ML20141A239
| ML20141A239 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 06/13/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20141A231 | List: |
| References | |
| 50-333-97-04, 50-333-97-4, NUDOCS 9706200189 | |
| Download: ML20141A239 (36) | |
See also: IR 05000333/1997004
Text
. . _
. . _ _ _ _ . - _ _ . _ _ _ _ - _ . _ _
_ __
_.
,
t'
.
-
,
..
.
U.S. NUCLEAR REGULATORY COMMISSION
Region I
l.icense No.:
Report No.:
97-04
l
!
Docket No.:
50-333
,
Licensee:
New York Power Authority
!
Post Office Box 41
Scriba, New York 13093
l
i
Facility Name:
James A. FitzPatrick Nuclear Power Plant
!
i
Dates:
April 13,1997 through May 25,1997
f
Inspectors:
G. Hunegs, Senior Resident inspector
l
R. Fernandes, Resident inspector
!
K. Cotton, Project Manager
!
J. McFadden, Radiation Specialist
W. Schmidt, Senior Resident inspector
R. Skokowski, Resident inspector
j
,
Approved by:
John F. Rogge, Chief, Projects Branch 2
Division of Reactor Projects
_
9706200189 970613
ADOCK 050LJ333
G
. - - _ _ _ _ _ _ _ _ _ _ .
.-
.-
EXECUTIVE SUMMARY
James A. FitzPatrick Nuclear Power Plant
NRC Inspection Report 50-333/97-04
Operations
On May 17, the licensee commenced a downpower to take the generator off line in
order to make repairs to a 345 KV line bolted connection in the switch yard. The
licensee's decision to take the unit off line to conduct repairs demonstrated a sound
thought process with a solid safety focus. Operators demonstrated good control of
the plant during the evolution.
The process to control operator workarounds appeared to be functioning well and
received good management attention.
The licensee is in the process of completing licensed operator requalification
examinations. On May 21,1997, the inspector observed simulator scenarios
conducted for an operating crew examination and noted that licensed operators
demonstrated solid performance.
,
An NRC team inspection was conducted to evaluate the effectiveness of licensee
controls in identifying, resolving, and preventing issues that degrade the quality of
plant operations or safety. These licensee controls include safety review
committees, root-cause analysis programs, corrective action programs, self
assessment programs, and other processes that provide for incorporation of
operating experience feedback.
The licensee implemented an effective problem identification and corrective action
program. The Plant Operation and Safety Review Committees provided an
appropriate level of oversight and the well supported Quality Assurance audits were
considered to be a strength. Additionally, licensee management was actively
involved in the self-assessment and corrective action process.
Based on interviews, the licensee has increased their awareness of human
performance issues and recently implemented semo programs to reverse the past
negative trends in human performance.
Maintenance
i-
Both the technical issue report and the maintenance rule processes appear to be
working hand-in-hand to allow proper management attention to system performance
issues. System engineers understood the problems of their particular systems.
However, based on equipment performance, it appeared that the licensee's previous
corrective actions taken to address emergency service water and primary
containment isolation valve issues were not fully effective.
ii
l
. . . _ .
_._
__
. _ . _ _ _ _
_ . _ _ _ _ . _.-__
_. _.
< .
.
4
d
-
.
,
.
Executive Summary (cont'd)
1
An anonymous concern about the quality of maintenance performed by a valve
'
maintenance contractor during the 1996 outage was brought to the licensee's
employee concern program through a handwritten report. The licensee's initial
i
review, followed up with a subsequent review of valve operating history, provided
!
an acceptable level of confidence that valve maintenance performed by the vendor
was adequate and had not contributed to system performance issues. Although
j
there were several valve maintenance performance issues identified during the
outage, those issues were addressed through the licensee's corrective action
'
program.
i
The inspectors considered the strong operations background of the work week
l
managers to be a positive attribute of the work control organization. Corrective
I
actions associated with identified work control process weaknesses have been
effectively implemented and an improved questioning attitude was noted. The
1
weekly and special evolution critiques were a good tool for the identification and
i
correction of problems within the work control process.
l
Enoineenna
l
i
Overall, good management oversight of the temporary modification program was
j
evident. The older temporary modifications appear to lack engineering support but
are not safety significant. The number of temporary modifications has been
'
consistent over the past two years and does not appear to adversely impact plant-
operations.
The licensee's response and planned corrective actions to the nonconforming scram
solenoid pilot valves demonstrated a good safety focus.
Plant Sucoort
Overall, the licensee's corrective action program for the radiological protection
program was acceptable. Identification and characterization of deviations and
events were also acceptable, however, weaknesses were identified in review for
extent of condition and in response to repetitive problems. Also, the evaluation and
documentation of each identified deviation and event for generic implications was
)
considered to be a weakness. The elevation of identified deviations and events to a
'
proper level of management was adequately addressed. Self-identification of
problems by front-line personnel and their willingness to do so seemed to be
increasing,
iii
.
.
. . - .
. . - _ -
- - . -
. . - - . -
- - - - .
. .
. .-
_ ~
. . . - . . --
.-
!
..
l
Executive Summary (cont'd)
l
!
'
Two separate incidents concerning improper entry into a radiological controlled area
l
{
occurred on April 16,1997. Also, in December,1996, two radiation workers did
'
'
not adhere to the radiation work permit, disregarded radiological posting
,
requirements and one worker improperly used the portal monitor. These failures of
j
radiation workers to comply with radiation protection instructions are a violation.
!
!j
As there have been several other cases where mistakes have been made concerning
radiation protection requirements, it appears that corrective actions for previous
'
,
similar licensee findings were not fully effective.
4
I
!
..
h
l
t
!
I
i
!
.
.iv
!
.-
l
..
TABLE OF CONTENTS
1
EXEC UTIVE S U MM A RY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ii
............
TA B L E O F CO NT E NTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Summ a ry of Pla nt Statu s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. O P E R AT I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
01
Conduct of Operations . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 1
01.1 General Comments
1
.................................
01.2 345 KV Boited Connection Repair . . . . . . . . . . . . . . . . . . . . . . . 1
01.3 Operational Safety Verification . . . . . . . . . . . . . . . . . . . . . . . . . 2
01.4 Operator Workarounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
O2
Operational Status of Facilities and Equipment . . . . . . . . . . . . . . . . . . . 4
O2.1 Engineered Safety Feature System Walkdowns
4
.............
05
Operator Training and Qualification . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
05.1 Licensed Operator Requalification Training . . . . . . . . . . . . . . .
4
.
07
Quality Assurance in Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
07.1 Corrective Action Program Overview . . . . . . . . . . . . . . . . . . . . 5
07.2 Problem Identification and Corrective Action
5
...............
07.3 Plant Operations Review Committee . . . . . . . . . . . . . . . . . . . . . 6
07.4 Safety Review Committee (inspector Followup Item 50-
3 3 3 /9 7 0 04-01 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
07.5 Quality Assurance Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
i
07.6 Self Assessment Program . . . . . . . . . . . . .
11
..............
07.7 Human Performance
11
...............................
11. M A I NT E N A N C E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
M1
Conduct of Maintenance
12
)
.................................
M 1.1 General Comments
12
................................
M1.2 General Comments on Surveillance Activities . . . . . . . . . . . . . . 12
j
M1.3 Conclu :ons on Conduct of Maintenance . . . . . . . . . . . . . . . . . 13
M3
Maintenance Procedures and Documentation . . . . . . . . . . . . . . . . . . . 13
M7
Quality Assurance in Maintenance Activities
14
...................
M7.1 Valve Maintenance Performed by a Contractor . . . . . . . . . . . . . 14
)
M7.2 Work Control
15
'
....................................
M8
Miscellaneous Maintenance issues
17
..........................
M8.1 (Closed) Unresolved item 50-333/95001-01
17
..............
,
M8.2 (Closed) LER 5 0-3 3 3 /9 5 00 8 . . . . . . . . . . . . . . . . . . . . . . . . . . 17
M8.3 (Closed) LER 5 0-3 3 3 /9 601 1 . . . . . . . . . . . . . . . . . . . . . . . . . . 17
M8.4 (Closed) Violation 50-3 3 3/9 600 2-01 . . . . . . . . . . . . . . . . . . . . 18
111. E N G I N E E RI N G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
i
El
Conduct of Engineering
18
..................................
E1.1
Control of Temporary Modifications
18
....................
E2
Engineering Support of Facilities and Equipment . . . . . . . . . . . . . . . . . 19
v
j
i
-
.
-
,
- - . _ .
- - - - .
. - - - . .
- -
- .
.
-.
-
. . --
.
-
.
.-
Table of Contents (cont'd)
E2.1
Nonconforming Scram Solenoid Pilot Valves
19
..............
E8
Miscellaneous Engineering issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
E8.1
(Closed) Violation 5 0-3 3 3/9 500 6-02 . . . . . . . . . . . . . . . . . . . . 20
E8.2 (Closed) LER 50-333/96-005
20
.........................
E8.3 (Closed) Inspector Followup Item (IFI) 50-333/92014-01
21
.....
E8.4 (Closed) Unresolved item 50-333/95002-01
22
..............
