ML20199A877

Insp Rept 50-461/97-19 on 970826-1006.Violations Noted.Major Areas Inspected:Operations,Maint,Engneering & Plant Support

ML20199A877
Person / Time
Site:	Clinton
Issue date:	11/12/1997
From:	Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20199A830	List: ML20199A825 ML20199A847 ML20199A877
References
50-461-97-19, NUDOCS 9711180135
Download: ML20199A877 (24)

See also: IR 05000461/1997019

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U.S. NUCLEAR REGULATORY COMMIS860N

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REGIONlil

Docket No: 50 461

Lloonse No: NPF 62 .

Report No: 50 461/97019(DRP)

Licensee: lilinois Power Company

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Facility: Clinton Power Station

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Location: Route 54 West

Clinton,IL 61727

Dates: August 26 October 6,1997

Inspectors: T. W Pmett, Senior Resident inspector

K K Stoodter, Resident inspector

D. E. Zemel, Illinois Department of Nucleer Safety

Approved by: Geoffrey C, Wright, Chief

Reactor Projects, Branch 4

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EXECUTIVE SUMMARY  !

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Clinton Power Station i

NRC inspection Report No. 50-461/97019(DRP)  !

This inspection included aspects of licensee operations, er#::t.ii, maintenance, and plant l

support. The repori covers a 6 week period of resident inspection.

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Operations ,

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i + The plant manager declared a site wide stand down on September 11,1997, due to an

l Increase in personnel errors. (Section 01.1)

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* ' One violation was identified due to a line assn mt shift supervisor failing to property

direct and monitor the activities of the reactor ogators such that a drain down of the  !

reactor vessel was promptly identified and corrected. Reactor operators did not property

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monitor and control reactor vessellevelin a safe and competent manner, (Section 01.2)  !

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• The failure to activate a readily available alarm and esiminate unnecessary licensed l

i. operator tralnee system reviews during a reactor vessel level drain down evolution was  ;

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considered a significant weakness in operator performance. (Section 01.2)

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+- One example of a corrective action violation was identified for the failure to prevent the p

recurrence of eleven near m!ss tagging events. (Section 01.3) j

f * During a review of the tagout program, several weaknesses with the implementation of ,

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the corrective action program were noted including: root cause analyses which did not

determine why previous corrective actions were ineffective, a lack of quality assurance

involvement in deficient areas, a lack of communication between departments prior to

extending corrective actions, and extending condition reports beyond 1 year without the l

approval of the corrective action review board. (Section 01.3)

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+ The inability to track corrective actions involving responses to NRC violations was a

, weakness in the licensee's commitment tracking system. (Sections 01.3 and 08.6) ,

i * One violation was identified due to the failure to provide complete and accurate

information to the Commission. Specifically, the response to Notice of Violation

No. 50-461/97009-01 stated that corrective actions in response to an inadvertent isolation .

of the reactor water cleanup system had been completed even though the actions were

not scheduled for completion until Februs:y 15,1998. (Section 08.2)

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+ One example of a corrective action violation was identifed due to the failure to revise

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procedures associated with the restoration from a Division i bus outage. The untimely

corrective action resulted in a second inadvertent isolation of the reactor water cleanup

system on August 22,1997, (Section 08.2)

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+ One weakness was identified for the failure to implement conective actions to ensure

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proficiency watches were property credited for senior reactor operators. (Section 08.4)

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• One exampio of a corrective action violation was identified for the failure to preclude a  !

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third loss of service building security lighting. Two root cause analyses were of poor j

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quality in that tlwy did not determine why corrective actions were untimeh, not j

implemented, or ineffective. The delay in initiation of root cause analyses and l

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' C..ri , of corrective actions until roosipt of an NRC Notice of Violation was

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considered a poor corrective action program practice. (Section 08.5)  ;

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Maintenance

- * One violation was identiflod for the failure to provide guidance whleh was commensurate

with the knowledge, sWils, and abilities of electrical maintenance individuals performing

the lubrication of the Division lil Shutdown Service Water Pump. This was the third

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example in 4 months where technicians were unable to congstently perform " tool box

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skills." (Section M1.3)

