ML20138B113
| ML20138B113 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 12/06/1985 |
| From: | Dodds R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | Chaffee A, Kirsch D, Richards S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| References | |
| NUDOCS 8512120214 | |
| Download: ML20138B113 (44) | |
See also: IR 05000344/1985035
Text
{{#Wiki_filter:k - , DEC 061986 MEMORANDUM FOR: A. Chaffee, SALP Board Member, RV -) D. Kirsch, SALP Board Chairman S. Richards, SALP Board Member, RV D. Pereira, SALP Board Member, RV K. E. Johnston, NRR T. M. Novak, NRR S. A. Varga, NRR FROM: R. Dodds, Chief, Reactor Projects Section 1 SALP Board Member SUBJECT: TRANSMITTAL OF DRAFT SaLP REPORT FOR TROJAN Reference (A): SALP Input Tasking Memorandum October 24, 1985 The draf t SALP report for Trojan covering the period f rom November 1, 1984 through October 31, 1985 is enclosed. This draft was compiled from the performance analysis inputs submitted to D. B. Pereira as requested in reference (A). Please review this report, particularly those sections in which you were involved, and be prepared to discuss the report at the forthcoming Regional Board meeting. The SALP Board meeting will convene in the Region V conference room at 8:30 a.m. on December 17, 1985. - a ? - {{ )L$ )W( R. Dodds, Chief Reactor Projects'lSection 1 Enclosure: As stated cc w/ enclosure: G. Kellund G. Yuhas M. Schuster R. Pate H. North L. Norderhaug T. Young R. Fish P. Qualls J. Crews F. Wenslawski K. Prendergast cc w/o enclosure: J. Martin B. Faulkenberry R. Scarano [ ' RV DPe ira:dh RD6 ds 12/ (, /85 '12/g /85 , h 8512120214 851206 PDR ADOCK 05000344 \\ G PDR . t -
_ }<. U.S. NUCLEAR REGULATORY COMMISSION REGION V $.9.E,I[.7
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. SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANCE FOR PORTLAND GENERAL ELECTRIC COMPANY TROJAN NUCLEAR ?LANT bh u . m.h U mr REPORT No. 50-344/85-35 EVALUATION PERIOD: 11/1/84 - 10/31/85 ASSESSMENT CONDUCTED: December 17, 1985
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, TABLE OF CONTENTS: ' . , . - Page , , I. Introduction ~ 1 ' t , , . II. Criteria 1 , III. Summary of Results , 3' ' IV. Performance Analysis ' f .._ ' , 1. Plant Operations f 2. Radiological Controls f 3. Maintenance g ' 4. Surveillance 9
5. Fire Protection /o i 6. Emergency Preparedness // 7. Security and Safeguards // 8. Refueling /2 9. Quality Programs and Administrative Controls jy Affecting Safety 10. Licensing Activities /dI 11. Engineering and Construction 2/ 12. Training- yy V. Supporting Data and Summaries .7f . ! 1. Licensee Operations Activities Jf/ ' 2. Inspection Activities 28 3. Investigation and Allegations Review 30 4. Escalated Enforcement Actions yo 5. Liceasce ConfegencesHeldDuringtheagraal Period 30 '6. Co n fir-alir= * E Ae fie= Lefter. 3 fe arts 7. S edal 31 Yeit v1hes -3' ' ?. Lie st TABLES 6 1. Inspection Activities and Enforcement Summary 3f/ ' 2. ' Enforcement Items 3f" 3. Synopsis of Licensee Event Reports 37 4. Licensee Event Reports JS j 5. Inspections Conducted $7 s -- - -~~ -
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t 1 % 1. INTRODUCTION The Systematic Assessment of Licensee Performance (SALP) is an integrated NRC staff effort to collect available observations and data on a periodic basis and evaluate licensee performance based upon this information. SALP is supplemental to normal regulatory processes used to ensure compliance with NRC rules and regulations. SALP is intended to be sufficiently diagnostic to provide a rational basis for allocating NRC resources and to provide meaningful guidance to the licensee's management to promote quality and safety of plant construction and operation. An NRC SALP Board, composed of the staff members listed below, met in the Region V office on December 17, 1985, to review the collection of performance observations and data to assess the licensee's performance in accordance with the guidance in NRC Manual Chapter 0516, " Systematic Assessment of Licensee Performance." A summary of the guidance and evaluation criteria is provided in Section II of this report. This report is the SALP Board's assessment of the licensee's safety performance at Trojan for the period November 1,1984 through October 31, 1985. SALP Board for Trojan D. F. Kirsch, Acting Director, Division of Reactor Safety and Projects (Board Chairman) A. E. Chaffee, Chief, Reactor Projects Branch (Board Member) R. Dodds, Chief, Reactor Projects Section 1 (Board Member - Secretary) S. Richards, Senior Resident Inspector (Board Member) D. B. Pereira, Project Inspector (Board Member) G. Kellund, Resident Inspector R. J. Pate, Chief, Reactor Safety Branch T. Young, Jr., Chief, Engineering Section P. Qualls, Fire Protection Specialist F. A. Wenslawski, Chief, Emergency Preparedness and Radiological Projection Branch G. P. Yubas, Chief, Facilities Radiological Protection Section H. North, Radiation Specialist R. Fish, Chief, Emergency Preparedness Section K. Prendergast, Emergency Preparedness Analyst M. D. Schuster, Chief, Safeguards Section L. Norderhaug, Physical Security Inspector K. E. Johnston, Project Manager, NRR S. A. Varga, Chief, Operating Reactors Branch.No.1, NRR , ma EbM f , 3 e o b
t 2 .. II. CRITERIA The following evaluation criteria were applied to each functional area: 1. Management involvement in assuring quality 2. Approach to resolution of technical issues from a safety standpoint 3. Responsiveness to NRC initiatives 4. Enforcement history 5. Reporting and analysis of reportable events 6. Staffing (including management) 7. Training effectiveness and qualification To provide consistent evaluation of licensee performance, attributes associated with each criterion and describing the characteristics applicable to Category 1, 2, and 3 performance were applied as discussed, in part, in NRC Manual Chapter 0516, Part II and Table 1. The SALP Board conclusions were categorized as follows: Category 1: Reduced NRC attention may be appropriate. Licensee management attention and involvement are aggressive and oriented toward nuclear safety; licensee resources are ample and effectively used so that a high level of performance with respect to operational safety or construction is being achieved. Category 2: NRC attention should be maintained at normal levels. Licensee management attention and involvement are evident and are concerned with nuclear safety; licensee resources are adequate and are reasonably effective such that satisfactory performance with respect to operational safety or construction is being achieved. Category 3: Both NRC and licensee attention should be increased. Licensee management attention or involvement is acceptable and considers nuclear safety, but weaknesses are evident; licensee resources appeared to be strained or not effectively used so that minimally satisfactory performance with respect to operational safety and construction is being achieved. . .
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III. SUMMARY OF RESULTS Performance Category Previous Current Functional Areas SALP Period SALP Period Trend * 1. Plant Operations 3 2 Improving i t 2. Radiological Controls 1 1 Improving 3. Maintenance 2 2 Unchanged 4. Surveillance 1 2 Declining 5. Fire Protection 2 2 Unchanged i 6. Emergency Preparedness 1 1 Declining 7. Security and Safeguards 1 2 Declining 8. Refueling 1 1 Unchanged
A 9. Quality Programs and 3 2 Improving i Administrative Controls Affecting Safety
10. Licensing Activities 2 2 Unchanged i 11. Engineering and Construction - 2 Improving 12. Training ' 2 Improving - l
- The trend indicates the SALP Board's perception of the licensee's
i performance during the current assessment period. It is not necessarily- , '
a comparison of performance during the current period with the previous ' period. For example, performance .in:the training area was conside ed to i be improving, even though performance in this functional area was not ! assessed during the previous SALP. period. i - ; f
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t 4 % IV. PERFORMANCE ANALYSIS The following is the Board's assessment of the licensee's performance in each of the functional areas and the Board's conclusions and recommendations with respect to implementation of the Commission's inspection program. 1. Plant Operations Inspections of plant operations.have been conducted on a continuous bais during the SALP evaluation period by both Resident and Regional Inspectors. One violation was identified in this area. A drain valve off the 'B' train containment spray header inside containment was found to be danger tagged open when-the tag out documentation indicated that the tag had been clea'ed and the valve shut. The . plant was in Mode 5 at the time, therefore system operability was not required and a technical specification limiting condition for operation was not violated. Four reactor trips and four safety injection actuations occurred during the SALP period. One reactor trip and three of the safety injections can be attributed in part to operator error. There were no LERs submitted associated directly with operator performance other than those discussing the trips and safety injections. In the area of operator training, the licensee has taken several significant steps to upgrade their performance. Operations manning has been increased to allow the operating shifts to increase from five crews to six. This in turn has allowed the operators training program to be conducted year around instead of the once a year session, as was previously the case. The licensee has also commenced action to purchase a plant specific simulator. Although the simulator will not be available for use for three to four years, the licensee's internal commitment to procure and operate a simulator is viewed as a significant positive step in ensuring well trained operators. Reviews by the inspectors indicated several weak areas where increased management attention appeared appropriate. In March, an event occurred where oxygen was introduced into the waste gas system. This system normally contains hydrogen, therefore preventing oxygen inleakage is of importance. The inspectors' review of this event indicated that the efforts by plant personnel to determine and correct the root cause of the problem lacked the proper emphasis at the working level. Turnover of plant information and logkeeping associated with this event were also observed to be weak. Additionally, general logkeeping was observed to be lacking in detail. The licensee concurred with this observation and has been working to upgrade the details contained in logs. Some improvemenuha"(beennotedbytheinspectors. In the area of system operating procedures, the inspectors identified several discrepancies with the operating instructions associated with the hydrogen recombiners. During the assessment period, the licensee has added the position of operations engineer to the plant staff.
