ML20134G048

Insp Repts 50-295/96-14 & 50-304/96-14 on 960824-1011. Violations Noted.Major Areas Inspected:Operations, Maintenance & Engineering

ML20134G048
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	01/28/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20134G033	List: ML20134G030 ML20134G042 ML20134G048
References
50-295-96-14, 50-304-96-14, NUDOCS 9702100257
Download: ML20134G048 (29)

See also: IR 05000295/1996014

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U.S. NUCLEAR REGULATORY COMMISSION l

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REGION III l

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Docket Nos: 50-295. 50-304

License Nos: DPR-39. DPR-48

Report No: 50-295/960014, 50-304/960014

Licensee: Commonwealth Edison Company

Facility: Zion Nuclear Plant, Units 1 and 2

Location: Opus West III

1400 Opus West III

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Downers Grove IL 60515

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Dates: August 24 - October 11, 1996

Inspectors: R. A. Westberg, Acting Senior Resident

Inspector

D. R. Calhoun. Resident Inspector

D. M. Chyu. Resident Inspector

E. W. Cobey, Resident Inspector

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D. E. Jones, Reactor Engineer

D. W. Rich, Reactor Engineer

Approved by: Marc L. Dapas, Chief

Reactor Projects Branch 2

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9702100257 970128

PDR ADOCK 05000295

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EXECUTIVE SUMMARY

Zion Nuclear Plant. Units 1 and 2

. NRC Inspection Reports 50-295/96 14: 50-304/96-14

This inspection included aspects of licensee operations, maintenance, and

engineering. The report covers a seven-week period of inspection activities

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by the resident staff and regional projects inspectors. l

Operational Jerformance was characterized by frequent operational events,

several of w1ich resulted in inadvertent limiting conditions for operation

(LCO) entries. The licensee was ineffective in averting the previously

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identified trend in personnel errors. Furthermore, several procedures were

deficient, rr ' ting in water spills and other events. l

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00erations

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An inadvertent isolation of component cooling water flow to the 2B

safety injection pump and resultant LCO entry was caused by inadequate

equipment attendant (EA) communications and understanding of duties. ,

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This event also resulted in a violation for the failure to follow i

procedures governing work controls (Section 01.1).

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The inspectors identified a violation involving multiple failures to  ;

stop withdrawing control rods and enter the appropriate abnormal '

operating procedure upon indications of rod misalignment. This event

manifested deficiencies in communication of expectations for ccaduct of

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startup, in command and control during rod withdrawal, and in operator

sensitivity to possible rod misalignment due to known position

indication problems (Section 01.2).

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The inspectors identified a violation in which, due to an incorrect

understanding of Technical Specifications (TS), the licensee did not

complete TS action requirements for inoperable emergency diesel

generators (EDGs) within the required time frame on several occasions

(Section 01.3).

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A demineralized water spill in the Unit 2 containment Tesulted from a

failure of a general operating procedure to provide sufficient plant

configuration controls (Section 01.4).

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The failure to properly unload EDGs upon completing surveillance tests

due to operator inattention to detail, resulted in a violation

(Section 01.5).

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Isolation of the wrong air supply to residual heat removal (RHR) valves

during out-of-service activities due to inattention to detail by the EA,

resulted in a violation (Section 01.6).

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A violation was identified lertaining to an inadequate test procedure

which contributed to a two lour delay in recognizing an LCO entry and  !

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taking appropriate action when the 2A atmospheric relief isolation valve

did not satisfy stroke time testing requirements. Some operators also

exhibited a non-conservative approach to operability (Section 03.1).

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' A violation was identified involving an inadequate test procedure which )

resulted in an inoperable penetration pressurization air compressor and '

inadvertent LCO entry. The lack of a cuestioning attitude by a  !

maintenance technician also contributec to this event (Section 03.2).

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Maintenance -

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Informal maintenance contractor work practices resulted'in inappropriate

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cross-connecting of the service air and demineralized water systems

(Section M1.1)

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Poor material condition of two check valves resulted in two radioactive

gas releases in the Auxiliary Building and the Unit 1 containment,

respectively. Initial licensee investigation of the releases was

deficient (Section M2.1). -

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A violation was identified involving an inadequate maintenance procedure

which resulted in a loss of instrument air (IA) to the Unit 2

containment during installation of valve blocks on the IA containment

isolation valves. An inadequate pre-job brief and deficient

communications between departments also contributed to this event

(Section M3.1).

A violation was identified involving a failure to correctly assemble two

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pressurizer power operated relief valves (PORVs) in accordance with

procedures during modifications, which resulted in the failure of one of

the PORVs. Repairs required a plant shutdown (Section M4.1).

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The inspectors identified a violation pertaining to the licensee's

failure to ensure that a quality control (OC) inspector remained

independent of a maintenance activity involving reassembly of the 2B EDG

jacket water cooler end cover, which the OC inspector was witnessing.

The mechanic and OC inspector were also not familiar with the correct

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bolting torque sequence (Section M7.1).

Enqineerina

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A violation was identified involving an inadequate leak rate testing

procedure which did not provide sufficient configuration controls,

resulting in the inadvertent transfer of 500 gallons of water from the

Unit 2 reactor water storage tank to the refueling cavity. The failure

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of an operator to follow verbal direction also contributed to this event

(Section E1.1).

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A violation was identified involving the inadvertent omission of a test

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• procedure step by a system engineer which resulted in actuation of the

. 2A servi.ce water pump breaker (Section E4.1).

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The inspectors identified a violation involving an unauthorized

'. temporary alteration. A fan was taped on the Unit 2 manipulator crane

over the refueling cavity while fuel assemblies were being moved

(Section E4.2).

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Report Details

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i Summary of Plant Status

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At the beginning of this inspection period. Unit 1 was at 100 percent power.

The unit was taken off-line on August 27 to repair an inoperable pressurizer

PORV. The unit was placed back on-line on September 18 and operated at

100 percent power for the remainder of the inspection period. i

I Unit 2 began this inspection period at 100 percent 30wer and remained there  !

until September 19 when it was taken.off-line for tle start of a refueling

outage.

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Operational performance during the inspection period was characterized by

frequent operational events, several of which resulted in inadvertent LCO

entries. The licensee was ineffective in preventing personnel errors. An

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adverse trend in personnel errors was the subject of escalated enforcement. l

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and corrective actions were described in the licensee's response dated  !

September 27, 1996, to the Notice of Violation and Proposed Imposition of j

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Civil Penalty - $50,000 (NRC Inspection Report Nos. 50-295:304/96007)).

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Furthermore, several procedures were deficient, resulting in water spills and

other events. Several of the events occurred as a result of problems in

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maintaining appropriate configuration of plant systems during testing and

other work activities. Examples are described in the following report  ;

sections. Although some examples were identified by the licensee, these

e; examples are included in the cited violations because their causes are similar

to previous underlying performance problems that thc licensee has not yet

effectively addressed.

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I. Operations

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01 Conduct of Operations

01.1 Inadvertent LC0 Entry for Isolation of Component Coolina Water (CCW)

, Flow to the 2B Safety In.iection (SI) Pumo

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a. Inspection Scone (71707)

On September 15, the Unit 2 control room received two unexpected alarms.