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Ennineerina

e A non-cited violation was identified for the failure to maintain required Technical

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Specification indications for leakage detection systems. (Section E3.1) -

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I * Three discrepancies with the Updated Safety Analysis Report were identified involving

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alarm set points, omission of sensitivity studies, and the detection capability of radiation

monitors. (Section E8.1)

Plant Sunbort

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• Several weaknesses with the implementation of the corrective action program were noted

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inclu#ng: the completica of root cause analyses which did not determine why previous

corrective actions were ineffective, poor integration of quality assurance (QA) findings, a

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lack of QA involvement during the closure of condition reports initiated by QA inspectors, '

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and poor trending of deficient conditions. (Section R8.1)

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Rasort Detaus  ;

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Summary of Plant Status l

The plant remained shut down throughout the inspection period and work continued to resolve

deflaiencies on Westinghouse 4160V breakers. On September 11, the licensee entered a 5 day i

site wide stand down due to a % crease in personnel errors. l

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L Oseratiena

01 Conduct of C;:.2:x

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01.1 Site Wide Ston Work Order

On September 11,1997, the Manager, CPS lasued a site wide stand down order c,ue to

several personnel errors involving: (1) work performed on wrong components,

(2) inadequate work packages (3) tegouts, (4) drain down of the reactor vessel water r

level below an administrative level, and (5) continued radiation protection deficiencies.

During the stand down, personnel were briefed on the purpose of the stand down, the '

specifics of the personnel errors, and actions to be taken prior to resuming work. In

addition, each person was required to submit a paragraph on methods to improve human

performance. The stand down was lifted on September 16.

01.2 Operator Inattention Results in Drain Down of Reactor Vassel Below Adinlnieti As Limit  !

a. Inspection Soone (71707)

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On September 11,1997, operators inadvertently lowered reactor vessel water level

approximately 16 inches below the administrative limit of 90 to 100 inches on the

shutdown range indication while preparing to start the "C" reactor water cleanup (RT)

pump. The inspectors reviewed the details associated with the event,

b. Observations and Findinas

The inspectors determined that the event occurred due to a leck of specificity by the line

assistant shift supervisor (LASS) and poor attention to detail by both reactor operators

(RO); Although a pre-evolution brief was held before commencing the drain down, a  ;

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Ictdown rate or final reactor vessel level was not specified by the LASS nor was the lack

of direction questioned by either RO.

The "A" RO established a letdown rate of approximately 150 gallons per minute. The

actions of the "A" RO were not peer chocked by the *B" RO because he was preoccupied

with documenting the midnight entry into the station log. In addition, supervisory

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oversight of the Ros was ineffective. The LASS was inattentive to the lowering of reactor

vessel level and continued to prioritize other whi;t activities as the letdown commenced

because he felt comfortable with the "A" RO's ability to control reactor vessel leval. The

failure to provide appropriate controls for this major reactor evolution was considered a

significant weakness in the conduct of plant operations.

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! Once the leidown rate was establisbod, the 'A' RO engaged in damaa% with a

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licensed operator trainee regarding another plant system. The system review created a

distraction and prevented the operator from monitoring artlical parameters during the ,

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draining evolution. The inspectors calculated that lowering the reactor vessel level to

go inches on the shutdown range should have taken less than ten minutes.

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Approximately 30 minutes after beginning the drain down, the 'A' RO checked his panel ,

j indications and noticed that reactor vessel level was at 74 inches in the shutdown range

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(16 inches below the administrative limit). The 'A' RO informed the I. ASS of the

abnormal level and Ihe letdown was scoured. The RT pump was started and level was

retumed to within th e administrative limit. The inspectors considered the conduct of

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training during this f naior reactor evolution to be a poor operating practice.

l Operations persornel initiated condition report (CR) 1 g7 Og 133 to document this event  !

and held a fact finding review. Both the I.A88 and the "A" RO were counseled by

operations management prior to retuming to watch standing duties. The inspectors -

i questioned the Assistant Plan *,":.+;+:- Operations as to the actions taken to correct ,

the performance of the "8" RO. -The Assistant Plard Y: +;+:- Operations stated that the  !

