ML20199A246
| ML20199A246 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 01/21/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20199A230 | List: |
| References | |
| 50-295-97-25, 50-304-97-25, NUDOCS 9801270162 | |
| Download: ML20199A246 (30) | |
See also: IR 05000295/1997025
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U.S. NUCLEAR REGULATORY COMMISSION
REGION 111
Docket Nos: 50 295, 50-304
Report No: 50 295/97025(DRP); 50-304/97025(DRP)
Lloonsee: Commonwealth Edison Company
Focility: Zion Nuclear Plant, Units 1 and 2
Location: 101 Shiloh Boulevard
Zion,IL 60099
Dates: October 11 through December 16,1997
Inspectors: E. Cobey, Acting Senior Resident inspector
D. Calhoun, Resident inspector
C. Brown, Resident inspector
N. O'Keefe, Resident inspector
J. Yesinowski, lilinois Department of
Nuclear Safety ilDNS)Inspectos
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Approved by: Kenneth G. O'Brien, Acting Chief
Reactor Projects Branch 2
9901270162 990121
DR ADOCK 0500 2 5
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EXECUTME SUMMARY .
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Zion Nuolear Fiant, Ugita 1 and 1
NRC Ineraction Report 50-295/97028(ORP); 50 304/97025(DRP) i
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o - This inspec6 son included aspects of licensee opwations, maintenance, enginewing, and piant
support. The report covers a nine week period of inspection activities by the resident staff. l
i During this inspection period, licensee performanos was s3ain inconsistent. Operations ,
- i;1;.c;t personnel continued to experience problems with system configuration control and
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the adequacy of p,; :ru=. wandowns. These probians contributed to inadvatent ,
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inoperability of an emergency diesel generator and testing procedure deflaiencies not being
identined una the evoluton was being conducted. In addition, control room operators continued
- to be unneosanarty ch Jianged by irW=C procedural guidance and inconsistent support of
other departments. Speci6cally, doRolent maintenance prachoes resuded in failure of a fuel oil
- ir$ection pump on an emergency diesel generator and an inadvertent engineered safety feature ,
actuation. However, an overall improvement was noted in the thoroughness of post event
tr f;"': ,s and the adequacy of immediate corrective actions.
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Ooerations
. The inspectors concluded that operations department management demonstrated a lack
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of communication and command and control of piant acSvities prior to and during the
spheting of the service water header between units which contributed to the inadvenant
loss of service water flow to an emergency diesel generator. in addition, a violation was
L identified involving the failure to provide appropriate guidance in a procedem to ensure
that adequate service wat;r flow was maintained to the 28 emergency diesel generator
(Section 01.1).
. The inspectors concludeo est the licensee continued to expwience prot;lems in the
L areas of pr d*n walkdowns and system configuration control. For example,
operatorwalkdowns of a procedure goveming splitting of the service water system
l_ between units were not sufficierd to identify procedural deficiencies and on shift
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managemed was not aware of pertinent aspects of plant configuration dunng the
subsequent evolution. These 7.roblems contributed to the inadvertent loss of service
I water flow to an emergency diesel generator (Sections 01.1 and 01P
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. The inspectors cou Juded that the inadvertent cross-connection of the Unit 1 and Unit 2
condensate storage tank event was due to the Unit Supervisor's failure to follow station
! pmoedures for performing an evolution when a procedure did not exist for that evolution.
Also, the inspectors determined that the lack of aggressive pommotor trencHng
contributed to the operator's failure to detect the level changes in the condensate storage
tanks (Section 01.4).
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. A violation was identified involving the licensee's failure to make the required four-hour
l notdication to the NRC for the plant being outside its design basis due to an inoperable
l. containmord penetration line (Section 08.1).
- A nort cited violation was identified involving the hcensee's failure to provide M=g:t
guidance in a procedure for moving fuel assembhos (Section 08.2).
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- The inspectors concluded that the licensee had perfotmed several thorough r-d :ma
br:; - r, during this period (Sections 01.1,01. 4,08.2,08.3, and M1.3). .
MaNananna
+ The inspectors concluded that a sidal based error contdbuted to the failure of a fuel oil
Ir(oction punip on the 1A emergsacy diesel generator (Section M1.1).
. A violation was identified involving the Ikarmee's failure to provide adequate guidance in
a surveillance procedare to test containment isolation and component actuation circuitry
(Section M1.2).
.. A violauon was iderdified pertaining to electrical maintenance personnel's failure to follow
a maintenance prosedure for replacing a safeguards relay. The ermr resulted in an
,- inadverterd engineered safety feature system *d% (Section M1.2).
- A violation was identified involving the licensee's failure to identify and perform a
post-mairdenance test following the replacement of a safeguards relay (Section M1.2).
EDGbtedGE
- A norsited violation was identified involving the leoensee's failure to perform inservice
testing on the 2A safety irjecuon pump suction valve within the specified periodicdy
(Section E8.1).
- The inspectors identified a violation involving tt "wuee's failure to maintain a control
room heating, ventilation and air corditioning system design drawing current with the
as budt system design (Section E8.2).
Plant Suncort
. The licensee identiced a third instance of inattentiveness by the sec.,urity guard force
. (Section 88.1).
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L neoert Detana
Sumnurv af Plani 8tatus
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- Dudne this '2;:+=, period, the hoensee maintained Unit 1 in a defueled condition and Unit 2 in
a cold shuM:wn, depressurtmed condiuon pending es.Tf:'!:5, of restart actions delineated in the ,
Zion " :-:;ri Plan.
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-01 Conduet of C-7-;^':n
) 01.1 Unit 2 R=Mua! Heat Re,T.sval (RHR) System Rendered it-* O_= to a Fd=e to
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Maintain the Reouired Number of Service Water (SW) Pumos
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s. Inspection Scoce (71707)
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The inspectors reviewed the circumstances surrounding the boensee's failure to maintain
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the required navnber of operable SW pumps on Odober 12,1997. The inspectors
Interviewed operators, reviewed applicable procedures and documentation, and ,
j evaluated the licensee's subsequent root cause investigation and corrective actions. ;
b. Observations and Findinas >
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' On October 12,1997, Unit 1 was defueled and Unit 2 was in cold shutdown. The SW
systr.,m was cross-connected between units with the 1A SW pump out-of-service (OOS)
- rnd the 18 SW pump inoperable, but available, due to the 1 A emergency diesel
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generator (EDG) being OOS for maintenance. The 1C,2A,2B, and 2C SW pumps were
all operable.
Seouence of Events on October 12.1997:
l . At 1335, the hoensee held the complex evolution knofing fx the performance of
- System Operating instruction (801) 61F, "Sp2tting Service Water Header for
Maintenance," Revision D.
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- At 1445, the kcences began performing Sol 41F. (This activity was conducted
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. from Unit 1.)
I . At 1515, a non-licensed operator isolated SW cooling fiert to the 2B EDG in
accordance with Sol 41F, Step 1.2. (This action rerW A the 2B EDG and the
2C SW pomp inoperabia.) i
- At 1525, the Unit 1 Nuclear Station Operator placed the control switch for the
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1C SW pump in pulHo lock in accordance with Sol 41F, Step 1.3.- (This action
rendered the 10 SW pump inoperable.)
. At 1540, the licensee held the pre-job briefing for the performance of Periodic Test -
(PT) 11E-0, 'O Ok sel Generator Cyhnder Liner Test," Revision 1.
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- M 1550, the licensee began performing PT-11E-0. (This activity was conducted j
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from Unit 2.)-
-* At 1554, the 0 EDO maintenance lockout switch was pieced in the 'Maint Lockout"
position in accordance with PT 11E 0, Step 5, which made the 0 EDG inoperable. .
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i CEry- ,r,y, the 2A SW pump was made inoperable due to the pump not hadne
c .an emergency power supply.
. . M 1650, the 0 EDG maintenance lockout switch was placed in the "Normer'
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position in accordance with PT-11E4, Step 34, which restored the 0 EDG and the
2A SW pump to an operable condition. -
cooline Sow.-
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I * At 1710, a non-licensed operator opened the normally closed Unit 2 EDG oross-tie
- - valve,2MOV-SW0023, which restored the 28 EDG and the 2C SW pump to an
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operable condition.
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- At 1720, the licensee completed PT-11E 4.
