IR 05000254/1996014
| ML20133A271 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 12/20/1996 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20133A253 | List: |
| References | |
| 50-254-96-14, 50-265-96-14, NUDOCS 9612310021 | |
| Download: ML20133A271 (23) | |
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U. S. NUCLEAR REGULATORY COMMISSION
REGION 111
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A Docket Nos: 50-254, 50-265
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- Report No
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50-254/96014, 50-265/96014
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Licensee: Commonwealth Edison Company (Comed)
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- Facility: Quad Cities Nuclear Power Station. Units 1 and 2 l
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Location: 22710 206th Avenue North I h Cordova, IL 61242 l.
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{ Dates: September 24 - October 26,1996 '
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i inspectors: C. Miller, Senior Resident inspector
! K. Walton, Resident inspector j L. Collins, Resident inspector j R Ganser, Illinois Department of Nuclear Safety i
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Approved by: Patrick L. Hiland, Chief
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Reactor Projects Branch 1
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9612310021 % 1220 PDR ADOCK 05000254 l i G PDR 1
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. EXECUTIVE SUMMARY Oead Cities Nuclear Power Station, Units 1 & 2 NRC Inepection Report 50-254/96014, 50-265/96014 This inspection included aspects of. licensee operations, maintenance, engineering, a1d plant support. The report covers a 5 week period of inspection from September 24 -
October 26,1996, by resident inspector ,
Operations
The inspectors identified an unapproved copy of a pressure-temperature limit graph from Quad Cities Operating Surveillance (OCOS) 0201-02, " Primary System Boundary Thermal Limitations," posted in the control room (Section O2.1).
Good panel monitoring by control room operators resulted in detection of a combined intercept valve drif ting closed. However, transient swings in generator
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output were not detected by control room operators in a timely manner (Section O 2.1 ) .
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A control room supervisor inadvertently contacted a computer touch screen which resulted in a station blackout diesel generator starting (Section 05.1).
Maintenance
The inspectors identified instancis where failure to adhere to procedures during maintenance on the shared standby diesel generator (SBDG) resulted in rewor The inspectors also identified poor supervisory oversight of some important job activities. Other problems identified by the inspectors included the use of unqualified workers for the SBDG and use of a vendor service representative who did not have a certification letter on file (Section M1.1).
Standby diesel generator maintenance planning was good and resulted in l completion of work and testing in accordance with the schedule. Although l improved implementation of risk significant work scheduling were noted, some aspects of risk planning were not fully considered (Section M1.1).
The inspectors observed good maintenance practices implemented during work on a residual heat removal service water pump. Some communications weaknesses between the vendor and licensee resulted in pump casing leakage. A poor quality pump casing also led to the leakage (Section M1.2).
The inspectors noted that neither the licensee' nor the vendor's quality control programs prevented substandard parts from reaching the maintenance shop. The parts were identified by workers during the maintenance and testing process (Section M7.1).
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, Control room ventilation original design errors led to system inoperability. A good questioning attitude by a system engmeer led to identification and subsequent repair of the design deficiency in the safets/-related portion of the control room ventilation system (Section E1.2).
A thorough root cause analysis by engineering staff helped to resolve problems associated with improper venting of the high pressure coolant injection system (Section E2.1).
The inspectors identified a discrepa":p between the Updated Final Safety Analysis Report and the Stan6by Diesel Gencrator (SBDG) design document relating to starting air requirements (Section M1.1).
Plant Suonort
Licensee response to a fire training exercise was good (Section F5.1).
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, - Spoort Details Summary of Plant Status: !
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Unit 1 operated at or near full power throughout this inspection period. The unit - 6
was placed in a 30-day limiting condition for operation (LCO) while the licensee 1 changed out the 1C residual heat removal service water pump. The work was i
successfully completed and the system returned to service as scheduled in
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approximately 21 day !
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l Unit 2 operated at or near full power during most of the inspection period, but I ( material condition issues necessitated several load drops. Ope /ators reduced power
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due to problems maintaining condenser vacuum.' Later, operators reduced power :
i ared removed the generator from service due to problems with a combined intercept i l valve (CIV) drif ting closed. The licensee experienced problems with venting the j high pressure coolant injection (HPCI) system during a routine surveillance. The l
l licensee took additional interim measures to assure proper HPCI system venting ;
, until engineering could determine the root cause of the proble '
On October 21,1996, the licensee entered a 7-day LCO, applicable to both units, to perform scheduled maintenance on the shared standby diesel generator (SBDG).
Maintenance and subsequent testing was completed within the LCO time perio . Ooerations 4
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01 Conduct of Operations'
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01.1 General Comments (71707)
Using inspection Procedure 71707ithe inspectors conducted frequent reviews of ongoing plant operation During the inspection period, several events occurred which required prompt notification of the NRC pursuant to 10 CFR 50.72. The events and dates are listed belo September 24 Emergency Notification System (El1S) call. The licensee lost the health physics network (HPN) phone line due to phone lines being severed off site. Communicaticns were restored to service one hour late September 26 Operators reduced Unit 2 power due to problems maintaining condenser vacuu October 9 Unit 2 HPCI was declared inoperable due to inability to verify the HPCI discharge piping filled.
- ' Topical headings such as 01, M8, etc., are used in accordance with the NRC standardized i
reactor inspection report outline. Individual reports are not expected to address all outline topics.
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!, October 12 ENS call. The safety-related control room ventilation system was declared inoperable due to the refrigerant crank case l heater being fed from non-safety-related power supply.
l October 23 Unit 2 power was decreased due to a CIV drifting closed.
l October 24 Operators remove Unit 2 generator from service after testing a
! CIV produced undesirable results to turbine auxiliary equipmen .2 Control Room insoections and Plant Area Walkdowns Insoection Scone
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The inspectors walked down various safety-related systems and observed various j operations and plant work activities to verify adherence to safe and proper work
, practices and plant procedures.