" Safety injection Cooling Water Low Flow" and " Charging Pump Cooling

Water Low Flow." The ins]ectors interviewed operations department

personnel and inspected t1e involved equipment.

b. Observations and Findings

The unexpected alarms were caused by equipment attendant (EA) actions

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while performing daily operator rounds. The Unit 2 Auxiliary Building

EA partially disassembled the 2B SI pump CCW flow transmitter in an

effort to reset the SI pump cooling water low flow annunciator, even

4 though the annunciator was not alarming. This action caused magnetic

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decoupling of the local indicator. In an attempt to recover local flow

indication, the EA shut the CCW isolation valve to the pump which

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caused one of the unexpected alarms. Since the SI pump would not have  :

performed its required safety function while CCW was isolated, the EA's '

actions caused an inadvertent entry into the LCO for TS 3.8.2.C.  !

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' During the subsequent performance of operator rounds, the EA found the

2A charging pump cooling water flow high. In an attempt to return the

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flow to the expected range, the EA lowered flow sufficiently to cause  ;

another unex)ected alarm in the control room. In both of these

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' instances, t1e EA did not communicate with the control room before '

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performing the manipulations.

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The inspectors determined th t no formal training had been provided to

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operations personnel on the manipulation of flow transmitters to clear

an annunciator. However, during the previous week, while returning a

residual heat removal (RHR) pump to service, local indication for CCW to

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the RHR pump was lost. In response to guidance received from an

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instrument maintenance supervisor, the same EA was directed to isolate

and slowly re-establish flow. This previous evolution caused the EA to

erroneously believe his routine duties included partial disassembly and

manipulation of the flow transmitter without the need for additional

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c. Conclusions

The inspectors concluded that: (1) the EA did not consistently

communicate with the control room before manipulating components in the

field which had a potential to cause control room annunciators: (2) the

EA partially disassembled and manipulated a flow instrument without any

controls: and (3) based on interviews with operations department

personnel. EA duties and responsibilities were not consistently

understood within the Operations Department.

Zion Administrative Procedure (ZAP) 1200-08, " Risk Significant On-line  ;

Maintenance," Revision 4, required: 1

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In Section F.1.d that the Risk Management Team identify i

compensatory measures and actions required to remove, test. or

restore the system to service for each voluntary entry into an LC0

or risk significant combination.  ;

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In Section F.3.a. that the Work Control Center pre-plan and

coordinate work activities by all involved work departments in

order to minimize the downtime of out-of-service systems and the

risk of losing redundant equipment.

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In Section F.5, that the Work Control Center be responsible for

initiating Attachment A " Voluntary LCO Entry Outage Approval

Form."

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The failure to establish work controls, as required by ZAP 1200-8. for

the work activities associated with the 2B SI pump CCW flow transmitter

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is considered a violation of 10 CFR Part 50. Appendix B. Criterion V

(50-295/96014-01a. 50-304/96014-01a), as described in the attached

Notice of Violation. - -

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01.2 Positive Reactivity Addition During Indications of Control Rod Position

, Misalignment

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a. Inspection Scone (71707)

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The inspectors observed Unit 1 startup activities on Septemoer 16-17

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which were conducted in accordance with General Operating Procedure

GOP-2, " Plant Startup," Revision 9. and Operations Special Procedure

OSP-96-016, "RCS Dilution to Criticality," Revision 0.

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b. Observations and Findings

' On September 16, the inspectors observed the infrequently performed

evolution shift briefing for OSP-96-016. The inspectors also observed a

subsequent control room operator briefing which was conducted just prior l

to commencing the control rod withdrawal. This second briefing was held

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' as a result of an eight hour delay in the initiation of the control rod  !

withdrawal and to focus the shift on the evolution.

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The inspectors were concerned that the guidance provided by operations

management / supervision on how to resolve expected control rod position

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indication deviation alarms, was different for each briefing. During

the infrequently performed evolution briefing, the operations manager

communicated the expectation that every deviation alarm would be

corrected prior to continuing with rod withdrawal. However, during the '

control room shift briefing, the shift engineer, unit supervisor, and

nuclear group supervisor stated that when rod position indication

exceeded 12 steps from the demand position, the nuclear station operator

(NS0) shall stop pulling rods and evaluate the deviation to determine

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whether the deviation was a rod misaligrment or a position indication

problem. If the deviation was due to red position indication, the NSO

shall continue withdrawing control rods to the desired position. Once

the rods were at the desired position, the rod position indication

system would be re-aligned.

The inspectors identified, through questioning of shift personnel

immediately following the briefing, that confusion existed regarding TS

requirements for control rod alignment and position indication. The

inspectors discussed with operators the appropriateness of withdrawing

control rods while in a TS LCO for rod position indication. An

Independent Safety Engineering Group representative noted that shift

personnel were unable to answer the inspectors * questions and he raised

a concern with operator confusion in this area to licensee management.

In response, the operations manager discussed the issue with shift

personnel and clarified the proper response to rod position deviation

alarms.

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During the withdrawal of shutdown bank D, the inspectors identified that

rod position indication appeared to deviate by greater than twelve steps

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near the top of the rod pull. The inspectors subsequently determined,

through interviews with selected operations personnel, that on several

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occasions during the withdrawal of shutdown banks, the NSO continued to

pull control rods even though control board rod demand and rod position

indication deviated by greater than twelve steps.

The NSO indicated his reason for continuing with the rod withdrawal was I

that the qualified nuclear engineer had stated that the computer was I

indicating an acceptable alignment. However, the inspectors were l

concerned with this justification because the computer-did not give real  !

time data and only provided information useful for evaluating rod l

position when rod motion had stopped and the computer had time to  ;

complete updating,

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c. Conclusions

The inspectors concluded that: (1) the infrequently performed evolution

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briefing was ineffective at communicating licensee management's {

expectations-for conduct of the startup: (2) command and control of the  :

shutdown bank control rod withdrawal was weak; and (3) due to known rod i

position indication problems, the shift performing the shutdown bank rod  ;

withdrawal was not sensitive to adding reactivity when control rod

indication was outside TS rod alignment limitations.

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TS 6.2.1.a recuired that written procedures be prepared, implemented,

and maintainec for procedures listed in Appendix A of Regulatory

Guide 1.33, Revision 2 dated February 1978. Appendix A of this

regulatory guide specified nuclear startup as an example of a general

plant operating procedure. General Operating Procedure GOP-2, " Plant  ;

Startup," Revision 9. Step 4.0.15, required, in part, that if any l

control rods were misaligned, refer to Abnormal Operating Procedure

A0P-2.1, " Rod Control System Malfunction " and contact the Qualified ,

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Nuclear Inspector for further guidance. Appendix C. " Stuck Rod, l

Misaligned Rod, or Inoperable RPI [ rod position indication]," of A0P-2.1

required, in part, that RPI be checked against the process computer.

