that both licensed and non-licensed
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operators were alert and attentive to their duties, and that the
administrative cor.trols' relating to the conduct of operation _were
being adhered to.
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Operator Requalification-
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From May 16 to May 24, 1990, the licensee gave its requalification
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examination to 20-licensed operators. This was'the first use of' thel
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new NRC examination method _ Region III operator-licensing examiners
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observed the requalification examination and' evaluated the" examination
process. The. examinees included two onshift crews land:three, crews of
offshif t personnel.
Four individuals failed to requalify.' 'Three-
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failed the written examination, and one failed the simulator section.-
The individuals who failed will be remediated and retested before
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being allowed to perform licensed duties.
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d.
ESF System Walkdown
The operability of selected engineered safety features was confirmed,
by the inspectors during walk-downs of the accessible portions' of
several systems.
The following items were included:
verificatior,
that procedures match the plant drawings, that equipment,_
instrumentation, valve and electrical breaker line-up status was .in:
agreement with procedure checklists, and verification that locks,
tags, jumpers, etc., were properly attached and identifiable.
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The following systems were walked down during this inspection
period:
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480 Volt-AC Electrical Distribution System
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Component Cooling llater System
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Emergency Diesel Generator-System
DC Electric Distribution System
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Service Water System
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c.
Plant Material Conditions / Housekeeping
The inspectors performed routine plant tours to assess
material conditions within the plant, ongoing quality activities
and plant-wide housekeeping.
Housekeeping.is good for an outage.
However, a housekeeping violation was~ identified and is discussed
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in Paragraph 7.
Plant deficiencies were appropriately tagged for_ deficiency
correction.
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No other violations or' deviations were identified.
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Refueling (60710)-
On April 27, 1990, the licensee commenced refueling operations. The-
inspectors observed operators performing fuel handling activities and.
noted that refueling practices,and radiological controls were in place.
Refueling of the reactor was completed on April 29, 1990._ The licensee
entered Mode 5 on May 4,1990,- at _7:22 p.m. and a vacuum was drawn in-
the condenser on May 14, 1990.
No violations or devistions were identified.
6.
Radiological Controls (71707, 92720, 84750)
The licensee now estimates a total dose for the outage of 470. person-rem
and 500 person-rem for the year.
However, the dose' for the outage will
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exceed the licensee's revised estimate as the total, dose was 470. person-rem
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at the end of the inspection. period. The most significant' contributors,to
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this- dose level are the tasks associated with- the steam. generators, _
pressurizer, reictor vessel bolt replacement and reactor coolant pumps,
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as well as the high pressure nozzle and inservice inspections.
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The-inspectors toured the emergency containment sump area on May 11,
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1990, and noted that an alarming dosimeter had: fallen into the: area. The
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inspectors notified the licensee of this fact. The licensee has remove'd-
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the dosimeter # rom the sump and.is investigating the cause. Work in .
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containment is nearly complete and containment closure is scheduled for
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May 31,-1990.
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The licensee's radiological controls and practices were routinely observed
by the inspectors during ~ plant' tours and during the inspection of selected
work activities. :The inspection included direct observations of health
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physics (iP) activities relating to radiological surveys and monitoring,
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maintenance of radiological control signs and barriers, contamination,.
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and radioactive waste controls. The inspection also included a routine
review of the licensee's radiological and water chemistry control records
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and reports.
Health physics controls and practices were satisfactory.
Knowledge and-
training of personnel were satisfactory;
No violations or deviations were. identified.
7.
Maintenance / Surveillance (37828, 61726, 62703, 37828, 60710; 73756,
92701, 93702)
Selected portions of plant surveillance, test and maintenance activities
on systems and components important'to safety were observed or reviewed
to ascertain that the activities were performed in accordance with approved
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procedures, regulatory guides, industry codes and standards, and-the
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Technical Specifications.. The following items were considered during these
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inspections:
limiting conditions for operation were met while components-
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or systems were removed from service; approvals were obtained prior'to
initiating work; activities were accomplished using approved procedures
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and were inspected as applicable; functional testing or calibration was
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performed pri7r_ to returning the components or systems to service; parts
and materials used were properly certified; and appropriate fire prevention,
radiological, and housekeeping conditions were maintained,
a.
flaintenance
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The reviewed maintenance activities included:
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Control room annunciator panel modification.
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Inspection and repair of main steam' check valves.
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Troubleshooting of service water (SW) flow control valve-
(SW1424) for component' cooling water to SW' heat exchanger.