"B" RO was not accourdable for the event since he was not responsible for manipulating ,

l the controls _ associated with reactor vessellevel. The inspectors disagreed with this  ;

[ reasoning since the "8" RO was also responsible for monitoring panels within his watch

area, including instrumentation for the shutdown range reactor water level. On e

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' - October 8, the Assistant Plant Manager Operations acknowledged the inspectors'

' assessment on operator performance.

! During the licensee's fact finding review for this event, the inspectors loamed that the

I operators had the opportunity to activate a performance monitoring system alarm which

i would have alarmed if level fell below go inches on the shutdown range. However, this ,

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alarm is for operator convenience and not required to be utilized. The inspectors .

considered the failure to utilize the alarm to prevent over-draining the reactor vessel to be

a poor operating practice.

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! Procedure CPS 1401.01, " Conduct of Operations," Revision 28, Section 8.1, states that '

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the L. ASS has the responsibility to detect the licensed activities of the Ros at the controls

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to ensure that the Ros can adequately monitor and manipulate the controls. The I. ASS is

l~ also responsible for monitoring cathode rey tubes (CRTs), indkators, annunciators and

j recorders in order to detect unusual or abnormal trends and initiate appropriate, timely

action to correct or mitigate the situation. The reactor operators are responsible for

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controlling and operating equipment and systems from the main control room in a safe

and competent manner. The failure to property direct, monitor, and control activities

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associated with lowering the reactor vessel level was considered a violation of Technical  !

L Specification 5.4.1 (VIO 80 441/97019-01).  ;

c. Conclusions

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One violation was identified due to a LASS failing to property direct and monitor the

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activities of the Ros such that a drain down of the reactor vessel below an adminletrative

level was promptly identified and corrected. The Ros failure to property mon _itor and

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control mactor vessel level in a safe and competent manner also contributed to de

violation. The failure to implement a readily available alarm and eliminate unnecpssar)

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licensed operator trainee system reviews during the reactor vessel level drain down

evolution was considered a significant weakness in the conduct of plant operatums.

01.3 Continued Tanout Enors ,

s. Inspection Scope (71707 and 62707) -

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The inspectors reviewed the effectiveness of corrective actions to improve the l

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. implementation of the tegout program following the initiation of numerous CRs.

b. Observations and Findinns ,

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Between July 14,1997, and September 10,1997, the inspectors noted that several CRs

were initiated by the facility to document deficiencies associated with all aspoots of the ,

tagout program including: (1) inadequate preparation - CR 1 97 07 139, (2) tagging the l

wrong component CR 197-07 257,(3) issuance of a tagout without approval .

CR 1 97-08 020, (4) inadequate boundaries - CRs 1-97-06 095,197-09-078, and

1 97 09-099, (5) failure to recognize the need for a tagout - CR 1 97-08 182, '

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(6) inadvertent release of a tegout prior to completing work - CR 197-09-057,

(7) improper temporary lifting of tags - CR 1 97-09-089, (8) commencing work on the

wrong component - CR 1 97-09-100, and (9) performing work without being signed onto

the tegout CR 1-97 09 103.

i- The inspectors expanded the scope of the review to include deficiencies between

l January 1 and September 10,1997. The review identified 39 CRs involving failed

barriers in the tagout process, Twenty-eight of the CRs involved failed barriors which

were detected by subsequent reviews during the verification process and did not result in i

the commencement of a work activity with inadequate protection. Eleven of the CRs

involved failed barriers which resulted in near miss events (a tegout near miss event is a '

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situation where work has been authorized to proceed with an inadequate tagout).

Because of the continuing problems, the inspectors reviewed previous corrective actions

developed in response to Safety Tagging Adverse Trond CR i 96-10-371. A common

cause analysis for CR 196-10-371 was completed on November 6,1996. As part of the

ana / sis the licensee reviewed 57 safety tagging CRs initiated between November 1,

1995, and October 27,1996. The analysis determined that the tagging ever,ts were most

commonly the result of errors in judgment (22 CRs), attention to detail (16 CRs), and

committed actions not carried out during the preparation of tagouts, coordination of tagout

activities, and work authorization (11 CRs). The licenw a further subdivided the tagout

deficiencies into categories which included, in part, the nine deficiency areas described

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above. The inspectors noted that the tagout deficiencies identified throughout 1997 were

repetitive of the deficiencies reviewed in CR 19610 371.