_ t 5 % This individual has been assigned responsibility for maintaining operating procedures and therefore should ensure an overall higher quality content in operating procedures. The licensee has taken several actions to provide added assurance that plant recovery from refueling outages will proceed in a controlled, formal manner. A " Ready for Startup" program was implemented. This program tracks all outage and preoperational activities just prior to commencing plant recovery. The purpose of the program was to increase the awareness of management and the plant staff in general as to actions requiring completion in order to commence plant operation. Preshift briefs were conducted with each operating crew during physics testing and on shift management coverage was provided until the plant obtained a stable operating status. These actions appear to have been successfully implemented. The recovery from the 1985 outage proceeded in a relatively uneventful manner. To minimize distractions to the operators, the licensee has made an increased effort to limit the number of personnel being admitted to the control room. This effort has met with some success. In general, the conduct of business in the control room has been good, however, the housekeeping in the area located behind the main control board has repeatedly been observed to be poor. This is an apparent result of the area being used as a study and meal area by operations personnel. In recognition of this problem, the licensee has initiated action to relocate the meal and study areas to locations outside the control room. This action had not been completed at the conclusion of the assessment period. An open topic of discussion at the conclusion of the assessment period was independent verification of safety-related activities. In response to NRC Information Notices discussing this subject and in recognition of problems which have occurred at other facilities that may have been prevented by a sound independent verification program, the licensee has reconsidered the adequacy of the scope of their presence effort. This area will be a subject of future inspection. Conclusion: Category 2. Recommendations: The licensee should continue their efforts to upgrade operator training and to establish and maintain a formal control room atmosphere. Operations personnel should be encouraged to have a questioning attitude toward plant problems and the determination of their root cause. The licensee should promptly identify any activities not receiving the appropriate level of independent verification and take action to correct any deficiencies identified.
_ - _ _ _ _ t 6 % 2. Radiological Controls A total of six inspections were performed by the Facilities Radiological Protection Section during the arpraisal period. A total of 301 inspector-hours were expended in onsite inspection activities and 16 hours on inoffice inspection. The areas inspected included: Operational and Outage Radiation Protection a. b. Waste Management c. Confirmatory Measurements d. Transportation Activities Of the total, 110 hours were devoted to followup topics including: Followup on an Unresolved Item / Violation a. b. Followup on Inspector Identified Open Items Review of Routine Reports c. d. Information Notices In addition, the resident inspectors provided continuing observation in these areas. . The licensee's radiation protection staff conducted an extensive evaluation of the steam generator insert handling extremity exposures received during the refueling outage preceding the SALP period. A subsequent review of the licensee's evaluation by NRC established that the licensee had failed to consider the extremity exposure due to nonpenetrating radiation. As a result, a severity level IV violation was issued. This represents'an increase over the last SALP cycle during which no~ violations.in'this functional area occurred. ' No LER's were received during this SALP' cycle-in-this functional area. Inspection activities during this cycle showed.a continuation of the previously identified management support.in this area. One evidence of this support was management's prompt and effec,tive response to NRC identified concerns rela,ted to radiation protection / chemistry technician unrest. The technician's concerns were, in part, related to the separation of the radiation , protection and chemistry functions. Management's aggressive response was demonstrative of support in this functional area. The training performed in support of the refueling outage in the areas of seal table and steam generator work was effective in reducing exposure. Although the unsuccessful attempt to use newly fabricated nozzle dams was costly in terms of exposure, it was not due to inadequate training or radiation protection support. The problem resulted from design inadequacies. As a result of the nozzle dam design experience, licensee management identified the need for a mechanism to promptly limit nonproductive exposure when confronted with activities which fail to progress properly inspite
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of careful preplanning. This demonstrated management's ability to recognize problems and learn from experience. During the SALP period, two minor instances of a lack of attention to detail and a reduced level of conservatism were observed. In the first case, during the first use of a high integrity container (HIC) the individual working near the top of the cask was not provided with supplementary extremity and head dosimetry. Based on the results of surveys, no significant exposure was received. The licensee agreed that the conservative approach would have been to provide such dosimetry for an initial operation until experience had been gained. In the second case, during cleaning of the auxiliary building sump, the Radiation Work Permit (RWP) failed to require the use of waterproof clothing in addition to the usual protective clothing. Workers were wearing appropriate clothing although it was not specified on the RWP. The sump cleaning activity required that filters be manually squeezed to remove excess water. When these matters were called to the licensee's attention, the licensee was responsive and took prompt corrective action. While the licensee has an adequate and well trained radiation protection, rad waste and chemistry staff, it appears that additional personnel in supervisory positions would be beneficial. During refueling, the radiation protection staff required augmentation from the corporate radiation protection staff to provide back shift supervision. It appeared that the chemistry staff would benefit from the addition of a laboratory first line supervisor or foreman. The licensee used care in selecting contract radiation protection technicians in support of the refueling outage. While some of the contract technicians arrived onsite sufficiently early to aid in outage preparation, delays in staffing slowed ALARA preplanning until adequate support was available. ALARA preplanning was not delayed by the licensee's outage planning and scheduling process. In the area of waste management, the licensee has established ALARA goals aimed at reducing liquid and gaseous releases. While not all goals have been met, the overall trend of such releases has been down. The volume of solid waste disposed in 1983 and 1984 remained substantially constant. Two confirmatory measurement inspections were performed during the appraisal period. No significant concerns were identified and split sample comparisons were generally good. The licensee's radiation protection program appeared to have experienced some loss of effectiveness during the early part of the appraisal period. This may have been attributable to the technician unrest and the somewhat delayed contract technician staffing for the outage. Licensee management promptly and effectively. resolved the first concern and recognized the need~to bring contract technicians on site in a timely fashion to support outage, activities. ._.
g 8 s Conclusion: Category 1. Inspection experience in this functional area indicates an upward trend. Board Recommendation: The licensee should bring contract radiation protection personnel on site early enough to support the outage planning and preparation phase. Management should continue the strong support of the radiation protection function demonstrated in the past appraisal period. 3. Maintenance ' Maintenance activities have been inspected on a routine basis by the Resident and Regional Inspectors. The effort has primarily been directed at assessing the effectiveness of the licensees maintenance program in ensuring the reliable operation of plant safety equipment. Three violations and one deviation were identified in this area. The first violation concerned inadequate documentation of completed maintenance activities. The second violation was associated with not properly considering fluid static head in the calibration of the pressurizer pressure instruments. The third violation concerned the attachment of gas storage bottles to a safety system pipe without consideration of the effect on seismic support of the line. A general area in which concern was identified was control of vendor manuals and drawings. The licensee has apparently been aware for some time that this area was weak and has implemented an effort to verify and update as necessary, these manuals and .irawings. This area is of particular importance in light of the heavy reliance the licensee has 9a using vendor supplied manuals and drawings to , perform corrective and preventative maintenance. b OncLER was submitted in this area. The LER described errors discovered by the licensee in the scaling calculations done for [ determining calibration data for the pressurizer level instruments . The licensee has drafted a procedure to check future calculations of ~ . this type. Board reviews of the instrument and control (I&C) area indicated weaknesses in the scheduling of calibrations and in the determination of calibration data. The licensee has installed a new computer scheduling system for scheduling maintenance activities. Although difficulties were originally encountered in making the system operational, the system now appears to be functioning reliability and should ensure ~ accurate' scheduling of future calibrations. As discussed in the operations section of this report, injections occurred during this assessment period. four safety Three of the four safety injections can be attributed in part to maintenance While all four safety injections occurred with the plant in errors. Modes 4 or 5, thereby minimizing the effect of the safety injections
