ML20065S344

Responds to Notice of Violation & Proposed Imposition of Civil Penalty & Notice of Deviation from Insp Repts 50-373/93-31,50-374/93-31,50-373/93-36,50-374/93-36, 50-373/93-40 & 50-374/93-40.Fee Paid

ML20065S344
Person / Time
Site:	LaSalle
Issue date:	05/13/1994
From:	Murphy W COMMONWEALTH EDISON CO.
To:	Lieberman J NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9405180148
Download: ML20065S344 (21)

Text

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Comrnonwealth Edison LaSalle County Nuclear Station 2001 N. 21st. Rd.

Marseilles, Illinois 01341 May 13,1994 Telephone 815/357-6761 Mr. James Lieberman Director, Office of Enforcement U.G. Nuclear Regulatory Commission Washington, D.C. 20555 Attention: Document Control Desk

Subject:

LaSalle County Station Units 1 and 2 Response to Notice of Violation and Proposed Imposition of Civil Penalty and Notice of Deviation (NRC Inspection Reports 50-373(374)/93031,50-373(374)/93036, and 50-373(374)/93040) NRC Docket Number 50-373 and 50-374, and payment of Civil Penalty.

References:

1. G. E. Grant letter to M. J. Wallace, Dated December 23,1993, Transmitting NRC Inspection Report 50-373/93031; 50-374/93031,

2. G. E. Grant letter to W. P. Murphy, Dated January 25,1994, Transmitting NRC Inspection Report 50-373/93036; 50-374/93036.

3. G. E. Grant letter to W. P. Murphy, Dated January 25,1994, Transmitting NRC inspection Report 50-373/93040; 50-374/93040.

4. J. B. Martin letter to M. J. Wallace, Dated Ap-il 4,1994, Transmitting the Notice of Violation and Proposed Impnsition of Civil Penalty.

5. April 29,1994 conversation between K. Ihnen, LaSalle NRC Resident inspector, and E. McVey, LaSalle Regulatory Assurance, granting LaSalle a 10 day extension to the original 30 day response requirement for the subject Notices of Violation and Notice of Deviation.

Enclosed is Commonwealth Edison's response to the subject Notice of Violation and Proposed Imposition of Civil Penalty, and payment of civil penalty. Per the Reference 5 discussion, a 10 day extension to the original 30 day response requirement was granted to LaSalle for submitting this response. The violations associated with the civil penalty are restated in Attachment A and our response to these violations is included in Attachment B. We do not contest your action to classify the violations, in the aggregate, as a Severity Level lil problem or the proposed civil penalty. Accordingly, enclosed is a check in the amount of $75,000.

There were also several violations that were not assessed a civil penalty. Each of these violations is restated in Attachment C and our response to these violations is included in Attachment D.

One Notice of Deviation was also identified. Our response to this deviation is included in Attachment E.

Please note that in responding to these violations, we have listed the violations under the corresponding inspection report tracking numbers.

Because the civil penalty was imposed on LaSalle as a result of deficiencies in the control of LaSalle's corrective action program, I would like to address how we are making improvements to that corrective action program. We understand that there are four key areas that make up an effective corrective action process. These areas are Problem Identification, Problem investigation, Problem Resolution and Effectiveness Reviews. We have identified where our corrective action process is deficient in each of these areas. We are taking aggressive actions that are focused on eliminating

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The first step, Problem Identification, is the responsibility of every worker at LaSalle. It is essential that each worker understand that we need to identify our problems and address them accordingly. We have already seen improvement in this portion of the process. When we initiated the Integrated Reporting Program (IRP), we did not do a good job of communicating what the system was, what it could do for us, and what was expected from the workers. Workers were skeptical of management's dedication to resolving the problems they identified. Consequently, there was little support of the system from the workers. To address these problems, we assigned ownership of the IRP to line management through the Station Manager, and increased communication of the process to all site personnel, including bargaining unit representatives, in order to gain their support. We have seen a marked increase in the number and quality of concerns identified by workers through the IRP.

We are working with Byron Station to improve our IRP process, including incorporation of Byron's Problem Identification Form (PIF) threshold guidance document and we will be providing further training to site personnel on the IRP process.

The second and third areas, Problem investigation and Problem Resolution, are areas that we need to make significant improvements. Both the ITE breaker and reactor buiding ventilation damper problems should have been resolved by station personnel earlier. Our performance on these two issues showed that we were narrowly focused in our approach to the issues, that we lacked dedication of proper personnel to assume ownership of and resolve the issues, and that we lacked management involvement in ensuring that the problem was identified and eliminated. Even when root causes of problems were identified in the past, we lacked ownership and accountability for ensuring the required actions were taken and management support of the resources necessary for carrying out the required actions.

To address these issues, we have recently established a dedicated, experienced root cause analysis group to aid in determining the root cause of identified problems. In an effort to improve our root cause investigations in the near term, we staffed this group with both CECO and contractor personnel. Eventually, this group will be fully staffed by CECO personnel. Additionally, improvemer ?

are being made to ensure that the correct individuals are involved in determining the root cause of problems. This is being done by assigning component / system experts to issues such as the ITE breakers. Ownership of required corrective actions and line management responsibility for ensuring completion of corrective actions on time has been clearly communicated. We will also be taking actions to improve the tracking of our corrective actions and to address the backlog of outstanding corrective actions that need to be taken.

The fourth area, Effectiveness Reviews, will ensure that actions determined to be necessary to correct a problem were performed correctly and in a timely manner. I expect my organization to be self critical of all their actions. I understand that we need to make cultural changes at LaSalle in order to sustain an effective self assessment culture. Establishment of a self critical culture is being aided through the Site Quality Verification (SQV) organization and the formation of a new Self Assessment Director position. Additionally, personnel will be assigned responsibilities for reviewing the effectiveness of our actions on key issues affecting the station.