! * At 1901', the hoensee notified the NRC of this event in accordance with
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10 CFR 50.72. ,
Following the discovery that the 28 EDG was without SW cooling flow, the licensee
, restored SW flow to the 28 EDG and initated a prompt investigation. The noensee
- determined that Technical Specification intery,eenen (TSI) 91-05, " Service Water (SW)
Pump OPERABluTY," Revision 4, specified that three SW pumps be operable for the
existing plant configuration, each with an independent oper28e emergeng power supply;
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however, from 1525 to 1710, the licensee did not maintain Gys required number of
opwabie SW pumps. Without three operable SW pumps, the SW system was inoperabie
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since it was not aUe to provide adequate cochn0 water flow to the common component
coohng water (CC) system during a dual unit loss of offsite power ever.t. The commor'
'. unit CC system was inoperabie since SW was a necessary support system and the U ,
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RHR system was also inoperable since the CC system was a necessary support system.
The hoensee determined that SO641F, Revision 0, was inadequate, in that, it did not :
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' address the Unit 2 EDG cross-tie valves. As a result, the procedure did not ensure that
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SW flow to the 2B EDG was available from the Unit 2 header prior to isolahng the supply
from the Unit i header in adddion, a technical review of the procedure, performed
during the procedure revision process, and operator walkdowns of the procedure were
. not adequate to identify that the procedure would not work as written. The failure of
Sol 41F, Revision 0, to provide appropriate guidance to ensure that adequate SW flow I
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was maintained to the 28 EDG YMin splitting the SW headers is considered ar. example
of a violation of 10 CFR Part 50, Appendix B, Criterion V (50-295/97025-01a;
. 50 304/97025-01a), as described in the attached Notice of Violation.
In addition, the licensee determined that during the everd the Unit 1 Supervisor was not
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aware of the existing pierd configuration. Specifically, on October 11,1997, the
Unit Supervisor had been involved in the development of an OOS to support isolating SW i
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loads such that ordy two SW pumps were required to be opwable in accordance wah
TSI 9106. This 008 isolated two of the three CC heat exchangers. Mr?=.4, on :
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the next shiR, the Shift Manager moddied the 008 to isolate only one of the three CC
heat exchangws, since this was the conneuration necessary to support splitting the SW
headmu. As a result, three SW pumps were required to be operable in accordance with
TSI 91-06. However, dunne the shift tumover the following day, the Unit Supervisor was
not made aware of the moddication to the 008. Consequently, the Unit Supervisor did l
not understand that three SW pumps were required to be opemble in accordance with l
TSI gi-06. l
The licensee also determined that the operating shift mtnagement exhhited a lack of
communication and command and control of plant acdvides leading up to and during this
evert Specifically: (1) the operating shift managemW did not ensure that the complex
evolution briefing for the performance of Sol 41F and the pre-job briefing for the -
performance of PT-11ti-0 addressed the configuration of plant systems or the impact of
other scheduled activides; (2) the UnN 1 Supervisor and the Unit 2 Supervisor did not
i discuss the impact of performing concurrent activities (Sol 41F on Unit 1 and PT-11E-0
on UnN 2) which would affect the SW system; (3) the Unit 1 Supervisor did not noufy the
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Shift Manager or the UnN 2 operating crew when a common system component
(1C SW pump) was made inoperable; and (4) both the Shift Manager and the UnN 2
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Supervisor failed to ensure that the minimum number of SW pumps would be operable
dunng the performance of PT-11E-0.
In response to this event, the licsnsee's planr,ed or completed corrective acGons included
the folichtng: !
- The licensee revised Sol 41F to reflect the nood to verify the position of the Unit 2
EDG cross-tie valves. ;
- The Operations Manager removed the Shift Manager and both Unit Supervisors
from their normal shift duties to participate in the root ause invesugation and the
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development of the corrective actions.
- Each operating shift will perform a " vulnerability assessment" to determine the
degree of vulnerability posed by the abnomal status of plant equipment to
heighten the awareness of shift management in priontizing recovery actions and
i anticipating casualues.
- The operations staff will clanfy the Zion Operations Department Standards to
require a control room announcement whenever a mapr piece of equipment is
being manipulated.
- The Complex Evolution era Pre-Job Brief Checklists will be revised to check for
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any shift activities that could affect tha planned evolution.
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- The operat6n procedures group will revise Zion Operating instruchon 001,
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" Procedure Walkdowns," to include additenal expectations including the '
verification of flow paths and that the procedure will work pmperly as written.
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c. Condusions
The inspedors concluded that: (1) the technical review and the subsequent operator
walkdowns of Sol 41F, Revision 0, were not adequate to ensure that the procedure
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provided pp'egtt guidance for maintaming SW coohng flow to the 28 EDG; (2) an
incomplete shin tumover resulted in the Unit 1 Supervisor not being lur;t t 9 of the ,
existing plant configuration; (3) the lack of communication between the operating shin i
mana0ement resulted in conflicung evoluuons being performed simultaneously; and
(4) the operating shift management's command and control of plant actMues was weak.
The inspectors also determined tuat the boensee's post-event investigation was thorough.
As documented in NRC inspection Reports 50L295/97022; 50-304/97022,50-295/97013; i
50 304/9701E 50-295/97012, and 50 295/97002; 50 304/97002, the failure to provide
operating procedures that contain guidance appropriate to the circumstances remains
problematic. (See also Section M1.2). Although the violation example was
self-disclosing, it is being cited as a repetitive issue.
-01.2 Control Room Heatina. Ventilation. and Air Conditionina (HVAC) System inoperable due
to incomolote Modification
On October 22,1997, the licensee made a 10 CFR 50.72 notification after discovering
that the station's non-safety related heating system was rehed on for maintaining the
control room HVAC system operable. Specifically, the licensee determined that operation
of the auxikary building supply fans was needed to ensure the control room HVAC system
was able to maintain the control room at a positive pressure. The station heating system
is lost dunng desi9n basis accident corxhtions which could cause the auxiliary building
supply fans to trip on low temperature during cold weather. Therefore, the control room
. HVAC may potentially not maintain the control room at a positive pressure during an
accident.
Subsequently, on November 10,1997, the bconsee made another 10 CFR 50.72
noufication stating that the station heating system was not required for control room
HVAC system operability as long as dampers property closed during accident conditions
to maintain the computer room at a positive pressure, thereby providing a buffer zone
between the control room and the auxiliary building. However, these dampers were
inoperable because an incomplete 1985 modification prevented the dampers from closing
on a safety irgection actuation.
This issue is considered an Unresolved item (50-295/97025-02; 50-304/97025-02)
pending NRC review of the licensee's completed investigation and development of
corrective actions to restore the control room HVAC system to an operable condstion
01.3 Unit 2 RHR System Rendered inoperable
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On October 30,1997, the hconsee identified that when cross tying Unit 1 and Unit 2 on
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October 25,1997, the licensee reduced the number of required service water pumps
below the number required for the plant conditions. As a result, the service water system
was rendered inoperable. The operators subsequently declared the CC and RHR
systems inoperable becat.se these systems were supplied by the SW system. The
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licensee reported thec ' 5+M"; of the RHR system in accordance with
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This error occurred while performing Sol 41E, " Service Water Component taoistion
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During Various Plant Conditions,* Revision 2. The operators opened a knife switch on *
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the 0 EDG for Bus 147 to that the EDG would preferentially load onto Bus 247 in the
event of a dual unit loss of offaite power. However, the operators failed to recognize that
this action alone was not aufEcient to cause the 0 EDG to loud onto Bus 247. This issus
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is considered an Unresolved item (50-304/97025-03) pendng the inspectors's review of .
j the hoensee's completed investigation and correctwo actions.
01.4 Condenaata Storane Tanks (CSTs) Inadvertentiv Cross-connected
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a. inspection Scope (71707) .
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The inspectors reviewed the circumstances surroundng the inadvertent crose connection
- of the CSTs. The inspectors interviewed operators, reviewed applicable procedures and
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documentation, and evaluated the hcensee's root cause investigation and =havt
corrective actions,
j b. Observations and Fin &nns
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On November 13,1997, the Unit Supervisor directed a norncensed operator to transfer
the auxiliary boiler makeup from the Unit 1 CST to the Unit 2 CST. The norWcensed
1 operator transferred the suction of the auxiliary boiler makeup pumps to the Unit 2 CST;
however, he failed to transfer the makeup recirculation path from the Unit 1 CST to the
Unit 2 CST. The auxiliary boiler makeup pumps were drawine a suction from the Unit 2
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CST and recirculating approximately 48 gallons per minute to the Unit 1 CST. As a
! result, the level in the Unit 1 CST was increasing and the level in the Unit 2 CST was
decreasing at approximately 2 feet per day. However, due to the scale of the CST level
instrumentation and a lack of aggressive parameter tron &ng, the operators failed to
detect the changes in the CST levels until the " Condensate Storage Tanks Level
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High-Low" alarm actuated on November 15,1997, when the Unit 2 CST level reached
approximately 8 feet.