Failure to stop pulling control rods and enter A0P-2.1 when the control l

board RPI display indicated rod misalignment, is considered a violation

of TS 6.2.1.a (50-295/96014-02).

01.3 TS Action Reouirements Not Completed Within the Reouired Time Frame

a. Insoection Scone (71707) I

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The inspectors observed portions of emergency diesel generacor (EDG) i

operability surveillances and reviewed the TS required actions  !

associated with the 28 EDG outages of August 12-13 and September 9-11,

and the 2A EDG outage of September 15-17.

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b. Observations and findings

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The inspectors identified that on two occasions during the

l September 9-11. 2B EDG outage. the licensee exceeded the required

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eight-hour time interval between ver-ifications of the availability of

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examples during the EDG outages conducted on August 12-13 and

September 15-17, where the required 8-hour interval between verification

of off-site power sources was exceeded. ,

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The inspectors determined that the failure to perform TS actions in the

required time frame was a recurring problem. This deficiency was

attributable to a misconception that a 25 percent extension could be ,

applied to the time interval of repetitive action re

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manner similar to that allowed for TS surveillances.quirements in a

A similar problem

was identified with different TS action requirements, as documented in

NRC Inspection Report 50-295:304/96-16.

c. Conclusions

The ins)ectors concluded that the failure to perform TS actions for ~

inopera)le EDGs within the required time frame resulted from an

incorrect understanding of TS. Technical Specification 3.15.2.C

required demonstration of the availability of two sources of off-site

power at least once every eight hours while the 2A or 2B EDGs were

out-of-service (00S). The failure to verify the availability of two

sources of off-site power at least once every eight hours while the 2A

and 2B EDGs were 00S, is considered a violation of TS 3.15.2.C

(50-304/96014-03), as described in the attached Notice of Violation.

01.4 3.000 Gallon Demineralized Water Soill in Unit 2 Containment

a. Inspection Scone (71707)

On September 22, 3,000 gallons of demineralized water were spilled

inside Unit 2 containment. The inspectors interviewed operations

personnel and inspected demineralized water valve, 20W-0035.

b. Observations and Findings l

In preparation for the Unit 2 outage, licensee personnel opened two

demineralized water containment isolation valves to supply water to the

containment for use by station personnel. The five demineralizer water

service taps downstream of the isolation valves were normally closed

between outages, and the licensee therefore assumed that these valves

were closed at the time the containment isolation valves were opened. l

However 2DW-0035, located on the 560' elevation of the reactor coolant '

pump deck, was open. As a result, water sprayed from the open tap

inside the missile barrier where it collected in the containment sump.

The containment sump water level set point was reached which

automatically started the containment sump pumps.

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A radwaste operator observed indication that the sump pumps were '

running. This unexpected condition was communicated to the control room

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shift engineer (SE) and the health physics (HP) supervisor, who l

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subsequently dispatched an HP technician into containment to l

investigate. The HP technician took immediate corrective action to shut I

the valve. The licensee determined that approximately 3,000 gallons of l

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demineralized water had been sprayed inside the Unit 2 containment.

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l At the conclusion of this inspection period, the licensee's i

i investigation was still in progress. However, the licensee tentatively '

l planned to revise the station shutdown procedure to require that  !

operations . personnel verify that valves off the demineralized water i

, , , header were closed prior to opening the containment isolation valves.

c. Conclusions

The inspectors concluded that General Operating Procedure GOP-4 " Plant

Shutdown and Cooldown," Revision 13, was inadequate, in that it failed

to require verification of the position of demineralized water service

tap valves prior to opening the containment isolation supply valves.

i This is not considered a violation of NRC requirements because the

l affected valves are nonsafety related and therefore, are not subject to

Appendix B of 10 CFR Part 50.

01.5 Procedure Steos Missed While Performing EDG Surveillances

a. Insoection Scone (71707)

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On October 6, the licensee identified that the 1A EDG was incorrectly

unloaded during shutdown when a licensed operator failed to perform a

i fifteen minute hold at one megawatt (MW). The inspectors reviewed the

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surveillance results and different revisions of procedures, and also

interviewed the unit supervisor and several NS0s.

b. Observations and Findings

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During shutdown of the 1A EDG in accordance with surveillance procedure

PT-11-DG1A, "1A Diesel Generator Loading Test," Revision 6.

Attachment 1. the operator was required to reduce power from 4 MW to

1 MW and hold the generator power at 1 MW for 15 minutes. However, the

operator reduced power from 4 MW to 0 MW and failed to hold power at

1 MW.

The inspectors subsequently reviewed the results of EDG surveillances

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performed during this inspection period and identified that on

September 9, the "0" EDG was run unloaded for seven minutes vice the

l 15 minutes recuired by surveillance procedure PT-11-DG0, "O Diesel

Generator Loacing Test," Revision 7, Attachment 1.

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c. Conclusions

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The inspectors concluded that this event was caused by inattention to '

detail by the licensed operator. The failures to follow surveillance

. procedures PT-11-DG1A and PT-11-DG0 for proper unloading of the EDGs

' following the respective surveillance tests, are considered a violation

of 10 CFR Part 50, Appendix B. Criterion V (50-295/96014-Olb.

50-304/96014-01b), as described in the attached Notice of Violation.

01.6 Out-of-service (00S) Errors on the Residual Heat Removal (RHR) System  !

a. Insoection Scone (71707) _

On October 7, arr equipment attendant (EA) identified two 00$' errors

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while performing independent verification for two RHR system 00S tasks.

' The inspectors interviewed the EA and the shift engineer. The

inspectors also reviewed the 00S documentation and walked down the  ;

affected portion of the RHR system. '

b. Observations and Findings 4

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Two EAs were performing a " child" (subordinate) 00S task on the RHR

system. Out-of-service Nos. 960006991 and 960009514 directed the EA to

close the instrument air (IA) supply to RHR system valves 2HCV-RH606 and

2HCV-RH618, res)ectively, by closing valves 2IA0662 and 2IA0663 which

would isolate t1e main air sup)ly to each respective RHR valve. '

However, the EAs isolated the Jackup air supply to the RHR valves

instead of the main air supply. The 00Ss were hung between 10:00 a.m.

and 1:00 p.m. on October 7. An EA, on the following shift, was

performing an IV of the two 00$s and identified the errors. The

licensee took immediate corrective action to isolate the main air supply

and unisolate the backup air supply.

During interviews, an EA stated he did not have a complete picture of

how the plant was being configured which contributed to his course of

action. The EA considered that isolating the backup air supply was

correct because he was performing a " child" 005 which he believed should

not isolate the main air supply. The EA further stated that the

" parent" 005, which was to be hung later, would actually isolate the

main air supply to the RHR valves.

An incorrect location on the 00S sheet also contributed to the EA's

actions. The sheet identified the 542' elevation of the Auxiliary

Building as the location for isolating the main air supply to the RHR

valves. But, the backup air supply, rather than the main air supply,

was located on this elevation.

c. Conclusions

The inspectors concluded that this event was primarily caused by the

EA's incomplete knowledge of the intended plant configuration. The

independent verification process barrier was effective in identifying

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the 00S error. However, the failure of the EAs to remove the main air

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supply to valves 2HCV-RH606 and 2HCV-RH618 from service in accordance

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with the DOS procedure is considered a violation of 10 CFR 50.