I assure you of our resolve to improve not only our performance in the corrective action process, but in all areas of plant operation. We are aggressively taking actions on key issues where we believe immediate attention is needed, such as radworker awareness of radiological conditions and requirements in the plant. In addition, senior engineers are being added to the System Engineering group to supplement the current staffing. We believe this willimprove the ability of System Engineering to identify and resolve system / equipment problems before they become a hindrance to plant operation.

All of these actions are focused on operating our plant safely and efficiently.

The Business Unit Plan (BUP) outlines the specific actions that we will be taking to make improvements in all of these areas. One of the key areas we will be focusing on in the BUP is the corrective action process. These improvements, though already yielding positive results, are long term corrections to a significant problem. Our corrective action process improvements will extend into 1995.

We have recently made substantial organizational c! anges at LaSalle with the purpose of providing a dedicated team of highly qualified individuals to oversee our actions in carrying out our BUP. We are confident in our ability to succeed in improving the overall performance at LaSalle.

The following commitments are made in this response:

1) A design change is being made to secondary containment isolation damper 1VR04YA to enhance its operation. This change involves replacement of the damper closing springs with larger springs in order to increase the reliability of the damper to close.

This design change will be installed during the current Unit i refuel outage. Operation of 1VR04YA will be evaluated during subsequent operation. Based on this evaluation, which will be completed by November 1,1994, we will determine the benefits of installing this enhancement on the other seven secondary containment isolation dampers.

2) A design change is being made to elirninate Reactor Protection System trips when operating on the alternate power supply and starting large pumps. We have scheduled completion of this design change on Unit i during the current refuel outage. This design change will be incorporated on Unit 2 no later than the end of its next refuel outage, currently scheduled to begin February 18,1995.

3) We have evaluated station procedures and determined that LaSalle Administrative Procedure (LAP)-100-29 will be revised to include enhancements that will provide ,

guidance on the application of operability evaluations versus surveillance evaluations in determining the operability of equipment. The procedure will be revised and Operations Shift Supervision will be trained on the procedure revision by July 1,1994.

If there are any questions or comments concerning this letter, please refer them to me at (815) 357-6761, extension 3600.

Respectfully, "I

W. Murphy Si ice Presi t)

LaSalle County Sterfion cc: J. B. Martin, Regional Administrator, Region ill A. Gody Jr., Project Manager, NRR D. Hills, Senior Resident inspector, LaSalle  ;

D. L. Farrar, Nuclear Regulatory Services Manager, NORS J. E. Lockwood, Regulatory Assurance Supervisor, LaSalle

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1 ATTACHMENT A VIOLATIONS ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)l93031-02 AND 50-373(374)l93036-01 VIOLATION 373(374)/93031-02:

10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures be 'j established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management. ,

i Contrary to the above, the licensee failed to promptly correct a significant condition adverse to quality, I namely, the degradation of safety-related electrical breakers. Specifically:

1. The licensee received a letter from Asea Brown Boveri (ABB) dated March 20,1989, with enclosures, which identified that periodic re-lubrication of Series HK breakers was required, at least when parts were replaced. The letter also identified that depending on cleanliness of the j environment, periodic checks for contamination should be performed, and if lubricant is found to be contaminated and dry, removal of the lubricant and re-lubrication is recommended.

2. A letter from Sargent & Lundy Engineers to LaSalle County Station dated June 13,1989, recommended that the licensee have ABB's service organization inspect a sample of HK breakers during the next refueling outage to determine if a lubrication problem exists and if_

periodic reinspection is required. The letter also recommended that inspection Procedure '

LES-GM-103 be revised to include ABB's current requirements to re-lubricate at least when parts are replaced. Determination of the requirement for periodic inspection for contamination would be determined as a result of the recommended sample inspection.

3. A LaSalte Electrical Maintenance Department interoffice memorandum dated May 10,1990, stated that LES-GM-103 falls short of providing real corrective maintenance for deterioration of lubrication.

4. On October 2,1992, the Unit 1 reactor recirculation pump breaker 3B, a safety-related HK breaker, failed to open during surveillance testing. The root cause was determined to be hardened Nebula lubricant (only Anderol 757 lubricant is recommended for use in the breakers).

The licensee failed to establish and implement measures to identify and correct tubrication problems with respect to safety-related electrical breakers. As of November 22,1993, the licensee had not thoroughly inspected a representative sample of HK breakers to determine if a lubrication problem existed, and inspection Procedure LES-GM-103 was inadequate in that it only required visualinspection of HK breakers which was insufficient to verify the vendor's lubrication recomrnendations. (01013)

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i ATTACHMENT A (continued)

VIOLATIONS ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)l93031-02 AND 50-373(374)193036-01 VIOLATION 373(374)l93036-01:

10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures @all assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to the appropriate levels of management.

Contrary to the above, as of January 3,1994, the licensee had failed to identify the root cause(s) and promptly correct repetitive failures of the reactor building ventilation system secondary containment .

isolation dampers, a significant condition adverse to quality. Since the beginning of 1989 there have been numerous damper failures as documented in surveillances, Work Requests, Problem identification Forms, Deviation Reports, Licensee Event Reports, and Operator logs. For example:

1. A Notice of Violation issued to the licensee on June 20,1989, stated that contrary to 10 CFR 50, Appendix B, Criterion XVI, on April 5,1989, and again on April 19,1989, the licensee failed to promptly identify the cause of the failure, and take corrective action to prevent recurrence, of the IVR05YA reactor building ventilation isolation damper. Corrective action to prevent recurrence was not taken until April 24,1989. In addition, the failure mechanism of the solenoid valves has been known since at least February 1985 but the licensee has not implemented corrective actions to prevent recurrence as of the date of the end of this inspection.