I V. PL A NT S U PPO RT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
R7
Quality Assurance in Radiological Protection and Chemistry (RP&C)
.
Activities
22
............................................
R7.1
Effectiveness of Licensee Controls in Identifying, Resolving,
1
and Preventing Problems
22
j
............................
R7.2 Improper RCA Entry by Escorted Visitors (Violation 50-
3 3 3 /9 7004-0 2 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
R8
Miscellaneous RP&C lssues (VIO 50-33 3/97004-02) . . . . . . . . . . . . . . 25
R8.1
(Closed) Unresolved item 50-333/95002-02 and EA 96-096 . . . 25
R8.2 (Closed) Unresolved item 50-333/96008-03
25
..............
F8
Miscellaneous Fire Protection issues . . . . . . . . . . . . . . . . . . . . . . . . . 25
F8.1
(Closed) Enforcement (EA) 50-333/95-142
25
...............
V. MANAGEMENT MEETINGS
26
.......................................
X1
Exit Meeting Summ ary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
X2
Review of UFSAR Commitments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
X3
Pre-Decisional Enforcement Conference Summary
26
...............
i
l
I
i
!
l
i
i
!
!
l
vi
_
.
. . . _
_.
_
__
.
.
Report Details
Summarv of Plant Status
The unit began this inspection period at 100 percent power. On May 17, the unit was
taken off line to effect repairs to a bolted connector on the 345 KV line. The plant was
returned to 100 percent power on May 19. On May 24, the number 3 turbine control
valve failed open. As the valve is normally full open, all pre-transient plant parameters
remained normal. The licensee began a plant shut down to make repairs. Originally, the
licensee intended to shut the valve manually, however, the valve would not operate. At
70 percent reactor power, the licensee inserted a manual reactor scram and tripped the
main turbine. Shutdown cooling was entered on May 25 and the licensee implemented a
short forced outage.
1. OPERATIONS
01
Conduct of Operations'
01.1 General Comments
The inspectors conducted frequent reviews of ongoing plant operations. In general,
operations were conducted well. Specific events and noteworthy observations are
detailed in the sections below.
01.2 345 KV Bolted Connection Repair
a.
Inspection Scope
The main generator provides power through transformers which step up the voltage
to 345 KV for distribution to the electrical grid. The licensee had been monitoring a
345 KV bolted connection located in the switchyard which was showing signs of
degradation. Due to a rapid increase in a thermography reading, the licensee
j
elected to take the unit off line to conduct repairs. The inspector reviewed the
j
work package and discussed the activity with operations and engineering personnel.
b.
Observations and Findinas
On May 17, the licensee commenced a downpower to take the generator off line in
order to make repairs to a 345 KV line bolted connection in the switch yard. The
licensee performs routine predictive maintenance on the bolted connections using
thermography. Inspection showed that the bolted connection was not tight, which
caused increased resistance and a higher temperature. The connection was cleaned
and reassembled using guidance provided by the manufacturer. Other connections
on the 345 KV line were checked and were satisfactory. The cause for the
j
connector degradation was indeterminate, but the licensee stated that it was
,
' Topical headings such as 01, M8, etc., are used in accordance with the NRC standardized
j
reactor inspection report outline. Individual reports are not expected to address all outline
topics.
1
.
,
.
2
possibly due to less than optimum original installation which caused slow
degradation over time.
i
The licensee had evaluated performing the repair wit.i the unit "n line. However
i
due to the nature of and risks associated with the job, the licensee concluded that it
was more prudent to take the unit off line to conduct the repair.
I
i
C.
Conclusions
'
The licensee's decision to take the unit off line to conduct the repair demonstrated a
j
sound thought process with a solid safety focus. Operators demonstrated good
control of the plant during the evolution.
01.3 Operational Safety Verification
The inspectors observad plant operation and verified that the facility was operated
2
safely and in accordance with procedures and regulatory requirements. Regular
tours were conducted of the plant with focus on safety related structures and
systems, operations, radiological controls and security. Additionally, the operability
of engineered safety features, other safety related systems and on-site and off-site
power sources was verified. No safety concerns were identified as a result of these
tours.
The inspection activities during this report period included inspection during normal,
backshift and weekend hours. Regular tours were conducted of the following plant
areas:
control room
,
secondary containment building
radiological control point
electrical switchgear rooms
,
emergency core cooling system pump rooms
'
security access point
protected area fence
intake structure
diesel generator rooms
i
Control room instruments and plant computer indications were observed for
correlation between channels and for conformance with technical srecification (TS)
requirements. Operability of engineered safety features, other safety related
systems and onsite and offsite power sources wt > varified. The inspectors
observed various alarm conditions and confirmed .r.:.t operator response was in
accordance with plant operating procedures. Compliance with TS and
,
implementation of appropriate action statements for equipment out of service was
inspected. Plant radiation monitoring system indications and coolant stack traces
were reviewed for unexpected changes. Logs and records were reviewed to
determine if entries were accurate and identified equipment status or deficiencies.
These records included operating logs, turnover sheets, system safety tags, and
.
.-
i
3
temporary modifications. Control room and shift manning were compared to
regulatory requirements and portions of shift turnovers were observed. The
inspectors found that control room access was properly controlled and that a
professional atmosphere was maintained. Daily supervisor meetings were attended
to assess personnel focus on risk significant items and plant priorities.
Specific plant issues which were followed up on included control rod drive hydraulic
control unit TS issues,345 KV line maintenance, fire protection hoso station
storage, uninterruptible power supply (UPS) motor generator (MG) set maintenance.
a low lube oil pressure alarm on "D" emergency diesel generator (EDG) and licensed
operator requalification training. These issues were managed effectively by the
licensee.
01.4 Operator Workarounds
j
a.
Inspection Scone
The inspectors revievied the licensee's program used to identify and track operator
workarounds and also discussed the status of workarounds with plant operator and
maintenance personnel,
b.
Observations and Findinas
The licensee uses a quarterly surveillance test (ST) 99H, Operator Workarounds
-
Assessment, to document the workaround, the procedures affected and the
compensatory measure in place. The procedure provides a good format for
identification and dc4cumentation of workarounds and the evaluation criteria for
workarounds appeaied to be well organized, enabling operators to assess the
impact on plant operations. The licensee defines an operator workaround as any
deficiency that would require compensatory operator actions in the execution of
normal operating prc,cedures, abnormal operating procedures, emergency operating
procedures, or annunciator response procedures.
Equipment issues appear to be tracked well and compensatory measures appeared
adequate. Additionally, the inspectors found that the list of workarounds received
good management attention, in part through routine discussions at morning
meetings.
c.
Conclusions
i
The process to control operator workarounds appeared to be functioning well and
!
received good management attention.
. __ .__ .._ _ _ _ ._ .__
_ . , . _ _..._ _. ._._ - - . _ . _ _ _ . . _. . _ . _ _ __ . _ _ .
.___
,
j .-
i
!
'
,.
t
2
i
4
!
i
,
02
Operational Status of Facilities and Equipment
O2.1 Engineered Safety Feature System Walkdowns
,
The inspectors performed a walk down of accessible portions of the following
systems and performed general area tours:
i
eemergency diesel generator
eintake structure
eemergency service water
oresidual heat removal service water
ehigh pressure coolant injection
i
r
Equipment operability, material condition and housekeeping conditions were good.
l
I
05
Operator Training and Qualification
'
!
05.1 Licensed Operator Requalification Training
'
a.
Inspection Scope
!
The licensee is in the process of completing licensed operator requalification
'
examinations. On May 21,1997, the inspector observed simulator scenarios
conducted for an operating crew examination. The inspector discussed training
with instructors including simulator fidelity, training requirements and training
initiatives and attended the post scenario critique.
i
1
b.
Observations and Findinas
,
1
During the exercises observed, the inspector noted good use of peer checking to
j
validate decision making, good use of appropriate procedures including alarm
response procedures, abnormal operating procedures, emergency operating
i
procedures and the emergency plan and good use of three point communications by
operators.
The evaluator's critique provided constructive criticism of the crews performance
using specific evaluation criteria.
)
- c.
Conclusions
Licensed operators demonstrated solid performance during recent licensed operator
requalification examinations which were observed.
,
,
,.
r-=e.e-e--
.
. . .
- -
-.~-
,
-- -- -
-
.-
.
5
,
i
07
Quality Assurance in Operations
07.1 Corrective Action Program Overview
An NRC team inspection was conducted to evaluste the effectiveness of licensee
controls in identifying, resolving, and preventing issues that degrade the quality of
plant operations or safety. These licensee controls include safety review
committees, root-cause analysis programs, corrective action programs, self
assessment programs, and other processes that provide for incorporation of
operating experience feedback.
To assess the ability of the FitzPatrick management and staff to identify and correct
'
problems at the site, the inspectors conducted structured interviews of plant
,
personnel. The team reviewed the deficiency event report (DER) process,
equipment performance trending and use of the maintenance rule, operator
workarounds, activities of oversight committees including the plant operations
review committee (PORC) and the safety review committee (SRC), the involvement
of the Quality Assurance (QA) organization and the use of self-assessment.
.
Further, based on several recent operational events and radiological control
problems, the inspectors specifically reviewed the identification of issues and
corrective actions taken in the areas of human performance, work control and
radiological controls.