t ' ' + 9 on the plant, the number of challenges of this type are indicative of a weakness. Additionally, our review indicates that eight of the cumulative total of fifteen plant safety injections have occurred during the past 24 months. The licensee has also noted this trend and has been considering action to take to reduce the rate at which inadvertent safety injections occur. One deviation was identified concerning inappropriate approval of deviations from overtime work guidelines. These guidelines have since been incorporated into the technical specifications as a licensee requirement. The licensee has instituted more rigorous administrative requirements to ensure compliance in this area. As a result of past failures of compression fittings, the licensee has commenced a program to inspect and repair, as necessary, compression fittings in selected systems'. This has been conducted in connection with providing additional training to maintenance personnel in the proper utile 'atita of these fittings. Our review of this activity indicates that in this instance, the licensee has followed up a past plant problem with significant corrective action. Conclusion: Category 2. Recommendations: Management should ensure that effort to update vendor manuals and drawings are achieving the desired results with a reasonable completion date established. Efforts to ensure complete documentat'on of maintenance and testing activities should continue. The licenste should investigate ways to reduce the number of inadvertent challenges of the safety injection system. 4. Surveillance The surveillance program has been reviewed on a continuing basis by both Resident and Regional Inspectors. Three violations were identified in this area. The first violation was associated with failure to perform a total time response test of the reactor coolant pump bus undervoltage and under frequency relays. The second violation concerned several failures to properly document data associated with surveillance tests of instrumentation. The third violation concerned failure to properly perform surveillance tests on relief valves. Inspections of the licensee's inservice inspection (ISI) and inservice testing (IST) programs indicated weaknesses in both areas. Management involvement in both programs appeared minimal with a heavy reliance on contractors for administration of the ISI program. Concern was also raised with regard to the length of time that elapsed between the point when a quality assurance audit identified a concern regarding scheduling of hydrostatic tests of nuclear class piping, and the point at which the 8nsite,Ieview[ommitteeconsideredthefinding. Additionally, in the j , ! i ( l l I l
_ - _ _ _ - - - i 10 ., area of IST, an error was noted in the determination of the acceptable performance range of the residual heat removal pumps. During this assessment period, the ten year . reactor vessel inspection was conducted. This effort was completed in a timely fashion. The licensee's efforts to monitor the integrity of the steam generators continues to be good. Conclusion: Category 2. Recommendations: Increased management attention is warranted in the administration of both the IST and ISI programs. 5. Fire Protection During the current SALP assessment period, one inspection totaling 34 hours of direct inspection effort was conducted in the area of fire protection. In addition, the resident inspectors provided continuing observations in this area. There was one violation and no Licensee Event Reports (LERs) in this area. The one violation was in the area of fire brigade training. The licensee was unable to produce documentation showing that fire brigade members had completed the requisite number of drills. In part this was because the licensees training records were not organized. The licensee's fire protection program is organized so that the person immediately in charge of site implementation is the Safety Supervisor whose duties include all fire brigade training and drills, fire protection program implementation and his plant safety duties. The only fire protection engineering supervision is from the fire protection engineer located in Portland. Although the plant housekeeping was good and fire suppression equipment appeared to be well maintained, minimal involvement by licensee management in the basic fire protection program was observable. The plant has an ongoire; review of their Appendix R compliance. This is a result of a 1983 NRC inspection, current licensee plans include completing Appendix R related work by the end of 1987. The schedule is being resolved between the licensee and NRR. Conclusion: Performance Assessment - Category 2 No trend was observed in licensee performance during this period. Board Recommendations:
' , r. 11 The licensee should continue to coordinate with NRR concerning implementation of the Appendix R requirements. Site management should be more involved in the program. 6. Emergency Preparedness Region V conducted two emergency preparedness (EP) inspections during this appraisal period. The routine inspection program examined changes to the Emergency Plan, licensee audits, and knowledge and performance of duties. Region V also observed the 1985 EP exercise. A total of 229 hours of direct inspection effort was expended in the area of EP. No significant deficiencies or violations were observed. The routine inspection program identified a few areas in the training program needing improvement. These areas included some topics to be stressed during Shift Supervisor Training and some recommendations for improving how the licensee tracks required EP training. The results of the exercise indicates these improvement areas were addressed by the Training Department. Corporate management is very involved in emergency planning. The licensee's staff appears competent and key positions are identified and responsibilities are well defined. The inspection program primarily focuses on the licensee onsite activities, however, discussions with FEMA and the findings of the 1985 exercise demonstrated an excellent working relationship exists between the licensee and offsite authorities. The findings of the 1985 EP exercise indicate a slight decline in performance from the previous years exercise. Problems were observed in air sample analysis and OSC operations. The decline in performance during the exercise may indicate a need for improvements in the training program. The exercise findings indicate that although some problems were encountered, the licensee is capable of protecting the health and safety of the public. Conclusion: Performance assessment - Category 1. This does not represents a change from the previous assessment. However,-based upon the results of the 1985 EP exercise there appears to be a slight decline in performance from the previous assessment period. Board Recommendations: 1) Continued management support an'd involvement in EP activities. 2) Improvements in the EP training program should be examined to increase the licensees performance in EP. ' 7. Security and Safeguards -
_ % 12 ,, During the period November 1, 1984 through October 31, 1985, two physical security inspections were conducted. In addition, the resident inspectors provided continuing observations in these areas. No material control and accounting inspections were conducted during the assessment period. The two routine physical security inspections to verify compliance with security requirements represented a total inspection effort of 72 inspection hours. While none of the routine inspections identified violations or deviations, security compensatory measures and permanent fixes related to lighting, alarm station operation, procedures for entering access authorization into the new computerized access control system and operational difficulties using hand-held metal detectors were identified as requiring management attention. Also, the licensee's corrective action related to concerns identified in the last material control and accounting inspection were reviewed. No further problems in this area were identified. Improvement has been noted and further efforts planned to strengthen the role of the licensee's Quality Assurance (QA) staff to assure continued compliance with security requirements. Corporate management was fully involved in the implementation and review of the security program and the remedial measures to expeditiously correct deficiencies identified in the course of the security inspections. Records supporting program completion were accurate, complete and available for review. One information notice and five event reports (10 CFR 73.71(c)) related to security were issued during the assessment period. The licensee's records relative to their analysis of the information notices and event reports were reviewed with no problems noted. The licensee's security organization was found to be staffed by qualified individuals dedicated to maintaining high standards in their areas of responsibility. Conclusion: Performance assessment - Category 2. The conclusion drawn in the previous SALP cycle was category 1. Certain difficulties, although not enforcement issues, appear to indicate the start of a trend requiring management attention. Recommendation: Licensee management is encouraged to maintain their increased support of the station security program particularly with respect to Quality Assurance Program involvement. 8. Refueling t -
. 13 f g The refueling outage, which occurred during this SALP period, commenced on May 2 and was completed on July 7 when the plant returned to power operations. Major activities conducted during the outage included the 10 year inservice inspection of the reactor vessel, steam generator sludge lancing and eddy current testing, containment local leak rate testing, modification of the reactor trip breakers and replacement of selected feedwater heaters. The movement of fuel and reactor components was conducted without incident. No violations were identified in this area and no LERs were submitted that were directly connected to refueling activities. The conduct of evolutions during the outage indicated that extensive preplanning had occurred. This was further evidenced by the fact that the outage was completed ahead of the original schedule. Although no major problems were encountered during the outage, management attention to problems which did develop was quite evident. Prompt action was particularly evident on any situations that could have affected the critical path to completion of the outage. Conclusion: Performance Assessment - Category 1. This is the same category as in the previous SALP period and no trend is evident at this time. Board Recommendations: The licensee should continue extensive preplanning and aggressive action to address refueling outage problems. 9. Quality Programs and Administrative Controls Affecting Quality The inspection review of this functional area has been a continuous effort by both inspection personnel and NRC management. During this assessment period, a number of significant actions has occurred in this area. The Quality Assurance-(QA) Manager was replaced in July by the former Manager, Operations'nid Maintenance. The new QA Manager had just completed a one year ,pp rt program with the Institude for Nuclear Power Operations (INPO). ~Undor-the new QA Manager, QA involvement in review of plant operational problems has increased. An example of this change of focus was the corporate QA review of modification testing. This effort followed the plant trip on July 20, after which both AFW pumps tripped sequentially due to a low suction pressure condition. QA findings appear to be more subjective than in the past. The QA Manager has actively participated in audit activities at the site. The QA department has taken action to reorganize their structure, such that the site QA group will report to the corporate QA Manager, instead of the plant manager, as is presently the case. The QA department has also taken steps to relocate a portion of their resources from the corporate office to the site. ._- _ _ __.