The boensee dotarmined that the cause of the event was the Unit Supervisor's fadure to
follow Zion Administrative Procedure (ZAP) 300 02, "Use of Procedures in the Operating
. Department," Revision 14. Zion Administrative Procedure 300-02 required, in part, that
when an evolution must be performed and a procedure does not exist, then complete an
Attachment B, " Operating Evolution Instructions (When A Procedure Does Not Exist),"
which would have ensured the evolution was reviewed and approved by two Senior
Reactur Operator hoensed individuals. In ad& tion, the hoensee determined that the
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Unit Supervisor and the norecensed operator placed a low level of attention on the
evolution since they both perceived that the task was routme. The licensee's corrective i
actions included:
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- The licensee aligned the auxiliary boiler makeup to the Unit 1 CST.
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+ The involved Unit Supervisor reviewed the event with each operating crew.
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- Operations Polloy 12, T)onAguration c 'rol," wel be revised to include
m; +;n Js expectations that one p. t conAguration change be lopoed and
that operators perform fotomup reviews c plant pe,ws.:::2 as a conWrmahon
that the conAguration change was correces nerformed.
. Non-C:i-r:':'-1 system opera 9ng instructions wGl be reviewed to determine if
sufAcient procedural guidance exits to perform routine evolutions.
c. Conclusions
The inspectors concluded that the event occurred due to the Unit Supervisor's failure to
follow the requirements of ZAP 300 02 for the performance of an evolution when no
procedural guidance existed; and, the lack of aggressive parameter trending contributed
to the failure of the operators to detect the unexpected changes in CST levels until the
C8T low level alarm was received. These deficiencies were not violations of NRC
requirements becaese safety related activities were not involved. ' The inspectors also
concluded that the licensee's investigailon was thorough and the proposed corrective
actiuns appeared appropriate.
01.5 Observations of Operational Readiness Demonstration Program Activities
a. Inamedian Scone (7170M
The inspectors observed oph departmord personnel perform surveillance testing
on the UnN 2 engineered safety features Bus 24g as part of the operational readiness
demonstration program. The inspectors observed control room activities, attended
pr. MM i briefings, interviewed operations department personnel, and reviewed
applicable documentation.
b. Observations and Findinos
The inspectors observed operations department pomonnel perform three periodic tests
(pts). The inspectors noted that although three-way communications had improved, at
various times, the operators did not consistently perform thrn ni communications and
routinely substituted a verbal shorthand method of communications in place of three-way
communications, in addition, problems in the area of system configuration control and
thoroughness of pre-evolution walkdowns as previously documented in NRC Inspection
Report 50-2g5/g7016; 50 304/g7016, continued to challenge operations department
personnel.
Periodic Test 18.1.16-24g. " Simulated Safety Iniection vpth Deoraded Voltane Start of
Diesel Generator 2B." Revision 0
On November 17,1997, the inspectors observed that the test coordinator performed a
thorough briefing, conducted a good dry-run to ensure test performers were prepared,
and ensured that observers of the PT understood not to disturb the test performers. At
the Gi.i,C":=, of the test, the test performers property recognized that the test
acceptance crMaria had not been met for the reactor containment fan cooler and
appropriately declared applicable equipment inoperable.
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During the dry-run and subsequently durine various sections of the PT, the inspectors
noted generally good use of three-way communication techniques. However, the
inspectors identified that operators were diiecting and reporting back, "Pedorm Step 1
[2. 3, etcf instead of readme the procedural step. This vert >al shorthand (perform Step
(X)) method of communications was used throu0hout the performance of the test. ARor
the operators cec.d the test, the inspedors queriod the Unit M+h (US) and the
test coordmator regarding the appropriateness and intent of using this verbal shorthand
practice. The test coordmator informed the inspectors that a decision had been made
and test performers informed that use of this verbal shorthand method would only be
- - allowed for sections of the procedure which were very time dependent. The inspectors
noted that this verbal shorthand method had also been used for other than time
, dependent portions of the PT. In either case, the licensee's operating standard did not
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address this practice. The use of this verbal shorthand method did not meet licensee
management's expectations for three-way communications. The inspectors noted that
three-way communication by the US slipped below licensee operating standards as the
evolution progressed, in that, the US did not repeat information but only stated, .
4 " understand."
PeriMic Test 11-DG2B-R1. *2B Diesel Generator Loadina. Load Reiection. and Hot
Restart Test." Revision 3
On November 20,1997, the inspectors attended the pre-job briefing and observed the
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PT. The inspectors determined that the pre-job briefing was comprehensive and
interactive, and appropriately emphasized procedural adherence. The inspectors also
noted that briefing participants demonstrated a questioning attitudw by verifying that the
PT would meet the appropriate TS requirements.
- The inspectors noted that the test performers again used the previously described verbal
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shorthand method of communication for other than time dependent portions of the PT.
The inspectors also noted that the formality of three way communications of test
j performers slipped below hcensee operating standards after the test was completed and
j as the shift progressed further into the day,
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l During the performance of the PT, the operators were to determine whmiinitiated the start
of the EDG and the uma it took for the EDG to close onto its respective bus. The
inspectors observed that the US did not know how to obtain the initiating event actuation
time from the strip chart recordor, which resulted in the US obtaining an incorrect
actuation time. This error was corrected by a Nuclear Station Operator after the
inspectors questioned the start time of the initiating event.
Periodic Test 3.8.1.10-249. " Loss of Offsite Power Testino of Diesel Generator 2B."
Revisions 2 and 3
On November 18 and 19,1997, the inspectors observed operations department
personnel's attempts to perform the PT On ooth days, the test was stopped due to
problems with the 2C auxiliary feed water (AFW) pump lubricating oil system.
On November 18,1997, the Shift Manager (SM) appropriately suspended the PT after
identifymg that water was mixed with the oil in the 2C AFW pump oil cooler. The SM
directed isolation of the coolmg water to the cooler so that the oil c;uld be replaced Due
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to the apparent leakage path, the SM decided to maintain the cooline J.ter isolated and
unisolate it only to perforrr, the PT. The SM's decision was not based on engineering
analysis, in that, the dedsion did not consider if the cooler could be adversely affected by
being in this con 6gurathn. Also, the SM did not document the abnormal con 6guration of
the cooler. This decis'on did not meet the licensee's operating standards.
! While subsequently performing N PT,16 procedural discrepancies were idenG6ed. The
> boensee charodottaed these changes as oddorial and procedural enhancements. The
a seders disagreed with this characterization because several danges included
<msuring that the correct components were identdied. The inspectors concluded that the
l walkdown of the procedure previously conducted on November 3,19g7, was inadequate
because 16 changes were subsequently made in order to perform the PT. The test
coordmator subsequently implemented the changes in Revision 3 of the PT to facilitate
performing the test the next day.
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Followng implementation of Revision 3 to the test procedure, a pre evolution briefing was
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held on November D.1997, in preparation for performance of the test. However, neither
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. the US nor the SM attended the brief, although the US was actively involved in the
subsequent activity. The inspectors considered this a de6cient mrangement oversight
practice. During the briefing, operators demonstrated a questioning attitude in querying if
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the root cause had been determined for water intrusion in the 2C AFW pump oil cooler.
Although the root cause was not determined, operations department personnel decided to
proceed with peifoswing the PT with the understandmq that the PT would be terminated if
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problems arose with the 2C AFW pump oil cooler. T'.e test performers stopped the PT
ader 45 minutes due to water in-leakage into the oil .molor.
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In adddion to the 16 procedural changes in Revision 3, the PT sisu iwd been revised to
address a scheduing change. After operators had walked down the JT on November 14,
1997, the service water booster pump, which needed to be verified as operating during
the PT, was unexpectedly taken OOS for planned work. This scheduling oversight
necessitated Revision 2 to the PT Although the test performers had been briefed on
Revision 2, the test coordmator elected tc proceed without having issued Revision 2. The
I
- inspectors considered this a deficient practice.
c. Conclusions
The control room operator's identification of the procedural inadequacies and the
immediate corrective actions taken to stop the evolution until the procedure deficiencies
were corrected was considered a positive attribute. However, the inspectors concluded
thct the occurrence of these testing problems indicated that weaknesses still exist in the
areas of procedure adequacy, scheduling, and communications. Specifically, the
inspectors were concemed with the repeated use of the verbal shorthand method of
communications while perfMning the pts, unexpected system configuration changes
r-aM%g a PT revision, the poor quality of the PT walkdown, and the SM's fadure to
use a technical basis for and document the altered cooler configuration.
