ML20149K185
| ML20149K185 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 07/01/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20149K174 | List: |
| References | |
| 50-010-97-09, 50-10-97-9, 50-237-97-09, 50-237-97-9, 50-249-97-09, 50-249-97-9, NUDOCS 9707300041 | |
| Download: ML20149K185 (25) | |
See also: IR 05000010/1997009
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> U.S. NUCLEAR REGULATORY COMMISSION
REGION 111
Docket Nos: 50 10; 50-237; 50-249
License Nos: DPR-2: DPR-19; DPR-25
Report No: 50-010/97009; 50-237/97009 50-249/97009
, Licensee: Commonwealth Edison Company
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j Facility: Dresden Nuclear Station Units 1,2 and 3
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Location: Dresden Station
j Commonwealth Edison Company
6500 North Dresden Road
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Morris, IL 60450
Dates: April 19 through May 30,1997
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inspectors: D. Roth, Resident inspector
C. Brown, Resident inspector
- J. Hansen, Resident inspector, LaSalle j
D. McNeil, Operator License Examiner, Rlli '
C. Settles, Illinois Department of Nuclear Safety
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Resident Inspector
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Approved By: W. L. Kropp, Chief
- Reactor Projects Branch 1
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9707300041 970701 -
{DR ADOCK 0500001o
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EXECUTIVE SUMMARY.
Dresden Nuclear Station Units 1,2 and 3
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NRC Inspection Report 50-10/97009; 50-237/97009; 50-249/97009
This inspection included aspects of licensee operations, maintenance, engineering, and
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plant support.
Ooerations
- The boric acid and borax staged for use during execution of Dresden emergency
operating procedures were in poor material condition. A violation for corrective
j action was identified. (Section O2.2)
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- For the activities observed, the operating staff performed four startups and three
i shutdowns in accordance with procedures during this period. Crew briefs and
heightened level of awareness briefs were informative, contingency actions were
discussed, and peer checks were performed. (Section 04.1)
- The inspectors identified no formal guidance for monitoring oil levels in
condensate / condensate-booster pump bearings. (Section 04.1) ,
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- As a result of operations not adequately monitoring condensate-storage tank water )
level, high pressure coolant injection was temporarily declared inoperable until
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engineering determined that a procedure was in error. (Section 04.1)
- * The licensee's site quality verification organization recently completed a review of
the initial license training and determined that the testing was not consistent with
NRC standards. (Section 05)
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- Maintenance
- Maintenance activities, observed by the inspectors, were generally performed
correctly. However, the inspectors identified two examples of failing to sign work
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steps. (Section M1.1)
! * The inspectors found the emergency core cooling system under-voltage relay and
l integrated functional testing to be adequately performed and technically sound.
(Section M3.1)
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- During this inspection period, errors committed by instrument maintenance staff
resulted in inadvertent equipment actuation. (Section M4)
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Enaineerina
i * Based on witnessing work, the inspectors identified that the methods utilized to
change procedures in the field could bypass required reviews defined in the
administrative procedures. (Section E3)
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Plant Suocort
- Overall, the licensee's radiation protection staff enforced the plant's radiological
control standards. (Section R1)
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flEPORT DETAILS
Summarv of Plant Status
Unit 2 was in a forced outage (D2F27) to repair Merlin-Gerin breaker upper auxiliary
switches and to repair flued head penetration anchors. The licensee also performed work
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in the switchyard and on a recirculation pump tachometer. On May 2, the unit was shut
down about 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> after startup when a recirculation pump's motor-generator speed was
observed to be oscillating. On May 4, the license started the unit up and subsequently
shut it down on May 6 when a turbine combined intercept valve failed to operate properly.
- The unit was started up on May 9 and the generator was synchronized to the grid on
May 10. On May 11, the unit was shut down and entered a forced outage (D2F28) due to
packing leaks on two main-steam-isolation valves. After completing repairs, the licensee
started the unit on May 15 and closed the generator breaker to the grid on May 17. On
May 19, as the unit power was being increased from about 790 MWe to full power, a
string of feedwater heaters tripped, and the operators rapidly reduced power by about
i 100 MWe. On May 21, full power was achieved. On May 26, power was reduced to
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about 370 MWe for planned work in the 345-kV switchyard. Power remained at the
reduced level until the end of the inspection period.
Unit 3 was in a refueling outage (D3R14) during the entire inspection period.
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I. Ooerations
4 01 Conduct of Operations
01.1 General Comments (71707)
The inspectors conducted frequent reviews of plant operations. During the 6-week
period covered by this inspection period, the conduct of activities was generally
characterized by safety-conscious operations. During control room tours, the
- inspectors assessed operator performance that included communications, command
! and control, control of work activities, and adherence to procedures.
- During the inspection period, several events occurred that required prompt
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notificatior of the NRC per 10 CFR 50.72 or licensee event reports (LERs) per
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10 CFR 50.73. The events are listed below:
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April 30 (Units 2,3) Unanalyzed bypass of the pressure suppression function
i of the suppression pool due to simultaneous opening of torus and
drywell purge valves during operation.
- May 20 (Unit 2) Unexpected Group IV isolation of high pressure coolant
injection (H?Cl) system due to incorrect setting on test equipment.
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May 26 (Unit 3) Full trip (scram) signal received due to manipulation of
wrong component during reactor protection system (RPS) logic
testing.
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May 29 (Unit 2) Secondary containment boundary found breached by
unauthorized installation of a drain hose.
02 Operational Status of Facilities and Equipment
i O2.2 (Units 2,3) Alternate Standby Liquid Chemical Control Storage
a. Insoection Scone (71707,62707)
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The inspectors assessed the material condition of the Borax and boric acid stored in ;
j buckets for use during performance of emergency alternate boron injection. The l
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inspectors also assessed the compliance with the station administrative controls for :
storing chemicals Procedures reviewed included: l
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DEOP 500-01, "Altemate Standby Liquid Control injection," Rev. 05, l
DAP 16-01, " Chemical Control Program," Rev.10, I
j DHP 0130-10, "Right to Know (OSHA Hazard Communication)," Rev. 00.
b. Observations and Findinas
The inspectors observed damage to some of the buckets of dry boric acid and dry
borax staged for use during alternate boron injection. Two of the containers had
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completely broken open and the contents subsequently placed into open, unlabeled
i pails. The inspector observed that pieces of duct tape were mixed with the borax
in one of the uncovered pails. Additionally, the lids of some buckets were cracked.