! Observations and Findinas The inspectors identified a copy of a pressure-temperature limit graph from procedure OCOS O201-02, " Primary System Boundary Thermal Limitations,"
Revision 5, posted in the control room. The graph was used during plant start-ups l and heat-up to ensure that important parameters remained within required limits.
l The gre 5 was not a controlled copy, was from an out of date procedure revision, and wa. . ot approved by the Shif t Engineer. The inspectors informed the unit supervisor who later removed the unauthorized copy from the control room. During i initiallicense examination inspections prior to this finding, NRC inspectors had '
identified a similar problem which the licensee had later indicated was correcte Having an unapproved posted version of the pressure-temperature limit graph was contrary to Quad Cities Administrative Procedure (OCAP) 217-2, " Plant Posting Control," Revision 0, August 5,1994, which required in-plant postings to be approved by the Shift Engineer and logged in the Plant Posting log index. Failure to follow OCAP 217-2 is an example of a Violation (50 254/265 96014-01a) of Technical Specification The inspectors observad operators and electricians perform post maintenance tests (PMT) on the 4 Kv feeder breaker to the 1C residual heat removal service water pump (RHRSWP). At the approximate time that the operator reinstalled the control power fuses and racked in the breaker for ground testing, annunciator power was i
lost to the 901-6 annunciator panelin the control room. The unit supervisor j terminated the breaker test until the cause for the loss of power to alarms was l determined. The cause for the loss of alarms was subsequently determined to be a l j blown fuse, apparently not related to the breaker testing. With this determine l breaker testing was satisfactorily completed by the oncoming shif Area walkdowns revealed only minor deficient conditions (excluding the reactor building basement area discussed in Section E2.3 of this report). General !
housekeeping in the 1B residual heat removal (RHR) room was acceptable. Dirt and l debris had accumulated on top of the 1D RHR pump motor. The handwheel for the ;
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- manual core spray pump discharge valve, 1-1402-8A, was in contact with the minimum. flow line. The valve could be operated normally and no signs of pip l damage were present. There was insulation damage on three sections of the 1C ;
RHRSWP piping. The inspector brought these issues to the attention of the unit i supervisor. The licensee expended effort to improve the condition and appearance of the RHRSWP room j
' Conclusions '
Corrective actions for improper postings in the control room failed to prevent similar '
occurrences and resulted in a violation. The unit supervisor made a conservative decision to stop breaker testing when power was lost to an annunciator pane {
02 Operational Status of Facilities and Equipment O 2.1 Combined Intercent Valve (CIV) Drifted Closed
{ Insoection Scone (71707)
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The inspectors observed the licensee's troubleshooting efforts and reviewed the work package and engineering evaluation for installation of jumpers in the electro- .l
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hydraulic control cabinet. The inspectors reviewed trend recordings associated with a transient induced by the troubleshooting efforts and Updated Final Safety Analysis Report (UFSAR) sections 10.2 and 15.2. Observations and Findinas Unit 2 op7rators noted the number 1 CIV slowly drifted from its normally full open condition to closed. Operators lowered Unit 2 turbine load in preparation for troubleshooting the CIV. With the reactor at about 25 percent power, technicians removed the servo amplifier, demodulator, and indicator (SADI) control board for '
the number 1 CIV. When the SADI board was removed, the number 1 CIV and number 4 ClV (slave to number 1 CIV) closed as anticipate The licensee determined the SADI board removed from the number 1 CIV was i faulted. A spare SADI board was bench checked satisfactorily, but a feedback parameter needed to be measured from the faulted SADI board with the faulted board installed in the electro-hydraulic control cabinet. Engineering prepared an evaluation for installation of jumpers to maintain both the number 1 and number 4 CIVs closed during calibration of the SADI card with the Unit 2 turbine on lin The faulted SADI board was reinstalled and the number 1 CIV was cycled to obtain information. Rapid and frequent cycling of the number 1 CIV produced feedwater heater alarms. Operators responded to the alarms, but were not aware of transient swings in generator output. Testing continued until operators noted a large swing in generator output (from 10 Mwe to 280 Mwe). Operators stopped troubleshooting activities until the Unit 2 turbine was removed from operatio _ _ _ _ -
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, Testing was suspended pending engineering determination of the cause of the -!
transient during testing. The inspectors considered this an inspector Folloviup item j- (50-254/265-96014-02) pending review of the licensee's root cause evaluation and corrective action . .
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l The inspectors concluded that panel monitoring by control room operators was ,
l good in detecting the number 1 ClV not fully open as required but could have been j better in detecting generator swings produced by troubleshooting activitie Operations' response to the CIV drifting closed was conservativ j
' i O2.2 Indication of Hiah Pressure Coolant Inieglion (HPCI) System Automatic initiation in
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- f-i The inspector reviewed UFSAR section 7.3.1.3,1,12 and institute of Electrical and Electronic Engineers (IEEE) Standard 279-1968 to verify compliance with f
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t Observations and Findinos
During a routine monthly surveillance, the licensee was unable to verify the l discharge of Unit 2 HPCI piping was filled and declared the system inoperable (See !
Section E2.1). The inspectors noted the operators engaged a mechanical device to j
! keep the Unit 2 HPCI trip push button on the main control board detented.
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Operators indicated the abnormal condition by placing an orange disc around the switc .