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03 Operatione Preesdures and Desumentation
03.1 Qoorations and Enaineerinn Department Personnel Exceeding Overtime Reauirements
a. Inapection Scope (71707)
The inspectors reviewed operations and engineering department personnel's adherence
to the station's overtime requirements during the performarre of Technical Specification
Surveillance 3.8.1.101, " Loss of Offsite Power Testing of Diesel Generators During
Refueling for Unit 1," from July 23 through 29,1997. The inspectors interviewed
i operations and engineenng department personnel L ed reviewed operating logs, ,
gatehouse access records, and the applicable procedures and documentation.
,
b. Observations and Findinns
The inspectors reviewed the gatehouse access records from July 15 through
August 6,1997, for 49 operations and engineering department personnel involved in the
,
performance of the test. Tne inspectors identified 25 examples of unapproved overtime
in excess of the guidelines specified in ZAP 20004, " Overtime Guidelines," Revision 2,
2
Section F.4.b. The inspectors also identified seven examples of overtime in excess of
the guidelines where the individuals involved in the instances had subsequently obtained
post approval.
,
As described in NRC Inspection Report 50-295/97013; 50 304/97013, dated
'
August 15,1997, a violation was issued for the licensee's failure to control the use of
overtime in excess of the overtime guidelines by operations department personnel. The
i inspectors noted that thosu adddional examples occurred prior to the issuance of NRC
Inspection Report 50 295/97013; 50-304/97013. As a result, a violation is not being
t issued since these examples were additional examples of a previously cited Violation
(50-295/97013-02; 50-304/97013-02),
c. Conclusion
The inspectors concluded that these additional examples further demonstrate that
deficiencies existed in the implementation of station's overtime policy.
08 Mieoellaneous Operations issues
08.1 (Closed) LER 50-304/97004-00: Small Bore Containment Penetration Line inadequately
Supported Since Plant Construchon.
On October 15,1997, engineenng department personnel identified that a containment
penetration line was not adequately supported as evidenced by piping deformation of the
line. The 2DT040 % line was the discharge piping line from the reactor coolant drain tank
to the auto gas analyzer. The line contained the reactor coolant drain tank to auto gas
analyzer containment isolation valves,2AOV DT9159A and B. The next day, engineering
,
department personnel per'ormed a design engineering calent=Han which indicated that
line 2DT040 % was inoperable due to tiv 'ine being over stressed due to the lack of
supports for the piping and inck of seismically mounted supports for the valves. With the
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penetration line inoperable, the pierd was placed in an unanalyzed conddion requiring
NRC noWication. Design engineering department personnel documented this deficient
condiuon in problem idenuncation form (PiF) Z1997-02272 and noufied onshift operations
management of the condiuon at approximately 1730, on Odober 16,1997. At that time,
,
the SM did not make the required 10 CFR 50.72 noulicahon. 9Ary,ty, the SM -
) screened the PiF against the station's reportability criteria and determined at 2300 that
,
this condson was nouspvisbes. Therefore, noWicauon was not made to the NRC. ;
j On October 17,1997, engineering department personnel informed an off-duty SM of the
inoperable condison of the penetration line. The SM determined that this condison met
'
the stah's reportabekty criteria but had not been reported. The SM subsequently made
the required noufication at 1504, in discussing this issue with station personnel, the
inspedors determined that the licensee had not initiated a PlF for the failure to make the
noufication within the four-hour time requirement. The failure of the 8'A on October 16,
1907, to notify the NRC of the piant being in an unanalyzed condation due to the
inoperabikty of the penetration line within four hours is considered a violation of
. 10 CFR 50.72(b)(2)(l) (50-304/97025-04), as described in the attached Notice of
i Violation. Although the violation was bconsee identified, it is being cited as a repoutive
4 issue since previously similar problems were documented in NRC inspection
'
Report 50-295/97002; 50-304/97002.
,
The licensee's entractive actions included:
- Engineering department personnel walked down other small bore piping and
documented any additional problems.
- Operations department personnel made the required notification to the NRC on
October 17,1997. j
'
- Engineering department personne! intuated actions to seismically support the
penetration line.
The inspectors concluded that engineering department personnel had performed a
j
thorough assessment of the deficant penetration line. However, the inspectors were
- concemed that the licensee had not formally documented that the NRC notifK;ation was
not made within the required time hmits until prompted by the inspectors.
08.2 (Closed) Unresolved item 50-295/97013-01: Damaged grid straps on fuel assembly (FA)
while transporting the FA to the spent fuel pool.
The inspectors reviewed the circumstances surrounding this event which occurred on
April 23,1997. When moving a FA to open water, aher approval by the Fuel Handhng
Supervisor (FHS), the bundle contacted the baffle and tore off parts of two grid straps.
The l'38 recognized the damage when hoisting the next fuel bundle, which contained
debris, and immediately stopped fuel moves with the bundle hoisted.
. !
The hcensee maintained centrol of t, a FA, by stationing a senior reactor oper.ator to
observe the FA. while it remamed hoated approximately 6 inches, during which plans for l
visual inspections were den ==ad. After approximately eight hours, the bundle was 1
lowered to its original location in 'accordance with a revised Nuclear Component Transfer !
,
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List. The licensee subsequently recovered the grid strap pieces. The licensee performed
visual inspections of 34 fuel bundles, the baffle, and the area around the E2 core location.
The hcensee did not identify any additional damage or foreign material. The inspectors
determined that although the bundle could have been lowered sooner, the lic.msee's
actions were acceptable.
4
The Westinghouse refuehng philosophy, which was followed by the licensee, was to
'
utilize open water moves to the maximum extent possible in order to minimize potential
damage from grid intsractions between adjacent bundles. For core offloading, this
involved hoisting each bundle up about 6 inches, overriding the hoist interlock, pe forming
a lateral move into an unobstructed area, then hoisting the bundle up into the mast. The
hoist interlock was intended to avoid damaging fuel bundles during lateral moves near
other objects by requiring bundles to be hoisted fully into the mast before allowing lateral
movement. The licensee incorporated this philosophy into Fuel Handlinc instruction
(FHl) 13, " Manipulator Crano " However, the inspectors noted tnat "open water" was not
defined in this procedure. Vendor documents required at least 2 inches of open space on
all sides to be considered open water.
The licensee's detailed root cause investigation was thorough and identified that the
event was caused by an inadequate fuel handling procedure and an error in judgement.
The decision to attempt to move the bundle into open water was incorrect because the
FA first had to be moved closer to the baffle. The latest revision of the vendor fuel
specification gave examples of safe move secuences for different configurations and
clearfy showed that this condition was not an open water move. However, that revision
had not been incorporated into licensee procedures. Also, the vendor had provided a
recommended officed sequence to maximize possible open water moves, which was also
not incorporated by the licensee,
The inspectors reviewed the licensee's corrective actions for this event. The licensee
i incorporated the vendors recommendations into the station procedures, including defining
open water moves and designing the fuel move sequence to maximize the possible
number of open water moves. Additionally, fuel move sheets will clearly indicate which
moves can be considered open water moves. The licensee also conducted training on
the event and the new procedural requirements. The inspectors concluded that the
corrective actions appeared to be adequate.
The licensee's failure to provide appropriate procedural guidance for performing open
water fuel movements without defining what e c ,ditions had to be satisfied to safety
accomplish such a move is considered a violation of 10 CFR Part 50, Appendix B,
Criterion V (50-2g5/97025-05). This non-repetitive, licensee-identified and conected
violation is being treated as a non-cited violation, consistent with Section Vll.B.1 of the
08.3 (Closed) LER 50-304/97003-00: Unit 2 Residual Heat Removal (RHR) Declared
inoperable Because Only One Component Cooling Pump Was Operable.
On October 14,1997, the 1B EDG failed to start during performance of PT-11-DG18,
"1B Diesel Generator Loading Test," Revision 11. The licensee subsequently declared
the OC component cooling water (CC) pump inoperable as a result of the failure of the
1B EDG, since the 1B EDG was the emergency power supply for the OC CC pump. Prior
14
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.
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to 18 EDG testing, control room aparators had declared the 08 CC pump inoperable due .
to excessive oilleakage imm the o: Aboard pump b aring ou sight glass. Corm =,::y,
only one CC pump remained operable which was not suflicient to provide the required
cooling to support operatnhty of the RHR system. As a result, the hoensee reported the
4
ovent to the NRC in accordance whh 10 CFR 50.72.