The inspectors initially brought the poor material condition of the chemical storage
to the attention of the licensee on May 9. On May 16, the inspectors noted that
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the poor material conditions still existed. The inspectors informed the operations
manager. At that time, the shift operations supervisor (SOS) told the inspectors
that a purchase order for an improved storage method had been issued about 3
weeks before the inspectors' observations. Also, the SOS stated that the storage
had beei. cleaned up, and that the licensee had assessed the condition and I
considered the alternate boron to be operable at ali times. The inspector informed I
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the SOS that the inspector had recently re-inspected the area and questioned if the !
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storage met the chemical control program requirements.
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On May 27, the inspectors discovered that the duct tape was still present and the
pails were still unlabeled, although the buckets and pails had been more neatly
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arranged. This was brought to the attention of the plant manager.
Procedure DEOP 500-01 described an alternate means of injecting sodium i
pentaborate solution into the reactor pressure vessel (RPV) to bring the reactor to
, cold shutdown. The procedure directed preparation of batches (each batch
containing 14 buckets of boric acid and 14 buckets of borax) of boron solution and ,
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subsequent injection into the reactor. Four batches would be required to inject the l
j cold-shutdown boron weight. The inspectors found that enough buckets of borax
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and boric acid were staged only if the two spilled-and-recovered pails were
included.
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' The duct tape in the spilled and recovered pail of borax was of concern because it
was an unknown quantity of foreign material that could have hindered preparation
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and injection of boron solution into the reactor. Additionally, the duct tape was
plainly visible on top of the pail, but had not been identified and corrected by the
, licensee.
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The fact that the pails were not labeled in accordance with the chemical control
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program was of concern because an error could occur during boron solution
preparation. Furthermore, Dresden Health Procedure (DHP) 0130-10, Step F.2.e.,
stated, " Labeling is required ... unless the small container is intended only for
immediato one time use by the employee." Not labeling the pails in which the
recovered chemicals were stored was contrary to this procedure.
The inspectors reviewed the material safety data sheets for the borax and boric
acid, and noted that both sheets cautioned that container integrity should be
maintained.
The licensee had identified the poor material condition prior to the inspectors.
Human / Equip / Process Performance improvement Form (PlF) 227A-121997-
011410, dated January 8,1997, documented the discovery by chemistry that the
borax and boric acid were spilled on the floor. The immediate corrective actions '
were that the chemicals were recovered and placed into " replacement containers."
The PIF also documented that the storage needed to be upgraded, and that the
chemical control program rieeded to be addressed. The PlF was screened as a
level 4, trending purposes only.
The inspectors considered the continued presence of foreign materialin the borax
staged for safety-related use to indicate poor corrective actions. In January 1997,
the licensee had identified the poor material condition of the buckets of boron and
boric acid. On May 9, May 16, and May 27, the inspectors had identified, to the
licensee, that the chemicals had foreign material and were not labeled in compliance
with the Dresden chemical control program. Appendix B of 10 CFR Part 50,
Criterion XVI, " Corrective Action," required that conditions adverse to quality be
promptly identified and corrected. The inspectors determined that failing to store
the borax free of contamination and in correctly labeled chemicals constituted a
violation of 10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action."
(50-237:249/97009 01(DRP))
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c. Conclusion
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The containers of boric acid and borax staged for use during execution of
emergency operating procedures were in poor material condition. Some containers i
had cracked and spilled. The recovered chemicals had foreign material present.
The labeling on the temporary containers was not in compliance with Dresden
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procedures. The inspectors identified a violation of the corrective action
requirements.
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04.1 (Unit 2. 3) Ooerations Performance
a. Insoection Scooe (71707)
l The inspectors conducted frequent observations of operations activities. These
i activities included startup, shutdown, and refueling operations. Major activities
I monitored included:
Unit 2 Startup on May 2,
1 Unit 2 Shutdown on May 2 due to recirculation system problem,
Unit 2 Startup from D2F27 on May 4,
Unit 2 Shutdown on May 6 due to combined intermediate valve problem,
- Unit 2 Startup from D2F27 on May 9,
Unit 2 Shutdown on May 11 due to main steam isolation valve packing leaks,
Unit 2 Startup from D2F28 on May 15,
Unit 3 Refueling operations
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i b. Observations and Findinas
Control Room Performance
Generally, operations observed were performed in a careful and controlled manner.
- Good communications were evident, and the operators were knowledgeable of the
- plant conditions and issues. For example, on May 2, the inspectors witnessed the
reactor startup. The crew performed correctly and maintained awareness of the
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plant status. The shif t manager and unit supervisor (US) maintained correct
command and control during the startup. The US held crew briefs as necessary.
The US directed entry into the correct procedures in response to double-notching of
some control rods.
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The startup and power ascension of Unit 2 were hampered by various equipment
problems. The inspectors concluded that the actions taken were appropriate to the
symptoms and in accordance with plant procedures.
2ARecirculation Motor Generator Tachometer Shutdown
On May 2, shortly af ter the crew made the reactor critical, an engineer in the plant
identified an oscillating sound coming from the 2A recirculation pump motor
generator (MG) set. The operating crew confirmed that slow speed, flow, and
motor current oscillations had begun. Operators tripped the MG set within a few
minutes of the onset of oscillations. The US directed a manual scram to shutdown
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the reactor following a crew brief. The inspector observed that the functions and
tasks assigned to the crew were understood.