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Section 4.13 of IEEE 279-1968 required that if a safety system had been rendered
inoperative, that this condition be continuously indicated in the control roo !
- Licensee procedure, OAP 300-13, " Tagging Equipment," required operators to !
j indicate abnormal conditions with an orange dis lt
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The inspectors concluded the licensee was in compliance with IEEE 279-1968 for ;
the trip functions listed in UFSAR section 7.3.1.3.1.12. Similarly, the use of the
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- orange disc adequately complied with IEEE 279-1968. However, OAP 300-13,
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] " Tagging Equipment," did not reference, and operations staff were not aware of, i
the IEEE standard which required continuous indication when the automatic
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initiation of a safety system was bypassed. The inspectors were concerned that j the lack of awareness of the IEEE standard was a potential weakness in the
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05 Operator Training and Qualification '
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i 05.1 Inadvertent Start of Station Blackout Die.cel Generator (SBODG)
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'- Insoection Scoce
) The inspectors reviewed the licensee's investigation of an unexpected start of the i
' Unit 2 SBODG The inspectors reviewed the SBODG controls and discussed its operation with operator Observations and Findinas ,
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During the midnight shift on October 5, a control room operator identified the i
SBODG was running unloaded based on indications on the touch-screen control
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- panel. No activities involving either of the SBODGs were in progress. The l operators immediately began an investigation to determine how and when the diesel j }
was started and also initiated the surveillance procedure for testing the SBOD '
Based on information from an equipment operator who heard a diesel start, the licensee concluded that the SBODG had been running for approximately 20 minutes
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before discovery by control room operators. There were no annunciators
! associated with the even The licensee concluded that the diesel was most likely started inadvertently by the :
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' shift engineer (SE) leaning up against the touch screen control panel. The SE was l
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in the control room for 20-30 minutes, standing next to the screen and talking with operators.
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j From the human factors perspective, this event was considered by the j
manufacturer to be highly unlikely. An operator would need to inadvertently scroll
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SBODG. However, the licensee's investigation did not find any other starting
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- To prevent future recurrences, the licensee has planned to include this information
! in future training classes. The operating crews were also keeping the control
] screen positioned so four screens must be scrolled through to start the d;asel.
j Conclusions The licensee concluded that the root cause of the event was a training deficiency.
4 Operators had been told this event could not happen. The inspectors concluded i
that the licensee's corrective action would be sufficient to minimize the potential :
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08 Miscellaneous Operations issues (92700, 92701) L
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08.1 (Closed) Inspector Followup Item (50-254/265-94004-19): Annunciator Indication Problems. During the Diagnostic Evaluation Team (DET) inspection, the inspectors identified operators failing to pursue annunciator albrms received in the control room. Additionally, operators were'provided no guidance on how many and how !
long annunciators could be disabled. The inspectors also observed green i annunciator windows indicating reactor vessal head sealleakage was an acceptable condition during operation i l
The inspectors noted increased sensitivity to acknowledging and respondins to annunciator alarms by control room personnel. The licensee remuved all green tiled i annunciators from the control room. Reactor vessel head sealleakage was repaired j on Unit 2 but remained in an alarmed status in Unit 1. The inspectors reviewed !
~ operator logs for disabled annunciators in both units and identified that no
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annunciators were disabled. Although allowed by an operating procedure, disabling annunciators were not routinely used. This item is close :
08.2 (Closed) Unresolved item 50-254/265-96012-02 and !
(Closed) LER 50-254-96020: Control Room Emergency Filtration System (CREFS) {
Inoperable. On September 7, operators unsuccessfully attempted to start the l CREFS for a routine surveillance test. The system failed to start due to the toxic l
gas analyzer (TGA) being doenorgized for preventive maintenance. The operators did not know that the TGA being deenergized would inhibit the CREFS booster fans from starting. The equipment performed as designed. The licensee attributed this event to an operator knowledge deficiency. The inspectors reviewed the licensee's immediate corrective actions and planned long term corrective actions. These items are close . Maintenance M1 Conduct of Maintenance M 1.1 Shared Standbv Diesel Generator (SBDG) On-line Maintenance Inspection Scone The inspectors observed portions of the shared SBDG 18-month preventive maintenance at d other corrective maintenance activities. The inspectors reviewed work packages, worker training qualifications, on-line maintenance risk assessment and contingency plans, and spoke with maintenance personnel, supervisors, vendor representatives, and system engineers during normal day shift and off normal shift hours. The inspectors also reviewed applicable portions of the Technical Specifications and UFSA _ . - _ . . - - . __ _ _ _ . . - _ _ - _ . _ _ _ _ _ . . _ . _ _ . _ _ . - _ _
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, Observations and Findinas i Poor Coordination of Relav Cabinet Maintenance The scope of this work included replacement of old wiring in the sharea SBDG control cabinet after similar wiring for the Un!t 1 SBDG was discovered to be brittle and cracked. The inspectors found that this work had been well-planned and l executed. This activity had been planned as the criticci path job and was completed well ahead of schedule due to detailed wctk plans and round-the-clock work coverage. Hcwever, the inspectors found that the post maintenance testing I (PMT) for this work had not been specified prior to entry into the LCO on the
- <nared SBDG. Complicating the issue further, electricians identified several {
crac,ted termmal blocks in the control cabinet which required additional lead lif ts, and also affected the PMT requirements. The final PMT for this activity was not approved until day 4 of the 7-day LCO and was inadequa 'e, as discussed belo As part of the PMT, the logic for starting the SBDG ventilation fan and the field flashing circuit was required to be tested and verified. Field flashing and fan -