07.2 Problem Identification and Corrective Action
a.
insoection Scope
Procedures which implement the problem identification end corrective action
program were reviewed and a sample of DERs were evaluated to assess program
effectiveness.
b.
Observations and Findinas
The licensee has developed several procedures to govern the problem identification
and corrective action program. These procedures included: Administrative
Procedure (AP)-03.02, Deviation and Event Reporting; AP-03.03, Deviation and
Event Analysis; AP-03.08, Action and Commitment Tracking System; ORG-SO-
03.02, Deviation and Report Screen:ng. The procedures address the identificction,
evaluation and corrective actions process for plant deficiencies. The procedures
provided controls for tracking, trending, and closure. Causal screening levels varied
'
from A (most severe) through D (least severe) and were used to screen deviations
and events based both on degree of risk of recurrence and on significance.
Deficiency and Event Report (DER) evaluation types, included root cause analysis,
team root cause analysis, post transient review, critique, equipment failure
evaluation, written response, and none (trend only). All evaluations shall, as a
minimum, include extent of condition when appropriate.
. .
4
1
,.
]
.-
6
The inspectors determined that the DER process was effectively used to identify
.!
and document issues at a proper level for resolution and operability /reportability
)
reviews appeared to be acceptable. The equipment failure evaluations (EFEs) and
root cause analyMs enclosures to the DER procedure were well developed and
provided good ger, err' formats and guidance for conducting such evaluations. EFEs
,
and root caun ane ysis completed for several DERs in the last year were of good -
]
quality and effec +.ive corrective actions were identified.
Several minor program weaknesses were identified including the fact that
procedures do not provide for the ideltification of repeat problems, although,
personnel who review DERs have an informal process to identify repeat problems.
Additionally, documentation did not always indicate that an extent of condition
1
i
review was completed. Although the licensee stated that an extent of condition
)
consideration is always performed, the lack of documentation of this evaluation was
j
considered a weakness. The licensee's QA department has previously identified
.;
i
this concern and several other issues, and correctivs actions were in process.
!
c.
Conclusions
The licensee implemented an effective problem identification and corrective action
program. DER tracking was conducted well; specific reviews specified by
)
procedures and the associated corrective actions generally appeared good. Several
2
areas for improvement including the identification and documentation of repeat
problems and the documentation of extent of condition reviews were identified.
-
07.3 Plant Operations Review Committee
a.
Inspection Scoce
'
The inspectors assessed the Plant Operations Review Committee (PORC) activities
and verified that selected PORC activities were performed in accordance with the
]
TS. A PORC meeting was attended, applicable procedures and PORC meeting
,
minutes were reviewed and six members of PORC were interviewed.
b.
Observations and Findinas
i
The inspectors reviewed Procedures AP-01.01, " Plant Operating Review
Committee," Revision 7, and ORG-SO-03.03, "PORC Administration," Revision 0,
and verified that TS requirements pertaining to PORC were adequately included.
i
The inspectors attended PORC Meeting 97-18 held April 1,1997. The inspectors
verified that the quorum requirement was met, and that the meeting was
accomplished in accordance with the approved procedures. Although the meeting
.
briefly discussed issues related to the overall safe operation of the plant, the
meeting was focused on a review of open PORC action items. These were ACTS
'
items opened during PORC meetings that PORC tracks for closure. Of the 14 PORC
j
action items due for closure, only one item was closed, and the remaining 13 were
extended. The PORC members seemed aware of the issues associated with each
item. However, only one item was challenged to ensure there was no safety
.
,
.-
.~
7
concern that should prevent the extension. In general, the PORC members seemed
,
cognizant of the issues discussed.
1
Based on the large percentage of PORC action items extended during the April 1,
1997, meeting, the inspectors reviewed previous PORC meeting minutes to
determine the extent to which PORC action items have been extended in the past.
Of the 16 PORC items closed in 1997, eight were closed on their original due date.
The inspectors reviewed the items extended in detail and identified no safety
concerns with the extensions. The inspectors discussed the issue of PORC action
item extensions with several members of the PORC and ascertained that, routinely
due dates are selected prior to the expected completion of the work to provide
j
PORC with a working status of the item. Additionally, the PORC members
expressed that other items were extended due to more significant emergent issues,
which required the planned work to be delayed. Although a large percentage of
PORC action item due dates have been extended, no safety concerns were
identified with the extensions.
PORC recently changed the controlling procedure to include requirements to discuss
)
the " Broad Assessment of the Safe Operation of the Plant" during each meeting.
According to the PORC Chairman, this section was adde, to ensure the PORC was
looking at the " big picture" during each meeting. The information for discussion
'
was to be provided by the PORC members on an impromptu basis. The inspectors
reviewed PORC minutes for eight meetings held after the incorporation of this new
requirement. Although two of the eight meeting minutes reviewed indicated no
discussion in tNs area, the minutes for the other six meetings indicated a wide
-
range of discussion topics that t,enefited PORC. For example, PORC Meeting 9713
discussed the impact of tne recent loss of engineers from personnel resignations.
c.
Conclusions
In general, the PORC members seemed cognizant of the issues discussed. Although
a large percentage of PORC action item due dates have been extended, safety
appeared to have been appropriately considered in the extensions. PORC's initiative
to routinely discuss the broad assessment of the safe operation of the plant
enhanced PORC's ability to identify potential problems.
07.4 Safety Review Committee (Inspector Followup Item 50-333/97004-01)
a.
Insoection Scope
The inspectors assessed the Safety Review Committee (SRC) oversight activities
and verified that selected SRC activities were performed in accordance with the TS.
Applicable procedures and the scheduled SRC meeting minutes since January 1,
1996, were reviewad and the plant manager was interviewed regarding SRC
activities.
.-
.
8
b.
Observations and Findinas
The inspectors reviewed Procedures SRCP1, " Charter," Revision 12, SRCP8,
" Reviews," Revision 8, and SRCP9, " Audits," Revision 10, and verified that the TS
requirements pertaining to the SRC were either met or exceeded.
The inspectors reviewed the minutes for the six scheduled SRC meetings completed
in 1996, and determined that the SRC provided an appropriate level of oversight on
corrective actions for significant issues, as evidenced by the tracking of "significant
areas of risk." During 1996, the SRC was tracking three "significant areas of risk"
at Fitzpatrick, including Radiological and Environmental Services (RES) human
performance, corrective action programs and engineering rigor. The areas of
significant risk were discussed during each SRC meeting until the issue was closed.
In addition to the "significant areas of risk," the inspectors noted that problems
pertaining to human performance and engineering performance appeared repeatedly
in the SRC meeting minutes.
SRC was tracking RES human performance and corrective action programs as
"significant areas of risk" prior to 1996. The concern associated with RES human
performance gained SRC's attention as a result of numerous deficiencies in the RES
area. This "significant area of risk" was closed in November 1996, following
indication of adequate corrective actions through the Fall 1996 refueling outage.
The concerns associated with the corrective action program related to corrective
action implementation and the assessment of whether these actions were effective.
Based on progress made in DER evaluation timeliness and management's focus on
l
the corrective action timeliness, SRC closed this "significant area of risk" for the
licensee in July 1996. The updates regarding RES human performance and
corrective actions programs provided to the SRC, as described in the meeting
,
minutes, were thorough and provided adequate information for the SRC to evaluate
the situations,
Engineering rigor was added as a "significant area of risk" in November 1996,
based on four NRC violations described in Inspection Report (IR) 50-333/96007,
with the purpose of monitoring the thoroughness and timeliness of engineering
processes, evaluations and response to events. Prior to classification as a
"significant area of risk," the SRC discussed engineering-related concerns on several
i
occasions. These discussions were based on other NRC Inspection Reports and QA
Audit A96-04J. This QA audit identified particular concerns with ineffective
corrective actions for past engineering-related deficiencies. Therefore, based on the
concerns raised by the QA audit, previous NRC inspection findings, and the
untimely completion of engineering-related corrective actions described in Section
07.5 (QA), the adequacy of the er rrective action program for engineering issues is
'
considered an inspector followup item (IFI) (50-333/97004-01).
c.
Conclusions
The SRC provided an appropriate level of oversight on corrective actions to
significant issues during 1996, as evidenced by the tracking of "significant areas of
risk." The updates provided to the SRC, as described in the meeting minutes were
thorough, and p;ovided adegaate information for the SRC to evaluate the situations.
l
l
.
1
,.
9
l
l
The SRC's perception of the licensee appeared to be consistent with the indications
l
provided in DERs, audits, self-assessments and trending reports. Concerns
associated with the timeliness and adequacy of the corrective actions for
engineering issues is considered an inspector followup item.
07.5 Quality Assurance Activities
a.
Inspection Scope
The inspectors assessed the licensee's OA Department's ability to identify problems
and adverse trends in performance. Also assessed was the timeliness, quality and
effectiveness of the licensee's actions taken in response to QA findings. The
inspectors reviewed selected QA audits, surveillances, procedures, and QA-initiated
j
Deviation / Event Reports (DERs) and Action / Commitment Tracking System (ACTS)
'
items, and applicable licensee trending reports. The inspectors also interviewed
licensee personnel, including QA management and QA auditors.
b.