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The crew inserted a manual scram signal, but the rod positions displayed on the rod
position information system (RPIS) did not respond as-expected. Ten of the
displays went blank instead of going to 00. The inspector observed that the crew
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the nuclear engineer determine if the reactor would stay shutdown under all
conditions. The nuclear engineer verified that 8 of the 10 rods were at position 00
before the scram, but also correctly stated that the reactor was analyzed to stay
suberitical with one rod full out, but not for two rods at unknown positions. The
crew continued executing the scram procedure (DGP O2-03) and the loss of RPIS
procedure (DOA 0300-06). The crew directed an equipment attendant (EA) to
close the 2-301-25, "CRD Charging Water Valve," (25-valve) in accordance with
DGP 02-03. As this was being done, the EA reported that the valve was vibrating
excessively, and was vibrating itself open. The EA also reported that the as-found
position of the 25-valve was too far open based on the EA's system knowledge.
As the EA closed the 25 valve, the RPIS indications on the full core display all
indicated 00. The licensee subsequently secured the 25-valve in its desired
position, and planned to investigate and repair the valve during an outage of
sufficient scope to take the CRD system out of service.
The inspectors considered operations performance during the startup and
subsequent shutdown to be correct and in accordance with procedures. The
responses to two emergency equipment problems were acceptable.
Relief Valve Testina
Another example of good operations performance was observed during the startup
of May 9th. The inspectors observed the crew prepare to cycle 2-203-3C
electrornatic relief valve in accordance with DOS 0250-04, " Relief Valve Testing at
Low and at High Pressure." The US conducted a heightened level of awareness
(HLA) brief with Unit 2 control room personnel and other support people. The
nuclear station operator (NSO), responsible for performance of the procedure,
walked through the steps and gave expectations to the personnel assigned for i
support. The US discussed contingency actions should the valve fail to seat )
following being cycled.
During the HLA, a representative from site quality verification identified a possible
problem with the wording of a prerequisite. The prerequisite was changed to
ensure the wording was clear regarding the required positions of the drywell and
torus purge valves.
Following ithe procedure change, the crew was again given a short brief. The US
announced the valve cycling to the control room and an additional SRO made the ,
applicable plant announcement. The NSO requested the US perform a second l
check of the correct valve being selected and cycled the valve. All personnel
observed performing control room communications incorporated repeat backs of the
initial direction and acknowledgement of the repeat back.
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The relief valve performed as expected and the test was accomplished
satisfactorily. The valve was not declared operable until the test results were
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l. The inspectors concluded that the carefulness and thoroughness with which the
surveillance test was done demonstrated good operations performance.
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Low-Level Condensate Storaae Tank Alarm
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Late in the inspection period, the inspectors observed that operations did not fully
anticipate the impact on HPCl operability caused by decreasing condensate storage
i tank (CST) levels. The condensate storage tanks were being used to fill the Unit 3
condensate system. The Unit 2 operators were monitoring and recording the tank
j levels and had requested that more water be added to the Unit 2 3A CST.
! However, the level continued to decrease to the 12.5 feet level, which was the
] setpoint for the low CST level alarm. One of the steps in the annunciator response
- procedure (DAN) 902(3)-6 A-5, Rev. 7, "U2/3A Cond Storage Tank Lvl Hi/Lo," was
j to declare the Unit 2 high pressure coolant injection (HPCI) system inoperable,
! which the crew did.
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J The licensee reviewed the notification requirements and initially determir:ed that the
j inoperability of HPCI required a 4-hour emergency notification system (Ells) call to
- the NRC. At operations' request, engineering reviewed the DAN 902(3)-0 A-5 and
j determined that HPCI was not inoperable at 12.5 feet in the 3A CST. Oparations
l concluded that an ENS call was not needed and retracted the entry into the LCO
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(limiting condition for operation).
Preliminary review by the inspectors determined that the operators were aware of I
i the decreasing levelin the 3A CST and had been recording tin level on the control-
i room logs. Additionally, the operators had requested that more water be s 3nt to all
l the CSTs, but the additional water was not ready before the low-level anntnciator
- came in on the 3A CST. The inspectors observed that the licensee followed the
correct response procedures and applicable technical specifications. l
The inspector noted several factors that contributed to the failure to realize that
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HPCI was going to become inoperable on low CST level: the crew had been on
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shift for just one hour and had inherited the decreasing CST level from the p'evious l
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shift, the activity using the water was on the other unit, the meters that indi:sted :
CST level did not have any special marks at the 12.5-foot setpoint, and the netpoint I
1 at which the annunciator alarmed was the same at which HPCI was declared
1 inoperable, so no advance warning was provided. I
The licensee directed a prompt investigation into the event. The report stated that
before the evolution, radwaste had established guidelines that the CSTs were to be
maintained at about 14 feet and was working with the main control room to
maintain that level. The prompt report did not discuss any contributing causES as
to why the CST was allowed to decrease to the low-level alarm setpoint.
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Field Performance
The inspectors noted that operations staff in the field were identifying problems
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several instances when the operations staff in the ' field r@ect'ed work that appeared ~
inadequate. The inspectors also saw that minor equipment problems (such as small
leaks) were identified and action request tags were promptly hung on the
equipment.
While observing non-licensed operator (NLO) performance of plant rounds, the
inspector noted that the oil level on the sight glass for the 2A
condensate / condensate-booster pump (CCBP) bearing oil was above the high-level
mark, and an additional mark had been hand-written on the sight glass at the oil
level. A placard by the sight-glass stated, " Maintain oil level between the marks
while the pump is in operation." The extra mark appeared to be acknowledgement
that the oil was not between the marks, yet no action request, caution card, or
other administrative control was present to indicate that the high oil level was
acceptable.
The inspector questioned the NLO about the high oillevel. The NLO stated that he
had noticed this and intended to question anothor operator. The NLO questioned a
second NLO, who stated that the level had been high, but no specific problems
associated with high oillevel had occurred.
The inspector noted that the oillevel for the 2C CCBP was also above the high
mark, but no additional marks were drawn on the 2C CCBP sight-glass.