Appendix B, Criterion V (50-295/96014-01c, 50-304/96014-01c). as

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03 Operations Procedures and Documentation

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03.1 Inadvertent LCO Entry for Containment Isolation Valves

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a. Insnection Scone (71707)

On September 18, the licensee identified that a TS LC0 for containment I

isolation valves had been inadvertently entered during stroke testing of

the 2A atmospheric relief isolation valve. The inspectors reviewed the

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completed surveillance, Inservice Testing (IST) Evaluation

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No. 10-9-96-3, and discussed the issue with an IST engineer.

b. Observations and Findings

On September 18, in preparation for the Unit 2 shutdown, the licensee

cleared the 00S for the 2A atmospheric relief isolation valve.

2MOV-MS-0017. This isolation valve had been 00S for main control board

position indication work. The subject valve was then stroked per ,

PT-27G-ST, " Steam Generator PORV Stroke Time Testing," Revision 1, for l

return-to-service. The valve's stroke time of 63.2 seconds was greater l

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than the action value, which was an operability threshold: however, the '

valve was not declared inoperable. Acceptable results were obtained

during a second stroke test and MS-0017 was returned to service.

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Two hours after the surveillance test had been completed, a licensed

shift supervisor (LSS) who was reviewing the test results, determined

that the motor-operated valve (MOV) was technically inoperable and that

the appropriate four hour LC0 action statement for TS 3.9.3,

" Containment Isolation Valves." had not been entered. The LSS directed

that a manual isolation valve, which had been reopened following the

test, be closed to comply with the TS.

c. Conclusions

The inspectors concluded that PT-27G-ST was inadequate in that the

procedure did not ensure that the valve stroke time was evaluated for

acceptability by the personnel performing the test. Step 8 of

Section 5.1 of PT-27G-ST required a yes or no answer for " stroke time in

the acceptable range." However, this step did not reference

Section 5.5, " Concluding Procedure," for guidance on actions to take

when valve stroke times are outside of the acceptable range.

S]ecifically, Step 1 of Section 5.5 required that an entry be made in

tle Unit Operator's Log that the valve was inoperable based on test

results in the action range. This step also required sign-off by a LSS,

which was not done at the time that the valve was stroked.

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-In addition. ZAP 300-02. "Use of Procedures in Operating Department."

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Revision 10. Attachment 2. " Valve Stroke Timing." required that if any

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valve stroke time was greater than the action limit then the valve i

immediately be declared inoperable. Procedure PT-27G-ST did not ensure

that the intent of ZAP 300-02 would be met. The failure of PT-27G-ST to

ensure a timely. operability evaluation of valve stroke time testing

results was considered a violation of 10 CFR Part 50. Appendix B.

Criterion V (50-295/96014-04a. 50-304/96014-04a), as described in the

attached Notice of Violation.

The failure of operators and the unit supervisor to recognize that valve

2MOV-MS-0017 should have been considered inoperable when stroke time

testing requirements were not met, regardless of the

deficiency, indicated a' lack of questioning attitude. procedure

Guidance in

Generic Letter 91-18. "Information to Licensees Regarding Two NRC

Inspection Manual Sections on Resolution of Degraded and Nonconforming

Conditions and On Operability." clearly indicates that when test i

performance data falls in the required action range. the valve must be

immediately declared inoperable. Using the results of a second stroke

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time test to conclude that the subject valve was operable following-

initial test failure, without interim evaluation and/or appropriate

corrective action, reflected a non-conservative approach to operability

determinations by the involved operators and supervisor.

03.2 Inadvertent LCO Entry for Inocerable Penetration Pressurization (PP) Air

Comoressors

a. Inspection Scone (71707)

On October 5. the licensee identified that Unit 1 had inadvertently

entered into TS LCO 3.9.2.B.a. " Penetration Pressurization Systems."

The inspectors interviewed the unit supervisor and site quality

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verification (SOV) personnel involved with this event.

b. Observations and Findings

The licensee was performing Technical Staff Surveillance (TSS) 15.6.123

" Leak Test of PP Check Valves." Revision 8. for Unit 2. The Unit 2 PP

compressor had previously been taken 00S in accordance with the

surveillance procedure. The procedure required the technician to lift

the Unit 2 lead for the PP header low pressure signal. Another lead for

automatic start of the "0" PP air compressor was at the same terminal

point. When the technician lifted both leads and re-landed the lead for

compressor automatic start, the "0" PP air compressor was rendered

inoperable. However, this momentary inoperability of the "0" PP air

compressor was not recognized until pointed out by SOV personnel in the

control room. Site Quality Verification personnel idertified that the

applicable drawing differed from the actual wiring configuration. The

licensee subsecuently determined that, in all cases, the, approved

procedure woulc have rendered the "0" PP air compressor inoperable

resulting in an LCO entry per TS 3.9.2.B.a.

13

.' c. Conclusions

'. The inspectors concluded that the technician exhibited a lack of

questioning attitude by lifting the additional lead without first

ensuring a complete understanding of the possible consequences. In

addition. TSS 15.6.123 was inadequate. The failure of TSS 15.6.123 to

indicate the existence of an automatic start lead that would render the

"0" PP air compressor inoperable when lifted, was considered a violation

of 10 CFR Part 50. Appendix B, Criterion V (50-295/96014-04b,

50-304/96014-04b), as described in the attached Notice of Violation.

08 Miscellaneous Operations Issues

'

08.1 (Closed) LER 50-304/96006-00: Licensed shift supervisor error resulted

in missed surveillance.

On June 12, the Unit 2 containment isolation valve, 2FCV-VN02A, was

taken DOS to repair an open limit switch. Two licensed shift

supervisors failed to obtain the appropriate post-maintenance testing

(PMT) requirements from the system engineer. Each licensed shift

supervisor independently and incorrectly determined that surveillance

procedure PT-300-ST, " Containment Isolation Valve Stroke Time

Verification," was sufficient to prove valve operability. Both

individuals were confident of their knowledge regarding the appropriate

PMT requirement. After the test was completed, the valve was declared

operable.

On August 7, an NSO identified that surveillance procedure PT-40-300,

" Valve Remote Position Indication " should also have been included in

the PMT requirements for the valve. After identifying this deficiency,

the licensee took the appropriate actions to return the valve to

service. Valve FCV-VN02A provided a containment isolation function

according to UFSAR Table 6.2-4. Therefore, when the valve had been

returned to service on June 12, without performing the required testing,

an inadvertent entry into TS 3.9.3 occurred.

The licensee's corrective actions included:

-

Returning the valve to service.

-

Counseling the involved individuals, and l

-

Discussing this event with other operators by January 1997. '

The failure to accomplish the appropriate PMT activity in accordance

with the applicable procedure, PT-40-300, before declaring containment )

isolation valve 2FCV-VN02A operable, is considered a violation of  !

