ML20133P695

Insp Repts 50-369/85-21 & 50-370/85-22 on 850521-0620. Violations Noted:Failure to Follow Procedures & Inadequate Procedure Resulting in Valve Misidentification & Failure to Perform Surveillance on Unlocked/Open Fire Doors

ML20133P695
Person / Time
Site:	Mcguire, McGuire
Issue date:	07/29/1985
From:	Dance H, William Orders, Pierson R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20133P668	List: IR 05000521/2006020 ML20133P666 ML20133P695
References
50-369-85-21, 50-370-85-22, NUDOCS 8508140422
Download: ML20133P695 (9)

See also: IR 05000369/1985021

Text

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o UNITED STATES

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NUCLEAR REGULATORY COMMISSION

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Report Nos.: 50-369/85-21 and 50-370/85-22

Licensee: Duke Power Company

422 South Church Street

Charlotte, NC 28242

Docket Nos. 50-369 and 50-370 License Nos. NPF-9 and NPF-17

Facility Name: McGuire 1 and 2

Inspection Conducted: M y 21 - June 20, 1985

Inspectors: _

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Division of Reactor Projects

SUMMARY

Scope: This routine, unannounced inspection entailed 300 inspection hours on

site in the areas of operations, safety verification, surveillance testing,

maintenance activities and refueling activities.

Results: Of the 5 areas inspected, no violations or deviations were identified

in 2 areas; I apparent violation was identified in each of the areas of opera-

tions, surveillance and refueling.

1) Failure to follow procedures and inadequate procedure resulting in valve

misidentification, failure to reposition interlock, and failure to complete

shift turnover.

2) Failure to perform surveillance on unlocked /open fire doors.

3) Breach of containment integrity.

8500140422 050002

PDR ADOCK 05000369

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REPORT DETAILS

1. Persons Contacted

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Licensee Employees

T. McConnell, Plant Manager

• G. Cage, Superintendent of Operations

• D. Rains, Superintendent of Maintenance

B. Hamilton, Superintendent of Technical Services

• L. Weaver, Superintendent of Administration

• B. Travis, Superintendent of Integrated Scheduling

E. McCraw, License and Compliance Engineer

*D. Mendezoff, License and Compliance Engineer

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• W. McDowell, Technical Specialist-Licensing

• G. Gilbert, Operations Engineer

• R. Phillips, Operations Engineer

• R. Michael, Station Chemist

P. Huntley, Health Physicist

• K. Carney, Shift Supervisor

• R. Johansen, Performance Engineer

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• D. Motes, Maintenance Engineer

Other licensee employees contacted included construction craftsmen,

technicians, operators, mechanics, security force members, and office

personnel.

• Attended exit interview

2. Exit Interview

The inspection scope and findings were summarized on June 25, 1985, with

those persons indicated in paragraph 1 above. The licensee acknowledged

understanding of the issues discussed and offered no substantive related

discussion. The licensee did not identify as proprietary any of the

mate. rials provided to or reviewed by the inspectors during this inspection.

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3. Licensee Action on Previous Enforcement Matters

No licensee action on previous enforcement items is discussed.

4. Unresolved Items *

Unresolved items were not identified in this inspection.

5. Plant Operations

The inspection staff reviewed plant operations during the report period,

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May 21 - June 20, 1985, to verify conformance with applicable regulatory

requirements. Control room logs, shift supervisors logs, shift turnover

! *An Unresolved Item is a matter about which more information is required to

determine whether it is acceptable or may involve a violation or deviation.

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records and equipment removal and restoration records were routinely

perused. Interviews were conducted with plant operations, maintenance,

chemistry, health physics, and performance personnel.

Activities within the control rooms were monitored during shif ts and at

shift changes. Actions and/or activities observed were conducted as

prescribed in applicable station administrative directives. The complement

of licensed personnel on each shif t met or exceeded the minimum required by

technical specifications.

Plant tours were taken during the reporting period on a systematic basis.