2. A Techno Corporation (vendor) letter to the licensee dated September 29,1989, stated that the blades were rubbing on the bottom inside surface of the body as they approached the closed position and recommended the addition of hangers to testore the original clearance at the blade bottom, and the addition of quick exhaust valves. The licensee did not fully evaluate or implement the vendor's recommendations. Supports were not added until November 1992, and then only on a trial basis. Quick exhaust valves were never added.

3. A Techno Corporation letter to the licensee dated March 17,1992, recommended that the damper actuators be replaced with ones that provide more than twice the return force as is current;y available. The licensee is still reviewing this proposal.

4. On September 18,1992, a letter was issued from the LaSalle Mechanical and Structural Design Group to the Engineering Supervisor documenting a proposed upgrade of the secondary containment isolation dampers. Previous problems were categorized in four areas including solenoid valve problems, damper actuator problems, blade sagging and speed regulator clogging. The report notes that dampers have failed to close 11 times in the last 5 years, and '

recommended adding a closing air supply system to the existing dampers. As of December 21, 1993, no action had been initiated to address the recommendation.

5. On October 27,1993, secondary containment isolation damper 1VR05YB filed to cycle (close) properly apparently due to friction within the damper actuator. The friction was caused by a hardened and dry grease-like substance.

6. On November 29,1993, and again on January 3,1994, secondary containment isolation damper 1VR04YA did not fully close as expected. (01023)

This is a Severity Level ill problem (Supplement 1). Civil Penalty - $75,000.

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4 ATTACHMENT B RESPONSE TO VIOLATIONS ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)/93031-02 AND 50-373(374)/93036-01 REASON FOR VIOLATION 373(374)l93031-02:

We agree that corrective actions for a 1989 Part 21 issue concerning hardened grease in operating mechanisms of ITE, HK Series, circuit breakers was not timely. Until recently, the relation of that Part 21 issue to failures experienced at LaSalle was not fully realized. These breakers are utilized in 4.16kV and 6.9kV applications at LaSalle.

We had several occasions where the hardened grease problem could have been identified. These included events at LaSalle, other CECO stations, and other industry experience.

Based on these evente, we had opportunity to identify the common mode failure mechanism in a more timely fashion. We had several occasions where the RR breakers opened slowly, but we did not understand that the slow time could be related to grease hardening. Only the RR system ITE breakers were being timed because they have a safety related function associated with the End of Cycle Recirculation Pump Trip signal. We suspected the failure of the RR system breakers to be electricalin nature. We did not consider a grease hardening problem because we believed our inspections in LES-GM-103 would identify hardening grease. Consequently, we did not consider the broader issue of a common modo failure of allITE breakers.

Overall, adequate technical expertise was not involved in the Part 21 and breaker failure problems.

This indicates deficiencies in our corrective actions program.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)l9303102):

1. An operability determination was performed on November 29,1993, by Site Engineering for the ITE Type SHK and 7.5HK medium voltage circuit breakers in question. It was concluded that the breakers were operable on Unit i and Unit 2. This was accepted by LaSalle Onsite Review 92 v3, Revision 1, dated November 29,1993.

2. All the Unit 1 and Unit 2 safety related and Technical Specification related ITE breakers have been recently refurbished. Breakers that have been tested on Unit 1 include the 4.16kV circuit breakers on switchgears 141Y and 142Y and the 6.9kV Reactor Recirculation pump breakers. Breakers tested on Unit 2 include the 4.16kV circuit breakers on switchgears 241Y and 242Y and the 6.9kV Reactor Recirculation pump breakers. LaSalle currently has two spare safety related ITE breakers that have not been refurbished. The breakers are on hold and will not be utilized until the refurbishment is completed.

CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)/93031-02):

1. The surveillance requirements for the Unit 1 and Unit 2 safety related, Technical Specification related, and all remaining ITE breakers have been revised. The station surveillance program (GSRV) has been updated to require periodic refurbishment of allITE breakers consistent with vendor recommendations.

2. Programmatic improvements in LaSalle's corrective action program are discussed in the cover letter to this response. ,

1 DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)l93031-02). .

With respect to the ITE breakers, full compliance was achieved on May 12,1994, when refurbishment of all safety related and Technical Specification related ITE breakers currently in use at LaSalle was completed. With respect to the corrective actions program, improvements in this area are an ongoing process.

ATTACHMENT B (continued)

RESPONSE TO Viol.ATIONS ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)l93031-02 AND 50-373(374)l93036-01 REASON FOR VIOLATION 373(374)l93036-01:

We agree that identification of the root causes of repetitive failures of reactor building ventilation (VR) secondary containment isolation dampers was not timely. Actions that were taken to eliminate these damper failures were not adequate to prevent recurring failures.

On November 29,1993, the Unit 2 "B" RPS 120 VAC bus deenergized due to an undervoltage trip of the Electrical Power Monitoring Assembly (EPMA) for the alternate RPS power supply. This resulted in a half-scram and severalisolations and half-isolations. One of the isolations that occurred was closure of the secondary containment isolation dampers. One of these dampors,1VR04YA, did not have a full closed indication in the control room following the initial closure signal. Subsequent cycling of this damper resulted in a full closure signal being received.

The above event led NRC inspectors to investigate the cause of the 1VR04YA damper not having full closed indication in the control room. In their investigation, the NRC inspectors identified failures of this and similar dampers over the last five years. Although LaSalle Station took actions to eliminate these failures, none of the actions were effective in doing so. The ineffectiveness of our actions can be attributed to inadequate implementation of our corrective action program.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)/93036-01):

1. Operationt pe*sonnel verified that the redundant damper,1VR04YB, was fully closed, thereby meeting Technical Specification isolation requirements for secondary containment.