. 14 s A weak area noted during this assessment period concerned QA involvement in procurement practices. QA audit activities of vendors was found to be weak in several areas. The licensee has commenced action to upgrade their practices in this area. The Trojan Nuclear Operations Board (TN0B) was reorganized during this assessment period. The previous TNOB had been-found to be generally ineffective, in part due to the fact that the group was primarily composed of personnel who had no authority to direct actions within the nuclear division. The licensee has now assigned senior management personnel to the TNOB, including the plant manager, quality assurance manager, and the manager, technical functions. The Vice President - Nuclear also attends TNOB meetings. The NRC review of TNOB activities indicates the reorganization has been effective in strengthening the TNOB as an oversight committee. NRC reviews of the Plant Review Board (PRB) have indicated that direct staff support for the PRB was minimal and that minutes of PRB meetings were weak. The PRB was found to be performing the functions required by the technical specifications adequately. 'The licensee has assigned an individual from the Nuclear Safety and Regulation Department (NSRD) to the site to function as the site NSRD representative. This individual now also serves as the PRB secretary, thus improving the administration of the PRB and the consistency of the meeting minutes. The licensee has also had problems on several occasions ensuring prompt review of issues by the PRB. Specifically, their review of cycle 7 physics testing data, the ISI hydrostatic test scheduling, and the improper calibration of the pressurizer pressure instruments, were not conducted in the timely manner expected. Overall management involvement in site activities has apparently increased. This has been evident through the implementation of the Management Assessment Program, by which licensee managers make observations at the site and report their findings in writing to senior management, and through the personal participation of senior management in the annual general employee training sessions. Increased management involvement in plant operations was also noted during the plant recovery from the refueling outage through the implementation of the " Ready for Startup" program and control roem coverage by management during the recovery. Other general management initiatives to improve overall performance include the formation of a " Teamworks" program, which provides monetary incentives to employees for good plant performance, the approval of approximately 70 new employee positions in the nuclear division to be added during calendar year 1986, and the decision to have the plant manager and the manager, technical functions, trade positions in January,1985, thus improving the interface between the site and corporate work groups. Several areas have been identified where management involvement appears to have been weak. Specifically, management control of the IST and ISI programs was lacking and management approval of deviations from overtime limits did not accomplish the intended goal. Additionally, the licensee has been reviewing their independent verification practices for approximately seven months, apparently without reaching any conclusions
' i g 15 regarding the adequacy of their~ program. This area would appear to warrant a higher priority. General housekeeping at the site has improved overall during the assessment period, although lapses have been noted, particularly in areas where modifications were being implemented. .One continuing problem area for housekeeping has been the area behind the main control board. This location has been used as a lunchroom and a storage area by operations personnel and has been generally observed to be poorly maintained. At the conclusion of the assessment period, the licensee had taken action to relocate this area outside of the control room. Conclusion: Performance Assessment - Category 2. Board Recommendations: Efforts to increase the effectiveness of the QA organization should continue as a high priority. The licensee should take action to ensure that events and issues are reviewed by the PRB in a timely manner. Management should continue in their efforts to be routinely involved in day to day activities at the site. Management oversight of the IST and ISI programs should be increased. 10. Licensing Activities The basis for this appraisal was the licensee's performance in support of licensing actions that were either completed or had a significant level of activity during the current rating period. These actions consisting of amendment requests, exemption requests, responses to generic letters, TMI items, and cther actions, and are classified as follows: - 15 Multi-Plant Actions (13 completed). Included in this category are:
Appendix I TS Implementation Review (RETS), A-02, Completed
TS Surveillance for Mechanical Snubbers, B-22, Completed
Hydraulic Snubbers Upgrade TS, B-17, Completed
EQ of Safety Related Electrical Equipment, B-60, Completed
TSs in Response to GL 82-16, NUREG-0737, B-72, Completed
TSs in Response to GL 83-37, NUREG-0737, B-83, Completed
Control of Heavy Loads - Phase II, C-15, Completed ATWS Items 4.2.1 and 4.2.2, PM Program for RTBs, Maintenance and Trending, B-81, Completed
ATWS Item 4.5.1, Reactor System Functional Testing - Diverse Trip Features, B-92, Completed
ATVS Item 1.1, Post-Trip Review Program Description and Procedures, B-76, Completed
ATWS Items 3.1.1 and 3.1.2, Post Maintenance Testing Procedures / Vendor Recommendations - RTS Components, B-78, Completed
ATWS Item 4.1, RTS Reliability - Vendor Related Modifications, B-80, Completed
Diesel Generator Reliability TS, D-19, Completed
__ __ _ __ - _ - __ - = 16 %
- ~ATWS Item 1.2, Post Trip Review - Data and Information Capability,
B-85
ATWS Item 4.3, Automatic Actuation of Shunt Trip Attachment, B-82 12 Plant Specific Actions (11 completed). Included in this category are:
Combine STA and Senior Operator, LCA 97, Completed
Delete Boron Injection Tank, LCA 98, Completed
RCS Cooldown Curve and Capsule Withdrawal Changes, LCA 99, Completed
Add a Tolerance Band to hydrogen Mixing System Flow, LCA 106, Completed
Clarify Test for PORV, LCA 110, Completed
Revision to TS 3.0.4, LCA 114, Completed
Request for Certification of Pollution Control Facilities, Completed
Delete IAEA License Condition, Completed
Request to Drop Radiography of 3-inch normal charging line thermal sleeves, Completed
Revised Test for M0-8812, Completed-
Silting of Intake, Review of LER 84-21, Completed
Fire Protection Appendix R Exemption Requests and Appendix R Review 6 TMI (NUREG-0737) Actions (1 completed). Included in this category - are:
SB LOCA Outline, F-57, Completed
- ~ Procedures Generation Package Review, F-05
RV.and SV Testing, F-14 . ' ' A
. , Safety Parameter Display System, F-09 ,' - .
Inadequate Core Cooling Instrumentation, F-26; . _ , ,
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Detailed Control Room Design Review Summary Report,;F-71 - 3; s . ASSESSMENT OF PERFORMANCE ATTRIBUTES
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, ,- .s , , ,s . - The licensee's performance evaluation.is bas'ed'on consideration of seven evaluation criteria as specified in NRC Ma'nual: Chapter 0516. For most of . the licensing actions considered in this evalua, tion, only three of the criteria were of significance. Therefore, the composite rating is . , heavily based on the following criteria: ~ . . y , .. - - Management Involvement and Controlfin-Assuring Quality , Approach to Resolution of Technical _ Issues from a Safety Standpoint - Responsiveness to NRC Initiatives ' - ' With the exception of Enforcement History, for which there was no basis within NRR for evaluation, the remaining criteria of - Reporting and Analysis of Reportable Events Staffing (Including Management) - Training and Qualification Effectiveness - were judged to apply only to'a few licensing activities.
i 17 % In addition to the above, Housekeeping and Control Room Behavior and Significant Hazards Considerations Determination Analysis in License Change Applications are also discussed. A. Management Involvement and Control in Assuring Quality The licensee's management has demonstrated various degrees of involvement and control in assuring quality during the rating period. Regarding multi plant actions, the licensee's management was highly involved in resolving the issues associated with Environmental Qualification of Electrical Equipment and demonstrated good involvement in the issue of ATWS Item 1.1. On the other hand, management involvement and control was inadequate on the Snubber issue and Generic Letter 82-16 issue. In the snubber case, it appeared that upper level management was not involved in assuring the quality of the submittals. In the Generic Letter case, it appeared that management was either inadequately involved in reviewing the submittals or endorsed poor responsiveness. Management's involvement and control was adequate for the remaining 10 multi plant issues. In regard to management involvement and control insofar as plant specific actions are concerned, the licensee's management showed noteworthy involvement and control in addressing the Boron Injection Tank issue. On the other hand, management involvement and control was inadequate on the issue of Valve M0-8812 Test Parameters and License Change Application (LCA) 99, RCS Pressure-Temperature Limits and Capsule Removal Schedule. Regarding the LCA 99 review, the staff is in receipt of the third version of the application and we have been informed by the licensee that a new version is being d ra f ted . The original application (version 1) was withdrawn. Version 2 of the application was denied because of errors found by the staff. This is a clear case of highly inadequate management involvement and control in a plant specific action. Management involvement and control was adequate for the remaining nine plant specific actions. Regarding TMI actions, an adequate level of management involvement and control was demonstrated for all actions. Based upon the above evaluation, management involvement and control for some licensing actions were high and some were inadequate; the majority were adequate. A rating of category 2 is assigned ' to this criterion. B. Approach to Resolution of Technical Issues from a Safety Standpoint The licensee has demonstrated various degrees of resolution of technical issues from a safety' standpoint. Regarding multi plant issues, technical resolution was noteworthy ~on the Diesel Generator issue, the EQ issue, the Appendix I-RETS issue, and the issues relating to ATWS Items 4.1, 4.2.1, 4.2.2 and 4.5.1. On the other i hand, the original technical' resolution.for the Snubber issue and issues relating to Generic Letter 82-16 was inadequate. In the Snubber case, the licensee submittals contained several deviations ! , 4
_ _ _ - - - - 3 t 18 '. from regulatory guidance; most of the deviations appeared to be based on operational convenience and the opinion that the regulatory guidance was unnecersary. In the Generic Letter case, there was little evidence of concern for the technical mertis of regulatory guidance; the primary concern appeared to be avoidance of any enforceable regulatory requirements. The licensee's technical approach to the remaining five MPA issues was adequate. In regard to resolution of technical issues insofar as plant specific actions were concerned, the licensee's technical approach was noteworthy on the Appendix R review and the Boron Injection Tank issue. On the other hand, the technical approach was inadequate for the issues relating to Valve M0-8812 Test Parameters and LCA 99. In the Valve M0-8812 case, the licensee's initial request was not technically sound or conservative. It appeared to have received little or no technical review or evaluation of the safety basis. In the LCA 99 case, technical problems were found with all three versions of the submittal. The technical approach to the other eight plant specific actions was adequate. Regarding the TMI actions, the technical approach to resolution was judged to be l , adequate based upon our reviews to date. ' Based upon the above evaluation, the technical approach to resolution of issues was good in some cases and inadequate in others; the majority was adequate. A rating of category 2 is assigned to this criterion. C. Responsiveness to NRC Initiatives The licensee has shown various degrees of responsiveness to NRC initiatives. Regarding multi plant actions, a high level of responsiveness was shown on the EQ issue, and the issues related to ATVS items 4.1, 4.2.1, 4.2.2, and 4.5.1. Responsiveness to the issues related to Snubbers and Gederic Letter 82-16 was inadequate. In the Snubbers case, the licensee was very unresponsive to the regulatory guidance provided. Repeated requests and discussions were held to resolve the issues. In the Generic Letter case, the licensee stated that it didn't agree that TSs were needed as a result of two staff requests for TSs in writing. The responses were argumentative. Responsiveness on the other seven multi plant issues was adequate. Insofar as plant specific actions were concerned, a high level of responsiveness was shown on the Appendix R issue, the Combined STA and Senior Operator issue, and the Boron Injection Tank issue. Responsiveness relating to the LCA 99 issues was lacking as discussed in the above evaluations. Responsiveness on the other eight plant specific issues was adequate. Regarding TMI issues, the licensee was very responsive to the SPDS issue and has shown an adequate level of responsiveness on the other TMI issues during the rating period. ______-_ _ _ _ - _- _ - _ - _ _ _ _ _ _ -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
