ML20069Q101
| ML20069Q101 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 06/20/1994 |
| From: | Horn G NEBRASKA PUBLIC POWER DISTRICT |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| CNSS941564, NUDOCS 9406270241 | |
| Download: ML20069Q101 (16) | |
Text
f P.O. BOX EB 68321 AQ~ Nebraska Public Power District "W3W" t
CNSS941564 June 20, B94 l
U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C.
20555
Subject:
NPPD Response to Inspection Report 50-298/93-202 Gentlemen:
This letter is written in response to your letter dated May 20, 1994, transmitting the Notice of Violation resulting from Inspection Report No.
50-298/93-202.
Therein you indicated that certain of our activities were in violation of NRC requirements.
Your letter also stated you had decided not to issue the apparent violation related to expedited resolution of those components on increased testing frequency.
We are taking aggressive actions to respond to your concern in this area by ensuring that the system engineers and in-service testing personnel are aware of management's expectations to expeditiously restore safety related components to the normal testing frequency. Management is maintaining a higher awareness of all components entering the " alert" range through an increased involvement ~in the in-service testing program. This issue is also being addressed by a self assessment presently being conducted on the in-service testing program.
In regards to your expressed concern in the areas of organizational interface, procedural controls, implementation of work activities and design modifications, and exhibiting a questioning attitude, we are making programmatic and culture changes to improve in these areas. We believe the improvement initiatives we are pursuing in the Near Term Integrated Enhancement Program and NPG Business Plan provide the fundamental direction we must take to resolve these concerns.
The following are the statements of the violations and our responses in accordance with 10 CFR 2.201:
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e Document Control Desk June 20, 1994 Page 2 Statement of Violation A.
10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," states, in part, activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances.
Contrary to the above, the following are examples of procedures not being appropriate to the circumstances:
1.
Procedures that provide for sampling the standby liquid control tank (Chemistry Procedure 8.4, Revision 6) and the diesel generator fuel oil storage tanks (Procedure 6.3.12.3, Revision 16) had not incorporated the housekeeping requirements specified in the Quality Assurance Program for Operations, Revision 8, and ANSI N45.2.3-1975, " Housekeeping during the Construction Phase of Nuclear Power Plants," and its associated Regulatory Guide 1.39,
" Housekeeping Requirements for Water Cooled Nuclear Power Plants."
2.
Preventive Maintenance Tasks 0200 and 0201 for the diesel generator fuel oil transfer pumps and the preventive maintenance r
task for the 24-Vdc battery chargers could not be performed as written.
Preventive Maintenance Tasks 0200 and 0201 specified that equipment be inspected; however, acceptance criteria, procedure reference, or precautions were not provided. The preventive maintenance task for cleaning the 24-Vdc battery chargers did not provide precautions, limitations, or instructions.
3.
Preventive Maintenance Task 07272 developed for the control building ventilation fan motors (HV-MOT-SF-SWGR-lF and HVT-MOT-SF-SWGR-lG), allowed the combining of Mobilux No. 2 or Chevron SRI No. 2 grease for motor-bearing lubrication.
These lubricants are not ccmpatible and if mixed could result in motor-bearing failure.
4.
Design Modification 88-0538, for the essential portions of the control building heating, ventilation, and air conditioning system, estchlished a weekly preventive maintenance to cycle Control Room Dampers HV-AD-1405, -1406, -1407, -1408, -1409, and
-1410.
The dampers were installed in 1992, but the weekly preventive maintenance had not been incorporated into the maintenance program and had not been performed.
5.
Surveillance Procedure 6.3.8.2, Revision 35, "SLC Pump Operability Test," was not adequate to perform the surveillance activity because two demineralized water valves (DW-416 and DW-417), which were required to be manipulated to fill the test tank, were not included in the procedure.
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Document Control Desk June 20, 1994 Page 3 6.
Conduct of Plant Operations Procedure 2.0.7, Revision 17, " Plant Temporary Modification Control," Paragraph 1, identifies that it i
controls temporary modifications in a manner that ensures operator awareness, conformance with design intent and optrability requirements, and preserves plant and personnel safety.