The licensee determined that the amuse of the 1B EDG's failure to start was a ruptured air
.
distribution pipe. A M inch threaded pipe nipple, betwoon the left air start header and the
tubing supplying air to both sir start distritraors, had broken. systems unterial Analysis
Department personnel's analysis of the brokon nipple indicated that cyche fatigue caused
the pipe nippie to fail.
The hcen6*(t corrective actions included:
. Engirmering deperimord personnel inspected the air distribution piping for the
other four EDGs with no other additional problems noted.
j . Mechanical maintenance department personnel repaired the 18 EDG.
4
'
The inspectors determined that the hcensee's investigation was thorough and subsequerd
corrective actions were appropriate.
08.4 (Closed) Unresolved item 50-295/96017-02: Practice of allow 6ng reactor power to exceed
the hcensed thermal power limit.
1
The inspectors identifi .n c nas where the hoensee operated shghtly above
100 percord power for k...p than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. The inspectors reviewed the hcensee's
procedures for maintaining operating power limits and compared the instructions to the
NRC Jordan Letter dated August 22,1980. The Jordan letter provided guidance on how
the NRC enfurced the operadng loconse maximum opoesting core thermal power. The
l Inspectors concluded that the licensee's procedure " Power History Log,' PT-0,
Revision 12, Appendix P, met the guidance set forth in the Jordan Letter. The inspectors
i
reviewed the computer logs for the periods in question which recorded the results of the
i 10-minute, 604ninute, and 8-hour calorimetric calculations of reactor thermal power.
L These indicated that the licensee met the guidance in the Jordan Letter chuing the
periods in question, and thus no violation existed. This item is closed.
08.5 (Closed) Licensee Event Report (50-304/g7002): Inadvertent isolation of Service Water
Ccoling to 28 Emergency Diesel Generator Dunng System Alignment (See Section 01.1).
! 08.6 Zion Station Restart Action Plan Review
l
a. Inspection Scope (71707)
l
The inspectors reviewed the hcensee's completed restart action items as specified in the
NRC Zion Station Restart Action Plan, dated September 11,1997.
,
b
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b. Observations and Findinos
'
C.2.1.b: Effectiveness of Industry Experience Review Proaram
- The inspectors vertned the w Tii-r, of Zion Station Unit 2 Recovery Plan hems 11.5
,
and 11.6. The licensee's review of both the open and closed operating exponence issues
was completed on July 30,1997. The review evaluated the issues contained in NRC
inspection Reports, NRC Information Notices, NRC Bulistins, NRC Generic Letters,
Nuclear Operations Noti 6 cations, Significant Condihons Adverse to Quality /Lovel ll
events, and Licensee Event Reports. This review was completed in accordance with the
Zion Unit 2 Restart Plan Program Review document. As a result of this review,173 items
were designated as restart ilums. However, prior to restart, the licensee planned to add
any addstional commitmot . :steCorized as a restart issue to the restart issue matrix in
accordance with Achon Plan 11,' Operating Experience."
C 2 2.a: Goals / Expectations Communicated To and Understood by the Staff
!
The inspectors veri 6ed the completion of Zion Station Unit 2 Recovery Plan items 3.1,
6.2.4, and 9.3.
'
. The licensee implemented the Zion Operations Department Standards.
- The licensee implemented the Operations and System / Component Engineering
interface Agrooment which was issued on June 25,1997.
- The licensee implemented standards for offshlR management command and
control which were issued on October 6,- 1997.
C.2.2.b: Demonstrated Expectation of Adherence to Procedures
The inspectors vert 6ed the completion of Zion Station Unit 2 Recovery Plan item 5.1. The
hcensee completed this item on May 30,1997, when ZAP 300-02, "Use of Procedures in
Operating Department," Revision 12, was approved. However, this procedure was
subsequently sevised twice. On September 30,1997, ZAP 300-02, Revision 14, was
approved.
fd.3.a: hAanaaement Sunnort
The inspectors reviewed the completion of Zion Station Unit 2 Recovery Plan item 2.5.
,
The hcensee developed position descriptions for operations department personnel
including the Shin Operations Supervisor, the Shift Mana9er, the Unit Supervisor, the
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ShlR Technical Advisor, the Non-Licensed Shift Supervisor, the Nuclear Station Operator,
the Non-Licensed Operator, and the Quahfied Nuclear Engineer. Each of these position
descnptions included areas of accramtability, responsibility, and position duties.
! On July 22,1997, the licensee approved the position descriptions for operations -
'
department support personnel including the Operations Work Control Center Supervisor,
the Operations Staff Supervisor, and the Assistant Superintendent Operations. Each of
these position descnptions included areas of accountabihty and responsabilsty and position
'
duties while =viewmg these roles and responsitsities, the inspectors noted that the
.
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operations department was =#r y= ,0i reorganized and the Assistant Superintenderd
Operations posidon had been e'iminated. In addition, the roles and r==g-:9W":: for .
some of the operations departmord support posidons, such as the Operations Training
Unison, had not been de;: :-;+1 As a result of the inspectors questions, the licensee
re opened this action plan item.
! C.2.3.d. Adeausta Plant Administratlye Procedures
l The inspectors vertAed the compleGon of Zion Station Unit 2 Recovery Plan items 5.1,
' 6.1.1, and 6.1.4.
!
. Zion Administrative Procedure 300 02, "Use of Procedures in Operating
- Department," Revision 12, was approved on May 30,1997. However, this
! procedure was subsequently revised twice. On September 30,1997,
ZAP 300 02, Revision 14, was approved,
i . Zion Operability Determina6on Mandal 0, " Operability Determination Program,'
Revision 11, was r-gs;d on October 17,1997.
!-
l- C. CQDClusions
! The inspectors concluded that the licensee was maidng Progress in completing the
i Zion Station Unit 2 Recovery Plan. However, the inspectors noted that once a recovery
j plan item was closed, the licensee was not updating the item to reflect any subsequent
'
changes.
l
l- 08.7 10 CFR 50.54m Letter Commitment Review
a. Insoection Scope (71707)
i
The inspectors reviewed the status of commitments pertaining to Commonwealth
. Edison's March 28,1997, response to the NRC's request for information pursuant to
10 CFR 50.54(f). The commdment numbers conospond to those used by the licensee in
' their March 28,1997, response.
'
b. Observations and Findinns
'
Commitment 1: "To reinforce these principles and assure that performance results are
i achieved, the CNOO [ Chief Nuclear Operat!ng Offir.or) conducts Management Review
,
Meetings (typically each month) at each site."
!
Commitment 75: "The CNOO conducts Managemord Review Meetings at endi site
- focused on safety performance and the effectiveness of improvement initiatives. These
-
meetings address trends of safety, performance, and cost indicators; results of third party
1 (NRC and INPO) inspechons; results of site self-assessments; status of material
1
condition in the plant; outage planning and performance; and assassments of the quality
of workforce product and training."
i Commitment 100: "We have established the actions to be taken if the performance
criteria are not met, in order to assess that effective and timely actions are taken,
- 17
i -
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.-
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- assessment of performance indicators and implementation of actions based on this
'
asassament win take place at the site, NOD [ Nuclear Operating Division), and Board
levels. Each of the performance indicators described in Sections 4.7.1 and 4.7.2 above i
- win be monitored by the Site Vice Presidents, and wiu 6 reviewed during the periodic
! Management Review Meeting for each station."
,
,
Gem 0iltment 271: "The CNOO (typica.iy monthly) conducts Management Review
4
Meetings at each site, focusing on safety performance and the effocuveness of
4
impro smentinitiatives."
Gemtr3mmoi.322: "Each month the Chief Nuclear Operations Officer conducts
,
Management Review Meetings at aN sites.'
i
i - The inspectors observed the Zion Station Management Review Meeting conducted on ,
- October 27,1997. The inspectors noted that the meeting accomphshed aH of the
objectives noted in the above commitments.
4
c. Conclusions
The inspectors concluded that the licensee was conducting Management Review
Meetings as descnbod in Commonwealth Edison's March 28,1997, response to the
,
NRC's request for information pursuant to 10 CFR 50.54(f).
,
11. Maintenance
M1 Conduct of Malr*.tenance .
'
M1.1 1 A Ememency Diesel Generator (EDG) Fuel Oil Leak Due to an Imorooerty Assembled
Comoression Fittino
' Inspection Scope (62707)
a.
The inspectors reviewed the circumstances surrounding the emergency shutdown of the
1 A EDG during testing on October 17,1997. The inspectors interviewed operations and
maintenance department personnel and reviewed the apphcable maintenance work
instructions.