. % 19 Based upon the above evaluation, the licensee has been very responsive for some issues, inadequately responsive for others, and adequately responsive for the majority of issues. A rating of category 2 is assigned to this criterion. D. Enforcement History The ORPMs reviewed the Trojan inspection reports during the rating period; however, no basis exists for an NRR evaluation of the criterion insofar as applicability to licensing actions is concerned. E. Reporting and Analysis of Reportable Events The licensee keeps the NRR staff informed in a timely manner of significant plant events that have licensing implications. Based upon our observations during the rating period, a rating of Category 1 is assigned to this criterion. F. Staffing (Including Management) The licensee has an appropriate level of staffing as far as licensing actions are concerned. Based upon our observations during the rating period, a rating of Category 1 is assigned to this criterion. G. Training and Qualification Effectiveness In our review of selected licensing actions, we paid particular attention to the training and qualification of licensee personnel working on the licensing submittals. We noted in our review of snubbers that the licensee's representatives did not appear to understand the concept of " standard technical specifications," and the uniform application of regulatory requirements except where deviations are justified on a plant specific basis. We believe that there is a need for additional training in this area. We also noted in our review of Generic Letter 82-16 that the licensee's representatives, or their supervisors, need training in responding to generic regulatory guidance such that the responses address the technical safety issues involved and modifications to guidance are limited to those changes which provide an equivalent level of protection or are based on unique, plant specific characteristics. There was also a training problem detected in LCA 99 for af ter three submittals there are still problems with the submittal. On the other hand, we noted for some reviews that the licensee's representatives were well trained and qualified. Two noteworthy examples are ATWS Item 4.1 and LCA 97. Based upon the discussion above, the rating of category 2 is assigned to this criterion. l ! i
' ., 20 H. Housekeeping and Control Room Behavior During our site visits, we paid particular attention to plant housekeeping and behavior of personnel _in the control room. We have noted that plant housekeeping is good and the behavior of personnel in the control room satisfactory. Based upon our observations during the rating period, a rating of Category 1 is assigned to this criterion. ' I. Significant Hazards Considerations Determination Analysis in License Change Applications Although significant hazards considerations determination analysis in license change applications is not a formal criterion in the SALP evaluation, we feel that it is necessary in this case to provide an - evaluation. Paragraph 50.91(a)(1) of Title 10 of the Code of Federal Regulations requires the licensee requesting.an. amendment to provide an analysis, using the standards in 10 CFR 50.92, about the issue of no significant hazards consideration. The standards in 10 CFR 50.92 are sometimes called the three factor test. We need this information in making a proposed determination or a final dete rmination. The NRC published guidance in the Federal Register (48 FR 14870) giving examples of actions which are likely and not likely to involve significant hazards considerations. We can use this information, if provided, in making a proposed determination, but it doesn't relieve the licensee from the requirements of providing an analysis using the standards in 10 CFR 50.92. The word " analysis" was purposely placed in the regulation to preclude a licensee from answering either yes or no for each factor of the three factor test. We paid particular attention to the licensee's significant hazards considerations determination analyses for license change applications during the rating period. We have found most of them to be inadequate. Earlier in the rating period, the licensee's no significant hazards considerations determination analysis consisted of citing an example of an action which would not likely involve significant hazards considerations. The three factor test was not discussed at all. This approach was unacceptable and the licensee was so advised. Later in the rating period, the licensee started using the words of the three factor test but did not perform the test. In general, the licensee provided a discussion and then concluded the discussion with the words of the three factor test. This is still inadequate but an improvement over past practices. The correct determination method that the licensee should adopt is to perform the three factor test for each change, and each factor should be analyzed on an individual basis. Examples of adequate significant hazards consideration determinations can be found in submittals by Duke Power and Iowa Electric Power and Light. On the basis of the above discussion, a rating of category 3 is assigned to this criterion. - - . - - .
. ., 21 s ' Conclusions: A large number of multi-plant and plant specific licensing actions were completed during the rating period. Some of them were the result of many years of effort on the part of the staff and the licensee. Many TMI related licensing actions are progressing on an acceptable level. The licensee has demonstrated various degrees of (1) management involvement and control in assuring quality, (2) resolution of technical issues from a safety standpoint, (3) responsiveness to NRC initiatives, and (4) training and qualification effectiveness in the support of licensing actions. The licensee keeps the staff informed in a timely manner of significant plant events that have licensing implications and has an appropriate level of staffing as far as licensing actions are concerned. We have noted that plant housekeeping is good and the behavior of personnel in the control room satisfactory. The licensee does not place enough emphasis on the significant hazards consideration discussion in license change applications. A complete performance rating of Category 2 has been assigned by the NRC SALP evaluation effort for the rating period. Recommendations: We recommend that the licensee ensure that all licensing submittals have an adequate level of management i'nvolvement and control in assuring quality, an adequate approach to resolution of technical issues from a safety standpoint, adequate responsiveness to NRC initiatives and adequate training and qualification effectiveness in the preparation of licensing submittal'se - 1 The licensee needs to raise i ainimum' standards for these criteria. , . e 3 We also recommend that the licensee continue'to keep the' staff informed in a timely manner of .significant plant events _ that have licensing implications and continue the appropriate level of , staffing as far as licensing actions are concerned. We recommend that the licensee continue'its' good plant housekeeping practices and continue to insure satisfactory behavior of personnel in the control room. Lastly, we recommend that the licensee place additional emphasis on the quality of the significant hazards consideration discussion in license change applications. , 11. Engineering and Construction Inspection efforts in this area focused on reviews of plant modification work and engineering response to plant problems. One violation was noted in this area concerning failure to properly document activities associated with (trading' of the spent fuel pool. One LER was submitted in this area detailing' flow rate problems with the service water system. Several engineering deficiencies were noted by the inspectors in this j functional area. The licensee had made an incorrect determination of the l
. 22 % lower performance limits of the residual heat removal pumps. A [ contributing factor in this area appears to have been the informkA method in which corporate and site engineering personnel co unicated. The error occurred in early 1983 and the licensee cont n s'that measures taken in response tolother previously identified engineering problems has improved thjd precq'nTg manner of doing technical work. Other minor _ errors noted'includb' improper calibration of the pressurizer pressure instruments and errors made in a license change application dealing with the heatup-cooldown curves for the reactor coolant system. These technical errors in combination with other problems noted by the licensee resulted in the NRC questioning the need for reinforcement of the licensee's review of technical work. Licensee management apparently shared this concern. At the close of the assessment period, the licensee was preparing to present to the NRC their nsiderations in this area. Another area of concern reviewed durin is assessment period was the reliability of the auxiliary feedwater system. Following a plant trip in July, both safety-related AFW pumps tripped sequentially due to low suction pressure. Although AFW flow was not totally lost during this event, review of the circumstances indicated weaknesses in the testing of the system following modifications made in 1980. The overall poor performance history of the AFW system resulted in a management meeting being held between the NRC and the licensee to discuss actions to be taken. At this meeting, the licensee described the actions they have planned to increase the reliability of the system. Other technical concerns under review by the licensee at the close of the assessment period included evaluation of the affects of snubber failures identified during the outage and review of a residual heat removal failure mechanism which could potentially affect both trains. The inspectors' review of the engineering effort made to understand and correct problems with the flow rates in the service water system indicated that this effort was broad in scope and thorough. Other actions which appeared well directed that have been observed by the inspectors included mock up training for modifications made to the seal table, engineering ef forts underway to monitor the secondary plant for pipe erosion, and overall plant actions to limit the introduction of oxygen into the steam generators. Another positive action has been the formulation of a system's engineer program. Although this program was only recently implemented, the successful future conduct of the program appears to have the potential to more accurately trend and maintain the plant safety systems. Conclusion: Performance Assessment - Category 2. Board Recommendations: The licensee should strive.to ensure the successful implementation of the systems engineer program. Efforts to upgrade the reliability of the AFW system should receive high priority. Management should reinforce the _
- . 23 '. . importance of strong technical reviews with all nuclear division departments. 12. Training The functional area of training is a newly created area reviewed for this SALP period. The training area includes the training programs for licensed and non-licensed operators, maintenance personnel, radiological protection and chemistry technicians, craft personnel and onsite technical staff and managers. During this SALP cycle the resident and regional based inspectors reviewed various aspects of the licensee's training program. The licensed operator training program appeared to be a positive contribution to plant operations. This was characterized by an above average passing rate based on Region V data for reactor (78%) and senior reactor operators (100%) written exams. The licensee has instituted an expanded training program for their reactor and senior reactor operators. This training consists of three weeks of theory, systems, and procedures, one = week of emergency instructions, one week of technical support center computer practice, and one week of simulator training. , The licensee is pursuing INPO accreditation for their operators, shift technical advisors, and for their maintenance and technician training programs. The INPO evaluation team reviewed ,the licensee's operator training program in September 1985, and the present time frame for accreditation is December 1985 for licensed operators and non-licensed c operators. The time frame for accreditation for shift technical, advisor programs, and for the maintenance and technician programs (is August 1986. During this SALP period, no enforcement items'were'i's' sued. ' Conclusion: - Performance assessment - Category 2. This is a new SALP functional area; no previous rating. Board Re' commendation Licensee management is encouraged to maintain their increased support of the retraining and replacement training program. - Y k L'
e 1 , ' 24 g . 3 n-J ' , 1 ! V. SUPPORTING DATA AND SUMMARIES ' - . 1. [icensee Operations Activities / lThe" facility' began increasing power from 90% steady-state conditions at 0740 on November 1 and reached 100% power at 0910. Full power steady-state operation was maintained for nearly the entire month with power reductions to 90% for main turbine control valve testing on November 9, 16, and 23. The facility operated at 100% power during December with the exception of a power reduction to 90% on December 7 and 21 for routine turbine control valve testing. Problems with the steam generator water level control system.were experienced on December 5 and 11. The main feedwater pump master controller and feedwater regulating valve controllers were promptly placed into manual and steam generator water levels restored. Two control circuit modules were replaced in the steam generator water level control system circuitry, one of which subsequently failed and had to be repaired. The facility entered the month of January 1985 operating at 100% ' po'wer. Power was temporarily reduced to 90% on January 4 and 18 for . reitine turbine control valve testing. . At 02i9,on January 24 during routine testing, it was determined that - 'shutdous bank C and D would not move due to a rod control system logic cabinet balfunction. A power reduction was commenced at 0819 tg shutdown the plant to comply with the 6 hour action statement of STS 3.1.3.1.b concerning inoperable control rods. Power was stabilized at 35% when it was determined that the plant did not need to be shutdown since the affected shutdown banks were actually still operable (i.e. could still be tripped). Despite the rod control system failure, the shutdown banks could still be tripped into the reactor which is their design function. Two faulty printed circuit cards in the rod control system were replaced. The plant was then returned to 100% power at 1320 on January 25 following elimination of axial flux difference " Penalty Time" accumulated during the power decrease. The facility entered February at 100% power and maintained that level for nearly the entire month. Short duration power reductions to 90% were'uade for main turbine control valve testing on February 1, 1985 (0020 through 0110), February 1, 1985 (1200 through i 1601),< and on February 28, 1985 (2320 through 0130 - March 1). Th2 facility entered March at 100% power and set a new generation record for days on-line, surpassing the old record of 133 days on March 3. The new record of 139 days was established at 2150 on March 9 when the main turbine tripped on high bearing vibration signal causing an~ automatic reactor trip. The pressure surge caused " by main feedwater isolation ruptured a 14-inch diameter pipe on the discharge of the 'N' heater drain pump (HDP). One operator received first and second degree burns and was hospitalized. f
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25 '.