2. The 1VR04YA damper was subsequently cycled open and then closed. This resulted in full closure of the damper.

CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)/93036-01):

1. A contractor ventilation engineer was assigned to supplement System Engir.eering staffing.

2. A root cause evaluation for the repetitive 1VR04YA damper failures was initiated. Rnsults of that evaluation identified actions that needed to be taken to improve the reliability of this damper. These actions were taken during the current Unit i refuel outage. Thus far, cycling of this damper has demonstrated improved performance.

3. Troubleshooting performed 6 inn the current Unit 1 refuel outage identified the need to replace solenoids on two of the Un1 tondah mntainment isolation dampers. The solenoids were replaced during the refuel otAage.

4. The actuators for all eight secondary containment isolation dampers (four on Unit 1 and four on Unit ,

2) were replaced during the current Unit i refuel outage. j l

5. A design change is being made to secondary containment isolation damper 1VR04fA to enhance its operation. This change involves replacement of the damper closirig springs with larger springs in order to increase the reliability of the damper to close. This design char.ge will be installed during the current Unit i refuel outage. Operation of IVR04YA will be evaluated during subsequent i operation. Based on this evaluation, which will bo completed by November 1,1994, we will i determine the benefits of installing this enhancement on the other seven secondary containment isolation dampers.  ;

6. Programmatic improvements in LaSalle's corrective action program are discussed in the cover letter to this response.

ATTACHMENT B (continued)

RESPONSE TO VIOLATIONS ASSESSED A civil PENALTY VIOLATIONS 50-373(374)/93031-02 AND 50-373(374)/93036-01 DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)l93036-01):

With respect to recurring VR damper problems, closure of the dampers has shown noticeable improvement. Final confirmation of this condition can only be verified through continued operation of the dampers. With respect to the corrective actions program, improvements in this area are an ongoing process.

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ATTACHMENT C VIOLATIONS NOT ASSESSED A CIVilPENALTY VIOL > TIONS 50 373(374)l93036-02,03A,03B,03C,03D,04 AND 50-373(374)/93040-01 VIOLATION 373(374)/93036-02:

10 CFR 50, Appendix B, Criterion XI, " Test Control," requires a test program be established to assure that all testing roquired to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents.

Contrary to the above, on June 3,1986, the licensee completed Work Request No. L54217 which increased the Unit i reactor protection system electrical power monitoring assembly overvoltage, undervoltage, and underfrequency relay settings to a 3 second time delay and did not test the change.

(02014)

This is a Severity Level IV violation (Supplement 1).

VIOLATIONS 373(374)/93036-03A,03B,03C and 03D:

10 CFR 50, Appendix B, Crite; ton V " Instructions, Procedures, ond Drawing,' requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Instructions, procedures, or drawings shallinclude appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished.

1. VIOLATION 373(374)/93036-03A Contrary to the above, as of November 29,1993, Procedures LES-GM-300, Revision 1, dated February 8,1993, and LES-GM-400, Revision 1 dated February 8,1993, " Reactor Protection System Electric Power Monitoring (EPM) Assembly Calibration by O.A.D," for Units 1 and 2 respectively, were Inadequate in that they did not require the recording of the as found and as left time delay settings for the EPM assemblies. (03014)

This is a Severity Level IV violation (Supplement 1).

2. VIOLATION 373(374)/93036-03B:

Contrary to the above, as of November 29,1993, Operating Procedures LOP-RR-04,

" Preparation and Startup of Reactor Recirculation Pumps in Slow Speed," Revision 23, dated June 10,1993; LOP-RR-05, " Changing Reactor Recire Pump Speed from Slow to Fast Speed,"

Revision 21, dated May 28,1993; and LOP-RR-06, " Restart of Tripped Reactor Recirc Pump,"

Revision 20, dated March 4,1992, were inadequate in that they failed to have a warning to the operators that whenever the reactor protection system (RPS) bus is fed from its alternate power supply and a reactor recirculation pump is started, the RPS bus wouki trip on undervoltage and i result in a half scram. (04014)

This is a Severity Level IV violation (Supplement 1).

ATTACHMENT C (continued)

VIOLATIONS NOT ASSESSED A CIVilPENALTY I VIOLATIONS 50-373(374)/93036-02,03A,03B,03C,03D,04 AND 50-373(374)/93040-01

3. VIOLATION 373(374)/93036-03C: )

Procedure LAP-220-5,

• Equipment Operability Determination," Revision 2, dated July 8,1993, Step F.8, requires, if a previous evaluation for a specific component does not exist, Shift l Supervision is to determine whether or not the component and its related system are operable '

based on the evaluation and document on Attachment A.

Contrary to the above, on November 29,1993, following the failure of secondary containment isolation damper IVR04YA to fully close, Shift Supervision did not determine whether or not the damper and its related system were operable based on an evaluation and did not document the evaluation on Attachment A. A previous evaluation for this damper condition did not exist.

(05014)

This is a Severity Level IV violation (Supplement 1).

Contrary to the above, as of November 29,1993, Procedure LAP-220-4, " Degraded Equipment Log," Revision 5, dated May 11,1993, was inadequate as follows:

a. The definition of " Degraded" equipment in Paragraph E.5.b lacks specificity. Degraded equipment is defined in the procedure as Operable equipment containing a deficient condition for which a log entry is desirable.

b. The requirements of E.7 are overly subjective. Specifically, the procedure states, "The Degraded Equipment Log (DEL) is meant to be a shift notebook...All entries in the DEL are made at the discretion of the shift operating personnel. It is not the intent of this procedure to provide an allinclusive listing of degraded and INOPERABLE equipment... Equipment which is degraded or INOPERABLE for a short time period may not require a DEL entry..."

(06014)

This is a Severity Level IV violation (Supplement I).

4. VIOLATION 373(374)/93036-03D:

Contrary to the above, as of November 29,1993, the instructions provided by corporate engineering in the Relay Setting Orders used by the Operational Analysis Department to set the reactor protection system electric power monitoring overvoltage, undervoltago, and underfrequency time delay trip settings were inadequate in that they specified 3.0 seconds with no tolerance. (07014)

This is a Severity Level IV violation (Supplement 1).