Observations and Findinas
j
The inspectors discussed the QA function with QA management and staff. The -
inspectors ascertained that the QA organization was staffed with individuals having
strong operations, engineering and maintenance experience. The inspectors found
this experience evident in the depth of the auditor's findings.
The inspectors reviewed all, or portions, of the following QA audits and
surveillances:
Audit Report A96-11J, "Results of Actions Taken to Correct Deficiencies,"
dated July 17,1996;
)
Audit Report A96-20J, "JAF (James A. Fitzpatrick] Results of Actions Taken
]
to Correct Deficiencies," dated January 27,1997;
Audit Report A96-09J, " Maintenance Activities Program Audit," dated
J
June 18,1996;
'
Audit Report A96-04J, " Design Control," dated April 12,1996; and
Surveillance 1913, " Management Controls PORC [ Plant Operations Review
Committee]/SRC [Sofety Review Committeel Activities," dated October 15,
1996.
The surveillance and audits were completed in accordance with the licensee's
Procedures, QAP 18.2 (J), " Quality Assurance Surveillance Program," Revision 1,
and QAP 18.1-J, " Quality Assurance Audit Program," Revision 4. The inspectors
found issues identified in these audit and surveillance reports consistently well
supported.
A review of the Quarterly Integrated Self-Assessment Trend Reports indicated that,
,
over the last six quarters, an average of 11 % of all DERs initiated for the station
j
I
were initiated by QA. The inspectors reviewed a list of those DERs initiated by QA
l
since January 1,1996, and, based on this list, the inspectors considered the
'
percentage and type of DERs identified by QA to be reasonable.
'
i
4
j
.-
10
The inspectors reviewed the weekly Corrective Action Monitoring Program Reports
issued by QA for the weeks of March 26 through April 9,1997. The reports
provided trend information regarding QA-initiated DERs issued, closed, and overdue
over the last 12 months; and corrective action QA ACTS itemr, open, overdue, and
pending QA review. Additionally, the reports described, in detail, the open QA
i
ACTS items greater than a year old, and listed all the open QA ACTS items with
selected information, such as the issue date, due date, the number of times the due
date had been extended, and the number of times the proposed corrective actions
had been rejected by QA. The inspectors considered these reports to be a good
tool to keep plant management abreast of long-standing issues.
The April 2,1997 Corrective Action Monitoring Program Report documented that
the due dates for 85 of the 151 open QA ACTS had been extended. The large
percentage of corrective action ACTS items being extended had been identified in
1
the last two QA audits of the licensee's corrective actions program. QA Audit 96-
11J indicated that " extension requests appear to be the norm, rather than the
)
exception," and QA Audit 96-20J indicated similar concerns. Although the practice
of extending ACTS items appeared excessive, no negative consequen :es were
)
identified from these extensions. Furthermore, as of the week of April 14,1997, all
extension requests for QA-related ACTS items greater than one year old were to be
reviewed by the plant manager.
The April 2,1997, Corrective Action Monitoring Program Report indicated that
13 of 21 QA-related ACTS items open for greater than one year were the
responsibility of design engineering. Additionally, of these 13 ACTS items, two
were associated with ineffective corrective actions. Further discussion regarding
engineering-related corrective actions is provided in Section 07.4 of this report.
Also, during the review of the April 2,1997, report, the inspectors noted that 11 of
the 151 open QA ACTS items had the associated corrective actions rejected by QA.
The corrective actions for one ACTS item were rejected three times. The inspectors
discussed the rejection rate with QA management and ascertained that since the
beginning of the year,10 out of 464 (appropriately 2.16%) proposed ACTS item
corrective actions reviewed by QA were rejected. The inspectors considered the
rejection rate to be rersonchte, and an indication of a good balance between
adequate corrective actions and adequate QA acceptance reviews.
c.
Conclusions
The strong industry experience of the QA auditors was evident in the depth of their
findings. Audit reports findings were consistently well supported. The weekly QA
Corrective Action Monitoring Provam Reports were considered a good tool to keep
plant management abreast of long t.tandicg issues. Although the practice of
extending ACTS items apreared excessa, no negative consequences were
identified from these enensions. The rocently implemented plant manager review
of all extension reques:s for QA-related ACTS items greater than one year old
indicated increased ma.vgement attention to long-standing issues. The QA
rejection rate of reviewed proposed corrective actions appeared reasonable, and
indicated a good balance between adequate corrective actions and adequate QA
1
.
=.
.-
-
-
-
. . -
-.
-
-.
- ~ _ - --. -_
4
,.
.-
11
07.6 Self Assessment Program
i
a.
Insoection Scope
I
't
The inspector reviewed department self-assessments, documented management
observations and the performance enhancement review committee meeting minutes
and interviewed personnel. Operation review group (ORG) quarterly reports for
,
1996 and 1997 were also reviewed.
-
.
b.
Observations and Findinas:
<
1
!
The licensee has a formal self assessment program as described in various licensee
"
internal audit procedures. The inspectors reviewed several self assessment reports
and found that these reports were self-critical and thorough.
,
i
.
ORG quarterly reports were considered to be an excellent resource for plant
!
'
managers to trend the overall and departmental performance. The report
statements were generally concise and provided specific insight into past
i
performance problems.
,
c.
Conclusions
,
,
Licensee management was actively involved in the self-assessment and corrective
i
action process. The evaluation of a sampling of the departmental self-assessment
,
findings showed consistency with previous inspecuon findings as well as other third
party audits. ORG quarterly trend reports were considered to provide a valuable
'
,
summary of plant performance.
'
07.7 Human Performance
a.
Inspection Scope
,
i
The inspectors reviewed a recently completed licensee human performance report
l
and interviewed licensee personnel. The inspectors attended a Performance
!
Enhancement Review Committee (PERC) meeting and reviewed several meeting
minutes and the associated lessons learned that had been generated,
b.
Observations and Findinas
!
Due to several significant human performance errors, the licensee developed a
human performance team to examine human performance and develop
t
recommended corrective actions. The inspector reviewed the report and corrective
actions recommended and considered that the report provided a good appraisal of
the licensee's performance in this area. Through interviews, the inspector
determined that the awareness of human performance issues has increased greatly
i
since this effort.
The PERC is a committee which meets on a regular basis to review personnel errors
in an effort to improve human performance. In reviewing the committee, the
inspectors found that DERs were properly screened for PERC review if personnel
.-
.
12
performance was possibly an issue. The inspector attended a meeting and noted
that the meeting was conducted well. The PERC reviewed severalissues regarding
an unauthorized exit of the radiologically controlled area. In this case, the PERC
focused on what corrective actions may be appropriate to prevent such an event in
the future. Meeting minutes were incorporated into DER packages for tracking and
trending purposes. However, there was an example where the corrective actions
specified by PERC were not documented on the DER form, although through other
document review, it was clear that some actions had in fact been taken.
The inspector noted that the licensee has also recently implemented several new
observation programs (Worker for a Day, Coach of the Day, and Coach of the
Week), in an effort to improve human performance at FitzPatrick.
c.
Conclusions
Based on interviews, the licensee has increased their awareness of human
performance issues and recently implemented some programs to reverse the past
negative trends in human performance. The PERC program was a generally
effective process to investigate human performance issues.
II. MAINTENANCE
M1
Conduct of Maintenance
i
M 1.1 General Comments
'
a.
Inspection Scooe
The inspectors observed all or portions of the following work activities:
- WR 97-02901 Uninterruptible power supply
- WR 97-02431345 KV bolted connection repair
- Various "C" Emergency diesel generator maintenance
b.
Observations and Findinas
The inspectors found the work performed under these activities to be professional
and thorough. Technicians were experienced and knowledgeable of their assigned
task.
M1.2 General Comments on Surveillance Activities
a.
Inspection Scoce
The inspectors observed selected surveillance tests to determine whether approved
procedures were in use, details were adequate, test instrumentation was properly
calibrated and used, technical specifications were satisfied, testing was performed
by knowledgeable personnel, and test results satisfied acceptance criteria or were
properly dispositioned.
. -
- . . - -
.
.
--
.-
.
. .
. .
. . .-
- - - - -.
a
L
g
.-
13
The inspectors observed portions of the following surveillance activities:
- ST 20T control rod time test
,
eST 24A reactor core isolation cooling pump test
eST 20C control rod operability
eST 8C emergency service water motor operated valve test
,
b.
Observations and Findinas
The licensee conducted the above surveillance activities appropriately and in
I
accordance with procedural and administrative requirements. Good coordination
and communication were observed during performance of the surveillance activities.
M1.3 Conclusions on Conduct of Maintenance
!
i
Overall, maintenance and surveillance activities were well conducted, with good
adherence to both administrative and maintenance procedures.
M3
Maintenance Procedures and Docurnentation
a.
Inspection Scoce
!
The inspectors reviewed the methods used to track equipment problems and failures
>
including the technical issues report (TIR) and maintenance rule (MR)
'
implementation. To assess maintenance rule implementation related to the
identification and tracking of system performance, the inspectors reviewed the high
pressure coolant injection system, safety relief valves, emergency service water
l
(ESW) and primary containment isolation valves (PCIV) and discussed the issues
with the applicable system engineer.
b.