The areas toured included but were not limited to the following: Turbine

Buildings, Auxiliary Buildings, Units 1 and 2, Electrical Equipment Rooms,

Units 1 and 2, Cable Spreading Rooms, Station Yard Zone within the protected

area, and Unit 1 Reactor Building. During the plant tours, ongoing

activities, housekeeping, security, equipment status and radiation control

practices were observed.

McGuire Unit 1 began the reporting period in Mode 6 in its second refueling

outage with core reload in progress. Fuel loading was completed at 6:29 a.m.

on Sunday May 26, 1985. The unit entered Mode 5 at 11:45 p.m. on June 5,

1985 where it remained until 9:48 a.m. on June 19, when the unit entered

Mode 4. The unit remained in Mode 4 recovering from a refueling outage for

the duration of the reporting period.

McGuire Unit 2 began the reporting period in Mode 1 operating at 100%

reactor power and remained at or about 100% power until 9:19 a.m. June 1,

1985 when the unit tripped from a turbine trip. This reactor trip is

discussed in paragraph 6. All systems responded normally following the

trip. The unit was restarted and entered Mode 2 on June 2,1985. The

reactor was critical at 5:29 a.m. and entered Mode 1 at 7:25 a.m. At

3:40 a.m. on June 3, the reactor reached 100% reactor power and remained at

or about 100% throughout the duration of the reporting period.

6. Reactor Trip

On June 2,1985, at 9:19 a.m. Unit 2 experienced a reactor trip from 100%

power. The reactor trip resulted from a feedwater isolation induced feed

pump trip and turbine trip. Subsequent evaluation determined that the i

feedwater isolation resulted from a dc ground in the exterior " doghouse" {

(mechanical penetration room) water level instrumentation. This water level

sensor, designed to isolate the feedwater system in the event of a feedwater

pipe rupture, has three level sensors providing an input to a relay which

subsequently initiates the feedwater isolation signal. One level sensor

provides alarm indication upon reaching 6" with hi-hi level at 12" from two

out of three sensors initiating the feedwater isolation. The ground appeared

on the wiring between the sensor and the relay which caused the hi-hi level

isolation signal to be initiated without a hi level alarm indication.

Following a determination of the cause of the trip the reactor was restarted

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with the unit reaching criticality at 5:29 a.m. on June 2,1985 and 100%

power at 3:40 a.m. on June 3, 1985.

7. Safety Injection Procedures

On June 5,1985 at 2:10 p.m. during a routine procedure required / actual

position equipment verification, the inspector detected that on page 1 of 8

of the valve lineup checklist, of procedure OP-2-A-6200-06 Safety Injection

System that valve 2 NI-162 was listed as the NI pump min flow valve. In

actuality valve 2 NI-162 is the safety injection discharge cold leg isola-

tion valve.

A review of the master file copy of the procedure revealed that the procedure

deficiency dates back to at least December 1983.

The above event constitutes an example of an inadequate procedure. This

example, in conjunction with events detailed in paragraphs 8 and 9 consti-

tutes a violation (370/85-22-01).

8. Personnel Airlock Integrity

On March 20, 1985, at approximately 11:00 a.m. , while Unit I was at 65%

power, two Performance Technicians discovered an interlock keyswitch inside

the Unit 1 lower personnel airlock in the " bypass" position. With the

keyswitch in this position, it was possible to open both the Reactor side

airlock door and the Auxiliary side airlock door, thus losing containment

integrity. With the keyswitch in the " bypass" position, the interlock

function is inoperable and consequently the containment airlock is techni-

cally inoperable.

The containment airlock is required by Technical Specifications (TS) and is

verified operable by TS 4.6.1.3c surveillance performed at least once per

six months. The discovery was made while performing section 12.8 of

PT/1/A/4200/01F, Lower Containment Personnel Lock Leak Rate Test, which is

performed pursuant to TS 4.6.1.3c. The technicians immediately ensured both

doors were closed and sealed and informed Control Room personnel of the

discovery. Containment integrity was not lost.