starting should have occurred as the diesel reached 800 rpm (normal operating speed is 900 rpm). However, during this slow start of the diesel, neither of these actions occurred at 800 rpm. At the time, engineers believed the problem to be with the setting of the relay which should have energized at 800 rpm. After consulting with operations, the decision was made to manually start the fan and l continue the testing which would culminate with an overspeed trip test. The overspeed trip test failed when the SBDG tripped at 1020 rpm, outside of the 1035 to 1050 rpm acceptable range. As the speed was increased during the test, the field did flash, contributing to the engineers' theory that the relay required calibratio After adjusting the overspeed trip setting, another test was performed. The field flashed and the ventilation fan started at an engine speed of 800 rpm without any adjustments. Engineers reviewed the previous test procedure and concluded that the PMT had lifted a lead in the control circuit prior to the diesel start such that the -
relay would not have energized. The lead was later landed during the overspeed test which was the actual reason the field flashed later, The engineers found that the sequencing of steps in the PMT had caused the problems with the ventilation fan and field flash circui The overspeed test was required to be performed a third time af ter further adjustment was made to the setting. The third test was successfu i Maintenance Procedure Adherence and Superviserv Weaknesses The inspectors observed several mechanical maintenance activities including injector testing, air start motor replacement, and seal replacements. Numerous l
findings pointed to the lack of adequate supervisory oversight for the work, i especially during off-normal shifts. The inspectors found weaknesses with worker 1 l l
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qualifications, procedure adherence, chemical controls, quality oversight, and communication On October 23, during replacement of the air start motors, the inspectors noted that the technicians were not performing certain steps of the guiding procedure OCMMS 6600-3 " Emergency Diesel Generator Periodic Preventive Maintenance inspection," in sequence. Steps 1.12.f and 12.g of the procedure required workers to add oil to the air start motors, rotate by hand, then check for proper rctation using air. Step I.12.h required workers to install the air motor Thc inspector noted that the workers were installing the raotors prior to oiling or testing. Additionally, when the workers tried to test the n.otors for rotation, there was not an acceptable air suprily available to perform the test. After unsuccessfully trying to use portable air tanks for the test, the workers eventually had to remove the motors, take them to a location for testing, and thua rein *; tall the When the inspector asked the workers if they had supervisory approval to deviate .
from the procedure, the workers indicated '.ney did,not. Later, when speaking to l the supervisor, the inspector found that the supervisor had no knowledge of the change in procedure sequence, of the iact that the workers tried an alternate means (portabic air tanks) to test the air motors, and that the air motors had been removed and reinstalled contrary to the procedure. The inspectors found later that a Problem Identification Form (PIF) had not been written to document the proble Quad Cities " Procedure Use and Adherence" procedure OCAP 1100-12 step D.4.d.(5) required: "Following procedural steps in sequence unless deviations are allowed by procedure." Procedurc QCMMS 6600-03 steps G.1 ar'd 1.2 allowed portions of the procedure to be performed out of sequence at the discretion of the supervisors involved. Step l.12.h was performed before steps 1.12.f and g. without authorization of the supervisor involved. Technical Specification 6.8.A required applicable procedures recommended in Appendix A of Regulatory Guide 1.33 Revision 2, February 1978 be implemented. This regulatory guide included administrative procedures dealing with procedure adherence and maintenance procedures dealing with safety related equipment. Failure to adhere to OCAP 1100-12 and OCMMS 660-03 is an example of a Violation (50-254/265-96014- .
01b) of station procedures and Technical Specifications . I The inspectors noted on several occasions little to no supervisory oversight of jobs l being performed, especially on jobs performed during the 11:00 p.m. to 7:00 shift. These observations were made during periods when the work being
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performed was on critical path for completion of the 7 day LCO. The inspectors !
questioned the supervisors and found a lack of knowledge about critical path I activities in some cases.
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The inspectors reviewed records for personnel entries into the power block and discovered that on the night shift involved with the air motor replacement and other i
- mechanical maintenance activities, the mechanical supervisor was only in the !
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- vicinity of the work for a total of 49 minutes on 3 visits. One of those visits of 15 ,
minute duration was accompanying an NRC inspector in response to NRC i questioning about job status and procedural adherenc Other minor discrepancies which demonstrated a lack of attention to detail by ' '
supervision and craft included failure to fill out a limited stainless steel use tag on lubricant used on the SBDG, an out-of-service tag which indicated a switch should be in the pull-to-lock position when that switch had no position labelled as such, and a failure to identify stray voltages to workers performing maintenance on the SBDG control cabinet. The inspectors review att-ibuted little safety significance to
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these individual issues, but noted a weakness in overall control of and attention to
maintenance activity detail ii Qualification of Maintenance Personnel The inspectors identified discrepancies during a review of the qualification records of the workers involved in the mechanical maintenance activities on the shared SBDG. None of the workers on the 11:00 p.m. to 7:00 a.m. shift were qualified in accordance with the licensee's training program and job assignment matrix to
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independently perform diesel generator maintenance. As indicated above, supervisory oversight was minimal during this period. A vendor technical representative was providing the supervisory oversight function for two of the three mechanical maintenance workers during most of this period.
Appendix B of 10 CFR Part 50, Criterion ll, " Quality Assurance Program," requires the licensee's quality assurance program to provide for indoctrination and training of personnel performing activities affecting quality as necessary to assure that suitable proficiency is achieved and maintained. Procedure OCAP 0900-01, Revision 6, " Quad Cities Training Program," required training programs to ensure personnel received training appropriate to applicable positions or tasks. The Quad Cities Maintenance Department Memorandum 800-01, dated February 28,1996, required department training coordinators to eselish a task qualification matrix to l ensure employee qualification prior to assignment to the task. The mechanical ,
maintenance job assignment matrix updated, September 18,1996, indicated that
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the three mechanical maintenance personnel working on the shared SBDG on the
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midnight shift of October 22 were not qualified on the criteria PSE-02 " Diesel J
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Engines."