Troubleshooting of containment wide' range sump level
"
indica tion.
,
Installation of new essential inverters.
Replacement of auxiliary feedwater (AFW) Valves AF599 and
608.
On May 16, 1990, the inspectors toured the AFW pump room and observed
. that the cavitating venturi was removed from the _ AFW pipe.and stored:
end up. The upward . facing end of the venturi was not protected by any
cleanliness covers and its internals were observed to be dirty.
DB-MN-00005, " Housekeeping Control," Rev 0, dated May 24, 1990, requires
that openings be covered to prevent foreign materia'l from entering in
areas from which-retrieval would be difficult. The maintenance manager
was notified of this condition.
Remedial action was to clean the venturi
prior to its installation back to the AFW system. Additional corrective
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action was to counsel the personnel involved in this activity. The
inspectors noted the following day that a cleanliness cover was installed
on the venturi. Thisisaviolation'(346/90009-05(DRP))ofTS6.8.1,
failure to properly implement DB-11N-00005.
The root cause of this
violation was inattention to detail.
The violation is not being cited
,
because the criteria specified in 10 CFR 2 Appendix C, Section V.A.
of the Enforcement Policy were satisfied (isolated Severity Level V).
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b.
Surveillance
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The reviewed surveillances included:
Procedure No.
Activity
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DB-MI-03013
Test of RPS and Reactor Trip Breaker
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DB-MI-04109
Source Range Functional Test
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DB-MI-09049
Test of the Incore to the liultiplexer.
DB-SC-03114
SFAS Integrated Time Response Test _
DB-SC-04024
13.8 KV Bus lockout Test
DB-SC-04052
4160 V System Transfer and Lockout
Test Busses D1 and D2
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DB-SC-04053
4160 V System Transfer and. Lockout Test
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Busses C1 and C2.
During the performance
!
of this test, electrical-loads were shifted
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from Bus C1 to prevent them from losing power
during the test. One load was Y-3, one of
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four 120 VAC essential instrument busses.
The operator who was sent to transfer this
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load apparently used the wrong section of
the operating procedure, so:Y-3, although
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supplied via a different motor control
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center was still powered from C1. When the
test was performed,-Y-3 lost power. This
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deenergized Channel 3 of_ SFAS, providing
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a-trip signal.
Since liaintenance had
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previously inserted a. trip signal in
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Channel 1 of SFAS, the SFAS received
the two of four trip signals required'for
,
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an actuation even though there was no plant _.
condition requiring an SFAS actuation.
All
safety equipment functioned as required
resulting in an injection of approximately
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1000 gallons to the reactor coolant- system.-
The safety injection lasted for about
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6 minutes. After the event, the licensee
recognized that during the injection it was
in an Unusual Event and made'the appropriate
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notifications.
The inspectors are continuing
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their review of this item which will include-
revfew of.the relevant Licensee Event Report
when+ issued.
DB-SC-04109,
EDG Air Compressor 2 Charging Test-
DB-SP-04153
Auxiliary Feedwater Pump Turbine 1
Overspeed Trip Test
,
Personnel performing = maintenance or surveillances used correct procedures
and proper work- control documents. Work authorization had been obtained
for the jobs performed.' _ Prerequisites for performing the job, such as
worker protection and tagging had been' performed.. Surveillance continues-
to be 'an area where only an: occasional problem arises.
'
No other cited violations'or-deviations were identified.
8.
Emergency Preparedness (71707, 82701)
]
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An inspection of emergency preparedness activities was performed to
assess the licensee's implementation of'the. emergency )lan and
,
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implementing procedures.. The ~ inspection: included mont11y observation
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of emergency facilities and equipment, interviews with' licensee staff,
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and a review of selected emergency implementing procedures,
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No violations or deviations were identified.
9.
Security (71707, 81070,- 81052)
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a
The licensee's security activities-were observed by the inspectors during-
routine facility tours and during. the inspectors': site arrivals 'and:
departures. Observations included the security personnel's performance
associated with access control, security checks.:and surveillance
activities, and focused 'on the adequacy o_f security. staffing, the
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security response (compensatory measures), and the' security staff's
- -
attentiveness and thoroughness.
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Security personnel were observed to be alert at their posts.. . Appropriate
compensatory measures were established. in a timely manner. . Vehicles-
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entering the prot (cted area'were thoroughly searched.
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No violations or deviations were identified..
10.