The inspector reviewed the operator rounds procedures and checklists and noted
that the CCBP received no specific checks. Discussions with operations staff ;
indicated the none were required. The NLOs are required to perform
undocumentM inspections of equipment conditions, including oil levels, during
routine rounds The inspector reviewed the UFSAR and found no commitments
regtuding inspections of the CCBP. The inspector reviewed the vendor manual
(VETIP Dresden Station Binder #D1301, "Ingersoll Rand Condensate and
Condensate Booster Pumps") and identified no specific guidance regarding the
slightly-high oil level.
The inspector discussed the observation regarding the oil level with licensee
management. The licensee reviewed the issue and concluded that training of NLOs
regarding oil level on various plant equipment could be improved. The licensee
documented this in a PlF. 1
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c. _Cpnclusiom l
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h general operations personnel exhibited safe operating practices. Crew briefs and j
heightened level of awareness briefs were informative, contingency actions were l
discussed, and peer checks were performed. The staff performed four startups and j
three shutdowns well and in accordance with procedures during this period. The l
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- inspectors determined no formal guidance existed for monitoring oil levels in CCBP.
! Late in the period, operations did not adequately monitor condensate storage level
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and as a result HPCI was declared inoperable. Subsequently, engineering concluded
that the procedure under which HPCI was declared inoperable was in error.
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j 05 Operator Training and Qualification
. 05.1 Trainina for Initial License' Candidates (40500)
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- The licensee's Site Quality Verification organization recently completed a review of
i the initial license training. The review assessed the causes of poor initial candidate
performance on licensee audit exams that had prompted the licensee to cancel '
scheduled NRC-administered initial exams. The results were documented in OAS
- 12 97-10, " Surveillance of Training Corrective Actions, Initial Licensing Training
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Certification Exam Failures, and Training Organizational and Programmatic issues."
i The inspectors reviewed this report. The report documented that candidates were
l not being trained or tested in the manner consistent with NUREG-1021, Rev. 7,
j Supp.1, " Operator Licensing Examiner Standards." The inspectors considered the
j surveillance to be good because the surveillance assessed the training against an
i NRC-established standard.
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j 08 Miscellaneous Operations issues
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l 08.1 (Closed) LER 50-237/95003-01: Unit 2 Technical Specification Violation During
- idle Reactor Recirculation Pump Start Due to Management Deficiency. This LER
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was an update to an LER that was closed in 50-237:249/95005. The update
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discussed additional corrective actions, including the plan to unplug the Unit 3 drain
- line during refueling outage D3R14. This action was accomplished during this
inspection period. This LER supplement is closed.
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i 11. Maintenance
M1 Conduct of Maintenance
M 1.1 General Comments
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a. Insoection Scooe (61726, 62707)
- The inspectors observed various maintenance activities and assessed the workers'
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performance and compliance with plant requirements and management
i expectations. The inspectors observed all or portions of the following work
- activities and work requests (WR)
i WR 960057246-01 repair body-to-bonnet leak on HCU 42-27, V15101 valve
p using Dresden Maintenance Procedure (DMP) 0305-05 liquid
nitrogen freeze seats for repair of CRD HCU isolation valves
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(305101 and 305-102)
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j WR 940096369-01 replace extraction steam nozzles at B3 LP feedwater heater
i WR 960069398-01 replace U2/3 EDG governor i
WR 94009798812 separate safety and non-safety-related cables on ATWS )
yarway modifications ~
- ... . . . . . . _.-- .VvTi 960049639'D7 instill th'eim' age'evb re'hiov53 fr6ih loc &tidrIR-7 "
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j WR 960049569-01 pull /put CRD SN #537C from position G-8 :
WR 960049569-05 pull /put CRD SN #A3180 from position H-7 l
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WR 950069199-02 rebuild valve 3-0305 54-19-111, HCU 54-19 nitrogen and )
instrument block valve using DMP 0305-01 nitrogen fill !
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cartridge valve (305-111) maintenance
2 WR 960118198-01 repair 3A 1503 LPCI heat exchanger partition plate
j WR 950061282-01 D3 RFL TS test ECCS UV relays, contact onsite OAD
WR 950065393 01 D3 RFL TS LPCl/ containment coolant logic test l
WP 950068434-05 replace 24/48 Vdc batteries and battery chargers, modification
I M12-3-95-003
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i The inspectors observed all or portions of the following surveillance activities and i
j assessed the workers' performance and compliance with plant requirements, J
, including TS and UFSAR requirements. !
} DES 6601-01 diesel generator governor oil change and compensation
! adjustment
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DOS 6600-04 bus undervoltage and ECCS integrated functional test for U3
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diesel generator
i DOS 6600-09 testing of ECCS undervoltage and degraded voltage relays
l DIS 1500 21 U3 DIV l LPCl/ containment cooling system logic system
DOS 0250-04 rel of valve e ting at low and at high pressure.
b. Observations and Findinas
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l In general, work was being performed in accordance with the procedures. For work
specifically observed, the workers were observed to use good communications,
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foreign material exclusion (FME), and radiation worker practices. When questioned
i about activities and procedural steps, the workers were aware of the purpose and
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status of the work. The unit supervisors maintained good order in the control room
i and maintenance workers stopped and discussed activities with the US and the
NSOs to ensure the work would not interfere with the operators. The inspectors
l noted some evidence of inadequate FME in areas where no workers were present
j (e.g., debris by open drains) and reported the conditions to the work execution
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< center or local work control point. The NRC has recently issued a violation for FME
(Violation 50-237:249/97007-03a, b, c), and the licensee had not completed its
response to the violation at the end of this inspection period.
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in general, the work observed went as planned and in accordance with procedure.
However, some exceptions are described below.
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Work on control rod drive hydraulic control units
On April 30,1997, the inspectors observed various activities on the control rod
drive (CRD) hydraulic control units (HCUs), including valve bonnet replacement on ~'~ ~'
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the'101 valves (HCU' insert 3alvesT. 'Ths'iMpecto'rs~rivte'd thut'the' valve 'connBtIs ^
were being removed, rebuilt, and replaced without tracking from which HCU the
valve bonnet originated. The inspectors located no requirements to track the
bonnets individually, so the inspectors concluded that placing the bonnet back on a
different HCU without tracking documentation was acceptable. The inspectors !
reviewed some of the work requests in the field and noted that the signatures and
initials for the work were being made by the supervisor without writing the initials
of the individual who actually did the work. The inspectors discussed this with the
outage control center personnel. The licensee corrected the signature errors and
discussed the issue with the workers, and documented the error in PlF 1997-3672.