Procedure 2.0.7 was determined to be inadequate for the control of temporary i
modifications because the procedure failed to provide measures to ensure that the necessary reviews associated with installed temporary modifications, which were deferred because the affected system was out of service, were performed in the event the system was placed back in service.
It was identified that Temporary Modifications 93-31 and 93-35 were placed back into service without having the required reviews performed.
This is a Severity Level IV violation (298/93202-01) (Supplement I).
Reason for The Violation Example 1:
Inattention to detail existed regarding confirmation that housekeeping commitments had been incorporated into appropriate station procedures.
Example 2: The balance between skill of the craft and procedural detail in the Preventive Maintenance tasks was inadequate.
Example 3: The process did not ensure an adequate review of lubrication criteria for design and maintenance documents.
Example 4:
The procedural requirements did not ensure that the Preventive Maintenance task was incorporated into appropriate procedures in a timely manner.
Example 5:
The procedure was inadequate in providing guidance for addition of demin water to the SLC System test tank.
Example 6:
There was a failure to recognize the necessary checks and balances required when returning out of service equipment to service with PTMs installed.
t Corrective Steps Which Have Been Taken And The Results Achieved Example 1:
The affected areas were immediately cleaned and actions have been taken to ensure that appropriate sampling procedures incorporate cleanliness requirements.
Example 2: As an interim action, PMs are being reviewed to ensure adequate detail in work instructions and acceptance criteria exists prior to use.
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- Document Cont _. Desk June 20, 1994 Page 4 Example 3: Maintenance procedure 7.0.2 " Preventive Maintenance" has been revised to ensure appropriate review of PM additions and/or chant es that involve lubricants.
Additionally, a detailed as mssment of all PMs was performed to provide further asse ance that safety related equipment did not contain incompatible greases.
I Example 4:
A discussion held with the damper vendor determined that a quartarly frequency for cycling the dampers was appropriate.
Surveillance Procedure 6.3.17.11, has been revised to incorporate the quarterly cycling requirements for the dampers.
Procedure 3.4.11 " Status Reports" has also been revised to riquire timely submittal, review, and implementat ion of PMs on safety related equipment.
Example 5:
A TPCN was initiated to provide interim guidance on filling the SLC test tank.
Management expectations concerning procedure adherence were stressed in a letter from the Operations Manager to all Operations Department personnel.
Also, procedure 6.3.8.2 "SLC Pump Operability" was reviewed and revised to clarify the procedure.
Example 6: Appropriate reviews of PTMs 93-31 and 93-53 were performed.
As an interim measure, a temporary procedure change was made to procedure 2.0.7, which deleted the screening question for out of service components.
A permanent change has been made i
to procedure 2.0.7 which now requires the necessary reviews, including SORC approval, prior to installation of any PTM, i
Corrective Steps Which Will Be Taken i
Example 1:
Based en the cumulative impact of recent events, NPPD will perform a reevaluation of housekeeping commitments.
Example 2:
Program enhancements are being implemented for PM tasks under the responsibility of the Maintenance Department to assess, and where necessary, revise those PMs that are t
inadequate. Additionally, the balance between skill of the craft and procedural detail is beine addressed.
Example 3:
pM 07272 will be revised before its next use.
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Example 4:
A review of open DCs and ESCs which could have similar deficiencies is being conducted.
Additionally, an evaluation has been conducted on the design change closecut process and an a: tion plan is under development to identify further procedure improvements.
Example 5:
Corrective actions have been completed.
Document Control Desk June 20, 1994 Page 5 Example 6:
Corrective actions have been completed.
Additional long term corrective action is being taken to review appropriate Maintenance Procedures and Preventive Maintenance tasks to verify the incorporation of accurate and sufficient information and to determine that sufficient technical detail is incorporated to provide the required balance between skill of the craft and procedural requirements. A state of the art trending program is also being established to monitor procedural and other deficiencies.