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1 ATTACHMENT C (continued)

VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50 373(374)/93036-02,03A,03B,03C,03D,04 AND 50 373(374)/93040-01 VIOLATION 373(374)l93036-04:

10 CFR 50, Appendix B, Criterion XII, Control of Measuring and Test Equipment," requires that measures shall be established to assure that tools, gages, instruments, and other measuring and testing devices used in activities affecting quality are properly controlled, calibrated, and adjusted at the specified periods to maintain accuracy within necessary limits.

Contrary to the above, as of November 29,1993, the Operational Analysis Department engineer used a wristwatch which was not properly controlled, calibrated, and adjusted to measure and calibrate the reactor protection system electric power monitoring overvoltage, undervoltage, and underfrequency time delay trip settings. (08014)

This is a Severity Level IV violation (Supplement I).

VIOLATION 373(374)/93040-01:

Technical Specification 4.0.5 requires, in part, that inservice testing of ASME Code Class 1,2,3 pumps and valves shall be performed in accordance with Section XI of the ASME Boiler and Pressure Code.

Subsection IWV-3511 of the ASME Code requires that valves shall be tested at the end of each time period as defined in Table IVN-3510-1. Note (1) of Table IWV3510-1 states that at each refueling all valves which have not been tested during the preceding 5 year period shall be tested.

Technical Specification 3.4.2 requires, in part, that the safety valve function of 17 of 18 reactor coolant system safety / relief valves shall be Operable in Operational Conditions 1,2, and 3. Technical Specification 4.0.3 states that failure to perform a Surveillance Requirement within the specified time interval shall constitute a failure to meet the Operability requirements for a Lirniting Condition for Operation.

Contrary to the above, the licensee completed the fifth refueling outage for Unit 1 on January 30,1993, and proceeded to Operational Condition 1 with two inoperable safety / relief valves (SRVs). Specifically, SRVs IB21-F0138 and IB21-F013J had not been tested since the first refuel outage which ended in October 1986, a period greater than five years. (09014)

This is a Severity Level IV violation (Supplement 1).

ATTACHMENT D RESPONSE TO VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)l93036-02,03A,038,03C,03D,04 AND 50-373(374)/93040-01 BACKGROUND INFORMATION FOR VIOLATIONS 373(374)/93036-02,03A,03B,03C,03D and 04 and DEVIATION 373(374)/93036-05:

On November 29,1993, the Unit 2 B" RPS 120 VAC bus deenergized due to an undervoltage trip of the Electrical Power Monitoring Assembly (EPMA) for the alternate Reactor Protection System (RPS) power supp'y. This resulted in the trip of the RPS channels B1 and B2 (half-scram) and several isolations and half-isolations. One of the isolations that occurred was closure of the secondary containment isolation dampers. One of these dampers,1VR04YA, did not have a full closed indication in the control room following the initial closure signal. Subsequent cycling of this damper resulted in a full closure signal being received. The initiating cause of this event was the start of the "2A" Reactor Recirculation (RR) pump while the RPS bus was being powered from its alternate power supply.

Power for the "A" RR pump and the attemate RPS power supply is received via the System Auxiliary Transformer (SAT). The start of a major piece of equipment, such as an RR pump results in momentary undervoltage conditions on the power source.

Two redundant EPMAs are provided on each of the normal RPS power supplies and the alternate power supply for each unit (six total per unit). The EPMAs are installed between the RPS and each of the power sources. The EPMAs provide redundant protection to the RPS and other systems which receive power from the RPS buses by acting to disconnect the RPS bus from the power source circuits for conditions of underfrequency, undervoltage and overvoltage. These conditions are specified in LaSalle Technical Specification 3.8.3.4. If one of these conditions exists, there is potential that equipment fed from this power source will be damaged and not be able to perform its design function. )

Each of the EPMA underfrequency, undervoltage and overvoltage relays are provided with a time delay. l The setpoint of this time delay is variable and determines how long the underfrequency, undervoltage or I overvoltage condition may exist before the trip occurs. The setting of the time delay is not specified in the Technical Specifications or the Updated Final Safety Analysis Report. However, LaSalle's response to Final Safety Analysis Report Question 031.278 states that the time delay will be set in a range of 0.1 to 3.0 seconds.

On November 29,1993, when the 2A RR pump was started, an undervoltage signal was received on j the Unit 2 SAT. The undervoltage condition existed for a period of time which exceeded the setting of i the time delay. Consequently, the EPMA tripped and removed the RPS from its power source which  !

resulted in the half-scram and isolation signals. Two similar events occurred at LaSalle in 1983 and 1984, in response to the 1983 and 1984 events, a modification was completed that installed a regulating ,

transformer on the alternate RPS feed to preclude spurious trips. Modification testing determined that l this did not correct the problem. A Work Request was initiated to increase the EPMA time delay relay settings to 3 seconds. The Work Request was completed in 1986, but no testing was performed to verify that this corrected the problem. The testing was cancelled by an Operating Engineer and no compensatory measures were taken. The November 29,1993 event revealed that these changes did not correct the problem.

t ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)/93036-02,03A,03B,03C,03D,04 AND 50-373(374)/93040-01 REASON FOR VIOLATION 373(374)/93036-02:

The work request test requirements for the Reactor Protection System (RPS) Electrical Power Monitoring Assemblies (EPMA's) were waived by an Operating Engineer in 1986. Because the event occurred in 1986, we have been unable to determine specific reasons why the test requirements were waived. The work was performed in 1986 under a Work Request. Practices are that the Operating Engineers assign and delete testing requirements in Work Request packages as they deem necessary.