Engineering and Technical Support (37828, 62703, 71707, 92701, 92720)
j
An inspection of engineering:and technical support activities was
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performed to assess the adequacy of support functions associated
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with operations, maintenance / modifications, surveillance and testing
activities.
The. inspection. focused on' routine engineering-involvement-
in plant operations and response to plant problems. .The inspection
3
included direct observation of engineering support activ'ities and
discussions with engineering, operations, and maintenance personnel..-
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The licensee determined that leakage existed on the reactor vessel head
vent at a flanged joint on steam generator (SG) 2.
An investigation
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revealed that the Flexatallic gasket installed was of the proper
i
dimensions but of the wrong material and pressure rating.
In addition,
the joint had a smooth gasket seating surface instead of the vendor
recommended ' phonographic' finish.
The licensee has machined the flange
seating surface and has installed the proper Flexatallic gasket.
The
l
stock' code and design drawing properly identified the gasket dimensions,
but failed to correctly identify the pressure rating, material, and the
intended application of the gasket. These failures were the root cause
which resulted.in the installation of the incorrect gasket. The stock
code and the design drawing have both been modified. The licensee's
research reveals that no other joint was assembled using a gasket of a
lower pressure rating than specified.
]
On January 22, 1990,. the licensee reduced reactor power and removed
reactor coolant pump (RCP) 2-2 from service due to high vibrations. A
failed motor bearing was identified as the cause of the high vibrations.
The licensee believes that the lower motor bearing failed due to-rotor
imbalance, pump / motor misalignment, poor bearing shoe fit up, non-
concentricity of the shaft journal and/or circulating electrical
1
-currents between the shaft stator via the lower bearing shoes.
RCP 2-2
was repaired during the refueling outage and an inspection plan for the
!
other RCPs has been developed.
Prior to the performance of DB-PF-10100, " Hydrostatic Test of SG 1-1",
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erformance engineering was concerned that venting the steam generator
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p(SG) during the filling evolution would possibly cause airborne
1
contamination to be released and issued a change to the procedure to
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vent the SG to the gaseous rad waste system.
While filling these on
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May 23, 1990, the-gaseous rad waste vent line became congested and
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develo)ed a back pressure.
In addition, the. gaseous radiological waste
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tanks 1ad a 3.5 psi cover gas which also provided a back pressure to
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the vent line. The operators were monitoring flow into the SG and SG
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water level. They were filling the SG with the motor _ driven feedwater
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pump and controlling level increase by opening a valve which allowed
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water to flow back to the main condenser.
Procedurally-SG' water level
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was to be maintained at approximately 610 inches. When indicated level
{
stopped increasing below the desired level, the operators thought this
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was due to the volume of water flowing back to the main condenser.
"
However, actual SG water level was greater than the indicated level
(the SG was full).
)
This faulty level indication was caused by the SG level sensor also being
vented for the plugged vent line. As a result, water flowed from a SG
atmospheric vent valve (AVV) into the Main Steam Line Room.
The Main
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,
Steam Line room floor drains had been taped over by radiological controls
a
personnel to prevent any SG effluent from entering the storm drain
!
sys tem. At least 4000 gallons of water issued from an AVV to the Main
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Steam Line room before the evolution was stopped. At least 2000 gallons
'
of this water leaked from the Main Steam Line room and flowed into the-
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electrical and mechanical penetration rooms below. The shift supervisor
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uncovered a taped floor drain to prevent the' water from flowing into the
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electrical penetration room. He thought that the floor drain discharged
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to the auxiliary. building drain system where it could'be collected and -
treated before discharge. He was unaware that these drains.went to the
,
storm drain system.-_A minimum of 2000 gallons _of water entered the storm
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drain'which discharged to the COB _po_nd.
Trace amounts of. radioactivity
were detected in the effluent and at.the storm drain radiation monitor.
Operators closed the outlet valve from the COB ~ pond to prevent a release
outside the owner controlled area. The pond was sampled for radioactivity.-
No radioactive contamination was detected in tne' pond.
The root cause
of this event is a failure of performance engineering to properly vent
the SG and to assess its affects on the SG level indicating system.
Review by the inspectors indicates that the licensee's review of the
procedure was inadequate because the effect of the containment vent
header pressure was not identified and-the-absence of a quantitative
value for drain capacity was not corrected. The procedure was also
deficient because there was'no requirement to use redundant level
-indication and there was no requirement to monitor the MS line vents-
during the fill.