Further corrective action will be implemented to correct, from a broad perspective, noted deficiencies.
Date When Full Compliance Will Be Achieved Full compliance will be achieved by July 31, 1995.
_Ratement of Violation B.
Technical Specification 3.2.F, " Primary Containment Surveillance Information," and Table 3.2.F specify a minimum of two suppression chamber / torus water level instruments (PC-LI-12 and PC-L1-13) shall be operable.
Action Statement E requires that, in the event both channels are inoperable and indication cannot be restored in 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, an orderly shutdown shall be initiated and the reactor shall be in hot shutdown in 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in cold shutdown in the following 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br />.
Contrary to the above, on January 30 and 31, 1993, with both suppression chamber / torus water level instruments (PC-LI-12 and PC-LI-13) inoperable, an orderly shutdown was not commenced after 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, and the reactor was not placed in hot shutdown within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />.
Instruments PC-LI-12 and PC-LI-13 were rendered inoperable on January 30, 1993, during the performance of Maintenance Work Request 92-0185 and were not declared inoperable until the following day at 1:19 p.m.
This is a Severity Level IV violation (298/93202-02) (Supplement I).
Reason for The Violation There was an inattention to detail in following established procedure requi reiaent s.
As stated in procedure 2.0.2, " Operations Logs and Reports," Technical Specification inoperability must be logged in the Shif t Supervisor's Log and should be logged in the Control Room Log.
There was also a failure to recognize that Post Maintenance Testing had not been performed and that the meter was still considered " inoperable" when the second meter was removed.
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- Document Control Desk June 20, 1994 Page 6 Corrective Steps Which Have Been Taken And The Results Achieved A review of past Technical Specifications Table 3.2.F-relatr,d MWRs was performed.
I&C Department tailgate sessions were held to tiscuss working on instrumentation listed in Technical Specifications. Training on Technical Specification sections 3.1 and 3.2 instruments was conducted for licensed operators.
As an interim action, procedural guidelines have been developed to prevent the inclusion of multiple Technical Specification components into a single MWR.
Corrective Steps Which Will Be Taken A review is being conducted to evaluate the feasibility of placing a Technical Specification field in the Equipment Data Field (EDF).
Additionally, permanent work control process refinements are being evaluated to determine the long term changes that are necessary to preclude recurrence.
Date When full Compliance Will Be Achieved Full compliance will be achieved by December 31, 1994.
Statement of Violation C.
Criterion V of Appendix B to 10 CFR Part 50 states, in part, activities affecting quality shall be prescribed by documented instructions or procedures of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions or procedures.
The following are examples of procedures not being accomplished in
'ccordance with prescribed instructions or procedures:
1.
Maintenance Procedure 7.0.1.3, Revision 1, " Maintenance Work Request-Documentation of Work," Section 8.2.1, stated, in part, that the shop supervisor shall ensure a craftsman obtains all designated maintenance work request approval signatures that are required just prior to starting the work activity.
Section 8.2.3.6 required that the shift supervisor be familiar with all aspects of the maintenance work request package; ensure that performance of the work activity will not compromise reactor safety or adversely affect existing plant operating conditions; ensure that assigned quality control, Post Maintenance Testing, special instructions, or engineering support documents adequately address the scope of the work activity and resolve any concerns; sign shift supervisor's approval to perform the work; and record the date and time on the maintenance work request.
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Document Control Desk June 20, 1994 Page 7 In addition, Procedure 7.0.1.3, Section 8.3, required that the shop supervisor sign that supervision reviewed all work, documentation has been completed satisfactory, equipment is ready for testing,and record the date and time.
The maintenance work request is then forwarded to the shift supervisor to review the maintenance work request package to understand the extent and effect of work activity, perform any Post Maintenance Testing assigned to the operations department, ensure that the results of all Post Maintenance Testing specified by the operations department have been recorded and are signed and dated, ensure that any discrepancies have been resolved, sign and date for the shif t supervisor's final review, sign equipment ready for service, and record the date and time.
a.