'
b. Observations and Findinas
On October 17,1997, during the performance of PT 11-DG1 A-R, *1 A Diesel Generator
24-Hour Loading Test," Revision 2, a nor9 censed operator initiated an emergency
shutdown of the EDG due to a severe fuel oilleak on the six left (6L) injection pump. The -
licensee immediately placed the control switch for the 1A EDG in punktM quarantined
the area, and initiated PlF Z1997-02284.
- The licensee determined that the leak occurred due to a failed compression fitting on the
low pressure fuel oil line to the 6L injection pump. This compression fitting had been
replaced on October 16,1997, in accordance with Work Request No. 970107757-01.
This work request did not contain any specific instrucSons on how to install the fitting
,
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. since the hoensee considered this activity within the ' cran capability" of the maintenance
j mechanics. This particular type of fitting was desi0ned to have bwen assembled by
tightening the nut 1% tums from fin 0er tight; however, the mocianic that assembled the
L fitting ti0htened the nut until no additional movement was achievable. Cor.::g4,
l upon the startup of the 1A EDG, the fuel oil pressure in the line caused the fitting to
j separate.
In response to the inspectors' er:r:5.s, the noensee indicated that mechanical
maintenance personnel were trained on the assembly of compression fittines during
- mechanical maintenance 'A' track training, in addition, the licensee indicated that the
involved mechanic had received this training during the first quarter of 1996 and had
-
since suoconvully pr.ormed this activity on numerous occasions
c. Conclusions
f The inspectors concludeo at the failure of the compression fPting on the 1 A EDG low
- prosa,ure fuel oil line to the ed. IrSoction pump was due to a skill based error during
l maintenance.
^
M1.2 incorrectiv Wired Si :ee-ds Relav Resulted in an inadvertent Enaineered Safety
- Feature (ESF) Actuation
1
I- a. inspection Scoce (61726 and 62707)
!
'
The inspectors observed the performance of selected portions of PT 10-3, ' Containment
,
Isolation Phase B Testing,' Revision 12, interviewed operations, work control, and
maintenance department personnel, and reviewed applicable procedures and
i
i documentation.
[ b. Observations and Findinns
! On December 2,1997, during the performance of PT 10 3, " Containment isolation
4
Phase B Testing," Revision 12, Section 5.1, " Train A Division 7 Continuity Check of
- Containment High High Pressure and Containment isolation Phase B and Componant
Actuation From Energizing Safety IrSection Relay SIX 1 A," the operators identified that
- relay SX1 had not de-energized as expected in Step 17. As a result, the operators
stopped the testing to determine the cause of the relay's failure to de-energize. The
- licensee determined that the procedure would not work as written, in that, the relay
,
remained energized through a seal in contact and a manual reset button until the reset
j - button was actuated in Step 34. The hcensee subsequently attempted to place the plant
in a safe and stable configuration by completing the remaining portion of Section 5.1.
'
The inspectors noted that the licensee revised PT 10 3 on October 31,1997, to
1
incorporate relays, including relay SX1, that had not been previously tested. The hoensee
-
identified the failure to test these relays during reviews conducted in response to NRC
Generic Letter 91601, " Testing of Safety-Related Logic Circuits." However, the inspectors
! determined that the technical review for this revision was not adequate to identify that the
i revised procedure would not work as written. ' The failure of PT 10-3 to provide
. appropriate guidance to test the Train "A" Division 7 containment isolation and component
actuation circuitry energized from safety irSection relay SIX 1 A is considered an example
19
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of a violation of 10 CFR Part 50, Appendix 8, Criterion V (50295/97025-01b;
50 304/97025 01b), as described in the atta&ed Notics of Violation.
'- While the hoensee was attempting to place the plant in a safe and stable configuration
following the identification of the above procedural Cl=-,cy, an inadvertent ESF
ww% occurred when an operator released reset push-button #11. "Divisien 7 Test," in
.
Sedian 5.1, Step 34. The 2A SW pump and the 28 charging pump auxihary lube oil
i pump autostarted. The licensee subsequently determined that all other ESF equipment
,
either were already running or were out-of-servios. As a result of the ESF actuation, the
i operating cWr emergency tripped the 0 EDG, which was running in accordance with
, PT 10 3, and declared the equipment associated with the ESF buses 147 and 247
'
' epeiv.ble. The hoensee subsequently determined that safety ir(ection relay SIX1 AX
s.
failed to unletch when push-button #11 was depressed. Consequently, the associated
seal in contact for the relay remained closed. Therefore, when the push-button was
released, the ESF :.ctuation occurred. The hcensee notified the NRC of this event in
l accordance with 10 CFR 50.72.
,
I
The hcensee subsequently determined that the cause of the failure of relay S!X1 AX to
unistch wws due to the relay being wired incorrectly during maintenance conducted on
October 4,1997. Specifically, while replacing relay SIX1 AX in accordance with Work
i Request No,960104192 and Zion Generating Station Maintenance Procedure E005-2,
"HFA Relay inspechon and Agustment," Revision 7, electrical maintenance technicians
connected the wire from the reset coil, wiro 2C #12, to Terminal 10 (a spare terminal)
instead of Terminal 12 as specified in the HFA Relay Data Sheet. Consequently, the
reset coil for relay SIX1 AX was d soonnected from the ckcuit.
! Based on interviews with the involved electrical maintenance technicians, the inspectors
' identified that the error occurred because the technicians installed the relay using a wiring
diagram instead of using the HFA Relay Data Sheet, which provided the physical
confipration of the relay terminals. In addition, the inspectors identified that ooth of the
technicians involved in the relay replacement documented the replacement by signing the
HF8 Relay Data Sheet. One signed the "Retermed By" block and the other signed the
" Verified By" block; but, both technicians were involved in the maintenance and neither
performed an independent veri 6 cation. Based on discussions with the maintenance
manager, the inspectors concluded that the technicians did not meet licensee
management's expectations for verifying completed maintenance activities, since an
4
independent verincation was not performed.
- Zion Generating Station Maintenance Procedure E005-2, "HFA Relay inspection and
Adjustment," Revisk,n 7, Sechon H, Steps 8.2 and 8.3, required that the relay be installed
and roterminated per the applicable relay data sheet. The failure of the electrical
maintanance technicians to follow E005 2 and install relay SIX1 AX in accordance with
the HFA Relay Data Sheet is considered a violation of 10 CFR Part 50, Appendix B,
Criterion V. (50 304/97025-06), as described in the attached Notice of Violation.
,
in addition, the hcensee determined that a post-maintenance test (PMT) was not
speciGed for the relay replacement conducted on October 4,1997. Consequently, the
maintenance error was not identified until following the resultant ESF actuation on
December 2,1997. The hcensee also determined that on September 1,1997, a work
. analyst identified and documented, in the note field of the work request, that the PMT
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requirements for the work activity were needed from the system engineer. However, the
work analyst did not initiate any action to ensure that the PMT was specined prior to the 1
mainannonce being completed. Based on intuviews with operauons, work control, and
>
maintenanos department pusonnel, the inspectors idenused that the hoensee staff did -
! not have a clear and consistent understanding of the PMT process. In addition, the ;
inspectors identined that at least 43 other work requests had been approved without PMT
requirements having been specEed.
10 CFR Part 50, Appendix B, Criterion XI, " Test Control," requires that a test program
shnu be nic,blished to assure that au tuting required to dernocatrate that structures,
systems, and components will perform satisfactor#y in service is identsfied and performed
in accordance with written test procedures which incorporate the requirements and
.
ecoeptance limits contained in appimable duien documents. The failure to idenufy and . ,
'
perform a post-maintenance test for the replacement of relay SIX1 AX is considered a
vioinuon of 10 CFR Part 50, Appendix B, Criterbn XI (50-304/9702507), as descnbod in
- the attached Notice of Violation.
'
c. Conclusions
The inspectors concluded that: (1) the technical review of PT 10 3, Revision 12, was not
adequate to ensure that the procedural steps were sequenced in a manner which allowed
the amaaaful testing of the train 'A' Division 7 containment isolation and component
actuation circuitry energized from safety irSection relay SIX 1A; (2) the inadvertent ESF
actuation resulted from the safety irSoction roiay SIX1 AX belig miswired due to the
electrical maintenance technicians not following E005-2 during replacement of the relay;
and (3) the maintenance ermr was not identified following the replacement of the relay
due to the hcensee's failure to conduct a PMT.
- As uocumented in NRC inspection Reports 50-295/97022; 50 304/97022, 50 295/97013;
50-304/97013, 50 295/97012, and 50-295/97002; 50-304/97002, the failure to provide
operating procedures that contain guidance appropriate to the circumstances remains
probiomatic (See also Section 01,1). Although the violation example was self-disclosing,
it is being cited as a repetitive issue.