No documented reason was given for deleting the test requirements. Therefore, the reason the test was waived could not be determined.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)/93036-02):

No immediate corrective actions were necessary to correct this problem. The event itself identified that setting of the time delays to approximately 3 seconds did not prevent RPS bus trips when starting large loads. Procedure revisions have been made to warn Operations personnel about the potential for RPS bus trips when starting the Reactor Recirculation Pumps.

tORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)/93036-02):

Under current procedure requirements, this type of work activity would have been classified as a Setpoint Change. Therefore, the work would have been controlled in accordance with LaSalle Administrative Procedure LAP-1300-9, Setpoint Changes. This procedure requires that engineering approve any testing which was required by engineering. Therefore, a more detailed, documented review would be conducted prior to cancellation of the test requirements. If the test were waived or deferred, compensatory measures would be taken.

DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)/93036-02):

In essence, this event itself was a performance of the test on the RPS EPMA time delay relays that was cancelled by the Operating Engineer in 1986. No further actions are being taken with respect to this violation.

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ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A CIVilPENALTY VIOLATIONS 50-373(374)/93036-02,03A,03B,03C,03D,04 AND 50 373(374)/93040 01 REASON FOR VIOLATIONS 373(374)/93036-03A,03D and 04:

LaSalle Electrical Surveillance (LES) procedures LES-GM-300 and LES-GM-400 did not contain requirements for measuring and recording the setting of the Reactor Protection System (RPS) Electrical Power Monitoring Assembly (EPMA) time delay relay (Violation 93036-03A) Because there was no requ'rement in the procedure for measuring the EPMA time delay relay, there was also no specified instrument for measuring the time delay setpoint (Violation 93036-04) nor a tolerance for this setpoint.

Tolerances are not routinely specified on the Relay Setting Orders (Violation 93036-03D). Instead, the tolerances are contained within the approved station procedures.

These violations occurred as a result of an administrative error. LES-RP-103, Revision 2, dated September 1984, and LES-RP-203, issued in the mid 1980's, were reviewed against the requirements in the Technical Specifications and FSAR and then issued. LES-RP-103 and LES RP-104 were later renamed to LES-GM-300 and LES-GM-400, respectively. The Technical Specification did not contain any time setting requirements for the EPMA relay. The review of the FSAR did not identify any time setting requirements because the EPMA time setting is not addressed in the main body of the FSAR, but is addressed in the " Questions and Answers" as Question 031.278. The review should have determined that testing and measuring of the time delay relay was desirable and should be included in the surveillance procedures. A tolerance would have been specified for this parameter had it been included in the surveillance. A calibrated instrument for measuring the time delay would also have been specified in the procedure.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)l93036-03A,03D and 04):

The setting of all the RPS EPMA time delays has been determined and adjustments made such that each time delay is set to an acceptable value.

CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)/93036-03A, 03D and 04):

LES-GM-300 and LES-GM-400 were revised on February 12,1994. The revisions include requirements for testing and measuring the RPS EPMA time delay relays with certified test equipment. An ,

acceptable setting with a tolerance specified is provided in the revisions.

DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)/93036-03A,03D and 04):

Full compliance was achieved on February 12,1994 when LES-GM-300 and LES-GM-400 were revised to include requirements for testing and measuring the RPS EPMA time delay relays with certified test equipment and the setting of those relays within an acceptable tolerance.

ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A civil PENALTY VIOLATIONS 50-373(374)l93036-02,03A,03B,03C,03D,04 AND 50-373(374)l93040-01 REASON FOR VIOLATION 373(374)l93036-03B:

LOP-RR-04, LOP-RR-05 and LOP-RR-06 did not contain warnings to the operators to inform them of the potential for RPS trips when operating on the alternate RPS power supply and a large pump such as the Reactor Recirculation (RR) pump is started. To the best of our knowledge, this potential problem did not exist. Therefore, there was no reason to have the waming in the procedure. Actions had been taken in the mid 1980's to correct this problem, which was identified in two similar events at LaSalle.

The testing that should have been performed to verify the success of those actions was cancelled (Violation 93036-02) by the Operating Engineer with no compensatory measures taken. Therefore, LaSalle personnel were not aware that the actions taken were not successfulin resolving the RPS trip problern.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)/93036-038):

Until the applicable procedures could be revised, caution cards were placed on key major equipment control switches to warn operators of the potential for RPS trips when operating on the alternate RPS power supply and starting this equipment. i CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)l93036-038):

1. LOP-RR-04, LOP-RR-05 and LOP-RR-06 were revised on February 1,1994. The procedures contain warnings to the operators of the potential for trips of the alternate RPS power supply when starting the RR pumps.

2. Other procedures were evaluated for similar impact on the plant. The evaluation determined that the following procedures should be revised to contain similar warnings to the operator:

a. LOP-AS-02, Startup and Operation of the Radwaste Electrode Boilers,

b. LOP-AS-04, Startup of the inerting Steam Electrode Boilers, Startup of the Steam Inerting of the Reheater Tube Bundles, and Shutdown of the Steam Inerting of the Reheater Tube Bundles, and

c. LOP-FW-03, Startup of the Motor Driven Reactor Feed Pump.

These procedures have been revised to include wamings to the operators of the potential for trips of the alternate RPS power supply when starting equipment covered in these procedures.

3. Long term corrective actions are focused on eliminating RPS trips when operating on the alternate power supply and starting large pumps. A design change is being made to eliminate this problem.

We have scheduled completion of this design change on Unit 1 during the current refuel outage.

This design change will be incorporated on Unit 2 no later than the end of its next refuel outage, currently scheduled to begin February 18,1995.

DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)l93036-03B):

Full compliance was achieved on February 1,1994 when LOP-RR-04, LOP-RR-05, and LOP-RR-06 were revised to include warnings to the operators of the potential for trips of the alternate RPS power supply when starting the RR pumps.

ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)193036-02,03A,03B,03C,03D,04 AND 50-373(374)/93040-01 REASON FOR VIOLATION 373(374)l93036-03C:

We agree that operators did not correctly follow the requirements of LAP-220-5. We also agree that the operators did not follow the requirements of LAP-220-4. However, we do not agree that LAP-220-4 is inadequate.

When the alternate RPS bus tripped on November 29,1993, a number of activities occurred in response to the loss of the RPS bus. The control room responded to all the isolation signals, including the reactor building ventilation (VR) dampers closing and the failure of the 1VR04YA damper to indicate full closed. Operators were dispatched to the 1VR04YA damper to determine the condition of the damper. Upon inspection of the damper, the operator determined that the damper was not fully closed.

Operators then cycled the damper full open and then closed. This time, full closed indication was received.

In determining equipment operability in accordance with LAP-220-5, Operations Shift Supervision is required to verify that a previous operability evaluation has been performed for the equipment condition in question. If no previous evaluation exists, an equipment operability evaluation will be initiated. No previous operability evaluation existed for the condition in question. However, the Station Control Room Engineer (SCRE) knew that there was a surveillance evaluation (LAP-100-29) that documented the condition of the damper. Using that information, the SCRE determined that the damper was operable, but degraded, and never entered the operability procedure (LAP-220-5). Although this action was not in accordance with LAP-220-5 and management expectations, it was a common practice of all the SCREs.

This is a result of a lack of clear procedural guidance on the purpose and application of operability evaluations and surveillance evaluations. LAP-100-29, Conduct and Review of Station Surveillances, provided the latitude that allowed the SCRE to bypass the need to enter LAP-220-5. It is not management's expectations that LAP-100-29 be utilized for the above purpose. LAP-220-5 requires more rigor in determining equipment operability, including screening for the need of a safety evaluation.

In declaring the 1VR04YA damper operable, but degraded, the SCRE t hould have initiated a work request for the damper and entered the damper in the Degraded Equipment L og (DEL)in accordance with LAP-220-4. Knowing that this problem had existed in the past, the SCRE assumed that a work request had already been initiated and a DEL entry made. The SCRE failed to follow through with verification of the existence of the work request and DEL entry.

The DEL is intended to be a tool for operators to utilize in tracking significant existing problems on systems important to safety, it provides information that can be easily tracked, retrieved and reviewed.

It is only a backup to other administrative controls utilized for tracking equipment problems, such as work requests, out of services, and caution cards. We believe that LAP-220-4, in combination with training and communication of management expectations,is adequate. In this instance, the SCRE failed to make the DEL entry that should have been made.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)l93036-03C):

1. Although the SCRE had not entered LAP-220-5 and did not enter the degraded equipment condition in the DEL, he did verify compliance with the Technical Specifications by observing that the redundant secondary containment isolation damper,1VR04YB, was fully closed. Additionally, the failure of the 1VR04YA damper was ncted by the SCRE in the Problem Identification Form that was completed to document the entire RPS trip event.

2. After inspecting the 1VR04YA damper, operations personnel cycled the damper open and then closed. The damper then went to the full closed position.

4 ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)/93036-02,03A,03B,03C,03D,04 AND 50-373(374)l93040-01

3. An operability evaluation was completed in accordance with LAP-220-5 on January 7,1994. The j evaluation documented the operabihty of the secondary containment isolation dampers, including 1VR04YA, for the conditions which were experienced during the November 29,1993 event. I CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)/93036-03C):

1. The operations personnelinvolved in this event have been counselled on the proper application of operabikty evaluations versus surveillance evaluations in determining the operability of equipment.

2. We have eva!uated station procedures and determined that LaSalle Administrative Procedure (LAP)-

100-29 will be revised to include enhancements that will provide guidance on the application of operability evaluations versus surveillance evaluations in determining the operability of equipment.

The procedure will be revised and Operations Shift Supervision will be trained on the procedure revision by July 1,1994.

DATE WHEN FULL COMPUANCE WILL BE ACHIEVED (373(374)l93036-03C):

Full compliance will be achieved by July 1,1994 when LAP-100-29 is revised and operations personnel are trained on the appropriate application of operability evaluations and surveillance evaluations.

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ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A civil PENALTY VIOLATIONS 50-373(374)/93036-02,03A,03B,03C,03D,04 AND 50-373(374)193040-01 REASON FOR VIOLATION 373(374)193040-01:

The Limiting Condition for Operation (LCO) of Technical Specification 3.4.2 for Unit 1 was exceeded on January 30,1993, when Unit 1 was started up following its fifth refuel outage with two inoperable safety / relief valves (SRVs).

LaSalle's inservice Testing Program is based on ASME Section XI 1980 Edition, Winter 1980 Addenda.

Subsection IWV, Table IWV-3510-1 of Section XI requires " ..that at each refueling all valves which have not been tested during the preceding five (5) year period shall be tested". While gathering and reviewing information requested by an NRC Inspector, LaSalle Station's Engineering Department discovered that two (2) Unit 1 SRVs did not meet this requirement coming out of the unit's fifth refuel outage. The 2 SRVs,1821-F0138 and 1821-F013J, were last setpoint tested during the Unit 1 first refuel outage which ended October of 1986. Thus, the 2 valves were not setpoint tested in approximately 7.5 years.

These 2 SRVs were conservatively determined to be inoperable per Technical Specification 4.0.3 due to the time period since verification of the lift settings for these SRVs. Technical Specification 4.0.3 states

" Failure to perform a Surveillance Requirement within the specified time interval shall constitute a failure to meet the Operability requirements for a Limiting CondMon for Operation." Technical Specification 4.0.5 provides surveillance requirements for inservice inspection and testing of ASME Code Class 1,2, and 3 components per ASME Section XI of the Boller and Pressure Vessel Code and applicable Addenda as required by 10 CFR 50.55a(g). The SRVs are included in the ASME Code components to be tested.