The inspectors followed-up with the supervisor a few days later, and the supervisor
indicated that the administrative requirements were now understood, and showed
the inspector examples of correctly signed or initialed work.
Dresden administrative procedure DAP 09-13, " Procedural Adherence," Fcep F.5,c.,
required that if a step sign-off was made by an individual, who was not the
individual who actually performed the step, then both individuals were to be i
indicated by signing, using the " doer / signer" form of signature. Centrary to this, on
April 30, the inspectors identified that a worker was not listing the " doer" while
performing signoffs.
Failing to follow procedures was identified as violations in NRC inspection report
50-237:249/97007, which was issued on June 13,1997. Since the licensee has
not yet responded to these violations, the failure to follow the signing requirements
listed in DAP 09-13 will not be issued as a violation, but will considered to be under
the auspices of the licensee's corrective actions to the violations in Inspection l
Report 50-237:249/97007
Following the discussions with the inspectors, SQV increased monitoring of the
work. The SOV staff then identified that the air piping for the scram pilot valves
had been assembled using mixed brands of compression fittings. This was
documented in a PlF. Engineering evaluated the use of mixed fittings and
concluded in an engineering memo (Dresden Document #0005410563) that the
installation was acceptable, but recommended that uniform fittings be used for any
future repairs. The use of mixed fittings was previously discussed in an NRC
inspection report, and was considered an unresolved item (URI 50-237:249/96009- l
'
07) pending the review of the licensee's justification for the adequacy of the test
program utilized to demonstrate the occeptability of interchanging compression
fitting hardware from different ma sufacturers. Specifically, the inspectors identified
in Report 96009 Section E2.1, concerns with Parts Evaluation M-1995-559-0. The
evaluation of the mixed fittings on the CRD HCU work in a memo from engineering l
(Dresden Document #0005410563) was based partially on Parts Evaluation M-
1995-559-0. The inspectors therefore considered the newly identified mixed
fittings to be another example of URI 50-237:249/96009-07.
.
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i As work progressed, the workers requested operations to clear some of the out-of-
service points on the CRD HCUs. The inspectors noted that operations refused to
clear the out-of service cards on the air systems for the CRD HCU because of
observed kinks in the piping. The inspectors also noted that the work was the
-
subject of otherPif Mcr someWil-of4fwcrGit inues. Based on the number of -
PlFs documenting poor work, on NRC findings, and on SOV subsequent
identification of mixed compression fittings, the inspectors concluded that the initial
SOV oversight of this work was low.
4 On May 28, the inspectors observed two workers rebuilding valve 3-0305-54-19-
111 (HCU 54-19 nitrogen and instrument block valve). The workers in the field had
the correct work package and procedure; however, the inspectors noted that none
of the steps in the procedure, not even the prerequisites, had been filled in, even
though work was in progress. When questioned about the lack of sign-offs, the
workers explained that the tasks being performed wore repetitive, and that although
- each item had not been filled in step-by-step, the work was being performed in
l accordance with the procedure. The workers stated that part of the reason for not
t
signing step-by-step was because the workers' hands were dirty, and the workers
did not want to soil the documentation. One of the workers (the work supervisor)
4 stated that the prerequisites had been met before starting the job. In followup
- discussions with the inspectors and the workers, licensee management informed
the workers that procedures are to be filled in step-by-step.
Step F.5 d. of DAP 09-13 permitted transcribing data from a contaminated or
deteriorated field copy to a clean copy; this step indicated that procedure steps
were to be signed even if the field copy might get dirty. Contrary to this, on l
May 28, the inspectors identified that workers were not signing steps, including the l
l
prerequisites, because the workers were concerned about getting the procedure
dirty. Since the licensee has not yet responded to the procedural adherence
violations identified in NRC inspection report 50-237:249/97007, issued on
June 13,1997, the failure to follow the signing requirements listed in DAP 09-13
i will not be issued as a violation.
c. Conclusions
,
Maintenance activities, observed by the inspectors, were generally performed
correctly. However, the inspectors identified two examples of failing to sign work
steps and considered them to be non-cited violations. In addition, following
discussions with the inspectors, the licensee's SOV department increased
,
monitoring of the jobs and identified that mixed fittings were being used on non-
safety-related air piping. Also, operations personnel rejected some work due to 1
workmanship issues.
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M2 Maintenance and Material Condition of Facilities and Equipment
!
M2.1 Unit 2 Material Condition and imoact on Startuos
" - ~ ~ ~ ~ " " ' ' ' ' " ' ' " ^ ^ - ' - ~ ~ - - - - - ' '- ~*
^ al InstiedtidnTcbbs l'ty2707) ~ ^
The inspectors assessed the causes of equipment problems that impacted the plant
startups. The inspectors reviewed the maintenance history of some of the
components to determine if the component failures were the result of past or
current maintenance practices. The inspectors also reviewed the packages
presented to the plant onsite review committee (PORC) and assessed the
performance of PORC.
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j
Documents reviewed included the prompt investigation entitled, " Unit 2
"
Recirculation Pump secured and initiation of Manual Scram due to improper
installation of 2A Recirc MG Set tachometer."
b. Observations and Findinas
Shutdown of May 2: Failed 2A Recirc MG tachometer
! On May 2, the unit was made critical. Unit 2 was shut down about five hours later
because of a recirculation pump motor-generator (MG) set's speed oscillating. The
,
inspectors assessed the licensee's prompt and follow-up investigation into the
speed oscillations.