There is no record of both lower airlock doors being opened simultaneously

af ter 1:00 p.m. on 0?cember 18, 1984. Unit 1 entered Mode 4, at 2:12 a.m.

on December 19, 1984, af ter containment integrity was verified. This

included having at least one airlock door closed at all times.

Operations personnel sometimes white tag both doors open on the upper and

lower personnel airlocks if the associated unit is to be in Mode 5 or 6

(with containment integrity not required) for an extended time. Opening and

closing both doors is performed using OP/0/A/6700/06, Personnel Airlock

Operations, which was revised and reissued in August 1984 with all sign-off

lines deleted. With no sign-offs required, the possibility of not fully

implementing the procedure was increased. Further there were no steps in f

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the unit start-up procedure to verify the airlock interlocks were properly

positioned prior to entering a mode in which they were required.

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Performance personnel found the interlock inside the lower airlock in the

" bypass" position. Since there is no documentation reflecting the posi-

tioning of the interlock keyswitch, no determination can be made as to when

the interlock failed to cet changed to the " active" position. It is highly

probable that the failure to reposition the keyswitch occurred when the

airlock was returned to service prior to the unit entering Mode 4 in

December 1984.

TS 6.8.1.a requires that current written approved procedures be established,

implemented and maintained for safety related activities. Implicit in that

stipulation is the requirement that procedure guidance be specific enough to

facilitate the successful accomplishment of the task.

The interlock keyswitch inside the personnel airlock as specified in procedure

OP/0/A/6700/06 was not returned to the active position in December 1984

prior to the unit entering mode 4. Further complicating and perhaps leading

to this event is the fact that operations procedure CP/0/A/6700/06, Personnel

Airlock Operations, does not require a sign-off step to verify tnat the

interlock key switches are in the " active" position when returning the

airlock to service. Further Units 1 and 2 operating procedures OP/1/A/6700/01

and OP/2/A/6100/01, Controlling Procedures for Unit Start-up, do not verify

the airlock interlock pcsition prior to entering Mode 4. The failure to

return the airlock inter'ock to normal is an example of a failure to follow

procedure. This in conjtnction with items discussed in paragraphs 7 and 9

constitutes a violation (369/85-21-01).

9. Shift Relief

On June 12 at 9 : 10 a .m. , while reviewing the current Shift Supervisor

Turnover Checklist, the inspector noted that the checklist had not been

completed. The inspector brought this matter to the attention of the Senior

Reactor Operator who then completed the form.

Station Directives 3.1.9, Relief at Duties of Plant Operation, specifies

procedures to promote continuity of safety and efficiency during the process

of relief of persons at duties of plant operation. Included in this shift

relief process is the compl-etion of the Shift Supervisor Turnover Checklist.

Secticn 4 of Station Directive 3.1.9 requires that the shif t supervisors

fill out and follow the "Snift Supervisor Turnover Checklist", during shift ,

turnover. The oncoming Shift Supervisor must determine the required minimum '

shift composition for h15. shift, and identify the individuals that will man

the positions.

TS 6.8.1.a requires that current written approved procedures be established,

implemented and maintained covering shift relief and turnover.

Contrary to those requirements, on June 12, the Shift Supervisors Turnover

Checklist was not completed and followed during shift turnover, in that page

3 of 4 was not completed identifying shift crew composition. This in I

conjunction with the items discussed in paragraphs 7 and 8 constitutes a

violation (369/85-21-01, 370/85-22-01).

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10. Fire Door Inspections

On April 14, 1985, during a routine QA audit of completed copies of procedure

PT/0/A/4250/12, Fire Door Inspections, the licensee noticed that PD-1 and

PD-2, fire doors for the Units I and 2 ETB switchgear rooms respectively,

were found unlocked on each weekly surveillance since February 14, 1985. It

was determined that no daily surveillance was being performed on these two

unlocked doors as required by TS 4.7.11.2a. On April 18 and 25,1985,

Health Physics personnel again listed fire doors PD-1 and PD-2 as unlocked

during weekly surveillance. Again no daily surveillance was performed on

these docrs by any group.