^
in addition, as previously documented in NRC Inspection Reports 50-295/97019;
50 304/97019, 50 295/97016;50 304/97016, 50 295/97013; 50 304/97013;
50-295/96017; 50 304/96017, and 50-295/96014; 50-304/96014, the failure.of
maintenance personnel to follow procedures continues to be an area of concem.
Therefore, even though the violation was identifwd as the result of a self-disciosing event,
it is being cited as a repetitive issue.
The failure to identify and perform a PMT for the replacement of relay SIX1 AX is being
cited, since by the end of the inspection period the licansee had not completed their
investigation and identified comprehensive corrective accons for the programmatic issues
===eia*ad with the post-maintenance testing process.
21
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. 7. .
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i- M1.3 Failure of the 2B Ememenor Diesel Generator Train 8 Startino Air Comoressor ,
- s. Insoadion Econe (82707)
! The inspectors reviewed the licensee's actions for determining the root cause of the
j * V,'c failure of the 2B EDG Train 8 starting air coinpressor during an operability
- run of the compromor. The inspectors interviewed root cause pwsonnel, operations,
l engineerine, and regulatory assurance departmord personnel, and reviewed =pp epi't
- station pmcedums and documentation,
j b. Observations and Findmos
- On October 17,1997, while operations departmord personnel were performing
PT-11C-28, "2B Diesel Generator Starting Air Compressor Capacity Test," Revision 0,
'
i the 28 EDG Train B, startmg air compressor failed. - A maintenance mechanic supervisor
l
was in the roorn when the compressor failed and informed onshift operations
i managemord of the event. The Shift Manager directed that the room be quarantined and
requested a prompt event investigation.
The inspectors reviewed the licensee's investigation report of the compressor's failure.
l
' The inspectors considered the investigation thorough, agreed with the conclusions
documented in the report, and determined that the proposed and completed cormctive
actions appeared appropriated. The licensee determined, as indicated by field
- inspecelons and laboratory mamination, that the comprenor failed due to severe gaang
i
between the third stage piston and its upper cylinder liner as a result of p;ston
'
misalignmord. The piston misalignment was due to maintenance personnel
mappropriately torquing the piston capscrew. The inappropriate torquing was performed
based on incorrect vendor manum, information.
- The licensee determined that on October 2,1997, mechanical maintenance department
- personnel performed preventive maintenance on the compressor, for the first time, as
govemed by DG050-03, "DG [ Diesel Generator) Air Start System five-Year Preventive
Maintenance," Revision 0. Procedure DG050-03, specified incorrect vendor information
which had been incorporated in 1992. Specifically, the procedure directed the mechanics
m to verify that each individual piston did not rotate. This was a correct verification action
i for the first and second stage pistons because the pistons were not supposed to move;
however, this was an incorrect verification action for the third stage piston because it was
supposed to rotate. Therefore, when the mechanics performed this step and identified
that the third stage piston moved, the mechanics contacted the system engineer for
- assistance. The system engineer subsequently contacted the vendor representative who
incorrectly confirmed that each piston should not move within its respective cylinder. The
licensee eliminating the piston movement by torquing the piston capscrew in accordance
with the torque table in the vendor manual. After completing the repairs, on
.
October 17,1997, while operators were performing PT-11C, the compressor failed after
running for approximately 29 minutes.
The licensee's failu o to provide appropriate procedural guidance for maintenance on the
emergency diesel generator starting air compressor is considered a vb!ation cf
10 CFR Part 50, Appendix B, Criterion V (50304/97025-08). This non repetitive
22
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_-_.________.o ____m_ _ _ _ _ _ ._ . , - . - --__.___--. _ _ . . , - .-.i. -~ . -- - .,
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0
,
,
hoensee identilled and corrected violation is being treated as a norHalted violation,
. noneistent wah section vil.a.1 of #w NRC Enforcement Poboy.
c. Conduaion
The inspectors concluded that the cause of the 28 EDG Train 8 starting air compressor
failure was h ' ;-c9 + vendor information concoming piston alignment, combined with a -
!
lack of a questioning attitude by engineering and maintenance personnel. However, the
L inspectors considered the licensee's investigation of this failure to be thorough.
i
!
'
Ill Enaineerina
.
E8 Miesellaneous Engineering leeuse
i
E8.1 (Closed) Ucensee Event rTeoort (50-304/979911 Missed TS Surveillance Test - Failure
to Test the 2A Safety IrSochon Pump Succon Valve in the Presenbod Periodicity.
'
- On October 24,1997, while corvbJng an audit of the Inservice Test (IST) Program,
, Quakty and Safety Assessment personnel identified that the 2A safety injection pump
.,
suction valve,2MOV-618923A, had not been stroke tested quarterty in accordance with
,
TS 4.0.5. Specifically, the hcensee stroke tested the valve on December 14,1995, and
,
did not perform the test again until May 29,1996. However, since TS 4.0.2 allowed a
25 percent extension to the surveillance interval, the testing was required to have teen
completed prior to April 8,1996. Consequently, between April 8 and May 29,199'.I, the
2A safety injection pump was inoperable. The licensee notified the NRC of this randhion
- in accordance with 10 CFR 50.72.
! The licensee determined that the cause for the missed surveillance testing was that the
,- IST program was inadequate, in that, the program did not verify that all of the IST
requirements, which were located in various procedures, wem completed. The licensee's
. planned corrective actions included:
1
- - The IST Group Lead will include in their review for acceptance cnteria a second
r
check to ensure the periodicity requirements for each component are met.
'
- The IST Group Lead will put into place a mechanism to ensure their review of
applicable periodic tests and technical staff surveillances is conducted prior to the
critical date for the componard tested.
. The Shift Operations Supervisor will ensure the periodic tests which require ICT
review will be provided to the IST Group Lead prior to the critical date.
.
- The System Engineering Supervisor will ensure the technical staff surveillances
. which contain IST components will be provided to the IST Group Lead prior to the
l cntical date.
!
- * The Work Control Superintendent addressed the issue with the operations
Department Predefine Coordinator.
.
t
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o'wt'T r'tr d e---*-T .%- g n-r-ey % 4y--en , w- ,-w- x -_ _ _ _ _ _ _ _ ___ _
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+ The IST group wis pursue acquiring a scheduling / monitoring tool that wls keep
track cf 68T surveillances on a component level.
The inspootors concluded that the licensee's conective actions appeared adequate to
prevent recurrence. The failure to perform IST on the 2A safety irSection pump suction
valve, 2MOV-sis 023A, within the speci6ed periodicity is considered a violation of
TS 4.0.5 (50 304/97025 00). This r,cr,4Es T';;, lloonsee identi6ed and corrected
violabon is being treated as a Non Cited Vunation, consistent with Section Vll.8.1 of the
i
NRC Enforcement Pokcy.
E8.2 (Closed Unresolyed item 50-295/97016-08: 50 304/97016-06: Review of the licensee's
evalushon of the as-busit con 6guration of the control room ventilation system and its
- abF,ty to fumu the required safety functions.
i
in response to inspectors' identincation, on July 17,1997, that three exhaust ducts wem ,
i missing or impmporty connected, the system engineer identi6ed 11 additional exhaust
ducts which had never been instaNed. Each of the ducts were intended to connect to the
top of control panels to cool panel components. The licensee determined that
construction drawings (circa 1971) noted these discrepancies. However, the licensee
.
had never created an as-built drawing of the system configurailon or evaluated the
'
=~ar8amy of the existing conddion. As a result, the licensee was using M-315. " Control
Hoom HVAC [Heatine. Ventilation, and Air Conditioning] System El 642'-0"," to maintain
control of the design of the system.
The inspectors determined that mechanical maintenance department personwl
were instalkng additional control room display monitors under Work Request
Nos 070044984-01 and 970044985 01. The work requests required the mechanics to
,
disconnect some of the ducts and speci6ed foreign material control measures to prevent ,
debris from entering the control boards; therefore, mechanics had to ins'all tape over the !
vent holes in the top of some uontrol boar (s after removing the ducts. The inspectors !
reviewed 50.59 Safety Evaluation No.97-413 for the work and determined that it did not
evaluate the irnpact of disrupting the coohng flow path for the control boards by
disconnecting the ducts or taping the duct openings, The inspectors concluded that there
were no safsty consequences for this technical oversight. In addition, the inspectors
noted that the impact of another condation created temporarily during the work (breaching '
of the control room envelope to route cables) was appropriately assessed in the 50.59
'
evaluation.