10 CFR Part 50, Appendix B, Criterion V (50-304/96014-05). Other

!

examples of inadvertent LCO entries due to the failure to perform l

appropriate PMT are described in NRC Inspection Re) ort No. 50-295/96007: '

50-304/96007. Hwever, these instances involved tle failure of

engineering to specify PMT when requested, whereas the inadvertent LC0

entry associated with containment isolation valve 2FCV-VN02A occurred

because the PMT requirements specified by operations personnel were

' I

14

[ incorrect. The inspectors concluded that the corrective actions for the

' events discussed in IR 96007 would not have precluded the event

. involving 2FCV-VN02A from occurring. Therefore. this licensee-

identified and corrected violation is being treated as a Non-Cited

Violation, consistent with Section VII.B.1 of the NRC Enforcement

Policy. Continuing inspector concern with inadvertent entries into LC0

action statements are discussed in other sections of this report.

'

II. Maintenance

M1 Conduct of Maintenance

'-

M1.1 Contract Maintenance Worker Cross Connected Service Air (SA) and

Demineralized Water Systems

a. Insoection Scone

The inspectors reviewed the recovery action following cross-connection

of the demineralized water system with the SA system. The problem was

identified when a worker in the Unit 2 containment noticed water flowing

from a SA valve and notified the control room.

b. Observations and Findings

On October 8, a contract worker attempted to clear a blockage on a steam

system valve. Apparently, the worker had been successful in clearing

blockages at another plant by connecting SA and demineralized water with

a "Y" connector. With air 2ressure higher than #r pressure, the

resultant mixture blew out tie blockage. However, at Zion the

demineralized water system is at a higher pressure than the SA system

and as a result, the SA system was partially filled with water when the

systems were cross-connected. Demineralized water and SA were isolated

to the containment until the "Y" connector was discovered and

l

disconnected and repairs and cleanup were completed. '

1

The licensee directed the contractor to stand down from all work and  !

brief workers on proper control of maintenance. The contractor

l

committed to revise pre-job checklists and walkdowns, and make additions

to its new employee orientation. The licensee commenced a root cause

investigation of the incident.

c. Conclusions

The event appeared to be the result of informal work practices. l

However, the work stoppage, work control briefings, and root cause '

investigation were appropriate. The root cause investigation was

hampered by the fact that the contractor fired the employee and removed

him from the site before the licensee could interview him.

I

15

l

l

.' M2

Maintenance and Material Condition of Facilities and Equipment

~,

M2.1 Poor Material Condition of Two Check Valves Resulted in Two Gas Releases-

. a. ..Insnection Scope (62703)

On October 5, there were two radioactive gas releases in the Auxiliary

Building and the Unit 1 containment, respectively. The inspectors

interviewed the unit supervisor, NSO, and mechanical maintenance lead:

' reviewed the plant and instrumentation diagrams (P& ids) and appropriate

procedures: and walked down the associating piping. ,

.

b. Observations and Findings

,

The Unit 1 volume control tank (VCT) hydrogen regulator valve,1VC8155,

was repaired by maintenance personnel because it was not working

properly. After the maintenance activity was complete, an equipment

operator (EO) was sent to adjust the regulator. The E0 performed a

bubble tesi. around the fittings and found that the fittings were

leaking. A check valve, 1VC8411, was also leaking which allowed

contaminated gases and hydrogen to escape from the VCT through the

regulator fittings into the Auxiliary Building, contaminating personnel,

During a non-related activity, the licensee was lowering VCT pressure by

venting the VCT to the waste gas system. Check valve 0WG9280 leaked and

released contaminated gases from the VCT into the Unit 1 reactor coolant

drain tank (RCDT), which pressurized it. The relief valve for the RCDT

opened and vented the gases to the containment sump, which caused a

containment radiation alarm. The licensee immediately stopped the

venting process and entered Abnormal Operating Procedure 5.1. A sample

taken by the radiation protection personne1 confirmed the alarm.

The licensee's initial review of this event was deficient. The licensee

did not identify that the source of the contaminated gases from the VCT

to the Auxiliary Building was through a failed check valve until pointed

out by the inspectors.

c. Conclusions

The inspectors concluded that poor material condition of the check

valves caused the radioactive gas releases. The failure to initially

identify that a leaking check valve allowed gases to escape from the VCT

into the Auxiliary Building, indicated a lack of questioning attitude by

operations and maintenance personnel.

16

.- - . - - -- - . - _ . ._ .

"

. M3 Maintenance Procedures and Documentation

'

,

M3.1 Loss of Instrument Air (IA) to Unit 2 Containment

i a. Insoection Scone (62703) .

On September 25, 1996, the licensee identified that IA had been lost to

the Unit 2 containment as a result of a maintenance activity involving

the installation of valve blocks on IA containment isolation valves,

2FCV-IA01A and B. The inspectors reviewed the results of the licensee's

4

investigation and the maintenance procedures used during the work

l activity.

b. Observations and Findings

Maintenance procedure M015-1, " Valve Block Fabrication. Installation,

' and Removal " Revision 2, required the installation of a hand loader

when installing a valve block on an air operated valve. The hand ioacer

would maintain the valve in the desired position during the valve block

,

installation. However, the procedure did not contain any guidance to

i

ensure control of plant system configuration during the installacion of

the hand loader. By observing the limit switches for valve 2FCV-1A01A,

the mechanics incorrectly determined that the valve was closed when in

-

fact, the valve was open. Believing that valve 2FCV-1A01A should remain

' closed, the mechanics isolated air to the valve actuator in order to

disconnect the air line and connect the hand loader. This resulted in

the valve shutting which caused a loss of IA to containment. Instrument  ;

air was restored 32 minutes later. '

During the pre-job briefing for this activity, the licensee specified

that the subject valves sMuld be left " blocked open." However, the l

need to reposition the vahes based upon the as-found condition was not '

discussed at this briefing.

c. Conclusions

,

The inspectors concluded that: (1) the pre-job brief was deficient

since it did not discuss the expected as-found position of the valves.

(2) mechanical maintenance did not contact the control room before

operating a plant system valve, and (3) Maintenance Procedure M015-1 did

4

not contain sufficient guidance to prevent the inadvertent isolation of

IA to containment.

!

The failure of M015-1 to provide appropriate guidance to control the

-

configuration of plant systems during the installation of a hand loader  !

was considered a violation of 10 CFR Part 50, A)pendix B, Criterion V

(50-295/96014-04c, 50-304/96014-04c), as descri]ed in the attached

Notice of Violation. i

17

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__ _ .. _ __

"

. M4 Maintenance Staff Knowledge and Performance

1 M4.1 Mis-installation of Hynoid Kev Resulted in Failure of Power Onerated

Relief Valve (PORV) Block Valve

a. Insnection Scone (62703)

I

On August 26, in preparation for isolating PORV block valve, RC-8000B,

in order to replace the PORV block valve stem and yoke in response to

Information Notice 92-60, " Valve Stem Failure Caused by Embrittlement," l

1

the valve tripped on thermal overload. The licensee visually verified

,

that the valve was closed and attempted to manually stroke open the

valve, but was not successful. On August 27, Unit 1 was shut down to

repair the valve. The' inspectors discussed the event with maintenance

engineering 3ersonnel and reviewed the maintenance procedures for

assembling t'le motor-operated valve (MOV) actuator.

b. Observations and Findings

The PORV block valve tripped on thermal overload. The licensee

-

calculated that the thrust applied to the valve was 35,000 lbs., with

the nominal thrust window being 9,200 to 11,000 lbs. Attempts to

manually open the valve resulted in several broken gear teeth on the

valve's handwheel. Upon disassembly of the valve actuator, the licensee

.

identified that the locating pin associated with the hypoid gear was

missing. The hypoid gear 0)erates the limit switch. Without the

locating pin in place, the typoid gear could rotate on the drive sleeve,

rendering the limit switch inoperable. No internal problems with the

valve were evident. The valve seat, disc, and guide were penetrant

tested with acceptable results.