Evaluation of the missed surveillances revealed that the security organiza-

tion for McGuire was initially given the responsibility for the daily and

weekly fire door inspections. TS 3.7.11 weekly and daily fire door inspections

were performed under PT/0/A/4250/11, Fire Door Inspections.

In August of 1984, a meeting was held between the Security Compliance

officer, a Security Specialist, the Mechanical Maintenance Technical

Specialist (MMTS) responsible for fire door repairs and the Station Health

Physicist to discuss fire door responsibilities in the Radiation Control

Area (RCA). Since Security personnel must contact Health Physics personnel

for access to the twelve fire doors located in the RCA, Health Physics

agreed to perform the weekly inspections on those doors. Procedure

PT/0/A/4250/12 (Fire Door Inspections) was written for Health Physics to use

for the inspections.

Health Physics personnel performed the weekly :urveillance of the twelve

fire doors from September 6, 1984 until April 30, 1985. From February 14,

to April 11, 1985, Health Physics personnel listed fire doors PD-1 and PD-2

as unlocked during the weekly surveillance.

Tersely stated there was a great deal of confusion as to which group was

responsible for the twelve fire doors in question following the August 1984

meeting. As a result no action was taken when PO-1 and PD-2 were found

unlocked. The matter was complicated further by the unclear delineation of

respensibiltty in PT/0/A/4250/11 and PT/0/A/4250/12. In both procedures,

Maintenance was identified as responsible for the review of completed

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procedures. Both Security and Health Physics assumed this review would

ensure that appropriate action was taken on fire doors if needed.

The net result is that fire doors PD-1 and PD-2, which are normally locked

closed, were unlocked from February 14, 1985 to April 14, 1985 during the

Unit 2 refueling outage. The doors were . then locked by operations but

l- subsequently were unlocked and remained unlocked, even though this problem

was identified by a QA audit conducted on April 14, 1985. The problem was

corrected on April 30, 1985 when daily inspections of the unlocked doors

commenced. As previously stated, the doors are normally verified closed on

a weekly basis ir, accordance with PT/0/A/4250/12 (Fire Dcor Inspections) and

TS 4.7.11.2c. While unlocked, the doors were not verified closed daily as

required by TS 4.7.11.2a.

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10 CFR 50, Appendix B, Criterion XVI as implemented by Duke Power Company

(DPC) Topical Report, Quality Assurance Program Duke-1-A, Amendment 7,

Section 17.2.16 requires that conditions adverse to quality be promptly

identified and corrected. In as much as this condition was identified by

Quality Assurance two weeks before corrective action was implemented, the i

intent of Criterion XVI was not met.

In summary, the requirements of 10 CFR 50, Appendix B, Criterion XVI,

corrective action was not taken until April 30, 1985 to verify fire doors

PD-1 and PD-2 were closed daily following identification of this problem by

a routine QA audit conducted on April 14, 1985. As a result the require-

ments of TS 4.7.11.2a, fire doors PD-1 and PD-2 were not verified closed

daily during the time April 14 - 30, 1985 while these fire doors were

unlocked. This is a violation (369/85-21-02, 370/85-22-02).

11. Containment Integrity

On May 25,1985 at 8:05 p.m., Unit I was in mode 6 actively reloading the

core, when the licensee detected that valve 1 RV-429, a containment ventila-

tion cooling water vent valve outside containment, was found open during the

performance of a containment integrity verification procedure PT-1-A-4200-02C.

This valve being open in conjunction with valve 1 RV-365, a vent valve on the

same line inside containment being open, resulted in a breach of containment

integrity. Valve 1 RV-429 was immediately closed and locked as required.