Observations and Findinos
l
!
The TIR appeared to be a good way of focusing emphasis on specific plant
i
equipment issues. For each item listed, the report contained a problem statement,
plant impact, corrective actions, and a place to note any particular problems in the
i
resolution. For systems categorized as (a)(1) under the maintenance rule, the report
also included a statement on when the system would be returned to an (a)(2) status
I
under the maintenance rule. The inspectors noted good tracking of equipment
failures and identification of systems to be placed in (a)(1) status. The recovery
1
plans for (a)(1) systems were detailed and provided good insight into past problems
'
and the plans for addressing performance concerns.
I
c.
Conclusions
Both the TIR and the maintenance rule processes appear to be working hand-in-hand
l
to allow proper management attention to system performance issues. System
engineers understood the problems of their particular systems. Based on equipment
]
performance, it appeared that the licensee's previous corrective actions taken to
address ESW and PCIV issues were not fully effective.
..
l
.-
I
14
M7
Quality Assurance in Maintenance Activities
M7.1 Valve Maintenance Performed by a Contractor
a.
Insoection Scoce
An anonymous concern about the quality of maint'enance performed by a valve
maintenance contractor during tne 1996 outage was brought to the licensee's
employee concern program through a handwritten report. The individual's key point
was that work, particularly documentation and use of procedures, performed by the
contractor was of poor quality. Additionally, a stripped stud was left in place rather
than replaced and valve bolting torque requirements were questioned. Concerns
with specific salves and valve maintenance requirements were not documented.
The individual also wrote to " turn over this report to the NRC."
The inspectors reviewed the licensee's investigation reports of the concern,
reviewed work history for applicable valves including post work and rework and
discussed the issue with the licensee. Additionally, a sample of valves were
inspected.
b.
Observations and Findinas
The inspector determined that the contractor repaired or performed preventive
'
maintenance on 114 valves and valve operators, primarily in the condensate
domineralizer system.
The licensee conducted a review of the contractor's work as documented in a
licensee memo dated January 8,1997. The review included a sample of
maintenance packages which the licensee found to be acceptable, although several
l
administrative errors were identified and corrected. The licensee also noted that the
maintenance valve engineer provide oversight of the contractor during the outage
j
and a QA surveillance report no. 96-0005 dated December 11,1996 also
documented good performance by the contractor.
The licensee conducted an additional review of the operating history including work
requests and deficiencies of all valves worked on by the valve contractor and
conducted walkdowns of a sample of valves. Results of that review were
j
documented in a licensee memorandum dated May 13,1997. The licensee
i
identified no adverse condition existed with valve operation based on the
maintenance history review and valve walkdown and concluded that sufficient time
had elapsed during which the applicable systems had been in service to provide an
opportunity for problems to surface.
c.
Conclusions
l
l
The licensee's initial review, followed up with a subsequent review of valve
i
operating history, provided an acceptable level of confidence that valve
I
l
maintenance performed by the vendor was adequate and had not contributed to
system performance issues. Although there were several valve maintenance
.
.
. .
. - - - . _ .-
- . -
_-~.
.
-
-
-
_.
I
-
'
'
-0
.-
15
performance issues identified during the outage, those issues were addressed
!
through the licensee's corrective action program.
M7.2 Work Control
a.
Lnsoection Scope
Due to recent events which had contributing causes related to the work control
process, the inspectors assessed the ability of the work control department to
identify and correct problems. To complete this assessment, the inspectors
reviewed a sample of DERs related to work control and work planning initiated
within the last nine months, and evaluated the root causes and corrective actions.
The inspectors also reviewed internal critiques performed by work control staff and
,
the actions taken to address identified concerns. Applicable procedures were
reviewed and work control management, supervisors, planners and work week
j
I
managers were interviewed.
b.
Observations and Findinas
The inspectors discussed the work control process and organization with work
control management and staff. The inspectors ascertained that the work control
i
,
organization was staffed with severalindividuals having strong operations
backgrounds. For example, three of the four work week managers were either
reactor operator or senior reactor operator qualified. The inspectors considered the
i
strong operations background of the work week managers to be a positive attribute
of the work control organization.
,
i
Through discussion with a work control supervisor, the inspectors ascertained that
since January 1,1997, approximately 3100 work requests have been implemented.
~
Of those work requests, there have been five cases where DERs were written
related to deficient plant impact evaluations. In addition, the inspectors reviewed a
j
list of DERs issued since January 1,1997. Of the 348 DERs liated, six were
i
associated with the work control program and 19 had an apparent cause related to
]
planning.
i
On September 16,1996, during the performance of a relay calibration, two
terminals were inadvertently shorted together, resulting in a main turbine trip and
subsequent reactor scram. The details associated with this event were described in
NRC IR 50-333/96006. The inspectors reviewed the work control-related corrective
actions contained in DER 96-1060 associated with the scram. The corrective
)
actions included changes to Procedure AP-10.03, " Work Control Planning," to
j
provide more detailed requirements regarding the pre-job walkdown of the work site
i
to assess the potential impact from equipment in the vicinity of the work to be
accomplished. Other corrective actions identified in DER 96-1060 were to reinforce
j
the need for technicians to protect adjacent equipment when working on energized
i
equipment, to reinforce the need for technicians not to become complacent or over-
confident in their work, and to stop work in situations when they identify a plant
impact not noted within the work package. The inspectors considered these
corrective actions associated with the work control process to be appropriate.
!
.
.
16
The effectiveness of the corrective actions for the September 1996 scram was
assessed by reviewing subsequent DERs associated with either the work control
process or that had an apparent root cause associated with work planning. Seven
DERS were reviewed, four of which were written for items where one or more of
the barriers in the work control process had f ailed, but the discrepancies were
identified prior to actualimplementation of work. In at least three cases, the
discrepancy was identified by the technicians. The three remaining DERs,
associated with discrepancies not identified until after the work was initiated,
related to missed administrative requirements or poor scheduling issues with little -
impact on plant safety. The inspectors reviewed the proposed or completed
corrective actions for these seven DERs and considered them to be appropriate.
The three DERs initiated for cases where the technician stopped work when
discrepancies were identified, indicated an improved questioning attitude.
The inspectors reviewed the corrective actions for DER 97-106 regarding the
January 23,1997, simultaneous removal of two traveling screens from service,
which contributed to plant shutdown when a large influx of fish clogged the screen.
The details associated with this event were described in NRC IR 50-333/97001.
Traveling screens were normally removed from service and inspected weekly under
minor maintenance controls. Minor maintenance activities required less review than
those activities performed under the work request process. The apparent causes
for the simultaneous removal of two traveling screen, as described in the DER,
included:
A lack of communications between work control and operations,
poor decision on operations part to take both screens out of service
simultaneously, and
a new requirement associated with the protective tagging process.
The proposed corrective actions were reviewed and found to appropriately address
the root causes. Furthermore, during the inspectors' review of DERS initiated over
i
the last nine months, no additional problems were identified regarding the minor
maintenance process.
Through discussion with various members of the work control organization, the
inspectors ascertained that, although work control had not performed a formal self
assessment, the organization routinely critiques the completed work week activities
and special evolutions. The inspectors reviewed a random sample of four weekly
critiques and the critique of the March 22,1997, down-power. The weekly
critiques provided statisticalinformation pertaining to schedule adherence and
shortcomings within the quality of the work packages and scheduling. When
appropriate, the weekly critiques provided recommendations to address the
identified shortcomings. The down-power critique was extensive; areas for
improvement and recommendations were identified. Discussions with the work
control supervisor indicated that the recommendations from the weekly and special
evolution critiques were normally incorporated into the schedule preparation
checklist. The inspectors verified that several previously identified
recommendations were in-f act added to the checklist. The inspectors considered
the weekly and special evolution critiques to be a good tool for the identification
and correction of problems within the work control process.
.
.-
17
.
c.
Conclusions
The inspectors considered the strong operations background of the work week
managers to be a positive attribute of the work control organization. The corrective
actions associated with the work control process initiated as a result of the
September 1996, scram were effectively implemented, and the proposed or
completed corrective actions for other DERs associated with the work control
process were appropriate. In addition, the three DERs initiated f r cases where the
technician stopped work when discrepancies were identified inucated an improved
questioning attitude. The weekly and special evolution critiques were a good tool
for the identification and correction of problems within the work control process.
M8
Miscellaneous Maintenance issues
M8.1 (Closed) Unresolved item 50-333/95001-01: Reactor pressure vessel (RPV) nozzle
examinations. During the review of inservice inspection (ISI) data, the inspector
identified a concern regarding the need for additional attention to procedural quality
and adherence. The licensee completed several action commitment tracking system
(ACTS) items to address the specific concerns identified in NRC inspection reports-
50-333/95001 and 95-400. In NRC inspection report 50-333/96-07 dated
December 13,1996, an NRC Region I non-destructive examination (NDE) technician
reviewed the licensee's ISI program and concluded that the program was well
documented, controlled and implemented. The documentation supporting the
examinations was accurate and readily available for review. Additionally, an ISI
program checklist was provided which was an improvement over previous controls
and that the licensee demonstrated good oversight of the NDE subcontractor and
NDE examinations. Based on the licensee's completion of the ACTS items to
address the specific concerns and a subsequent ISI program review by the NRC, the
issues identified in the URI have been addressed.
i
M8.2 (Closed) LER 50-333/95008: High Pressure Coolant Injection (HPCI) System Trip on
Overspeed Due to Procedure Deficiency. On March 26,1995, while conducting
post refuel outage testing, the HPCI turbine tripped on overspeed when a cold quick
start test was attempted. The licensee determined that the system flow controller
j
output current limit circuit adjustment was not included in the calibration procedure
1
and therefore, not properly adjusted following replacement during the refuel outage.