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I i The water / steam release in the turbine' building caused extensive damage to lighting, cable trays, parts of the electric AFW pump, condenser, and several deluge and~ sprinkler systems. An ultrasonic test of the ruptured pipe showed a wall thickness of 90 mils vs. the required 280 mils. The cause of the wall thinning was erosion / corrosion downstream of a throttle valve. No cause has been determined for the turbine high vibration signal. The facility was cooled down to Mode 4 at 1020 on March 10 and maintained on RHR. Due to the large loss of water inventory, demineralized water was trucked in from a PGE gas turbine plant. At 1344 on March 13 a spurious safety injection occurred. Both SI pumps were inoperable per S.T.S 3.5.3.2 (Mode 4); all other ESF equipment actuated as required. Cause of the SI was traced to a faulty bistable that in the tripped position, unblocks the permissive that allows SI to be blocked below 1915 psig. Since I&C had another bistable already tripped for a test, the 2/3 logic unblocked the low pressure SI signal; with RCS pressure at 350 psig, the SI occurred. The bistable was replaced. The main generator was synchronized to the grid at 1323 on March 16. Power reached 90% on the 17th at 0021 and was maintained at steady-state with only the south heater drain pump in service. The facility averaged between 98% and 100% power for the month of April 1985. Operations slEP slightly limited due to difficulty in controlling feedwater heater levels due to leakage in heaters 2 and 4, and erratic generation of the EHC Control System. The plant experienced some small (approximately 40 MWe) load perturbations (increases) during the month due to EHC control problems with the load limit potentiometer. The facility began the month of May operating at 99% power while preparing for the annual refueling outage. Power reduction commenced at 0100 on May 2nd as planned. Prior to shutting down the reactor, testing was performed which demonstrated that the supply of feedwater to the steam generators could be transferred from the auxiliary feedwater system to the main feedwater system without using the feedwater control bypass valves. The main turbine was tripped at 0601, and the reactor was take subcritical (Mode 3) at 0625 on May 2nd by manual insertion of the control rods. After performing required testing, cooldown of the reactor coolant system commenced at 1230 on May 3rd. The plant entered Mode 4 (Hot Shut /w.n) at 1824 on May 3rd, and entered Mode 5 (Cold Shutdown) at 03 Cy May 4th. The plant entered Mode 6 (Refueling) at 1830 on s M: 5 27 h. cot. & loading began at 2345 on May 17th, and was completed at 1620 on May 22nd. The lower internals were removed on May 23rd in preparation for inservice inspection of the reactor vessel welds, with the inspection being completed at month's end. On May 21st, an inadvertent safety injection occurred during testing of stream line pressure transmitters. One group of instrument technicians was testing reactor protection and engineered safeguards feature signals s
r . y 26 'L , , in Protection Set I while another group of instrument technicians i was performing calibration checks on the steam pressure signals at the same time, completing the logic required for a safety injection based on one steam line being 100 psid lower in pressure than 2 of 3 other steam lines. , The facility entered the month of June in refueling Mode 6. After ' completion of the inservice inspection of the reactor vessel, the lower internals were installed. Core reloading began at 1743 on June 4th and was completed on June 9th. After installation of the upper internals and reactor vessel head, the plant entered Cold Shutdown (Mode 5) at 1525 on June 17th. A bubble was drawn in the pressurizer on June 25th and cold control rod drop testing completed on June 26th. An inadvertent safety injection (SI) occurred on June 30th during Instrumentation and Control (I&C) testing of the reactor protection system. The plant was in Cold Shutdown at the time with RCS pressure at 350 psig. During testing of the reactor trip breakers, the low pressurizer pressure safety injection signal was inadvertently unblocked by simulating a high pressurizer pressure ' signal. Upon completion of the testing the elevated signals were removed and a'SI actuation occurred due to the actual low pressurizer pressure conditions. ' After recovering from the SI the plant entered Hot Shutdown (Mode 4) at 1830 on June 30 in preparation for a return.to power operation. ' The facility began the month of July in: Hot SNutdown and ended the month in Power Operation at 100% power. On July 1 at 0540 the plant secured heatup and cooled down to Cold Shutdown to investigate and repair a RTD bypass manifold flow blockage on; Loop A. Valve 8067A (' A' RTD bypass isolation valve) was removed, replaced, -rewelded, and the RTD bypass flow was tested satisfactorily. On July 2, the plant began heatup and entered. Hot Shutdown'at 0410 and subcritical on July 3 at 0850. Hot rod drop: testing was com'pleted satisfactorily on-July 3. At 2140'a Reactor Vessel Flange Leakoff high-temperature alarm was .receAved, ~ the inner seal was isolated and the outer seal was valved ~in. On July 4 at 0612 during recovery from the 10-year reactor coolant system Class 1 test, A and D RCS ~ loop ' first-off and second-off drain valves were determined to be leaking and at 0700 an Unusual Event was dec]sred, based on greater 3 than 10 gpm uncontrolled leakage fron. tie Reactor Coolant Drain Tank (RCDT) to the Containment Recirculat' ion Sump via the RCDT relief valve. t The RCS . loop drain valves were prouptly retorqued closed and . the leahage stopped. At 0805, the Unusual Event was terminated. On July 4 at 1630,.the plant entered criticality and the reactor was brought critical at 1712.for Low Power Physics Testing. On July 5 at 1242, the reactor was ' tripped from zero (0%) power as part of physics testing. At 1940 the turbine-generator unit was synchronized onto the grid and at 2350 the unit was disconnected from the grid as part of turbine generator testing. On July 7 at 0513, the turbine generator unit was again resynchronized with the grid. Reactor power was then increased at 3% per hour to 35%, 45%, ,
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. 50%, and 75% with holds and 10% power reductions for physics testing. On July 20 at 0706, the reactor tripped from 100% power. The trip was caused by a short circuit in the auxiliary transformer unit cooling system which tripped all of the oil circulation pumps and cooling fans. The auxiliary transformer then tripped on high winding temperature causing an electrical bus generator lockout. The generator lockout tripped the main turbine and caused a reactor trip. After the reactor trip, the diesel auxiliary feedwater pump started automatically and then tripped due to low suction pressure. The diesel AFP suction pressure. The auxiliary transformer problem was corrected and the reactor was brought critical on July 20 at 1447. At 1734 the reactor was manually shutdown due to high sodium and calcium in the condensate system. Further investigation revealed a condenser tube leak. A tube plug on the 'B' train outlet of 'C' condenser shell had become dislodged during the turbine trip and subsequent condenser pressure transient. On July 21 at 1830, the plant began a cooldown to Mode 4 to facilitate main condenser repairs and allow secondary water chemistry cleanup. In order to maintain uninterrupted auxiliary feedwater pump operation during auto starting, tests were conducted on both pumps to determine discharge valve positioning, required net positive suction head, and optimum time delay for suction pressure trips. On July 21 at 1035, the plant entered Mode 3 and criticality was attained at 2233 on July 24. The turbine generator was synchronized at 0502 on July 25. The plant returned to full power and remained there through the end of July. The facility entered the month of August in Mode 1 at 100% power. Except for the turbine control valve testing on 2, 16, and 29 of August, no major power reductions occurred with the exception of the August 26 plant trip. Due to warm summer weather, slight decreases in turbine load were necessary due to high condenser back pressure. The warm weather caused higher transformer temperatures on August 16 and main transformer spray cooling was initiated to maintain full power operation. At 1155 on August 26, the reactor automatically tripped from full load. The reactor trip was caused by an instrument and control technician accidentally shorting a heat trace circuit on the flow instrument (FI-3043C2) while Reactor Protection Set IV was tripped for routine testing (PICT-11-1). The short caused a voltage dip on preferred 120 vac bus Y13 which supplies Reactor Protection Set III. The voltage dip caused several bistable.s to actuate in Protection Set III, thus completing 2-out-of-4 trip logic for multiple reactor trips in coincidence with Protection Set IV. The trip-was immediately identified and corrective action taken to correct the heat trace circuit. The Trojan staff is presently re-evaluating the adequacy of preferred instrument power supplies. At 2041 on August 26, the reactor was taken critical. At 2107, a turbine trip occurred during turbine ~ roll testing from-steam - . - - - - - - - - - - - - - - - - - . - - - - - - - - -