The valve's failure was caused by a maintenance error. During the

Fall 1995, Unit 1 refueling outage, maintenance personnel modified six

MOV actuators from Limitorque SMB-00 to SB-00 style actuators.

Following the PORV block valve failure, the licensee disassembled all

six valves and identified that two block valves were missing the

locating pins. The other four valves had the locating pin correctly

installed. In addition, the licensee identified that among 51

safety-related Unit 1 MOVs, work had been performed on 10 of the valves

during which the locating pin could have been removed. The licensee

selected five valves based on relative risk significance and inspected

each valve to determine if the locating pin was installed. No

discrepancies were identified. Based on the inspection results. the

licensee determined that the Unit 1 MOVs were operable.

While Unit 2 did not have any SB-00 style actuators, the licensee

identified 12 safety-related MOVs that could have missing locating pins

due to previous work performed. The licensee planned to inspect 5 of

the 12 MOVs during the Unit 2 refueling outage. This decision was based

i

on the absence of identified problems during inspection of the Unit 1

MOVs.

18

[ c. Conclusions

1 Maintenance Procedure P/M016-2N, "Limitorque Motor-0perated Valve

Actuator SMB-00," Revision 2, required the installation of the locating

pin and hypoid gear on the NOV drive sleeve. However, during the 1995

Unit 1 refueling outage, maintenance Jersonnel failed to install the

hypoid gear locating pin on two PORV ] lock valve drive sleeves. The

failure to follow procedure P/M016-2N is considered a violation of

10 CFR Part 50, Appendix B Criterion V (50-295/96014-01d,

50-304/96014-01d), as described in the attached Notice of Violation.

M7 Quality Assurance in Maintenance Activitie's

M7.1 Incorrect Torouinq Technioue During 2B Emergency Diesel Generator (EDG)

Maintenance and Inadeouate Quality Control (OC) Insnection

a. Inspection Scone (62703)

On September 9, the 28 EDG failed the monthly operability surveillance

test due to high lube oil temperature. The inspectors interviewed

maintenance and OC personnel, observed selected portions of the

maintenance activities associated with the inspection and cleaning of

the lube oil and jacket water coolers, and observed the replacement of

the EDG intercooler and the lobe oil temperature control valve.

b. Observations and Findings

The inspectors observed that mechanical maintenance 3ersonnel performing

the maintenance activities were generally knowledgea]le of their

assigned task. The mechanics placed an appropriate emphasis on foreign

material exclusion control. Work packages were available at the work

location and were used by the mechanics. The work packages were also

adequate, based on the inspectors review.

However, the inspectors identified that an improper torque sequence was

used by the mechanic during the reassembly of the 2B EDG jacket water

cooler end cover. The inspectors were concerned that the OC inspector

performing the inspection of the joint reassembly did not identify the

use of an improper torque sequence. The licensee considered reassembly

of mechanical joints within the skill-of-the-craft, and as a result, a

torque se

addition,quence

the OCwas not specified

inspector was not as part of theofwork

independent procedure. In

the maintenance

activity since the inspector was setting the torque wrench for each

torque increment.

During an interview with the QC inspector, the insJectors learned that

the OC inspector's training background was not meclanical in nature, and

that he did not know the proper torque sequence for reassembly of

mechanical joints. The OC inspector was aware of the recuirement to

remain independent from the work activity being inspectec , however, he

involved himself in the work activity by setting the torque wrench.

19

- - - - _ - . - _ - - - - - - . . - - - _ - - - - - -

1

1

!

.

j -

c. Conclusions

1

,

j .

The ins)ectors concluded that: (1) the mechanic performing the

i

reassem)ly of the 2B EDG jacket water cooler end cover used an impro)er

i

torque sequence. (2) the OC inspector performing the inspection of t1e

torquing of the end cover was not knowledgeable of the proper torque

sequence for the reassembly of mechanical joints, and (3) the QC .

t

inspector was not independent of the work activity since he set the

I torque wrench for each torque increment. A similar problem was

.

identified involving an inadequate quality control inspection during EDG

j maintenance in NRC Inspection Report 50 N /96006. 50-304/96006. <

' ~~

_

ZionIdministrativeProcedure(ZAP)520-08."StationOCInspection

Program for Maintenance Work." Revision 3(G). requires, in part. that

j

4

independent inspection / quality verification be performed by qualified >

individuals other than the group performing the maintenance task. The '

failure to ensure that the quality control inspection of the jacket

i

water cooler end cover reassembly was independent of the work activity.

'

in accordance with ZAP 520-08. is considered a violation of 10 CFR

Part 50. Appendix B. Criteria X (50-304/96014-06). as described in the

i

i

attached Notice of Violation.

.l III. Enaineerina

El _ Conduct of Engineering  !

b El.1 Safety-Related Pinino Sunnort Anchor Plates Exceeded the Soecified Gao

Criteria Between the Plate and the Building Structure

a. Inspection Scone (37551)

During plant tours and system walkdowns, the inspectors identified

piping supports with gaps between the building structure and the piping

support anchor plate.

b. Observations and Findinos

On September 3. during a tour of the Auxiliary Building, the inspectors

identified at least ten examples of piping supports for the containment l

spray and safety injection (SI) systems with gaps between the building

structure and the support anchor plate. As described in Nuclear Station

Work Procedure NSWP-S-05. " Concrete Expansion Anchors." Revision 3.

Section 6.20. the acceptance criteria for the gap between the building

structure and the piping support anchor plate is less than or equal to

1/32 of an inch, not to exceed 30 percent of the length of the anchor

plate, for each side of the plate.

In response to this issue, the licensee initiated a Problem

Identification Form and performed limited scope walkdowns of the SI and

auxiliary feedwater systems in order to better characterize the

magnitude of the issue. The walkdowns revealed that 15 of the 29 piping

i'

20

I

1

l

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. - _ . , _ _ , - - - - - , - , _ _ _ _ _ _ . . _ _ . I

_ _ . .__._ _._.___.__ _ ___ - _ _ - _ _______

,

.

1

i

! .' supports inspected had gaps in excess of the acceptance criteria

!

'

,

specified in NSWP-S-05. The license initiated an o)erability assessment

.

to determine if the piping supports could perform t1eir intended

function with the gaps present.