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Other options in the licensee's maintenance program when qualified persons were not used included direct oversight of the unqualified workers by (1) qualified i
technicians or supervision, or (2) by use of an original equipment manufacturer
technical service representative " assigned to support the employee." The licensee failed to ensure direct oversight of all three technicians working on the shared SBDG by either a qualified technician or supervisor, and failed to assure the qualification of the technical service representative assigned to averview two of the
, technicians. When the inspector asked Quality Assurance personnel to verify the qualifications of the vendor representatives from Engine Systems, Inc., the licensee discovered these certifications were never sent or verified even though this was
- required by the Commonwealth Edison purchase order number 356975. Based on additional discussions with the licensee, the inspector determined that the licensee did not have a process in place to verify the qualification of the vendor or to qualify the vendor for supervisory oversight activitie . .
Based on the information above, the inspector concluded that the licensee failed to ensure the work affecting quality on the shared SBDG was properly performed by qualified technicians or technicians with oversight by qualified personnel, which is a Violation (50 254/265-96014-03) of Appendix B of 10 CFR 50, Criterion 11 " Quality Assurance Program."
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The inspector noted further weaknesses in the maintenance program in that the supervisor assigned to provide direct oversight was 'n'ot . required to have any specific technical training for the task. Alco, the level of technical service -
representative qualifications for oversight were not specified by the purchase orde nor was the level of support to the unqualified technician by the service representative specified by the 800-01 memorandum. Maintenance department supervisors interviewed expressed a wide variety of opinions on the level of oversight required for unqualified personnel on equipment such as SBDG The inspectors noted maintenance quality oversight reviews were not scheduled for most backshift periods. Quality controlinspectors were present but had not identified similar maintenance problems during the backshift periods when the NRC inspectors found maintenance weaknesses and violations. Site Quality Verification management indicated that quality control personnel were only looking for traditional hold point discrepancies. However, expanded use of quality control inspectors was planne i Good LCO Plannina With Post Maintenance Testina Weaknesses The original planned duration of the LCO was 109 hours0.00126 days <br />0.0303 hours <br />1.802249e-4 weeks <br />4.14745e-5 months <br /> and the actual duration was 128 hours0.00148 days <br />0.0356 hours <br />2.116402e-4 weeks <br />4.8704e-5 months <br />. The actual maintenance work was completed ahead of schedul but delays associated with the return to service and testing extended the LCO duration. The inspectors found the planning of the maintenance work was thorough but that the coordination of the post maintenance testing requirements was not specified in as great detail and therefore resulted in delay The inspectors found the LCO planning with respect to work package preparation to be good. The inspectors found an excellent example of good work package preparation in the control panel wiring work, as work analysts had performed a thorough review of the panel wiring with the electrical prints and prepared lead lif t sheets in a logical working order. Based on interviews with electrical maintenance personnel and field observations, the inspectors concluded that the rewiring on the shared SBDG was a success based on good planning and lessons learned from the same job on the Unit 1 SBD Two other on-line maintenance activities concluded during the inspection perio The licensee completed the work associated with the 1C RHRSW pump and also
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- finished the cleaning of the circulating water bay which rendered the shared "A" fire pump inoperable, requiring entry into an administrative (not a Technical Specification) LCO. The LCO for the 1C RHRSW pump was planned for 21 days and was completed in 21 days, even with the problems found with the pump casing (see Section M1,2). The inspectors found that both the shared SBDG arid 1C RHRSW LCO schedules were well executed. However, the licensee underestimated the scope of work on the circulating water bay, which resulted in the shared A fire pump being inoperable for 3 days versus the 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> originally planned. Other problems contributed to the delays, such as badging of contract divers and turnover communication problem Incomnlete Risk Assessment and UFSAR Discrepancy While reviewing the risk assessment performed for the shared SBDG work, the inspectors questioned the SBDG system engineer about the impact of the degraded air start system on the Unit 2 SBDG. Two of the four air receiver tanks (one pair)
on the Unit 2 SBDG were depressurized and isolated due to faulty pressure switches that maintain the required air pressure in the tanks. The Technical Specification bases clearly stated that with either pair of air receiver tanks at the minimum specified pressure, there is sufficient air in the tanks to start the associated diesel generator. Therefore, the Unit 2 SBDG was still considered operable. However the UFSAR, stated that with p_q1h pairs of air receiver tanks at a pressure of 230 pounds per square inch gauge (psig), there was sufficient air in the tanks to allow two 15-second starting attempts. The licensee's design basis document for the SBDGs, approved in January 1996, stated that one pair of air receiver tanks was sufficient for two unsuccessful plus one successful start of the SBDG. The inspectors concluded that there was a discrepancy between the UFSAR and the current design basis document with respect to the possible number of SBDG start attempts with one or both pairs of air receiver tanks at minimum pressure. The Technical Specification bases only stated that the SBDG can be started with one pair of tanks but not specified how many start attempts were possibl The inspectors noted that the starting air system for the Unit 2 SBDG was degraded but operable, and that this effect on risk was not explicitly considered in the on-line maintenance risk assessment that was performed. However, the licensee had verified, prior to the LCO entry, the operability of the single pair of air tanks and compressor on Unit 2 SBDG by performing the monthly surveillanc The licensee's plan also had not considered the effects of performing this work in conjunction with the Unit 1 alternate 125 volt battery being inoperable. Also, when troubleshooting the Unit 2 CIV which could have impacted plant stability was considered, the licensee chose to perform the troubleshooting rather than wait for the return of the SBDG. Finally, the risk associated with the SBDG maintenance could have been significantly reduced had it been performed from May through August of 1996 when both units were in cold shutdown condition i
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, , Conclusions ,
i The inspectors concluded that the control of risk significant activities had improved i somewhat in that activities were being controlled in accordance with a schedul However, the poor supervisory oversight and procedure adhererce shown in parts of the SBDG work were indicative of a broader problem in maintenance activities.