The immediate cause of the oscillation appeared to be the improper installation of
the 2A recirculation motor generator (MG) tachometer during the forced outage for
repairing the Merlin-Gerin 4kV breakers. Personnel who responded to the MG set
. during the oscillation observed that the tachometer, which was mounted at the end
of the shaft, was being impinged on with such force that the tachometer was
bending the tachometer mounting plate.
1
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immediately following the trip of the MG set, the inspector observed that the shaft
coupling from the tachometer to the MG shaft had insufficient clearance. This was
- not noticed during installation because the clearance was reduced during operation
4 due to thermal growth and magnetic centering of the MG shaft. During operation,
i force against the tachometer shaf t was sufficient to flex the tachometer's mounting
platform up and down, and the movement and pressure caused the tachometer's
output signal to the speed control circuitry to vary, thus causing the MG speed
oscillations.
The licensee's investigation determined that the installation instructions for the
tachometer were inadequate, as no clearance values had been specified. The
electrical maintenance department work analyst based the work instructions on
previous work history. The inspectors determined that not all coupling alignment
4 instructions included gap clearance instructions.
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Prior to the outage to repair the Merlin-Gerin 4-kV breakers, the tachometer's
indicated speed was off-set from the actual speed. When the unit was shut down
to repair the breakers, licensee management added the replacement of the
tachometer to the outage scope.
. .. . . , . .. .. . . . . - - . . -
Criterion V of Appendix B to 10 CFR Part 50 states,in part, that activities affecting
quality shall be prescribed by documented instructions, procedures, or drawings, of
a type appropriate to the circumstances. Contrary to this, the work instructions
were inadequate for the task. This licensee-identified and corrected violation was
being treated as a Non-Cited Violation, consistent with Section Vll.B.1 of the LL6L
Enforcement Policy. (NCV 50-237:249/97009-02(DRP))
May 6 Failed Shut Combined Intercent Valve
The operators started up U2 on May 4 and subsequently shut the unit down on
May 6 due to a failed-shut turbine combined intercept valve (CIV). The licensee
determined the cause to be a stuck shutoff valve that prevented opening the CIV.
Dresden was still equipped with the original design of the shutoff valve and the
valve had not previously failed. The valves' vendor had recommended two design
improvements (replacement of the original shutoff valve with a " Group 3" valve and
then, some years later, replacement of the Group 3 valve with a " Group 6" valve.)
The licensee had evaluated the Group 3 recommendation and rejected replacement
because of good past performance. The licensee has created nuclear tracking
system (NTS) items to replace the original Vickers EHC shutoff valves with GE
Group 6 shutoff valves by D2R15 and D3R15, and, as of this report date, one of
ten on Unit 2 and eight of ten on Unit 3 have been replaced.
May 11 Main Steam Valve Packina Leakaae
Unit 2 was started up on May 9, and paralleled to the grid on May 10. On May 11,
l
Unit 2 was shut down and entered forced outage (D2F28) due to packing leaks l
noted on two main steam isolation valves. The licensee analyzed the valves and I
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noted that the as-found leakage exceed the allowed leakage, but that the leakage
was through the packing. Also, the packing nuts were found to be below the
required torque value. The last dates the nuts were torqued were October of 1994
for the "B" MSIV and February of 1995 for the "D" MSIV. The licensee created a
NTS item #97 240175 to evaluate the MSIV packing preload. The inspectors did
not identify any recent work that could have contributed to the packing leaks.
M3 Maintenance Procedures and Documentation
M3.1 (Unit 3) Division l' Undervoltaae test
a. Insoection Scoco (61726)
The inspectors reviewed the procedures and the results and witnessed portions of
the performance of Unit 3 Division ll testing: Dresden Operating Surveillance (DOS)
6600 09, Testing of ECCS Undervoltage and Degraded-Voltage Relays and DOS
16
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6600-04, Bus Undervoltage and ECCS Integrated Functional Test for Unit 3 Diesel
Generator. The review included:
WR 950061282-01, "D3 RFL TS TEST ECCS UV RELAYS CONTACT OAD"
i
WR 950061286-01, "D3 RFL TS 34-1 UV AND ECC31NTEGRATED FUNC ~ ~ ~
l TEST"
TS 4.2.B-1, ECCS Actuation Instrumentation Surveillance Requirements
TS 4.9.A, AC Sources - Operating, Surveillance Requirements
TS 4.5.3.a, ECCS Surveillance Roquirements
<
UFSAR 8.3.1.5, " Standby Diesel Generator System"
i'
UFSAR 8.3.1.2, "4160-system"
Dresden Administrative Procedure (DAP) 07-02, Conduct of Shift Operations
'
< DAP 09-02, Procedure and Revision Processing
DAP 09-11, Conduct of Surveillance, Special, and Complex Procedures
DAP 09-13, Procedural Adherence
b. Observations and Findinos
The inspectors reviewed the TS requirements and verified that procedures
incorporated all the required surveillance testing listed in the applicable Technical
Specifications. The inspectors also reviewed the UFSAR and selected electrical
instrumentation and supply circuit diagrams. The inspectors found no discrepancies
- in the procedure requirements.
1
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The portions of the surveillance test observed by the inspector were performed by
the licensee in a coordinated manner, utilizing three-part communications and good
commanJ-and-control. Data and signatures were entered by the workers as the
work progressed.
The licensee first performed DOS 6600-09, " Testing of ECCS Undervoltage and
l Degraded-voltage relays," to ensure that the proper voltage settings were in place
- before the integrated testing was performed. The surveillance test included the as-
- found and as-left values for the relays as well as the acceptance criteria listed by
i
each relay to be tested. The actual testing involved removing the undervoltage
relays, the degraded-voltage relays, and the timing relays from the breaker circuitry
and testing the relays individually. The results of the individual relay tests were
reviewed by the US, who then informed the crew before the integrated functional
test. The functional test was then performed and the test acceptance criteria met.
c. Conclusions
The inspectors found the emergency core cooling system under-voltage relay and
integrated functional testing surveillence to be adequately performed and technically
sound.