Corrective actions included proper adjustmerit of the flow controller and satisfactory
retest of the HPCI turbine. The reactor core isolation cooling (RCIC) flow controller
)
was also verified by the licensee to be properly set. The calibration procedures for
the flow controllers were revised to include the requirement to adjust the current
limit circuits. The inspector verified that corrective actions had been completed and
reviewed subsequent quick start surveillance testing of HPCI and RCIC systems for
i
similar problems.
M8.3 (Closed) LER 50-333/96011: Both Standby Liquid Control Subsystems
inoperable Due to Inoperable Pump Discharge Pressure Relief Valves. On
October 29,1996, while in cold condition for refueling the licensee
'
determined that both standby liquid control (SLC) system pump discharge
relief valves were found with lift setpoints below the technical specification
required range of 1400 to 1490 psig. Relief valve 11SV-39A lifted at 1380
j
.-
.
18
psig and 11SV-39B lifted at 1310 psig. Corrective actions included replacing
one valve and adjusting the relief setpoint for the second valve. In addition,
the licensee completed an equipment failure evaluation and test interval
evaluation as the B side relief valve had failed during the previous test. The
licensee determined the setpoint drift of the relief valves to be the result of
cyclic pressure spikes from the operation of the reciprocating positive
displacement SLC pumps. Additional corrective actions included increased
frequency of bench testing baseo on setpoint drift data and evaluating the
reinstallation of the hydraulic accumulators which were part of the original
system design.
M8.4 (Closed) Violation 50-333/96002-01: Foreign material exclusion (FME) controls.
Requirements to maintain system cleanliness while performing maintenance on the
pressure relief system were not met. The licensee programmatic corrective actions
included additional training, assessment of the effectiveness of the corrective
actions, review of refueling outage work packages and changes to the
administrative procedure for maintaining system and component cleanliness. The
inspector reviewed training records, procedural changes, licensee program
assessment and audit documentation, and recent plant deficiency report history for
FME issues. Licensee corrective actions appear to have been effective.
lli. ENGINEERING
E1
Conduct of Engineering
E1.1
Control of Temporary Modifications
a.
Insoection Scope
The inspector reviewed the temporary plant modification control program
including procedures, performance indicators and implementation.
Additionally, specific temporary rnodifications were also assessed.
b.
Observations and Findinas
Historically, the average number of temporary modifications has been about
34 over the past two years. The current number is 37, with the oldest two
involving modifications to enhance the chemistry of the service water system
which are scheduled for permanent installation. There are currently 16 non-
outage temporary modifications and 21 which require an outage to address.
Six of the " outage required" temporary modifications are scheduled for the
next forced outage. The inspector determined that five temporary
modifications were for additional plant performance monitoring, four were
equipment enhancements waiting permanent installation, and 28 were the
result of equipment deficiencies. Ten temporary modifications involved
system leakage, seven of which are steam leak repairs on non-safety related
equipment. Twenty-five of the temporary modifications to correct equipment
deficiencies were on balance-of-plant components and not safety significant.
,
.
_
.
. _ .
-
- - - . --
.
4
.
19
4
!
The inspector reviewed the status of the temporary modifications following the
'
completion of last refueling outage and noted that of the six open temporary
modifications, four were installed on start-up as a result of equipment deficiencies,
one was of a housekeeping nature and one lacked engineering support.
Modification 95-098, which lacked engineering support, could have been done
during the outage but was not. The modification involved the installation of
.
capacitors on several reactor manual control system (RMCS) relays which had
contributed to some previous RMCS timing problems during the previous cycle.
Although the problem has not repeated itself to date, no clear explanation was
available as to why the permanent modification was not completed during the
outage.
~
The inspector also reviewed deficiency event reports for the last year which
documented problems with the temporary modification program. In general,
J
the inspector noted that problems were of an administrative nature and were
being addressed by the licensee,
c.
Conclusions
Temporary modifications were being effectively managed and all temporary
'
modifications were scheduled for removal or permanent installation. The
older temporary modifications appear to lack engineering support, but are not
,
safety significant. The number of temporary modifications has been
i
consistent over the past two years and does not appear to adversely impact
'
plant operations. Overall, good management oversight of the temporary
,
I
modification program was evident.
)
E2
Engineering Support of Facilities and Equipment
E2.1
Nonconforming Scram Solenoid Pilot Valves
4
a.
Insoection Scope
On May 5,1997, the licensee was notified by General Electric that an
>
investigation into observed air leakage past the core disc in the scram
solenoid pilot valves (SSPV's) at another facility was caused by incorrect
!
core disc elastomer material supplied with some valves. The NRC was
notified through the Emergency Notification System in accordance with
-
10 CFR Part 21 of the potential safety related problem. The inspector reviewed the
licensee's response to the issue and reviewed the justification for continued
operation (JCO) completed by the licensee,
b.
Observations and Findinos
l
The safety function of the scram solenoid pilot valves is to ensure rapid
insertion of the control rods during an automatic or manual scram. To
perform this, the core disc in the SSPV has to isolate the air system from the
scram valves when the SSPV is de-energized. The vendor had determined
!
that some of the SSPVs it had provided to various licensees had nitrile
(BUNA-N) vice the intended material, fluorocarbon (Viton). The concern
.- -
_ _ - _ _ _
.
20
involved the susceptibility of the BUNA-N to harden due to thermal stresses
from elevated temperatures, and subsequently lack the ability to provide a
good seal. The licensee received 50 of the suspected SSPVs and determined
that 24 had been installed in the plant. As each control rod drive unit
contains two SSPVs, the installed group encompassed 18 control rod drive
units.
The licensee determined, based on vendor information, that the drives were
operable. The basis for the decision was focused on the vendor's
information that the disc have a service life of three to four years. The
SSPVs were shipped to the licensee in October of 1994. Corrective actions
by the licensee includes replacing the suspected SSPVs by October 17,1997
and development of augmented leakage testing as suggested by the vendor,
c.
Conclusions
The licensee's response and planned corrective actions to the nonconforming
SSPV demonstrated a good safety focus.
E8
Miscellaneous Engineering issues
E8.1
(Closed) Violation 50-333/95006-02: Fire protection program procedures not
maintained. On March 19,1995, Carbon Dioxide was inadvertently discharged into
the relay room during a surveillance test. The cause was that the surveillance test
was not changed to include a portion of a logic change modification. The causes
for the condition were that the engineering design organization did not identify the
logic change and the review of the surveillance test procedure for implementation of
the modification change was inadequate. To address these causes, the licensee's
engineering department developed a system to review major modifications including
procedure changes and their impact on operations and maintenance and developed
an adequacy review process to ensure that all changes are reflected on modification
documents and affected procedures. The licensee implemented their corrective
'
actions through a new procedure, Site Engineering Standing Order (SESO)-11,
Modification Teams and Adequacy Review Process, implemented on October 2,
1995, to formalize a modification team concept. The procedure provides
instructions and a framework to minimize the amount of design and personnel
errors. Attachments to the procedure include system drawing markup guidance and
a modification adequacy review checklist. The checklist provides a list of key
modification requirements which were overlooked on past modifications, issues
j
identified through the licensee's corrective action process and items from
modification critiques. Additionally, the inspector verified that the commitments
documented in the licensee's response to the Notice of Violation dated June 8,
l
1995 were completed.
E8.2 (Closed) LER 50-333/96-005: Error in Safety Limit Minimum Critical Power
Ratio Calculation. On April 16,1996 General Electric (GE) informed the
4
licensee that preliminary recalculation of the cycle specific safety limit
minimum critical power ratio (SLMCPR) may be more limiting than
determined by the original calculations. Subsequently the licensee was
notified by GE that the cycle 12 SLMCPR in the technical specifications,
. _
_.
_
_
. .
.
_
_
_
-
.
4
-
.
21
1.07, was incorrect and should be 1.08, which was a non-conservative
.
error. The licensee reviewed the operating records for the cycle and
determined that the fraction of the operating limit MCPR had at no time
exceeded 0.98 and therefore there was no potential that the new SLMCPR
would have been violated in the event of a limiting abnormal operating
'
occurrence. In addition the SLMCPR for cycle 13 was verified to be correct
and an Operating License amendment request for the cycle 12 SLMCPR was
submitted. The inspector reviewed the Technical Specification change
request and the administrative controls that were put into place at the time
of the event. The corrective actions were complete and no other concerns
were identified.