? Some post maintenance testing activities were not well defined prior to the LCO, f and some risk aspects of the maintenance were not fully considered.
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M1.2 Observation of Mechanical Maintenance Rentacement of 1C RHRSW Pumo i
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, Insoection Scone
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- The inspectors observed activities by mechanical maintenance division (MMD) ~
during replacement of the 1C residual heat removal service water pump (RHRSWP)
l for modification of the low pressure pump. Activities observed included work in the j shop and in the field. The inspectors reviewed documentation associated with the
work package, modification testing, and final test results for pump operability. The a inspectors interviewed workers and maintenance supervisors associated with J RHRSWP work.
' Observations and Findinas
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j Quad Cities has had a history of poor performance from these pumps ce tra past
! maintenance difficulties and operation of the low pressure pump near the "run-out"
) portion of the pressure and flow curve. Resultant cavitation, combined with
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' excessive system vibration, had resulted in a high pump failure rate. The licensee
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modified six of the eight low pressure RHRSWPs by enhancing impellers and re-cutting pump casings. This resulted in the RHRSWPs operating in a more efficient portion of the pump curve.
- The work area in the RHRSWP room was generally orderly and well controlled. The i inspector observed alignment work in various stages of pump assembly and noted j workers exercised care to properly align the pumps to the motor and to the system j piping. The rotating equipment engineer worked closely with the other maintenance workers. The licensee's quality control inspector identified that the l work package needed to be revised to control and document the shop leak test of
] the new pump. The licensee identified problems with the casing surface of the i vendor supplied pump and the gasket material the vendor had used for the pre-
! shipment pressure test (See Section M7.1).
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!, Conclusions
The station MMD's valve and rotating equipment team performance through this maintenance activity was good. There were no significant deficiencies throughout the entire job except problems with the casing surface of the vendor supplied pump and the gasket material the vendor had used for the pre-shipment pressure tes Effective work management and teamwork were demonstrate l i
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, M1.3 Work Control Process Performance The inspectors reviewed the licensee's trends on work control performance for the
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past several months. The licensee adopted a 13-week rolling work planning process late in 1995. However, the majority of the time since the new process was warted, one or both units were involved in an outage. Since outage work and schedules were not managed by the 13-week system, the licensee had difficulty in j
measuring true performance of the work control process. During the current inspection period, the licensee showed some progress in the implementation of the work control process, as exhibited by a small decrease in corrective maintenance backlog and some increase in schedule adherence.
, M7 Quality Assurance in Maintenance Activities' '
l M7.1 Maintenance Workers identified Problems with Ouality Parts 1 Sconc i I
The inspectors observed maintenance work being performed on the 1 "C" RHRSWP and "B" CREFs. The inspectors spoke to workers and supervisors and reviewed maintenance procedures. The inspectors reviewed receipt inspection documentation associated with the 1 "C" RHRSWP. The inspectors also attended a meeting between the licensee and Ingersoll-Dresser Pumps, the RHRSWP vendor, to discuss quality of part Observations and Findinas Unit 1 "C" RHRSWP Af ter assembling 1 "C" RHRSWP, workers conducted a pressure test on the newly installed pump casing. The pump casing inboard seal area leaked at about 10 psig pressure. This failed hydrostatic test required workers to remove and replace the pump. Workers later identified the casing surface was machined by the vendor l with some low spots, and that the vendor had used a different gasket material (more compressive) for the pre-shipment pressure test thare the licensee used on site. The licensee replaced the new pump casin Licensee and vendor representatiws met to discuss this and other parts problems recently identified by workers at the facility. The vendor noted the subject pump casing was hydrostatically tested satisfactorily prior to delivery to the licensee's CRIT (Central Receipt inspection and Test) facility. The CRIT facility verified proper i paper work but was not required to perform any dimensional checks of the pump casing. An independent inspection contractor determined the vendor used a different type of gasket for hydrostatic testing than was used by the licensee. This information was not transferred to the site.