Contrary to the above, a maintenance work request was improperly used since the work identified on the maintenance work request had been completed.
The maintenance work request was used to perform additional work on the component to include Post Maintenance Testing and correcting a level instrument incorrect reading.
b.
Contrary to the above, maintenance work requests were identified as being left open for extended periods of time.
This practice permitted multiple work activities to be performed at the component and the use of an open maintenance work request on a component to perform a rework-type activity without specific instructions.
For example, the licensee prepared to investigate and repair the cause of an oil leak on the recently repaired Reactor Water Cleanup Pump A using the original (unrevised) maintenance work request.
The original maintenance work request, under which the repair work was performed, was still open, in the review process, and was to be used for the lube oil leak repair.
Secondly, Maintenance Work Request 93-3895, which had been closed by the department supervisor, was used to perform troubleshooting activities, November 2,1993, on the Standby Gas Treatment Temperature Indicator SGT-TI-537A.
2.
Maintenance Procedure 7.0.4, Revision 0,
' Conduct of Maintenance,"
Section 8.2.4, required that craftsman perform a work activity through to completion per the maintenance work request package.
If during the performance of the maintenance activity, the scope of work changes (not designated in the section that identifies work failures), the craftsman shall stop the work activity and contact shop supervision.
This includes any additions to the maintenance work request package (i.e., CGls, QA, etc.).
Shop supervision shall contact the maintenance planning office so the work activity instructions can be revised or a new maintenance work request package issued.
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Document Control Desk June 20, 1994 Page 8 Contrary to the above, Maintenance Work Request 93-3590 instructions were not followed as this work request set the oil pressure on the high pressure coolant injection, turbine lube oil system, but did not specify what the required range for the oil pressure should be.
The pressure for Indicator HPCI-PI-2783 was required to be adjusted to read 82.7 kPa (12 psig) with no tolerance provided.
The craftsman adjusted the pressure indicator to 75.8 kPa (11 psig), with no explanation for the discrepancy.
3.
Procedure 2.0.9, " Control of Plant Labeling and Operator f. ids,"
Revision 3, specified the controls needed for operator aids / labeling.
Contrary to the above, operator aids found, including " green band" markings, in the plant were not being controlled in accordance with the requirements specified in Procedure 2.0.9.
4.
Procedure NII-02, " Training Records," Revision 10, Section A.6.a, required, in part, a single line in ink will be drawn through an entry in a record that is to be changed, leaving it legible, with the new entry near the old entry.
Contrary to the above, the start and completion dates, in various attendance records concerning the fourth quarter of 1992 and first quarter of 1993 of fire brigade training, were changed by overwriting the original dates on the form.
This is a Severity Level IV violation (298/93202-03) (Supplement I).
Reason for The Violation Example 1:
There was unclear procedural guidance in Maintenance Procedure 7.0.1.2 or what should be considered within the
" scope of work" for Maintenance Work Requests.
The i
procedural requirements for troubleshooting was also inadequate.
Example 2:
Personnel did not fully recognize the need to document and i
explain deviations to work instructions.
Example 3:
NPPD mistakenly did not consider the orange dots or green banding on field instruments to be an operator aid.
Additionally, a procedural weakness existed in procedure 3.26.1, " Meter Banding Change Control" because it did not specifically address meter banding installed on field instruments.
i Example 4:
There was a failure by an individual to implement QA requirements for modifying official records.
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Corrective Steps Which Have Been Taken And The Results Achieved Example 1:
A review of the work performed in the maintenance work requests referenced in the violation was performed to ensure that work was performed appropriately.
A maintenance work request was issued to allow the additional work on the S6T temperature indicator SGT-TI-537A.
In addition, maintenance procedure 7.0.1.2, " Maintenance Work Request - MWR Generation and Review" was revised to more clearly define
" scope of work" and " troubleshooting" for maintenance work activities.
Example 2:
The adequacy of the as-left condition of the HPCI pressure indicator HPCI-P!-2783, was assessed and determined to be within an acceptable tolerance rar.ge.