E8.3 (Closed) Inspector Followup Item (IFI) 50-333/92014-01: Relay room Carbon
Dioxide (CO2) discharge test. NRC inspection report 50-333/92014 section 6.6.3
documented the performance of a discharge or an acceptable National Fire
l
Protection Association (NFPA) code test on the relay room carbon dioxide system.
i
The test performed identified significant problems with the relay room and control
I
room ventilation system and the licensee developed an action plan to address the
issues. NRC inspection report 50-333/92023 provided a detailed review of the
licensee's action plan and concluded that the plan was acceptable for unit restart
and power operation. Specifically, the proposed modification to the relay room
ventilation system and the subsequent CO2 full discharge verification testing
appeared to be appropriate and that no additional or immediate safety concerns
remained. The licensee installed a modification which consisted of altering the relay
'
room ventilation system to isolate prior to a CO2 discharge, relocating the relay
room CO2 vent path and replacing a fire door to minimize leakage into the control
room. in lieu of performing a full CO2 discharge test, an alternate test methodology
~
was utilized. The alternate test was an enclosure integrity test and tracer gas air-
exchange test. In NRC inspection report 50-333/95002, the inspector witnessed
i
the performance of a relay room CO2 test as a follawup. The purpose of the test
was to collect data for a subsequent engineering analysis and confirmation of the
relay room es a carbon dioxide protected enclosure. IFl 50-333/92014-01 remained
open pending review of the results of the test. In NRC inspection report 50-
333/95006, the completion of the relay room CO2 system modification and
subst,quent testing was determined to satisfy the licensee's commitment to the
'
NRC to return the relay room CO2 fire suppression system to an operable status
prior to startup from the 1994-95 refueling outage. However, the inspector
questioned the adequacy of alternate trace gas CO2 fire suppression system testing
j
in meeting requirements.
Alternate CO2 fire suppression system testing is discussed in NRC Information Notice (IN) 92-28, Inadequate Fire Suppression System Testing, dated April 8,
1992. The IN documents that full discharge testing of CO2 fire suppression
i
systems may present certain hazards at operating nuclear power plants and that
some licensees have used alternative testing methods which avoid these hazards.
The alternate testing is an enclosure integrity test and tracer gas air exchange test
which is acceptable per NFPA standards. Data is obtained from the tests for use in
an engineering analysis.
-
.
l
,.
22
The inspector reviewed the engineering analysis and discussed the issue with the
fire protection engineer. The inspector noted that the engineering analysis, using
the data from alternate tracer gas testing, demonstrated that an adequate
concentration of fire suppression agent for the required soak time was available.
E8.4 (Closed) Unresolved item 50-333/95002-01: Discrepancies with containment spray
system. During the performance of a containment spray header and nozzle air test,
the licensee identified that one of the spray nozzles had no air flow due to an
internally instz!Ied plug. A subsequent engineering review of the condition
determined that this condition was acceptable and that the system was operable.
However, several engineering aspects of the issue were still under review at the end
of the inspection period. Specifically, the reason the nozzle was plugged had not
been determined and drawing and design basis documentation did not reflect the as
found condition.
The inspector reviewed design basis document (DBD)-010, Residual Heat Removal
System, and verified that the design basis document was updated to reflect the
actual condition concerning the number of drywell spray header nozzles.
Additionally, the inspector noted that a design document open item (DDOI) had
been initiated to revise applicable drawings to indicate the actual configuration. The
1
licensee determined that there were no modifications which would have installed
the plug. However, it was determined that the plug was internally installed, which
was most likely from original construction.
IV. PLANT SUPPORT
R7
Quality Assurance in Radiological Protection and Chemistry (RP&C) Activities
R7.1 Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing
Problems
a.
Inspection Scope
t
To determine the effectiveness of licensee controls in identifying, resolving and
preventing problems in the radiological protection area, the inspector reviewed the
licensee's corrective action program including procedures, documentation, root
cause analysis performed and discussed the program with RP&C personnel.
Additionally, walkdowns of the radiological controlled area (RCA) were performed.
b.
Observations and Findinas
The licensee's Quarterly Integrated Self-Assessment and Trend Report for the
Fourth Quarter of 1996 noted that the number of DERs written in the Radiation
Protection functional area during the fourth quarter of 1996 was more than three
times the average number written during previous outage quarters. Of the seventy-
five DERs generated, fifty-two were for personnel contaminations, and nine others
were for contamination control issues. The licensee characterized this three-fold
increase as an improving trend based on the increased willingness and instruction
for self-identification of problems by plant personnel at the worker level rather than
by management, the quality assurance organization, or external organizations. Plant
.
-. -
. -
-
.
.
-
.-
,
.
23
personnel at the worker level identified 87.2% of the DERs written for this period.
The licensee stated that their review of outage personnel contaminations, triggered
by the large documented number, was an example of escalation of characterization
and evaluation type required for a DER. Their review concluded that most of the
contaminations were unrelated and of low safety significance. Findings in NRC
Inspection Reports 50-333/96007 and 97001 documented similar low safety
significance concerning the personnel contaminations. The licensee also pointed
out that a DER (97-0427) was written on April 17,1997, which would escalate the
characterization and the type of evaluation required for recurring non-adherence to
radiological safety postings at RCA boundaries. However, the fact that this
escalation and subsequent effective corrective action intended to prevent recurrence
did not occur eallier in time was considered a weakness in this area.
The evaluation of each identified deviation and event for generic implications
(extent of condition) was not apparent. Procedure AP-03.03, Deviation and Event
Analysis, provided the methodology for evaluating deviations and events, identifying
their causes, and recommending corrective action to prevent their recurrence.
Section 8.3.3.E stated, in part, that all evaluations shall, as a minimum, include
extent of condition when appropriate. A large number of inspector-reviewed DERs
did not include any documented statement concerning extent of condition.
Although the licensee stated that an extent nf condition consideration is always
performed, the lack of documentation of this evaluation and the evaluation's basis
was considered a weakness.
The elevation of identified deviations and events to a proper level of managemes,t
appeared to be adequately addressed. Responses to DERS required two levels of
management approval before submittal to the ORG. To track action items
generated to resolve DERS to completion, Procedure AP-03.08, Action and
Commitment Tracking System (ACTS) was used. ACTS items associated level A
and B DERS required two levels of management approval before closure. ACTS
items associated with lesser level DERS required at least one level of management
approval before closure.
c.
Conclusions
l
Overall, the licensee's corrective action program for the radiological protection
program was acceptable. The adequacy and timeliness of corrective actions were
acceptat,
axcept that the corrective actions for non-adherence to radiological
safety postings at the boundaries of radiologically-controlled areas (RCAs) was
found to be inadequate. Identification and characterization of deviations and events
were also acceptable, but evaluation of extent of condition and corrective actions of
possibly recurrent deviations and events in appropriate situations were not evident
in the documentation and therefore considered to be weaknesses. Also, the
evaluation and documentation of each identified deviation and event for generic
,
i
implications was considered to be a weakness. The elevation of identified
deviations and events to a proper level of management was adequately addressed.
i
Self-identification of problems by front-line personnel and their willingness to do so
seemed to be increasing.
._
..
.-
24
R7.2 Improper RCA Entry by Escorted Visitors (Violation 50-333/97004-02)
a.
Insoection Scoce
On April 16,1997, two licensee-identified events occurred concerning improper
RCA entry. The inspector reviewed the events, past performance in RCA access
controls and discussed licensee corrective actions with RP&C management.
b.
Observations and Findinas
April 16 and 17,1997, had been designated career days during which parent
employees were allowed to bring and si ow their children around their workplace.
On April 16,1997, at approximately 9:45 a.m., with the plant operating at
approximately 100% power, the licensee discovered that, in two separate incidents
at times earlier that morning, minor visitors (two children by one parent employee
and one child by another parent employee) were escorted inadvertently into a RCA
(the cable tunnell by their parent employees without authorization for RCA entry.
The two parent employees were both currently trained radiation workers and
qualified to be visitor escorts. The visitors were not authorized or monitored for
radiation exposure as required by procedure. The access point used was posted
with a yellow and magenta Caution Radioactive Material posting, which stated that
the area was an RCA, that only authorized personnel were to enter, and that a TLD
was required for entry. This area was not controlled with a radiation work permit
(RWP). The licensee had posted the area because the condensate piping and
chemical drain piping in the area were internally contaminated with small amounts
of radioactive material and because this radioactive contamination resulted in low
gamma dose rates external to the piping.
The dose consequences to the visitors involved in these events were calculated to
be negligible. A licensee survey of general area dose rates in the cable tunnel
shortly after the incident indicated that
the maximum and average exposure rates were 0.3 and approximately
i
0.1 millirem / hour, respectively. A documented dose evaluation by the licensee for
thesc two incidents indicated that the maximum transit time in the cable tunnel was
6 minutes, that the maximum individual dose to the unmonitored individuals was
O.03 millirem, and that the calculated individual dose is less than the minimum
l
reportable dose of 10 millirem for the licensee's personnel TLD radiation badge.
The area was scheduled to be surveyed for removable contamination on a quarterly
basis due to its low potential for such contamination to exist. Quarterly surveys of
this area on February 13,1997 and on April 23,1997 indicated that general area
removable radioactive contamination was less than 1000 disintegrations per 100
square centimeters. The visitors exited the protected area through radiation portal
monitors in the security access building without exceeding the alarm setpoint of the
monitors. These latter facts indicated that there was no significant removable
'
contamination in the cable tunnel area.