, Based on direct observations and interviews, the inspectors determined that maintenance workers on this job expended the majority of their time and effort on
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' verifying dimensions of newly supplied vendor parts prior to pump reassembly. The leaking RHRSWP casing resulted in an additional 4 days of pump inoperability in a 30 day LCO to correct the conditio i "B" Control Room Emeroency Filtration System During repair of an old design deficiency, (see Section E1.2), maintenance workers identified that a red-tagged (quality part important to safety) terminal board was bowed. During installation of the part, a hair-line fracture developed requiring the part to be replaced. A replacement part staged in supply was similarly bowed. The licensee later determined that the wrong type of terminal board was ordered. The proper type of terminal board was located and installed. The system was later
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successfully teste ii Site Ouality Verification (SOV) Response in response to parts problems identified by maintenance personnel, SOV planned to review all receipt and inspection packages for material received from CRIT for the Quad Cities Station. Additionally, all six comed SOV organizations planned to audit the CRIT facility in the near futur Quad Cities staff met with the pump vendor and personnel from Comed CRIT facility to discuss product quality and other issues. The Quad Cities SOV manager issued a "stop work" order on the leaking RHRSWP casing until Comed could observe the vendor rework the defective pump casing and to audit the vendor's quality assurance progra As a result of an audit by an independent inspection contractor, both Comed and the pump vendor were tasked to address various quality assurance discrepancie l The licensee documented Comed assigned discrepancies on PlFs for resolutio l The independent auditor also placed a procurement warning on the Comed Quality Approved Bidders List to limit new procurements or changes to existing ,
procurements due to programmatic concerns with the pump vendor's quality l processe I c. Conclusions The licensee has the responsibility to ensure the quality of safety-related components procured through vendors. This was primarily accomplished through licensee quality verification audits of vendor processes and facilities. Other assurances were through ComEds' CRIT quality assurance processes, including review of purchase specifications ( id receipt inspections. Previously, defects in safety-related materials had not been found until the equipment was installed in a plant syste The inspectors concluded that neither the licensees' nor the vendors' quality assurance program inhibited the delivery of substandard quality parts to the
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- maintenance shop. However, in these two cases the substandard parts were -
detected prior to returning the systems to operatio '
M8 Miscellaneous Maintenance issues (92902)
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M8.1 (Closed) Insoector Followun Item (50-254/265-95007-01): Misapplication of ;
Muriatic Acid in the Unit 1 Station Blackout Building (SBO). In late September 1995 a contract work force misapplied a highly concentrated acid solution to the l
floor of the SBO building in preparation for coating the floor with an epoxy !
compound. In both units SBOs, sensitive electrical components were damaged by I the effects of the acid. The licensee restored Unit 2 SBO equipment and returned j the equipment to operations by December 27,1995. All Unit 1 major equipment l was inspected, repaired as necessary, and reinstalled later. Obit 1 SBO was tumed over to Operations on June 28. The licensee implemented numerous changes to construction department work procedures, contractual agreements, and first line supervisor expectations. The inspectors reviewed the licensee's corrective actions -
and consider this item close k lli. Enaineerina El Conduct of Engineering E Control Room Ventilation System inocerable Insoection Scoce (37551)
The inspectors reviewed the UFSAR sections 6.4, and observed maintenance and testing activities associated with the safety-related control room ventilation syste Observations and Findinas A system engineer, questioning a design feature of the Control Room Emergency Filtration System (CREFS), identified a vulnerability in the refrigeration compressor
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unit, (RCU). Specifically, a refrigerant crankcase heater was fed off a non-safety
[ related power supply. The UFSAR section 6.4.2.E required the CREFS be capable of functioning during and after a design basis accident including a loss of offsite power (LOOP). Since the CREFS' RCU heater would become deenergized during a l LOOP, the CREF system was considered inoperable. The licensee reported the design deficiency to the NRC.
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The condition was corrected by routing a safety-related power supply to newly installed heaters. Operators then declared the system operable. The inspectors will continue to review this item and its relation to other recently discovered design discrepancies on control room ventilation as Unresolved item (50-254/265 96014-04).
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, Conclusions Design deficiencies could have allowed control room ventilation to become inoperable if the non-safety related power supply was lost. The inspectors concluded a good questioning attitude by a system engineer resulted in -
identification of the design vulnerability with the RC E2 Engineering Support of Facilities and Equipment E Unit 2 Hiah Pressure Coolant Iniection (HPCI) Vent Verification Problems Insoection Scone (37551)
The inspectors reviewed the operations surveillance test and compliance with T The inspectors reviewed engineering root cause analysis process and performed a walkdown of Unit 2 HPCI syste Observations and Findinas On October 9, during routine monthly surveillance to vent the Unit 2 HPCI l discharge piping, operators were unable to verify the piping was filled as required l by TS 4.5.A.1.a. Operators declared Unit 2 HPCl inoperable and notified the NRC.
l Operators switched the HPCI system suction from the normal source (contaminated condensate storage tank (CCST)) to the alternate source (torus) and successfully vented the system. Operators declared Unit 2 HPCI operable. The licensee later switched the HPCI suction back to the CCST and vented the piping successfully on a daily basis until an engineering evaluation could determine the root cause of the conditio The venting surveillance had been successfully completed in August and September 1996. The routine quarterly pump surveillance, completed on October 8, cycled a valve in the pump discharge piping which was not operated during the monthly venting surveillance. Engineering determined that cycling the valve during the quarterly surveillance had allowed a pocket of trapped air to move. The combination of the trapped air and the configuration of the vent piping resulted in a ,
l " water trap" which produced a static condition that prevented venting the HPCI l pipin l The root cause appeared to be the air pocket trapped in the HPCI pump discharge piping after work had been performed on the HPCI discharge check valve in August 1996. The licensee determined that the pocket of air was small and would not have rendered HPCI inoperable. Engineering determined this condition could not exist in Unit 1 and recommended corrective actions to prevent recurrence in Unit 2.