The personnel involved with adjusting the HPCI turbine lube oil pressure, were counseled on the necessity of strict compliance to procedures.
Example 3:
The uncontrolled operator aids that were " orange dots" were removed.
A plant walkdown was conducted to identify and remove any other orange dots and to remove or prepare work items to remove inappropriate " green band" markings installed on field instruments.
Example 4:
The training attendance records were corrected and the involved instructor was disciplined regarding the event.
In addition, the Training Department Manager held a departmental meeting to outline the circumstances of the event and to emphasize the importance of correctly changing training records.
Corrective Steps Which Will Be Taken Example 1:
All corrective actions have been completed.
Example 2:
Tailgate sessions will be conducted with Engineering Department personnel regarding the necessity of strict compliance to procedures.
NPPD Management has also initiated long term programmatic corrective actions to improve attention to detail and better ensure an appropriate questioning attitude.
Example 3:
Procedure 3.26.1, " Meter Banding Change Control", will be modified to include banding control for instruments in the field.
Field meter banding not required as a result of the procedure revision will be removed.
Example 4: All corrective actions have been completed.
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' Document Control Desk June 20, 1994 Page 10 Additional long term corrective actions will be taken to review selected Maintenance Procedures and Preventive Maintenance tasks to verify the incorporation of accurate and sufficient information and to determine that sufficient technical detail is incorporated to allow the craft to perform the activity.
1 Date When full Compliance Will Be Achieved full compliance will be achieved by July 31, 1995.
Statement of Violation D.
Technical Specification 6.1.3, " Plant Staff-Shift Complement," requires, in part, the shift complement shall at all times meet the requirements specified in Section I.
Section I requires that a shift technical i
advisor shall be available, except during cold shutdown conditions, to serve in an advisory capacity to the shift crew on matters pertaining to the engineering aspects assuring safe operation of the plant.
Contrary to the above, from October 14-21, 1993, with the plant in the run mode, five shift technical advisors stood watch even though their training had expired.
This is a Severity Level IV violation (298/93202-04) (Supplement 1).
Reason for The Violation There was an inadequate overview and commitment to the STA Training Program implementation by management and the involved individuals.
Corrective Ste.ps Which Have Been Taken And The Results Achieved Delinquent training was completed by the five STAS before they stood another watch.
The Vice President - Nuclear issued a memorandum to all personnel that reaffirmed management commitment to training and specified training program ownership and management overview.
The STA training program description was revised to more clearly outline the STA training requirements.
Corrective Steps Which Will Be laken The Training Tracking System is being re-designed to make the system more user friendly and to permit custom reports and real time data review.
This will permit more efficient tracking when various certifications or requalifications are required and who the af fected personnel are; and allow for appropriate management overview of the training process.
Additionally, a Training Compliance Matrix is being developed to better define the basis for existing training programs and to ensure that internal and external training requirements are being met.
Document Control Desk June 20, 1994 Page 11 Date When Full Compliance Will Be Achieved full compliance will be achieved by December 31, 1994.
Statement of Violation E.
Technical Specification 6.1.3, " Plant Staff-Shift Complement," requires, in part, the shift complement shall at all times meet the requirements specified in Section G.
Section G requires that a fire brigade of at least five members shall be maintained at all times.
Two support members may be from other departments inclusive of security personnel.
Section 27 of the National Fire Protection Association (NFPA) code requires quarterly training sessions for fire brigade members.
Contrary to the above, during 1993, personnel (including security officers), who were members of the fire brigade, did not receive quarterly fire brigade training.
This is a Severity Level IV vio'ation (298/93202-05) (Supplement I),
Reason for The Violation NPPD improperly concluded that the requirement for quarterly training did not apply to fire Brigade members who did not come from the Operations Department.
There was also inappropriate supervisory guidance and a perceived priority of Operator License Training over Fire Brigade Training.
Corrective Steps Which Have Been Taken And The Results Achieved The training delinquencies for the fire brigade members were resolved.