'

c.' Conclusions

! The issue with piping supoort gaps exceeding acceptance criteria is

j considered an Inspection Follow-up Item (50-295/96014-07:

50-304/96014-07) pending NRC review of the licensee's operability

l assessment and supporting engineering calculations. In addition, a

,

related issue involving the failure of VT-3 inspections, conducted-in

i accordance with the inservice inspection program. _t,o include

, verification of the clearance between the building structure and the

i"

piping support anchor plate, was discussed in NRC Inspection Report

50-295/96013., 50-304/96013.

i

E1.2 Hiah Ambient Temoerature in 125 Volt-DC Battery Room

{

, a. Insoection Scope (37551)

-

.

On September 3. during a walkdown of the 011 125 Volt-0.C. station

! battery, the inspectors identified that the ambient temperature of the

1- battery room was abnormally high. The inspectors reviewed the results )

of a surveillance test performed earlier in the day, the logs for

auxiliary operator tours, and battery vendor information.

b. Observations and Findings

The inspectors noted that the licensee had perfobmed maintenance

procedure EMSP-01. " Station Battery Monthly and Quarterly Surveillance"

on September 3. During the surveillance test, the licensee identified

that the ambient tem)erature for the 011 battery room was approximately

99 Fahrenheit (F) w1ile the expected value was between 60 and 90 F.

The licensee attributed the cause of the high ambient temperature to the

closed position of the battery exhaust fan discharge damper. The  !

licensee determined that the damper had failed closed.. The licensee

started the redundant train of ventilation, but did not evaluato the .

hydrogen concentration of the room before initiating ventilation flow.

As a result, the licensee was unable to use the hydrogen concentration

to determine the approximate duration that the exhaust ventilation

system had been inoperable and therefore was not able to evaluate the '

associated operability of the battery.

,

Through a review of auxiliary operator logs, the inspectors determined

that o)erability of the battery exhaust ventilation system was checked '

daily )y verifying that the exhaust fan was energized rather than

verifying that air flow existed. In addition, the expected range for

the battery pilot cell temperature specified in licensee procedures was

between 60 and 100 F. However, the nominal temperature range specified

in battery vendor information was between 60 and 90 F.

21

. . . . --- - -_ - - - - . ._

___.______

,

l I

1

i

4- .

!

. c. Conclusions

l

'

.

Zion Operability Determination Manual guidance allows the 011 125

Volt-D.C. battery to be considered operable for five days without

-

battery room exhaust . ventilation. This issue is considered an

' Inspection Follow-up Item (50-295/96014-08: 50-304/96014-08) pending NRC

" review of the basis for this guidance and operation of the battery in an

environment with an ambient temperature greater than that specified by

! the vendor.

t

!

E1.3 Inadvertent Transfer of 500 Gallons of Water From the Refuelina Water

j Storace Tank (RWST) to the Refuelina Cavity

! a. Insoection Scoce (37551)

l -

!

4

On September 26, during testing performed by system engineering, I

500 gallons of water were inadvertently transferred from the Unit 2 RWST l

4

to the refueling cavity. The inspectors interviewed operations l

1

department personnel and reviewed both Technical Staff Surveillance  :

! (TSS) 15.6.108, "S 1

j- the control room "pecial

postedType B and Cdrawing."

instruction Leak Rate Test," Revision 3, and

<

j b. Observations and Findings

l

i

While performing TSS 15.6.10B for the refueling cavity to refueling j

!

water purification pump (RWPP) valve, 2SF8767, a drain path was created

between the Unit 2 RWST and the refueling cavity. Valve 2SF8758 (RWST

i

to RWPP valve) had been left open after filling the transfer canal with

water from the RWST to support fuel moves. The drain path was created

I

4

when valve OSF0012, the refueling cavity to RWPP containment isolation

valve, and valve 2SF8767 were opened during the surveillance test.

The surveillance procedure for TSS 15.6.10B was inadequate in that it

did not require verification of initial valve positions to assure that a

leakage path was not created during the-performance of the surveillance

test. In addition, a barrier that should have prevented the inadvertent

water transfer from the RWST failed. in that a non-licensed operator did

not follow the Unit 2 supervisor's direction to review the Posted

Instruction Drawing. This drawing provided the status of the valves in

the spent fuel pit cleanup and cooling systems, and had the operator

referred to this drawing, he may have recognized that specific valves

were not positioned for performance of the surveillance test.

c. Conclusions

The failure of TSS 15.6.10B to require verification of initial valve

positions contributed to the inadvertent transfer of 500 gallons of

water from the Unit 2 RWST to the refueling cavity and is considered an

example of a violation of 10 CFR 50, Appendix B Criterion V

(50-295/96014-04d, 50-304/96014-04d), as described in the attached

Notice of Violation. The failure of a non-licensed operator to follow

verbal direction also contributed to this event.

22

i

!

I

.  ?

-

E3.1 Review of UFSAR Commitments

~

.

The discovery of a licensee operating its facility in a manner contrary

to the Updated Final Safety Analysis Report (UFSAR) description  !

highlighted the need for a special focused review that compares plant l

practices, procedures and/or parameters to the UFSAR descriptions. The i

inspectors reviewed the applicable portions of UFSAR that related to the !

areas inspected. The inspectors verified that the UFSAR wording was  :

consistent with the observed plant practices. procedures, and/or l

parameters. '

!

l

E4 Engineering Staff Knowledge and Performance

E4.1 Inadvertent Plinio Breaker Actuation Due to Engineerina Personnel Error

a. Insoection Scoce (37551)

On September 23. a system engineer did not perform the action required  !

in a 3rocedural step resulting in actuation of the 2A Service Water (SW)

-

pump 3reaker while it was racked out in the test position. The

inspectors interviewed the system engineer and the electrical engineer

supervisor and reviewed the procedure and electrical prints.

b. Observations and Findinos '

While performing Technical Staff General Procedure (TSGP) 97. " Test of  !

the Autostart Inhibit Circuitry for Bus 47 Pumps." the system engineer

signed off a step which was not yet performed. This step directed the

system engineer to energize undervoltage relay 427TD1 before

de-energizing relay SDR/27-2. When the system engineer did not perform

this step and de-energized relay SDR/27-2 the logic was satisfied for

automatic closure of the 2A SW pump breaker. The pump breaker had

previously been racked out to the remote test position. and thecefore,

closing of the pump breaker did not cause the SW pump to start,

c. Conclusions

Inattention to detail and lack of self-checking by the system engineer

resulted in the failure to perform a required procedural step causing

closure of the 2A SW pt,1mp breaker. The failure to ensure undervoltage

relay 427TD1 was energized prior to de-energizing relay SDR/27-1. in

accordance with TSGP 97, is considered an example of a violation of

10 CFR Part 50. Appendix B. Criterion V (50-295/96014-01e.

50-304/96014-01e) as described in the attached Notice of Violation.