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, Conclusions
The inspectors concluded the root cause analysis was good. Engineering l systematically identified potential causes of failure and eliminated causes based on {
analysis and/or testin E2.2 Facility Adherence to the UFSAR i
While performing the inspections discussed in this report, the inspectors reviewed the applicable portions of the UFSAR that related to the areas inspected. The {
inspectors compared plant practices, procedures, and/or parameters to that !
described in the UFSAR and documented the findings in this inspection report. The inspectors reviewed th~e following sections of the UFSAR:
IR Section UFSAP Section Acolicability O .2 Turbine-Generator I
15. Accident Analysis - Turbine Trip O .3.1.3.1.12 indication of HPCI Bypasses
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E .4 Control Room Habitability E .3. Volt D.C. alternate battery E2.3 Insoection of Torus Baseolate Bolts Insoection Scone (37551)
The inspector performed an inspection of the under-torus area and observed inconsistencies in the cleararmes and angular relationships in the torus baseplate mounting bolts, Observations and Findinas The licensee installed these baseplates to add support to the torus in the Mark I containment modification program. The design allowed movement of the support feet for thermal expansion. The bolting specification stated the baseplate mounting nuts on the baseplates were to be finger tight against the upper of two beveled washers, bar.ked off 1/6 turn, and secured with a lock nut. The inspector observed some nuts appeared snug, other nuts appeared to have excessive clearance, and some had an angular relationship to the beveled washers. Several lock nuts were not secure I The inspectors were concerned that angular orientation between the lower nut to the upper surface of the beveled washer would produce a shear force to the mounting studs rather that a linear force in the event of vertical acceleration forces !
caused by dynamic loading. The inspector contacted licensee structural engineers
, who accompanied the inspector on a subsequent walkdowr, of the baseplates.
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The licensee and NRC were unable to determine during the walkdown whether the apparent discrepancies would adversely effect the structural support of the torus.
l l The inspectors consider this an inspector Followup item (50-254/265-96014-05)
j- pending review of the engineering evaluation of the existing conditio l i
( i IV. Plant Sypport ,
F5 l
} Fire Protection Staff Training and Qualification !
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F Observation of Fire Trainino Exercise
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! The inspectcr observed a training scenario that simulated a plant fire at the electro-l
} hydraulic control reservoirs. This exercise combined a simulator training activity j with the fire brigade facility and included response from a number of offsite fire t
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departments. This combined exercise provided a more realistic challenge for the i
operating crew and response team to respond to an emergency in the control roorn,
! activate the onsit.o fire brigade, and facilitate the assistance of the offsite fire ;
- fighter !
The operators in the simulator maintained good command and control. The onsite
fire brigade responded effectively. When offsite units arrived, the onsite Fire ;
Brigade Leader coordinated the fire fighting effort while maintaining communication j between the control room and the scene of the fire.
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4 i V. Manaaement Meetinos
X1 Exit Meeting Summary
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- The inspectors presented the inspection results to members of licensee management at the l conclusion of the inspection on October 25,1996. The licensee acknowledged the j findings presented.
3 The inspectors asked the licensee whether any materials examined during the inspection
- should be considered proprietary. No proprietary information was identified.
i E. Kraf t Site Vice President
$ B. Pearce Station Manager j D. Cook Operations Manager j M. Wayland Maintenance Manager J. Hutchinson Engineering Manager F. Tsakeres Radiological Protection / Chemistry Manager C. Peterson Regulatory Affairs Manager M. DiPonzio Corporate Licensing F. Famulari Site Quality Verification Manager
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4 INSPECTION PROCEDURES USED IP 40500: Ef fectiveness of Licensee Controls in identifying, Resolving, and Preventing Problems IP 62703: Maintenance Observation IP 64704: Fire Protection Program IP 71707: Plant Operations IP 73051: Inservice inspection - Review of Program IP 73753: Inservice Inspection
IP 83729: Occupational Exposure During Extended Outages IP 83750: !
Occupational Exposure IP 92700f Onsite Followup of Written Reports of Nonroutine Events at Power Reactor
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Facilities (
IP 92902: Followup - Maintenance IP 92903: Followup - Engineering IP 93702: Prompt Onsite Response to Events at Operating Power Reactors ITEMS OPENED, CLOSED, AND DISCUSSED Onened 50-254/265-96014-01 a VIO Failure to adhere to QCAP 217-2 50-254/265-96014-02 IFl CIV drifted closed 50-254/265-96014-01 b VIO Failure to adhere to QCAP 1100-12 and OCMMS 660-03 50-254/265-96014-03 VIO 10 CFR 50 Appendix B Criterion il 50-254/265-96014-04 URI Control room ventilation system inoperable 50-254/265-96014-05 IFl Inspection of torus baseplate bolts
_Q0 fled 50-254/265-94004-19 IFl Annunciator indication problems 50-254/265-96012-02 URI CREFs inoperable l 50-254/96020 LER CREFs inoperable 50-254/265-95007-01 IFl Misapplication of muriatic acid in the Unit 1 SBO l
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Combined Intercept Valve CREF -
Control Room Emergency Filtration
. CRIT . -
Central Receipt inspection and Test DET -
Diagnostic Evaluation Team ENS -
Emergency Notification System ESF -
Engineered Safety Feature HELB -
High Energy Line Breaks HPCI -
High Picssure Coolant injection System HPN -
Ingersoll-Dresser Pumps ~
IDNS -
Illinois Department of Nuclear Safety -
IEEE -
Institute of Electrical and Electronic Engineers LCO -
Limiting Condition for Operation LER -
Licensee Event Report LOCA -
Loss of Coolant Accidents LOOP -
Loss of Offsite Power MEL -
Master Equipment List MMD -
Mechanical Maintenance Division NRR -
Nuclear Regulatory Commission Office of Nuclear Reactor Regulation PlF -
Problem identification Form PMT -
Post Maintenance Tests psig -
pounds per square inch gauge RCU -
Refrigeration Compressor Unit RHR -
Residual Heat Removal RHRSWP - Residual Heat Removal Service Water Pump SADI -
Servo Amplifier Demodulator, and Indicator SBDG -
Standby Diesel Generator SBGTS -
Standby Gas Treatment System SBO -
Station Blackout Building SBODG -
Station Blackout Diesel Generator SE -
Shift Engineer SOV -
Site Quality Verification TGA -
Toxic Gas Analyzer UFSAR -