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M4 Maintenance Staff Knowledge and Performance
- M4.1 (Units 2. 3) Instrument Maintenance Staff Performance (62707)
t_._ ._ --
-Enm ara &byhstensOMnenFMe stat-dwing thirinr,paction paic&resulted - - - - .
,
in inadvertent equipment actuation. The following two events will be documented
by the associated LERs:
1
4 * On May 20, a Unit 2 unexpected Group IV isolation of high pressure coolant
injection (HPCI) system occurred due to incorrect setting on test equipment.
- e On May 26, a Unit 3 full trip (scram) signal was received due to
'
manipulation of wrong component during reactor protection system (RPS)
- logic testing. The personnel performing these evolutions were not the same,
- and there was no history of errors associated with those workers.
l Ill. Enaineerina
i E3 Engineering Procudures and Documentation
i"
E3.1 Surveillance Procedure Performance (37551) ,
.
- a. Insoection Scone
a 1
, 1
The inspectors witnessed the licensee's efforts to install and flush a new governor
, on the Unit 2/3 (swing) emergency diesel generator (U2/3 CDG). The work was
4
performed under Dresden Electrical Surveillance (DES) 6600-01, " Diesel Generator
Governor Oil Change and Compensation Adjustment," Revision 12, as required ;
under WR 960069398-01, "U2/3 diesel generator, replace governor." The l
,
inspectors also reviewed: i
,
DOS 6600-01, Diesel Generator Surveillance Tests
DAP 09-01, Station Procedures
DAP 09-02, Procedure and Revision Processing
DAP 09-11, Conduct of Surveillanco, Special and Complex Procedures
DAP 0913, Procedural Adherence
Woodward "UG" Dial Governor Manual 03040, Controlled Vendor Manual
V-144
TS 4.9.A, AC Sources - Operating Surveillance Requirements
TS 6.8, Procedures and Programs
UFSAR Section 8.3.1.5, Standby Diesel Generator System
UFSAR Section 13.5.1.1, Conformance with Federal Guidelines
American National Standards Instruction (ANSI) N-18.7-1972, Administrative
Controls for Nuclear Power Plants
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b. Observations and Findinns
The inspectors identified a concern with the licensee's procedure review and
-
performance activities. The inspectors identified that the procedure and work
- request revicw process could potentially Oypa'ss retj0 ired revid0vs." - ~~
~~"'l
On May 23, the inspectors monitored a heightened level of awareness (HLA)
briefing for flushing the newly installed U2/3 EDG governor. After conferring with
, the system engineer, the unit supervisor (US) conducted the HLA briefing and
stated that the purpose of the evolution was to drain, flush, and fill the new EDG
governor with new oil. The inspector accompanied a non-licensed operator (NLO)
i and the system engineer to witness the evolution at the U2/3 EDG. The system
angineer briefed the NLO on which parts of DES 6600-01 would be performed. The
"
inspector noted that the system engineer waived parts of DES 6600-01. The
inspectors inquired what authorized performing only parts of the procedure and
were informed that the system engineer was allowed to decide what portions
would be performed. The inspector noted that during the HLA briefing, it was not
stated which portions of the procedure would be skipped.
The inspectors reviewed the procedural authorization to perform only portions of
- the procedure. The engineer cited DES 6600-01, Step G.4, which stated, "This
procedure may be used in sections to do maintenance testing, providing the entire
section is used." However, DES 6600-01 did not define what constituted a
"section" of the procedure.
4
The inspectors reviewed the history of procedure revisions to DES 6600-01, " Diesel
Generator Governor Oil Change and Compensation Adjustment," and found the
- following:
,
Revision Date Purpose
i No.
7 3/24/97 Change to set frequency to 60 vice 61 Hz (to
come into TSUP range of 60 1.2 Hz af ter
surveillance had come in high when the as-left
setting was 61 Hz)
8 3/25/97 Established initial conditions of droop and speed
settings to adjust governor compensation
(necessary after the EDG started hunting at the
new as-left setting)
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Revision Date Purpose
No.
r- . - - ._ 9 .. _ _ 3/,25/9 7 Revised from a running time,of. 45-60. minutes,to,a.
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time perio'd determined by the system engineer to
ensure that the governor oil was at the proper
operating temperature for compensation
adjustment (necessary because the shorter running
time did not warm the governor oil sufficiently to l
properly set the compensation) l
10 3/26/97 transposed two steps of Rev 9 to place the l
LOCAL / REMOTE switch to LOCAL before lowering I
engine speed (necessary because the EDG tripped l
off at about 800 rpm when the control room
operator tried to lower the EDG rpm per the '
i
procedure and the EDG trips functioned as
designed while the switch was in the REMOTE
position)
11 4/19/97 added steps to verify compensation at rated speed l
and to direct raising rpm to normal range after i
system engineer had verbally changed the '
procedure during performance of Rev 10 on
3/26/97 (actually added two steps and revised one I
'
existing step, however, did not direct that rpm had
to be raised locally before changing
LOCAL / REMOTE switch to REMOTE)
12 5/21/97 Issued to correct inaccuracies in Rev 11 after
inaccuracies were noted by the NRC
The revision history indicated that inadequate planning had gone into the revisions
before implementation. Rather than going through the whole process and assessing
the effects of each change and incorporating all changes at once, the changes were
reactive to problems encountered. This was particularly evident after Revision 10
reversed two steps (switching to LOCAL control before lowering the EDG speed,
thereby bypassing an EDG trip at about 800 rpm) and did not incorporate a step to
locally raise the EDG speed before switching back to REMOTE operation.
The system engineer used step G.8 of DES 6600-01, Revision 10, which stated
"These procedure instructions MAY BE supplemented by the Governor
Vendor / System Engineer recommendations with concurrence from System Engineer
or Lead Work Analyst," as authority to provide verbal directions to the operator
performing the procedure.
Procedure DAP 09-13, " Procedural Adherence," Part F, required that procedures
shall be followed as written and,if steps could not be followed, then the workers
.
20
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were to place the system in a stable condition and notify the cognizant supervisor.