Valve 1 RV-429 had been verified closed during be performance of

PT-1-A-4200-02C which had been run during the period spanning May 17 and

May 19, 1985. Sometime during the period between May 19 and May 25, 1985,

valve 1RV-429, a valve which is required by procedure to be locked closed,

was unlocked and misaligned. No documentation can be found either authoriz-

ing or documenting the realignment. Apparently a personnel error during the

above period resulted in mispositioning of this valve.

Procedure OP-0-A-6400-09, Containment Ventilation Cooling Water System,

specifies the inboard and outboard vent valves to be closed and locked

during operation. This procedure is specified for completion before unit

startup and placing the ventilation cooling water in service.

TS 3.9.4, Containment Building Penetrations, requires during core altera-

tions that each penetration providing direct access from the containment to

the outside atmosphere, shall either be closed by an isolation valve, blind

flange, manual valve or be exhausting through operable reactor building

containment purge exhaust system HEPA filters and charcoal absorbers.

Contrary to those requirements, penetration M 385, Containment Ventilation

Cooling Water In, was not isolated or exhausting through an operable filter

during the period May 19 - May 25,1985 when core alterations were in

progress. This is a Violation (369/85-21-03). Licensee Event Report

370/85-06 also described a containment integrity problem during core

alterations involving maintenace/ surveillance activities.

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12. Surveillance Testing

The surveillance tests categorized below were analyzed and/or witnessed by

the inspector to ascertain procedural and performance adequacy.

The completed test procedures examined were analyzed for embodiment of the

necessary test prerequisites, preparations, instructions, acceptance criteria,

and sufficiency to technical content.

The selected tests witnessed were examined to ascertain that current written

approved procedures were available and in use, that test equipment in use

was calibrated, that test prerequisites were met, system restoration completed

and test results were adequate.

The selected procedures persued attested conformance with applicable TS and

procedural requirements, they appeared to have received the required adminis-

trative review and they apparently were performed within the surveillance

frequency specified.

PT/2/A/4252/02 M/D CA Pump 2A Performance Test

PT/2/A/4209/01A NV Pump 2A Performance Test

PT/1/A/4252/02P CA Valve Stroke Timing Quarterly

PT/1/A/4204/018 RHR Pump 1B Performance Test

PT/0/A/4250/04G Turbine Trip Reactor Trip Functional Test

PT/1/A/4208/02 Containment Spray Stroke Timing Test

PT/1/A/4209/01B Centrifugal Charging Pump Performance Test

PT/1/A/4204/018 Residual Heat Removal Pump Performance Test

13. Maintenance Observations

The maintenance activities categorizej below were analyzed and/or witnessed

by the resident inspection staff to ascertain procedural and performance

adequacy.

The completed procedures examined were analyzed for embodiment of the

necessary prerequisites, preparation, instructions, acceptance criteria and

sufficiency of technical detail.

The selected activities witnessed were examined to ascertain that where

applicable, current written approved procedures were available and in use,

that prerequisites were met. Equipment restoration completed and maintenance

results were adequate.

The selected work requests / maintenance packages persued attested conformance

with applicable TS and procedural requirements and appeared to have received

the required administrative review.

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WORK REQUEST EQUIPMENT

113095 Repair INC-18

106134 Repair / Plug Leak on 1NV-239

950479 1 CA-22 Check Valve Installation and Hydro

036677 PM/PT on Limitorque Operator

14. Licensee Event Reports

The following licensee event reports (LER) were reviewed inorder to deter-

mine the adequacy of corrective actions the implications as they pertain to

safety of operations, the applicable reporting requirements, and licensee

review of the event.

Based on the results of this review, the items are closed.

Unit 1, LER's

83-03 83-42 83-62 83-71

83-04 83-45 83-63 84-05

83-26 83-49 83-64 84-04

83-28 83-52 83-66 84-20

83-33 83-59 83-68 84-21

83-40 83-60 83-69 84-24

83-41 83-61 83-70

Unit 2, LER 85-15

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