During previous cycles, it was LaSalle Station's interpretation that each SRV required testing once within each fixed 5 year period. All SRVs were setpoint tested during the first fixed 5 year period, January 1984 to January 1990. This first 5 year period actually lasted six years. This is acceptable per ASME Section XI due to the length (one year) of Unit 1's first refueling outage. The end of the Unit i third refuelin January 1990 marked the start of the second fixed 5 year period. LaSalle was on a schedule to have each SRV setpoint tested again by the end of this period. This testing meets LaSalle Station's originalinterpretation.

Recent review of Table IWV-3510-1 has rendered a different interpretation. This interpretation concludes that when coming out of a refueling outage, each installed SRV must have been tested within the previous 5 year span, regardlers of what fixed 5 year period the unit is in. Since the testing of SRVs was in a different sequence between fixed periods, the most recent setpoint test of the *B" and "J" SRVs do not fall within the 5 year envelope preceding the Unit 1 fifth refuel outage.

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED (373(374)/93040-01):

1. The Action requirements of Technical Specification 3.4.2 required shutting down the urit to a Cold Shutdown condition within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />. Therefore, LaSalle requested and received Enforcement Discretion from Technical Specification 4.0.3 for SRVs'"B" and "J" to allow continued unit operation until approval of an exigent Technical Specification amendment.

2. LaSalle Unit I had a maintenance outage in January 1994. During this outage, the "B" and "J" SRVs were replaced with two new SRVs which were setpoint tested. Consequently, the exigent Technical Specification amendment was not necessary.

3. LaSalle Unit 2 SRVs were verified to have been tested in the last 5 years.

d ATTACHMENT D (continued)

RESPONSE TO VIOLATIONS NOT ASSESSED A CIVIL PENALTY VIOLATIONS 50-373(374)/93036-02,03A,038,03C,03D,04 AND 50-373(374)193040-01 CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS (373(374)l93040 01):

1. LaSalle Technical Surveillance procedure LTS-600-10, Safety and Relief Valve inservice Test, has been revised to include the correct test frequency requirements.

2. All Unit 1 and 2 SRVs have been added to the station's General Surveillance Program (GSRV) by serial number to ensure independent verification of compliance.

DATE WHEN FULL COMPLIANCE Witi BE ACHIEVED (373(374)/93040-01):

Full compliance was achieved on January 28,1994 when SRVs "B" and "J" were replaced with new SRVs, which were then satisfactorily tested.

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ATTACHMENT E RESPONSE TO NOTICE OF DEVIATION NRC INSPECTION REPORT 50-373(374)/93036 DEVIATION 373(374)/930,16-05:

During an NRC inspection conducted on November 29 through December 21,1993, a deviation from ,

your Final Safety Analysis Report (FSAR) was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action",10 CFR Part 2, Appendix C, the deviation is listed below:

Section 2.a of the licensee's response to FSAR Question 031.278 states that the nominal operating range of the Electrical Power Assembly (EPA) independent trip units is 0.1 and 3.0 seconds for qualification testing.

Contrary to the above, as of November 29,1993, the licensee had been setting the EPA independent trip unit time delays above 3.0 seconds and as high as 4.69 seconds.

REASON FOR DEVIATION:

The Reactor Protection System (RPS) Electrical Power Monitoring Assembly (EPMA) time delay settings for LaSalle Units 1 and 2 were not set consistent with FSAR Question 031.278. This deviation occurred as a result of an administrative error. LES-RP-103, Revision 2, dated September 1GS4, and LES-RP-203, issued in the mid 1980's, were reviewed against the requirements in the Technical Specifications and FSAR and then issued. LES-RP-103 and LES-RP-104 were later renamed to LES--

GM-300 and LES-GM-400, respectively. The Technical Specification did not contain any time setting requirements for the EPMA relay. The review of the FSAR did not identify any time setting ,

requirements because the EPMA time setting is not addressed in the main body of the FSAR, but is addressed in the " Questions and Answers" as Question 031.278. The review should have determined that testing and measuring of the time delay relay was desirable and should be included in the surveillance procedures.

Consequently, there was no formal requirement for measuring this time delay setting. The Relay Setting Order (RSO) specified that the time delay setting be 3.0 seconds. However, no tolerance was specified for this setting. Although the RSO was a source ofinformation for the technician calibrating the EPMA's, the procedures were the governing document that were used to determine testing requirements. Since the procedures did not specify testing of the time delay setting, any testing of the time delay was viewed as above and beyond the requirements for meeting operability of the components. The technician attempted to set the time delay near 3 seconds, but did not view it as a problem if the setting was greater than 3 seconds since he believed he was performing testing above and beyond the procedural requirements.

Therefore, the reason this deviation occurred is that testing of the time delay was not included in procedures LES-RP-103 and LES-RP-104 (later renamed to LES-GM-300 and LES-GM-400). Had testing of the time delay relays been included in the procedures, a tolerance would have been specified for this parameter and use of a calibrated instrument would have been required.

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ATTACHMENT E (continued)

RESPONSE TO NOTICE OF DEVIATION NRC INSPECTION REPORT 50-373(374)/93036 CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED:

The setting of all the RPS EPMA time delays has been determined and adjustments made such that each time delay is set to an acceptable value.

CORRECTIVE ACTIONS TO BE TAKEN TO AVOID FURTHER VIOLATIONS:

LES-GM-300 and LES-GM-400 were revised on February 12,1994. The revisions include requirements for testing and measuring the RPS EPMA time delay relays with certified test equipment. An acceptable setting with a tolerance specified is provided in the revisions.

DATE WHEN FULL COMPUANCE WILL BE ACHIEVED:

Full compliance was met on January 25,1994 when all of the RPS EPMA time delay settings were set to values consistent with the FSAR.

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