E4.2 Unauthorized Temocrary Alteration of the Unit 2 Manioulator Crane

a. Insoection Scope (37551)

On October 4. the inspectors observed that a fan was taped to the Unit 2

manipulator crane over the refueling cavity while fuel assemblies were

being moved. The inspectors interviewed involved system engineers and i

23

i

_. . _. __ _ .. _ _ . _ _ . _ _ _ _ _ . . _ _ _._________ _

,

l

!

-

,

'

-

their supervisor, fuel handling personnel, and an administrative

.

operating engineer, and reviewed ZAP 510-05 " Temporary Alteration

! . Program." Revision 4.

b. Observations and Findings .

While observing fuel moves, the inspectors noted that a fan was taped to  ;

the manipulator crane. The fan was being used to blow air to cool the

manipulator crane motor and the pilot generator. The licensee concluded

that the fan was originally taped to the crane to address the generation

,

of heat due to excessive use of the jogging function while performing

incore shuffling of the fuel assemblies.

After the licensee decided to Jerform a full core offload for the

refueling outage, the use of t1e jogging function was limited. However,

the fan was not removed and the crane was never tested for operation

without cooling from the fan. The condition with the taped fan had

existed since the late 1970's and the licensee had not determined

whether or not use of the fan impacted the function of the manipulator

crane.

The licensee planned to remove the fan from the crane and test the

operation of.the crane without additional cooling. If additional

cooling was warrarited, the licensee planned to install the fan according

to ZAP 510-05 requirements and process an exempt change to install a

permanent fan.

c. Conclusions I

Zion Administrative Procedure (ZAP) 510-05, " Temporary Alteration j

Program." Revision 4. defines a temporary alteration (TA) as an

alteration made to the plant configuration, including equipment and

facilities, intended to be temporary, that does not conform to approved l

drawings or other plant documents.

The failure to process a TA for the installation of a portable fan on '

the Unit 2 fuel manipulator crane in accordance with design controls

specified in ZAP 510-05 is considered a violation of 10 CFR Part 50,

Appendix B. Criterion III (50-304/96014-09) as described in the attached

Notice of Violation. ,

V. Manaaement Meetinas

XI Exit Meeting Summary

The inspectors ) resented the inspection results to members of licensee

management at tie conclusion of the inspection on October 21, 1996. The  ;

licensee acknowledged the findings presented. '

The inspectors asked the licensee whether any materials examined during the

inspection should be considered proprietary. No proprietary information was

. identified.

24

-

X2 Management Meeting Summary

'. On October 7. a public management meeting with Comed was held in Region III.

The topic of discussion was the continuation of personnel errors at Zion and

the licensee's plans to stop this trend. -

.

l

l

I

25

. - .

,

~

-

Partial List of Persons Contacted

.

..

Licensee

'

3. Mueller Site Vice President

G. Schwartz, Station Manager

W. Stone, Regulatory Assurance Supervisor

B. Fitzpatrick, Operations Manager

j

'

B. Giffin. Engineering Manager

j

K. Hansing, Site Quality verification Director i

W. Strodl, Radiation Protection Supervisor -

1 D. St. Clair, Work Control Manager

M. Weis, Services Director ~~

NRC

M. Dapas, Chief Reactor Projects Branch 2

M. Parker, Senior Resident Inspector, Palisades

R. Westberg, Acting Senior Resident Inspector

,

i

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1

,

4

,

26

.. . . . .-. - . -- -

-

List of Inspection Procedures Used

.

IP 37551 Engineering

IP 62703 Maintenance Observation -

IP 71707 Plant Operations

IP 93702 Prompt Onsite Response to Events at Operating Power Reactors

List of Items Doened. Closed. and Discussed

Opened '

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50-295/304-96014-01a VIO Inadvertent LCO entry for inoperable SI pump

50-295/304-96014-01b VIO EDG was not cooled down for 15 minutes as l

required by surveillance procedure

50-295/304-96014-01c VIO EAs performing 00S, isolated the backup air

supply to the RHR valves vice the main air i

supply

50-295/304-96014-01d VIO Maintenance personnel failed to install the

hypoid gear locating key for two PORV block I

valve drive sleeves -

50-295/304-96014-01e VIO System engineer omitted step during surveillance

resulting in automatic closure of the 2A SW pump

breaker

50-295-96014-02 VIO Failure to stop pulling control rods and enter

abnormal operating procedure following indicated

rod misalignment

50-304-96014-03 VIO Failure to demonstrate the availability of two

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sources of off-site power at least once every

eight hours while the 2A and 2B EDGs were 00S

50-295/304-96014-04a VIO Inadequate procedure for stroke time testing of

the 2A atmospheric relief valve

50-295/304-96014-04b VIO Inadequate procedure for leak testing of Unit 2

penetration pressurization system check valves

50-295/304-96014-04c VIO Failure to have a ste) in maintenance procedure

for installation of tle hand loader

50-295/304-96014-04d VIO Failure to have a step in test procedure for

verification of initial valve position

50-304-96014-05 HCV Licensed shift supervisor error resulted in

missed surveillance

50-304-96014-06 VIO Failure of quality control inspector to remain

indepeadent of activity involving jacket water

cooler end cover reassembly

50-295/304-96014-07 IFI Operability assessment and su) porting

engineering calculations for Jase plates gaps

50-295/304-96014-08 IFI Basis for 125 volt battery operability without

battery room exhaust ventilation

50-304-96014-09 VIO Unauthorized temporary alteration for portable

fan on fuel manipulator crane

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I Closed

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50-304/96014-05 NCV Licensed shift supervisor error resulted in missed

surveillance

50-304/96006-00 LER Licensed shift supervisor error resulted in missed

surveillance

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v List of Acronyms

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AB Auxiliary Building

AOP Abnormal Operating Procedure .

CCW Component Cooling Water

EA Equipment Attendant

EDG Emergency Diesel Generator '

E0 Equipment Operator

GOP General Operating Procedure i

IA Instrument Air

IFI Inspection Followup Item

IP Inspection Procedure i

)

IR Inspection Report ,1

ISEG Independent Safety Engineering Group i

ISI Inservice Inspection l

IST Inservice Testing '

IV Independent Verification

LCO Limiting Conditions For Operation

LSS Licensed Shift Supervisor i

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MOV Motor-Operated Valve -

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NCV Non-Cited Violation l

NRC Nuclear Regulatory Commission

NSO Nuclear Station Operator

DOS Out-of-service

OSP Operations Special Procedure I

P&ID Plant and Instrumentation Drawing

PDR Public Document Room

PIF Problem Identification Form

PMT Post-Maintenance Testing ,

PORV Power Operated Relief Valve l

PP Penetration Pressurization '

OC Quality Control

RCDT Reactor Coolant Drain Tank

RHR Residual Heat Removal

RWPP Refueling Water Purification Pump

RWST Refueling Water Storage Tank

SA Service Air

SE Shift Engineer l

SI Safety Injection l

S0V Site Quality Verification I

SW Service Water

TA Tem)orary alteration

TS Tec1nical Specification

TSGP Technical Staff Group Procedure

TSS Technical Staff Surveillance

UFSAR Updated Final Safety Analysis Report

URI Unresolved Item

VCT Volume control tank

VIO Violation l

ZAP Zion Administrative Procedure

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