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generator C water level swell which occurred when turbine control valve CV-2 came off its closed seat position. This trip caused a feedwater isolation signal, main feed pump trip, and auxiliary feedwater system automatic actuation. Steam generator levels were returned to normal and the main turbine was synchronized to the grid at 2207. The plant continued through the month at full power without incident. The facility entered the month of September in Mode 1 at 100% power. On September 9th, pressurizer safety valve leakage increased to roughly 4 gpm, with tailpipe temperatures indicating leakage from the 'B' and 'C' safety valves. Reactor Coolant System (RCS) pressure reductions to 2100 psig and then to 2010 psig were made in an unsuccessful attempt to reseat the safety valves. At 0838 on September 24th, a reactor trip occurred due to lo-lo level in the 'D' steam generator. The south main feedwater pump had tripped at 0836 due to low suction pressure resulting from condensate flow oscillations caused by cycling the 'E' condensate demineralizer outlet valve for maintenance repair. The trip of the main feedwater pump initiated an automatic turbine runback; however, the runback was unsuccessful in preventing the 'D' steam generator lo-lo level reactor trip. The decision was then made to cooldown to cold shutdown to repair the pressurizer safety valves. Cold shutdown was entered at 1550 on September 25th, and the plant remained shutdown for the rest of the month. The facility entered the month of October in a suberitical state at no-load operating temperature and pressure. At 0446 on October 1, 1985, the reactor attained criticality, and at 0948, the turbine gencrator unit was synchronized with the grid and remained on line for the rest of the month. During the SALP interval the facility experienced four unplanned reactor trips. Three trips were caused by equipment failure and one trip was caused by operator error. The facility experienced three safety system actuations during the SALP interval. Major outage activities included: refueling of the reactor, complete ultrasonic inspection of the reactor vessel welds, local leak rate testing of containment penetrations, steam generator sludge lancing, perform steam generator T-tube inspection, and reactor trip breaker auto shunt trip modification. 2. Inspection Activities' Two NRC resident inspectors were onsite for most of the SALP period. A total of 38 resident inspector and region-based inspections were conducted, involving approximately 3448 inspector hours. A summary l of inspection activities,is provided.in Table 1. A listing of l inspections conducted is provided in Table 5. Enforcement items identified during~this SALP period are summarized in Table 1 and listed Table 2. A total of 13 licensee event reports i ! ! '
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29 were submitted during this SALP period. A synopsis of Licensee Event Reports (LERs) is provided in, Table 3 and they are listed in Table 4. The 13 LERs were evaluated by Region V and by the Office for Analysis and Evaluation of Operational Data (AE0D). AE0D's examination of seven randomly selected LERs was conducted following the instructions and procedures described in NUREG-1022. ~AE0D's observations of areas most needing improvement for Trojan LERs are as follows: Areas [ Comments Root cause information More details should be provided. Root'cause can sometimes only be inferred from the corrective actions. Personnel error discussions Detail's should be explicitly stated; the.cause of personnel error should be discussed, (e.g. , cognitive or procedural). Contributing factors should be provided when appropriate. Manufacturer and model Component identification information number information should be included in the text whenever a component fails or is suspected to have contributed to the event because of its design. Safety train unavailability Sufficient dates and times should be included in the text to enable the reader to determine the length of time that safety system trains or components were out of service. Previous similar events Previous similar events should be referenced (LER Number) or the text should state there are none. EIIS codes Codes for each component and system involved in the event should be provided. Test presentation and The use of the outline is good, readability Text presentations should start on page 2 (Form 366A). Abstract Root cause and corrective action information should be summarized in every abstract. The space available in the abstract field should be more fully utilized. Coded fields: I
> t 30 , a. Titles Titles need to be written such that they better describe the event. Cause information is generally omitted. - i b. Operating mode Item 9, operating modey's required to be filled in. (, In conclusion, the licensee has provided adequate LERs, but, some improvements are needed in the orras as described above. 3. Investigation and Allegations Review a. Investigations During the assessment period of November 1, 1984 through October 31, 1985, the Office of Investigations (OI) did not open any investigations on the Trojan Nuclear Plant. OI presently has an Inquiry, QS-84-036 which concerns the practices of a vendor, Familian Northwest, a supplier of piping and related hardware. b. Allegations Two allegations were opened during the SALP period. Allegation No. RV-85-A-050 was received on August 13, 1985, in Region V and the allegation stated that while in Mode 5 on May 6, 1985 (Day Shift) and solid plant operation, Technical Specification 6.2.2 an administrative order requiring a minimum shift crew of six operators was violated. Allegation No. RV-85-A-051 was received on August 19, 1985, in Region V and the allegation stated that an Oregon State PUC railroad inspector potentially contaminated during site visit on August 18, 1985. Both allegations are presently being reviewed and are considered open. 4. Escalated Enforcement Actions a. Civil Penalties: None, b. Orders: None. 5. Licensee Conferences Held During Appraisal Period 2-1-85 - SALP Review Heeting (Report No. 84-35) 8-8-85 Technical Meeting - Discuss History of Equipment / - System Problems with Auxiliary Feedwater System (Report No. 85-26). 6. Confirmation of Action Letters None. - - - - - - -- - -
V ' > t 31 7. Special Reports 11-2-84 Operational Readiness Actions 11-2-84 Fire Suppression System Inoperable 11-6-84 Response to Generic Letter 84-15 - Diesel Generator Reliability 12-11-84 Report of Violation of National Pollutant Discharge Elimination System 12-12-84 Fire Suppression System Non-functional 12-31-84 Summary Report on Detailed Control Room Design Review (DCRDR) 1-4-85 NUREG-0737, item II.F.2, Inadequate Core Cooling Instrumentation 2-12-85 NUREG-0737, TMI Action Plan Item, III.D.3.4 3-1-85 Annual Report for the Trojan Nuclear Plant for Year 1984 4-2-85 Spray, Sprinkler and/or Deluge Systems Inoperable 4-17-85 Revision to DCRDR Summary Report for Trojan . 4-30-85 Operational Environmental Radiological Surveillance Program Annual Report 5-1-85 Cycle 8 Radial Peaking Factor Report. _ 6-14-85 Fire Barrier Penetration Non-functional 7-3-85 Fire Watch not Continuous' , 8-9-85 Post-accident Monitoring Instrumentation _ Channels Less than the Required Number (Condenser air ejector effluent monitor PRM-6 was inoperable) 9-3-85 Implementation Letter Report - Safety Evaluation of Reactor Vessel Level Instrumentation System 10-4-85 1985 Inservice Inspection Report 10-11-85 Fire Barrier Penetration Non-functional 10-25-85 Leak-Before-Break Evaluation for Trojan 8. Licensing Activities
., 32 % NRR/ Licensing Meetings a. None. b. NRR Site Visits February 25-28, 1985, DCRDR Audit March 10-13, 1985, Regulatory Effectiveness Meeting April 6-8, 1985, SPDS Survey September 10, 1985, ICCI Review c. Commission Briefings None. d. Schedular Extensions Granted None. e. Reliefs Granted None. f. Exemptions Granted None. g. License Amendments Issued Amendment No. 107 Diesel Generator Reliability Tech. Specs., October 4, 1985 Amendment No. 106 TSs Associated with GL 82-16 and GL 83-37, April 24, 1985 Amendment No. 105 TSs Associated with GL 83-37, April 4, 1985 Amendment No. 104 Clarify PORV Test, March 15, 1985 Amendment No. 103 Delete BIT, March 4, 1985 Amendment No. 102 TSs on Mechanical and Hydraulic Snubbers, February 6, 1985 Amendment No. 101 Delete IAEA License Condition, February 5, 1985 . Amendment No. 100 Combine STA and SRO, January 9,1935 Amendment No. 99 Appendix I, RETS, December 20, 1984 k. Emergency Technical Specifications Issued None.
, - . ') A 33 [, Orders issued None. J. NRR/ Licensee Management Conferences None. ., .
o A 34 TABLE 1 INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY (11/1/84 - 10/31/85) TROJAN NUCLEAR PLANT Inspections Conducted Inspection * Percent Enforcement Items Functional Area Hours * Effort Severity Level ** .l M M IV 1 Dev. 1. Plant Operations 1449 42.02 -1 1 ' , 2. Radiological Controls 191 5.54 1 3. Maintenance 185 5.37 -1 4. Surveillance 344 9.98 4 5. Fire Protection 38 1.10 1 6. Emergency Preparedness 229 6.64 7. Security and Safeguards 72 2.09 8. Refueling 99 2.87 9. Quality Programs and 716 20.77 1 1 Administrative controls 10. Licensing 0 0 11. Engineering and 75 2.18 Construction 12. Training 50 1.44 TOTAL 3448 100 9 1 1
- Allocations of inspection hours to each functional area are approximations
based upon NRC Form 766 data.