This is an apparent violation of 10 CFR 50, Appendix B, Criterion V
which requires that activities affecting quality shall be prescribed
by documented instructions or procedures of a type appropriate to the
.
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circumstances (346/90009-06). Procedure DP-PF-10100, " Steam Generator 1
Rydrostatic Test," was not appropriate to the circumstances in that it
did not evaluate the effects of connecting.the steam generator level-tap'-
t
to the containment vent line, nor did it require diverse level indicators-
or the monitoring of open vents.
No other violations or deviations was identified.
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11.
Safety Assessment / Quality Verification-(35502, 92701', '92720, 30703,
35702, 92720, 35701, 92700, 90712)
,
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An inspection of the licensee's' quality programs was performed to assess
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the implementation and effectiveness of programs associated with management
'
control, verification, and: oversight activities. The inspectors considered
1
areas indicative of overall management involvement in quality matters,
self-improvement programs, response.to regulatory and industry initiatives,
the frequency of management plant tours and control room observations,. and
management personnel's participation in technical and planning meetings,
The inspectors reviewed Potential Condition Adverse to Quality Reports
u
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(PCAQR), Station Review Board (SRB) and Company Nuclear-Review Board
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meeting minutes, event critiques, and related documents; focusing on
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the licensee's root cause determinations and corrective actions.
The
inspection also included a review-of quality records and selected quality-
(
assurance audit and surveillance activities.
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On April 26, 1990, Cresap, Inc. issued its report on'the results of
its management review of the Centerior Energy Corporation.
Cresap
,
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recommended that Centerior be restructured into three groups; Power -
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Generation, Customer Operations, and Finance and~ Administration.
The
recommended changes for Davis-Besse were minimal.
The inspectors will
continue to monitor actions related to the. proposed changes and their
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effects.
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12.
Enforcement Conference (30702)
On June 1, 1990, an enforcement conference was held in Region III to
discuss the events surrounding the April 25, 1990, core support assembly
(CSA) lift and the draining of the refueling canal on May 1,1990.- These
events are described in Inspection Report No. 50-346/90012(DRSS).
The
licensee also described subsequent events (described in Sections 4 and 11
of this report) and-their overall corrective action program. A
supplemental enforcement conference was held by telephone on July 17,
1990, to discuss potential escalated enforcement for apparent violations
described in Sections 4 and 11 of this report and other violations
-described in Inspection Report No. 50 -346/90013(DRP).
The enforcement
conference will be documented in Inspection ~ Report No. 50-346/90014(DRP).
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13. Commissioner Visit
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On May 7.-1990, Commissioner Rogers and.the Director of the Division of
Reactor Projects Region III met with the inspectors and senior licensee
management and members of their staff and toured the facility,
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14.
Violations for Which a " Notice of Violation" Will Not Se Issued
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The NRC uses the Notice of Violation (NOV) as a standard method for
i
formalizing the existence of a violation of a legally binding requirement.
i
However, because the NRC wants to encourage-and support licensees'
initiatives for self-identification and correction of problems, the NRC
will not generally issue a Notice of Violation _ for an issue that meets
the tests of 10 CFR 2, Appendix C, Section V.G.I.
These tests are:
(1) the issue was identified by the licensee;_ (2) the issue would be
categorized as Sev_erity Level -IV or V violation; (3) the issue was reported
.
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to the NRC, if required;.(4) the issue will be' corrected,' including-
measures to_ prevent recurrence, within a reasonable time period;-and
(5) it was not an issue that could reasonably be expected to have been
prevented by the licensee's. corrective action for a previous violation.
!
In addition, in accordance with Section V.A. of the enforcement policy,
i
for isolated Severity Level V violations, a . Notice of Violation normally
I
will not be issued regardless of who.idertifies the violation provided-
that the licensee has initiated appropriate corrective action before'
the inspection ends.
Issues. involving the failure to meet regulatory
requirements,' identified during the inspection, for which a Notice of
Violation was not issued are discussed in Paragraphs 3 and 7.
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15.
ExitInterview(30703)
The inspectors met with licensee representatives (denoted in Paragraph 1)
throughout the inspection period and at the conclusion of the inspection
t
and summarized the scope and findings of the inspection activities.
In
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addition, a conference call was, held on July 17, 1990 to discuss the
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apparent violations identified during this inspection period.
The-
licensee acknowledged the findings. After discussions with the licensee,
the inspectors have determined there is no proprietary data contained in-
this inspection report.
16