The Vice President - Nuclear issued a memorandum to all personnel that reaffirmed management commitment to training and specified training program ownership and management overview.
The Fire Brigade training program description was revised to clearly define the Fire Brigade training requirements.
Corrective Steps Which Will 8e Taken The Training Tracking System is being redesigned to make the system more user friendly and to permit custom reports and real time data review.
This will permit more efficient tracking when various certifications or requalifications are required and who the affected personnel are; and allow for appropriate management overview of the training process.
Additionally, a Training Compliance Matrix is being developed to better define 'the basis for existing training programs and to ensure that internal.and external training requirements are being met.
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Document Control Desk June 20, 1994 Page 12 Date When Full Compliance Will Be Achieved full compliance will be achieved by December 31, 1994.
Statement of Violation F.
10 CFR Part 50, Appendix B, Criterion II, " Quality Assurance Program,"
states, in part, the quality assurance program shall provide control over activities affecting the quality of the ide9tified structures, systems, and components to an extent consistent with their importance to safety.
Contrary to the above, the licensee failed to maintain configuration control as identified by the following:
1.
Engineering controls were not properly applied to work done under maintenance work requests.
Maintenance Work Request 93-2691 fabricated a replacement restricting orifice plate for HPCI-RO-137C, which was found to be missing by the licensee during a plant walkdown.
The licensee fabricated a duplicate orifice, using an adjacent flange as a model, in lieu of determining the design requirements for the missing orifice plate.
Secondly, Maintenance Work Request 93-0855 was used to modify a drain line from a 24-inch pipe in the residual heat removal cystem. This modification was performed in accordance with two memoranda from the Nuclear Engineering Department and the maintenance work request rather than a design package.
Thirdly, Maintenance Work Request 93-0801 was used to replace the residual heat removal pump suction spool piece. The spool piece was torqued to the maximum value allowed in Maintenance Work Practice 5.1.2, "Flexatallic Flange Joints," Revision 0.
When the pipe was filled with water for the inservice leak test, the craftsman tightened the bolts to prevent leakage.
No engineering involvement was obtained to ensure that the bolts were not overstressed.
2.
Configuration of the plant was not adequately controlled when interferences were removed and replaced for maintenance purposes, as exhibited by numerous licensee-identified discrepancies involving small-bore pipe supports and the configuration of thermal insulation.
This is a Severity Level IV violation (298/93202-06) (Supplement I).
Reason For The Violation Example 1:
Existing procedures for configuration control were not utilized or followed and in some instances were too limiting.
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Document Control Desk June 20, 1994 Page 13 Example 2:
There existed a lack of attention by personnel performing maintenance, in that personnel did not take the necessary steps to ensure insulation and small-bore pipe supports, which were damaged or removed, were properly restored to their correct configuration.
Corrective Steps Which Have Been Taken And The Results Achieved Example 1:
Tailgate sessions were held with all Engineering personnel on procedural adherence and working around problems. A visual inspection of the spool piece was conducted to identify if flange deformation had occurred.
Maximum torque for bolts was assessed and a sampling of break-away torques was checked. As an enhancement to flange / bolt torquing practices and bolt torque criteria has been placed in Maintenance Work Practice 5.1.2 "Flexatallic Flange Joints".
Example 2:
As a result of System Engineer walkdowns performed prior to start up from the 1993 refueling outage an action plan has been put in place which provides resolutions to the pipe support discrepancies discovered in the walkdowns.
Corrective Steps Which Will Be Taken Example 1:
Engineering Procedure 3.21, " Fabrication of Replacement Parts" will be reviewed to facilitate the application of the procedure.
In addition, a procedural process will be developed for a graded approach to design change evaluations. Configuration Control will be addressed by site-specific industry events training.
Dr. going corrective actions include evaluating the configuration control and design change process. In addition, a review of maintenance procedures is being performed to ensure that sufficient technical detail is provided.
Example 2:
Engineering Department personnel will continue to conduct routine system walkdowns per Engineering Department Instruction 91-03, " System Walkdown Checklist." These walkdowns will assess the condition of plant systems in general and identify pipe support and insulation discrepancies which require correction.