- Severity levels are in accordance with NRC Enforcement Policy (10 CFR
Part 2, Appendix C). Data reflects Reports 84-30 through 85-38 (85-37 omitted)
.. . . . . .. -- - _ .-. z . - - .-- - . _ . . . . - . - _ . y , M 4. 35 ' ~ 'b. . .< , J .- < t.
TABLE 2' ' c " . TROJANNUCLEARPLANTE'FORCEMENTITkIiS N ~ f
(11/1/84 - 10/31/85) ' , i Inspection Severity Functional - Report No. Subject . Level Area 84-30 Fire Protection Personnel had no IV 5 drills for the year.
85-04 f Total channel response time for IV 4 i , Reactor coolant pump undervoltage
and underfrequency reactor trips l had not been demonstrated every . 18 months. '
85-08 Testing Installation Results , i . IV 3 section of Maintenance Request (MR) + forms was left blank and unsigned '. af ter completion of quality related maintenance. i ' Deviation - Overtime Authorization . was not granted for various personnel. , I ! 85-14 Licensee failed to evaluate the . IV 2 extremity exposures due to non- penetrating radiation following i- the steam generator insert i handling occurrence. 85-16 Four of twelve SFP racks were not V 9 verified by signature as having , , t the second set of rack feet properly installed.
Danger tag number 4 of clearance IV 1 i 85-1066 was on a drain valve off i 1- the 'B' train containment spray header downstream of the contain- , ' t ment penetration. The tag was 4 shown as cleared on the clearance sheet that had been filed in the ' released clearance file.
i , ' 85-20 Companion valves of failed valves IV 4 l were not tested in accordance with ASME Section XI, Subsection -, IWV-3513.
. i I 1 ' i h ! , . - - , , - . . . . _ . , _. . . - . _ _ __ ,,.~...i,__._... m, , _ _ . . , . - - _ - - - _ .
9. t' 36 TABLE 2 TROJAN' NUCLEAR PLANT ENFORCEMENT ITEMS (11/1/84 - 10/31/85) , Inspection Severity Functional Report'No. Subj ect Level Area 85-32 Calibration of Pressurizer IV 4 Pressure Instruments. ~ 85-36 Inadequate Documentation of IV 4 Test equipment and Setpoint Tests. '85-38 Safety-Related Procurement. IV 9 " i , p , s+a f
^ t j g y; ( ,. . . . . , L.. .' < 3 - , . . . & - .,- , , \\ i t 6 9 e ,e s 3 A$ @
I 8
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- ' g -) 37 TABLE 3 SYN 0PSIS OF LICENSEE EVENT REPORTS ** TROJAN NUCLEAR PLANT Functional SALP Cause Code * Area A _B C D E X Totals 1. Plant Operations 1 0 1 0 3 0 5 2. Radiation Protection 0 0 0 0 0 0 0 3. Maintenance 0 0 0 0 1 0 1 4. Surveillance 1 3 0 2 1 0 7 5. Fire Protection 0 0 0 0 0 0 0 6. Emergency Preparedness 0 0 0 0 0 0 0 7. Safeguards 0 0 0 0 0 0 0 8. Refueling 0 0 0 0 0 0 0 9. Quality Programs and 0 0 0 0 0 0 0 Administrative Controls Affecting Safety 10. Licensing 0 0 0 0 0 0 0 11. Engineering and 0 0 0 0 0 0 0 Construction 12. Training 0 0 0 0 0 0 0 TOTALS 2 3 1 2 5 0 13
- Cause Codes:
A-Personnel Error B-Design, Manufacturing or Installation Error C-External Cause D-Defective Procedures E-Component Failure X-Other
- Synopsis includes LER Nos. 84-21 through 85-12.
L
,.
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.p. 9 38 TABLE 4 TROJAN NUCLEAR PLANT Licensee Event Reports (11/1/84 - 10/31/85) LER TITLE SALP AREA /CAUSE CODE * 84-21 Service Water System Flow Rate Problems 1/C 85-01 Incomplete Seismic Qualification of 4/B Auxiliary Feedwater Control Valve Control Elements 85-02 Turbine Trip, Reactor Trip and Subsequent 1/E Heater Drain Piping Failure- 85-03 Inadvertent Safety Injection Due to 3/E Circuit Failure 85-04 Inadvertent Safety Injection 4/A 85-05 Penetration Failed. Containment Local Leak 4/E Rate Test 85-06 Pressurizer Level Transmitters Out of Calibration 4/B 85-07 NIS Power Range Rate Trip Setpoints: Exceeded 4/D Allowable Values 85-08 Inadvertent Safety Injection 4/D 85-09 Reactor Trip Resulting From Unit. Auxiliary 1/E Transformer Cooling Failure. ' , 85-10' Reactor Trip Due to Overpower delta T 'and .1/E Over temperature delta T trip signals , 85-11 Pressurizer Pressure Instruments Incorrectly 4/B-' Calibrated . 85-12 Reactor Trip from Personnel Error Causing Loss . 1/A of Main Feedwater Pump Suction ' 4 ' i
- Cause Codes:
4 - 1 A-Personnel Error ,
B-Design, Manufacturing or Installation' Error i C-External Cause l D-Defective Procedures ! E-Component Failure l X-Other , ! i e f l i
__ - . ~ O t 39 TABLE 5 Inspections Conducted Report No. Dates Inspector (s) Area Inspected Hours 84-30 11/5-9/84 Engineering Fire Protections 46 84-34 11/5-12/21/84 Residents Routine Monthly 133 Inspection 84-35 9/1/83-10/31/84 Staff SALP 200 85-01 1/7-11/85 Radiation Radiological' 51 Specialist Organization and Management 85-02 1/7-11/85 Reactor Projects Procedures, Indepen- 38 dent Inspection Effort 85-03 1/18-2/8/85 Emergency Prep. Emergency Planning 70 85-04 1/7-2/15/85 Residents Routine Monthly 173 Inspection 85-05 2/4-3/1/85 Safeguards Security / Safeguards 37 85-06 1/21-25/85 Reactor Projects TMI Action Plan 57 Inspection Followup LER Followup 85-07 1/28-31/85 Engineering Inservice Inspection 30 85-08 2/11-15/85 Operations Team Inipection 208 85-09 2/25-3/1/85 Radiation Radiological Protec- 73 Specialist Lion, Plant Chemistry, Training, Qualifications 85-10 2/25-4/1/85 Residents Routine Monthly 178 Inspection 85-11 2/11-3/1/85 Reactor Projects Follow IE Circulars, 76 Information Notices, Bulletins, Part 21 Followup 85-12 2/1/85 Staff SALP Management 15 Meeting _ _ _ _ _ _ _ _ - _ _ _ _ _ _ __ __ _ __
o 0 t' 40 TABLE 5 (Cont'd) Inspections Conducted Report No. Dates Inspector (s) Area Inspected Hours 85-13 4/2-5/13/85 Residents Routine Monthly 266 Inspection 85-14 5/13-30/85 Radiation Outage Exposure, 37 Specialist ALARA Program, Followup Inspt. Identified Problems 85-15 5/13-17/85 Reactor Projects Design Changes and 36 Modification Program Maintenance Routine 85-16 5/14-7/1/85 Residents Routine Monthly 305 Inspection 85-17 6/3-6/7/85 Engineering Inservice Inspection 58 Procedure and Data Review 85-18 6/3-6/7/85 Reactor Projects Offsite Staff and 37 Committee Review 85-19 5/30-6/6/85 Radiation Radiological Controls 2 Specialist Test Sample Results 85-20 6/12-21/85 Engineering Surveillance 100 Procedures and Records 85-21 7/2-8/30/85 Residents Routine Monthly 342 Inspection 85-22 7/22-26/85 Engineering Followup on Salem 70 ATWS Events 85-23 7/29-8/2/85 Reactor Projects Document Contral 36 Program Test and Measurement Equipt. Program 85-24 8/5-8/9/85 Radiation Internal Exposure, 36 Specialist transportation, facility tour, and followup on IE Information Notices
f a e 4 41 l N
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TABLE 5 (Cont'd) Inspections Conducted Report No. Dates Inspector (s) Area Inspected Hours 85-25 8/9-8/16/85 HQ VPB Effectiveness of 183 Vendors of Safety- Related equipment 85-26 8/8/85 Reactor Projects Management Meeting 36 on Auxiliary Feed- water system past history and reliability 85-27 8/26-9/23/85 Security Security Safeguards 35 85-28 10/14-18/85 Emergency Emergency Planning 181 Preparedness 85-29 8/26-30/85 Engineering TMI items, open 42 items followup, Followup IE Circulars, INF0, Bulletins 85-30 9/9-13/85 Reactor Requalif. Training 72 - 9/23-9/27/85 Projects Program , 85-31 9/9-9/27/85 Radiation Radiological'and 60 , Specialist
- Chemistry Confirma-
- ,
' tory Measurements, Water Chemistry Control and Chemistry . Analysis 85-32 8/31-10/2/85 Residents Routine Monthly 170 Inspection 85-34 10/3-11/16/85 Residents Routine tfonthly Inspection 85-36 10/21-25/85 Reactor Instrument and 39 Projects Electrical Main- tenance and Open items Followup V 85-38 10/30-10/31/85 HQ %PB Effectiveness of 76 Engineering Vendors of Safety- Related Equipment Followup Inspection }}