Technical Specification 6.11 states that procedures for personnel radiation
protection shall be prepared and adhered to for all plant operations. Procedure
i
'
AP-07.00 (Rev. 0), Radiation Protection Program, in Section 6.1.5, states that
radiation workers shall comply with written and oral Radiation Protection (RP)
-
.
_ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - _
.
.
25
instructions. The inspector noted that, during the last six months, there had been
four similar incidents involving non-adherence to radiological safety postings at the
boundaries of RCAs, including an incident on December 7,1996, involving a non-
licensed operator who improperly exited the RCA. It appears that past corrective
actions concerning RCA access were not fully effective. The failure of radiation
workers to comply with posted RCA access instructions resulted in minors entering
a posted RCA and is a violation (VIO) (50-333/97004-02),
c.
Conclusions
The two separate incidents on April 16,1997 constituted two examples of failure to
,
comply with written instruction (i.e., postings) since the escorted visitors had not
been provided TLDs and had not been authorized for entry into a RCA. Corrective
actions for previous similar licensee findings were not effective in preventing these
incidents.
R8
Miscellaneous RP&C issues (VIO 50-333/97004-02)
R8.1
(Closed) Unresolved item 50-333/95002-02 and EA 96-096: Improper dosimetry
use by a visitor. The licensee determined that a visitor entered the RCA using
dosimetry not issued to him by the site dosimetry office. Additionally, the
contractor supervisor had the visitor log into and out of the RCA using a different
persons name. The NRC Office of Investigations (01) reviewed the event and a
violation concerning this willful act was issued in a letter to the licensee dated
May 2,1996. The licensee's response dated May 31,1996 documented corrective
,
actions including changes to dosimetry control procedures to provide more stringent
administrative control and the conduct of pre-outage briefings to discuss the
violation and station requirements. The inspector verified that the licensee's
corrective actions have been completed. Additionally, the inspector reviewed DERs
and discussed the event with licensee personnel and determined that there have
been no similar events.
R8.2 (Closed) Unresolved Item 50-333/96008-03: Improper radiation worker practices
by a non-licensed operator. This item documented that there were several
radiological control barriers and radiation worker practices which were not adhered
to by two workers which resulted in one worker becoming contaminated. These
requirements which were not met included the failure to obtain a radiation control
brief, not adhering to the radiation work permit, wearing inadequate anti-
contamination clothing, disregarding radiological postirg requirements and improper
use of the portal monitor. The deficient radiation wo'ker practices are similar to the
event described in paragraph R.7.2 above in that inJividuals exhibited poor radiation
j
worker practices. Accordingly, this Unresolved item is closed based on including
this issue as an example of violation 50-333/97004-02.
F8
Miscellaneous Fire Protection issues
F8.1
(Closed) Enforcement (EA) 50-333/95-14'2: Unauthorized approval of combustion
control permit. On February 3,1995, the licensee informed the NRC that results of
an internal investigation of a combustible control permit (CCP) authorization
identified that a fire protection supervisor / fire inspector inappropriately used the Fire
.-
.-
)
i
.
i
!
!
26
I
(
Protection System Engineer's signature on a permit. On July 27,1995, the NRC
issued a violation of NRC requirements set forth in 10 CFR 50.9. In the cover letter
'
to the violstion, the NRC recognized that significant corrective actions had been
taken, including comprehensive review of all current and previously issued / closed
combustion control permits to identify any further discrepancies; conduct of a
i
formal critique of the unauthorized CCP and related events, training to reemphasize
procedure compliance and procedure revisions. The licensee responded to the
Notice of Violation in a letter dated August 28,1995 and committed to completion
of a Quality Assurance assessment of the fire protection program. The inspector
verified that the corrective actions documented in the licensee's response had been
'
completed and reviewed the Quality Assurance audit report A 95-15W, Annual and
Biennial Fire Protection Audit. The audit identified weaknesses in the area of
management attention to address human performance errors, the need to sirnplify
the combustible control permit procedure, development of trending in fire protection
and review of fire protection documents. The licensee addressed the issues
i
identified in the OA audit,
j
V. MANAGEMENT MEETINGS
X1
Exit Meeting Summary
The inspectors presented the inspections results to members of the licensee management
at the conclusion of the inspection on June 10,1997. The licensee acknowledged the
findings presented.
J
'
The inspectors asked the licensee whether any materials examined during the inspection <
should be considered proprietary. No proprietary information was identified.
The preliminary results of the team inspection were discussed with licensee management
on April 18,1997 and an exit meeting with licensee management was conducted on
April 24,1997.
l
1
X2
Review of UFSAR Commitments
A recent discovery of a licensee operating their facility in a manner contrary a the Updated
Final Safety Analysis Report (UFSAR) description highlighted the need for a special focused
review that compares plant practices, procedures and/or parameters to the UFSAR
,
'
description. While performing the inspections discussed in this report, the inspector
reviewed the applicable portions of the UFSAR that related to the areas inspected. The
inspector verified that the UFSAR wording was consistent with the observed plant
practices, procedure and/or parameters.
X3
Pre-Decisional Enforcement Conference Summary
On May 8,1997, a pre-decisional enforcement conference was held in the NRC Region I
office, to discuss potential enforcement issues identified in Inspection Report 50-333/
97-003. The issues related to a March 3,1997 inadvertent control rod withdrawal event,
j
Results of the enforcement conference including slides used in the presentation at the
I
conference are included with the letter to the licensee under EA No.97-118.
.-
-
- .
. - -
_ . .
- - . . -
. - .
..
. - .
. .
- - .--.
. .
l.*
,-
I
27
I-
PARTIAL LIST OF PERSONS CONTACTED
l
Licensee
t
l
'
l
J. Bracy, Administrative Coordinator (RES)
i
J. Maurer, General Manager, Support
,
A. McKeen, Manager, Radiological and Environmental Services (RES)
l
E. Mulcahey, General Supervisor, Radiological Engineering
l
P. Policastro, Radiological Supervisor
l
C. Sherman, Radiological Technician
!
R. Steigerwald, Acting Manager, Operational Review Group
S. Wisla, General Supervisor, Health Physics
l
!
E
l
None
i
I
.
i
l
l
l
I
s .
-.
..
- - -.
.
. - . _-
_
_ _ _ - -
-
. . -
.
. . .
.-
,
28
INSPECTION PROCEDURES USED
l
37551
Onsite Engineering
40500
Effectiveness of Licensee Controls in identifying, Resolving, and
Preventing Problems
62707
Maintenance Observations
61726
Surveillance Observations
71707
Plant Operations
l
71750
Plant Support
!
l
92902
Maintenance Followup
92903
Engineering Followup
92904
Plant Support Followup
ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
50-333/97004-01
IFl
adequacy of corrective action program for engineering issues
50-333/97004-02
failure to comply with radiation control requirements, two
examples
,
Closed
50-333/92014-01
IFl
relay room Carbon Dioxide (CO2) discharge test
j
l
50-333/95001-01
reactor pressure vessel (RPV) nozzle examinations
50-333/95002-01
discrepancies with containment spray system
i
50-333/95002-02
(E 95-005) improper dosimetry use by a visitor
l
50-333/95006-02 VIO
fire protection program procedures not maintained
'
50-333/96002-01
foreign material exclusion controls and the pressure relief
system
50-333/96008-03
improper radiation worker practices by a non-licensed operator
'
.
i
I
_.
0'
-
29
50-333/95-142
Unauthorized approval of combustion co..tol permit.
50-333/95008
LER
HPCI System Trip on Overspeed Due to Procedure Deficiency.
50-333/96-005
LER
Error in Safety Limit Minimum Critical Power Ratio Calculation.
50-333/96011
LER
Both Standby Liquid Control Subsystems Inoperable Due to
j
inoperable Pump Discharge Pressure Relief Valves
Discussed
None
j
1
i
l
i
i
l
l
l
1
)
I
%
_ . _
. _ _ _ _ _ . _ _ _ __ _ . _ .
_ _ _ _ _ . .
_
i
e-
30
LIST OF ACRONYMS USED
ACTS
Action and Commitment Tracking System
Administrative Procedure
Combustible Control Permit
Design Basis Document
Design Document Open item
DER
Deviation and Event Report
Equipment Failure Evaluations
Emergency Service Water
High Pressure Coolant injection
IN
Information Notice
Inservice Inspection
JCO
Justification for Continued Operation
Motor Generator
National Fire Protection Association
NRC
Nuclear Regulatory Commission
01
Office of Investigations
ORG
Operational Review Grcup
l
Primary Containment Isolation Valves
PERC
Performance Enhancement Review Committee
Plant Operations Review Committee
Quality Assurance
Radiological Controlled Area
Reactor Core isolation Cooling
Radiological & Environmental Services
j
Reactor Manual Control System
Radiation Protection
'
RP&C
Radiological Protection and Chemistry
Radiation Work Permit
SESO
Site Engineering Standing Order
Safety Limit Minimum Critical Power Ratio
Safety Review Committee
Surveillance Test
Technical Issues Report
TS
Technical Specification
Uninterruptible Power Supply