'
The hcensee measured temperature profiles in the control room and performed a 50.59
'
saf9ty evaluation to assess the impact of the as-built configuration. The kcensee
concluded that the existing natural circulation of air in the panels was adequate in au
casas because panel temperatures were less than 10 degrees F above ambient room
temperature. Also, the host input into the general area of the control room was smaN and
i did not impact temperature control under normal or accident conditions.
The inapoctors reviewed the control room temperature profile data and the 50.59 safety
. evaluation results for the as-built condition. The inspectors verified that control room
design for maintaining positive pressure was not sffected based on the most recent
surveillance test results conducted on August 26,1997. While reviewmg the design and
hoensing basis of this system, the inspectors noted that Updated Final Analysis Report
.
24
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.'
(UFSAR) Section 9.4.1.2 system t ='.-;-U=i included the statement: "Retum air passes
'
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through the control boards into a retum duct system which is connected to outlets at the ,
top of the boards." Since the licensee evaluated the actual con 6guration with roughly half
of these duct connections not installed, this UFSAR statement was generalin nature and
not speci6cally descriptive of the actual configuration. The design engineering supervisor
stated that the 60.59 evaluation concluded that the UFSAR did not require any chan0es
- because this statement was correct since some of the ducts were installed as described.
,
The licensee's failure to hairdain drawing M-315, " Control Room HVAC [ Heating,
Ventila' ion, and Air Conditioning) System El. 642'-0"," consisterd with the as-built design ,
con 6guration is considered a violation of 10 CFR Part 50, Appendix B, Criterion lil,
(50295/97025-10; 50304/9702510), as described in the attached Notice of Violation.
. IV. Plant Suonnet
SS Mieoelianec .a Security and safeguards laaues
88.1 (Ocen) Inspection Follow-un item (50 304/97022-09): Review the hcensee's investigation
, ar.d corrective schon for inattentive sect.nty officers.
Ca October 21,1997, a security supervisor discovered a security ofncer asleep while
'
standing watch for a vital barrier associated with the Unit 2 unit auxiliary transformer. The
I
security post had been established on September 23,1997, as componaatory measures
for an earlier problem. Although the vital barrier was intact, the post 'or the transformer '
had not been closed. Therefore, the secunty officer was still required to be alert to
perform compensatory measures. The hcensee's corrective schons included relieving the
security ofncer of the post and posting a new officer. The security ofhoor was
subsequently terminated. This was the third instance of an inattentive secunty officer
within a four week period. This inspection follow-up item will remain open pending further
review of this issue by the regional security specialist.
. V. Mananoment Meetinas
X1 Exit Meeting Summary
The inspectors presented the inspection results to members of licensee management at
i the conclusion of the inspection on December 16,1997. The licensee acknowledged the
findings presented.
J The inspectors asked the licerwee whether any matsrials examined during the inspection
should be considered proprietary. No proprietary information was identified.
25
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Partial Ust of Persons Contacted
'
Licensee
J. Brons, She Vlos Presiderd
R. Starkey, Mont General neonager
K Dickwoon, Execuuve Assistant to 6ite Vice President
, . T. Sakserski, Execuuve Assistant to Site Vee President
D. Bump, Restart n4anager
R. Zyduck, Site Quauty Veri 6ceuon Manager :
E. Katzman, Radiation Protocuon Manager
T. O'Connor, Operauons Manager
L schmeling. Training Managw
R. Thorson, Electrical Maintenance Superirdenderd
C. wintws, shin Opwaung supervisor '
J. Brandes, Assistant Shin Operaung 94+r;:::=
' D. Beutel, Regulatory Assurance
F. Jones, Regulatory Assurance
. Nf1G
A. Vogel, Achng Chief, Reactor Projects Branch 2
E. Cobey, Acting Senior Residerd inspector
D. Calhoun, Resident inspector
C. Brown, Resident inspector
IDNE
J. Yesinowski
26
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[
,
List ofinsmention Procedures Used
,
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F 37551 Enginsedne
IP 81728 - Survolgence Observations ;
i *
! IP 42707 Maintenance Observation
j. IP 71707 - Plant Operatione
, .P 71750 Plant Support ,
4
h
,.
Llat of llams Onaned. Closed. and Discussed
i
QQAfted
,
l 50 295/304 9702501a VIO Failure to provide appropriate guidanno in 80441F '
to ensure that adequate SW Sow was maintained to
'
r the 28 EDG while splitting the SW headers
- - 50 295/304-97025-01b VIO s - Failure of PT10 3 to provide ==rg'r'
- guidance to
test the Trair: "A" Division 7 containment isolation -i
,
and component actuation circuitry energized from
i safetyinjection relay SIX 1A
' 150-295/304-97025 02 URI Rsview of the licensee's completed investigation
and corrective actions for the restoration of the
control room ventRation system
50-304/97025 03 - URI Review of the licensee's completed inc:7:-r. of
1
the circumstances which resulted in the RHR
system being rendered inoperable
i
- 50 304/97025 44 VIO ' Failure of the Shift Manager to make the required
noufication, within four hours, for an inoperable
+ containment penetration line
!
-50 295/97025 05 NCV Failure to have an adequate pie for moving
4- fuel assembhos
t
!
50 304/97025 06 VIO ' Failure of the electrical maintenance technicians to
'
install relay SIX1 AX in accordance with the
- maintenance procedur.
-
50 304/97025-07- - VIO Failure to identify and perform a post-maintenance I
test for the replacement of relay SIX1 AX
l
b 50 304/97025-08. NCV Failure to have Mey ^ procedure for emer9ency u
diesel generator starting air compressor
maintenance
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_ - _ . _ . _ _ _. _ _ - _ _ __ _ _ _ _ _ _ _ - _ __ __ . _ _ . . _ _ . _ _ . . _
,y.
g >
1
,
50 30W9702509 NC,V Failure to perfoem IST on the 2A safety inhotion ,
pump sucuon valve,2MOV Si4923A within the
spoolred pwlodx% -
50-29W304 9702510 VIO Failure to mainthin design drawing for the control
room venuladon system current with the as built ;
configurauon
'
Q9Afd
5029W96017 02 URI Practice of allowing reactor power to exceed
licensed thwmal power limit.
50 296/97013-01 URI . Failure to have an adequate procedure for moving
, fuel asse'oblies
,
50 295/304 97016-M URI - Failure to maintain design drawing for the control
room system current with the as-built configuration
50 30/197002 LER inadver*ent loolation of Service Water Cooling to i
2B emegency diesel generator during system
alignment
,
50 304/97003 LER Unit 2 residuhl heat removal doolared inoperable
because only one component cooling pump was ,
'
operable
~
50-304/97004 LER Small bore containment penetrstion line
inadequately supported since plant construcuon
50 304/97005 LER Missed technical specification surveillance test .
failure to test the 2A safety 'qhotion pump suction
valve in the presenbod periodicity
50 295/97025 05 NCV Failure to have an adequate procedure for moving
fuel assemblies
, 50-304/97025-08 NCV Failure to have adequate procedure for emergene,
diesel generator starting air compressor
,
maintenance
50 304/97025-09 NC\/ Failure to perform IST on the 2A safety injection
pump suction valve, 2MOV-SI8923A, within the
Specifed periodicity
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Discusand
229W9702240 FI Review We lloonsee's Irwesti0ation and correceve
actions for the inatteneve soomity omoors
S29W304 9701342 NOV Failure to control use of overtime in excess of
9uidelines
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$
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. ._ _ . _ _ _ _ _ _ . _ _ _ _ ____...._ _ _
7___-_..___.__
!.'
e
> Last af Aarannne
- APW Amdllary FeeWW System
cc cw consne Walw
- CST Condensate Storage Tank
>
DRP Olvision of Reactor Projects ;
EDG Emergency Diesel Generator
ESF Engin*ered Safety Feature
FA Fuel Assembly ,
'
4 FHI Fuel Handling instrucuan
c FHS Fuel Handling Supervisor
HvAc Heatine. Ventinauon, and Air Conditioning
IONS Winois Department of Nuclew Safety
IFl e.mpaction Follow-up item
iP inspecuan Procedure
IST inservice Test
- LER- Uconsee Event Report l
NcV Non Cited Violation i
NRC Nuclear Regulatory Commission
004 Out-of-Serv 6os
POR Public Documord Room
PtF Problem identiecauon Form
PMT Pc Mf*c.r.ru Test l
l PT Periodic Test i
' !
i OM SNft Manager
Sol system opwoung instrucsons
SW service W at w
TS Technical specifications
TSI Technical Spedfication interpretation i
. UFSAR Updated Final Safety Analysis Report :
'
URI Unresolved item j
-
US Unit Seporvisor .
VIO Violation '
.
ZAP Zion Administrative Procedure
,
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