Maintenance procedures will be revised to address the removal and replacement of pipe supports during maintenance.
Additional long term corrective actions will be to conduct a reengineering study of the configuration control and design change process within the NPG.
This will include the design change process as well as the technical issues / programs associated with the Design Change and the Maintenance Work Request procedures.
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Page 14 Date When Full Compliance Will Be Achieved Full compliance will be achieved by July 31, 1995.
Statement of Violation G.
Technical Specification Section 3.19. A requires that fire barriers and fire wall penetration fire seal integrity be maintained.
Contrary to the above, on November 2 and November 13, 1993, Fire Doors R1 and R3, respectively, were found inoperable.
Further inspection resulted in a total of 20 fire doors being declared inoperable.
The is a Severity Level IV violation (298/93202-07) (Supplement I).
Reason for The Violation There was inadequate management oversight of the fire door inspection program.
There was also an erroneous assumption that personnel inspecting the fire doors had the necessary skills.
Accordingly, based on the actual skill level of personnel, the procedure used for the fire door inspection was inadequate.
Corrective Steps Which Have Been Taken And lhe Results Achieved fire watches were posted as compensatory measures.
Maintenance Work Items were issued to repair affected fire doors with details provided on how to perform the inspections.
Fire doors were reinspected with Fire Protection personnel present and repaired as needed and promptly returned to full operable status.
Active participation by the Fire Protection Engineer has been initiated for fire door inspections until appropriate procedures are reviewed and the effectiveness of fire door inspection training is confirmed.
Additionally, a Corrective Action Review Board was formed to evaluate the event and make recommendations to management to prevent recurrence of this event.
Corrective Steps Which Will Be Taken Corrective actions include revising fire door control procedures to ensure that operability requirements can be properly assessed; implementing a quarterly PM program for high traffic fire doors; ensuring suf ficient technical detail has been incorporated into related 3
maintenance procedures; and developing a fire door inspection training program.
Date When Full Compliance Will Be Achi-"od Full compliance will be ach' December 31, 1994.
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i Statement of Violation H.
10 CFR Part 50, Appendix B, Criterion 111, " Design Control," states, in part, design changes, including field changes, shall be subject to design control measures commensurate with those applied to the original design and be approved by the organization that performed the original design unless the applicant designates another responsible organization.
Contrary to the above, changes to the design and configuration of the insulation installed on piping and equipment was routinely made without the use of the design change process, and as a result, reviews were not performed in a manner commensurate to those applied to the original insulation design.
The is a Severity Level IV violation (298/93202 08) (Supplement 1).
Reason For The Violation Personnel had unclear guidance on maintenance of the plant configuration.
Also, management oversight was less than adequate.
Corrective Steps Which llave Been Taken And The Results Achieved Tailgate Sessions were conducted to inform CNS Engineers of this issue and resulting action plans.
Interim insulation controls were developed and discussed with craft and Engineering to ensure that insulation work is captured under the Maintenance Work Request process and has appropriate Engineering involvement. A walkdown of important to safety systems was performed to check for proper insulation.
Resulting discrepancies were evaluated and no operability concerns existed.
Corrective Steps Which Will Be Taken A schedule for resolving the discrepancies resulting from the insulation walkdowns will be developed.
Lessons learned from this event will be incorporated into General Orientation Training and Industry Events Training.
An insulation reference document is also being developed to identify the original insulation design requirements for CNS.
This document will be incorporated into the Design Criteria Document Program and references to the document will be added to appropriate Engineering and Maintenance procedures.
I Date When Full Compliance Will Be Achieved full compliance will be achieved by December 31, 1994.
Document Control Desk l
June 20, 1994 Page 16 If you have any questions regarding this response, please contact me.
Sincirely,
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G( R. l-orn Vico-resident - Nuclear
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U. S. Nuclear Regulatory Commission Regional Office - Region IV Resident Inspector Cooper Nuclear Station i
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