Further work was fiQI to be performed until the procedure is changed and
approved in accordance with DAP 09-02, " Procedure and Revision Processing." It
appeared that the guidance regarding changing or " supplementing" procedures
given ny Step G.8 of DES 6600-01 was contrary to the requirements of DAP
09-13.
The procedure use and change process during performance of DES 6600-01 was
originally discussed as an unresolved item (URI 50-237:249/97006-05(DRP)).
Pending further NRC review of the procedure usage during maintenance activities,
this matter will continue to be unresolved.
c. Conclusions
Based on further examination of the performance of DES 6600-01 and the
administrative requirements for procedure changes, the inspectors identified a
generic concern with the licensee's procedure process that could potentially allow
procedure and work request changes to bypass required reviews.
IV. Plant Support
R1 Radiological Protection and Chemistry (RP&C) Controls
R 1.1 General Comments (71750)
During routine inspections in radiologically controlled areas, the inspectors assessed
licensee performance. Overall, the licensee's radiation protectior, staff enforced the
plant's radiological control standards. The inspectors observed several instances
when workers who were holding discussions in elevated dose rate areas were told
by radiation protection staff to move to a low-dose area. The licensee continued to
use personnel functioning as "greaters" to assure that workers entering the
radiologically controlled area were aware of dose rates and administrative
protection requirements. The inspectors noted that workers in elevated dose areas,
such as under the reactor, were equipped with electronic dosimetry that
transmitted the dose rates and accumulated dose to radiation protection staff
monitoring the workers through video, thereby facilitating dose control.
V. Manaaement Meetinas
X1 Exit Meeting Summary
The inspectors presented the inspection results to members of licensee
management on May 30,1997, following the conclusion of the inspection period.
The licensee acknowledged the findings presented.
The inspectors asked the licensee whether any materials examined during the
.
21
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inspection should be considered proprietary. No proprietary information was )
identified.
X3 Management Meeting Summary l
4 On May 12 and 13,1997, A. B. Beach, Regional Administrator for Region 111,
visited Dresden. Mr. Beach met with senior licensee management and with
members of the operating crew and discussed the status of Dresden.
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PARTIAL LIST OF PERSONS CONTACTED
1
Licensee
S. Barrett, Operations Manager
S. Butler, Quality Audit Supervisor
E. Carrell, Regulatory Assurance
E. Connell, Desi0n Engineering Superintendent
R. Freeman, Siie Engineering Manager
K. Hayes, Maintenance
J. Heffley, Units 2 and 3 Station Manager
J. Hill, LRPS I
S. Kuczynski, Shift Operation Supervisor
M. Milly, General Supervisor :
R. Peak, Supervisor
S. Perry, Vice President, BWR Operations
P. Planing, Plant Engineer
J. Richardson, Human Resources Supervisor
J. Strmec, Lead Chemist
P. Tzomes, Support Services Director
J. Vieaux, General Supervisor
L. Weir, Design Engineer Superintendent
D. Willis, Superintendent
D. Winchester, Safety Ouality Verification Director
8. Wong, Material ITEC
INSPECTION PROCEDURES USED
j IP 37551: Onsite Engineering
'
IP 40500: Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing
Problems
IP 62707: Maintenance Observations
IP 61726: Surveillance Observations
IP 71707: Plant Operations
IP 71750: Plant Support Activities
ITEMS OPENED, CLOSED, AND DISCUSSED
i
Ooened
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50-237:249/97009-01 VIO Corrective action for storage of Alternate Boron
chemicals.
50-237:249/97009 02 NCV inadequate instructions resulted in recirc motor-
generator speed oscillations
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23
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Qigsed
50-237/95003-01 LER Unit 2 Technical Specification Violation During idle
Reactor Recirculation Pump Start, Dye to Ma,nagement. .. . -
Deficiency.
50-237:249/97009-02 NCV Inadequate instructions resulted in recirc motor-
generator speed oscillations
Discussed
50-237:249/96009-07 URI Installation of Compression Fittings With Interchanged
Hardware From Different Manufacturers
50 237:249/97006-05 URI Verbally adding steps to a procedure to DES 6600-01
LIST OF ACRONYMS USED
ACAD Atmospheric Containment Atmosphere Dilution
BRC Business Review Committee
CCST Contaminated Condensate Storage Tank
CCSW Containment Cooling Service Water
CFR Code of Federal Regulations
CR Control Room
DAP Dresden Administrative Procedure
DATR Dresden Administrative Technical Requirements
DEOP Dresden Emergency Operating Procedure
DES Dresden Engineering Surveillanco
DGP Dresden General Procedure
DIS Dresden Instrument Surveillance
DOA Dresden Operating Abnormal
DOE Department of Energy
DOP Dresden Operations Procedure
DOS Dresden Operations Surveillance
DTS Dresden Technical Surveillance
ECCS Emergency Core Cooling System
EDG Emergency Diesel Generator
EMD Electrical Maintenance Department
EOF Emergency Operations Facility
ERO Emergency Response Organization
FHA Fire Hazard Analysis
FME Foreign Material Exclusion
gpm Gallons Per Minute
GSEP Generating Station Emergency Plan
HPCI High Pressure Coolant injection
HVAC Heating, Ventilation, and Air Conditioning
.
24
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(o *
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,-
IFl Inspector Followup item
IMD instrument Maintenance Department
(RB Issues Review Board
j kW Kilowatt
+...,.. , , , , , , , , _ . , , , .,.. . _. . . . . . . - . J
" ~ kV ' ' ' Kilovolt
LER Licensee Event Report
LOCA Loss Of Coolant Accident
MG Merlin-Gerin l
MMD Mechanical Maintenance Department
MW Megawatt
NCAD . Nitrogen Containment Atmosphere Dilution
NSO Nuclear Station Operator
NTS Nuclear Tracking System
OSC Operational Support Center
OE Oparability Evaluations
Pi Problem identification Form
psig Pounds Square Inch Gage
RPT Radiation Protection Technician
SOV Site Quality Verification
UFSAR Updated Final Safety Analysis Report
URI Unresolved item
)
25