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Four corrective actions were recommended in response to CR 1-96-10 371. The first

action was to provide sensitivity, attitude, and increased awareness seminars to

operations personnelinvolved in the safety tagging process. This item had an original

due date of January 1,1997. However, on September 9,1997,8 months after the

original due date, the Assistant Plant Manager- Operations extended the item until

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October 15,1997, due to delays during the outage which postponed plant start-up. The

licensee was unable to provide a CR extension request form for this corrective action

item. ,

The second action was to train users on the safety tagout process and the

implementation and expectations of the process. This item had an original due date of

April 30,1997. The inspectors noted that the lesson plan was assigned for development

on September 1 and completed on September 15,1997. However, on September 23,

1997,5 months after the original due date, the Assistant Plant Manager- Operations,

extended the item until April 1,1998, due to delays during the outage which postponed

plant start-up.

The third action was to develop goals and a monitoring system for tagging process

events. This item originally had a due date of March 28,1997. The inspectors noted that

operations support had dowloped a method to track and trend deficiencies with the  ;

tagging process in June 1997. The first trend report was provided to management on

September 1,1997. Because of the recent implementation of the trending program, the

inspectors were unable to assess if the trend data was effectively utilized.

The fourth action was to re-engineer the tagging process, This item had an original due

date of July 1,1997. However, on September 23,1997,3 months after the original due

date, the Assistant Plant Manager- Operations, extended the item until October 15,

1997, due to delays during the outage which postponed plant start-up.

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The inspectors noted that a common theme in delaying corrective action implementation

was plant start-up. Errors continued to be made during these delays. Substantive efforts

to improve the quality of the tegout program were not taken until repetitive near miss

events and prompting by the NRC occurred.

Between January and July 1997, the licensee performed root cause analyses for

Gas 197-01 133 (inadequate tagout boundaries), 197-01254 (inadvertent reactor scram

due to tagout), 197-03-208 (improper removal of tags), and 1-97-07-257 (tag hung on

wrong component). The inspectors noted that the corrective actions from these root

cause analyses failed to prevent continued recurrence of tagging errors. The failure of

the root cause analyses to determine why previous corrective actions were ineffective

was considered a weakness in the corrective action program.

The inspectors requested the results from all QA audits and surveillances performed

between October 1,1996, and September 1,1997, involving the tagout program. No

audits and only two surveillances had been performed during the period. The last QA

audit (Q38 96-07) involving the tagout program was performed during a review of the

operations area in April 1996. The audit report stated that safety tagging was evaluated

as satisfactory during the audit. The inspectors noted that 15 CRs had been initiated

against the tagout process during the 5 months preceding the audit and concluded that

the satisfactory assessment may have been misleading.

QA Surveillance Q-17231 performed between September 3-20,1996, determined that the

overall performance of the tagout process was in keeping with management

expectations. Surveillance 97-B-461 involved activities for scheduling and tagging high

voltage breakers and did not assess the adequacy of the tagging program. The

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i :;::4:- . noted that QA was not actively involved in assessing the quality of the tapout

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inspectors considered failure of QA to recognise the probioms with the tapout program a  !

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signlAcant oos.tributor to the ineffectiveness of the conective action program. t

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10 CFR Part So, Appendix B, CrHerts XVI, requires, in part, that measures be established

l to assure that signiAcent conditions adverse to quality are identined, the cause of the  :

conditions is determined, and that corrective actions are taken to preclude repetition. The ,

Inspectors noted that the corrective actions to improve personnel performance with

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! respect to the tagout progrom had not been implemented. Consequently, donciencies

with tegout program implementation continued to be pervasive throughout the i

organization. The failure tc implement corrective actions to preclude repetNion is a  ;

violation of 10 CFR Part 50, Appendix B, CrHerion XVI (VIO 80441/9701942a).

The inspectors discussed the tagout program deAciencies with the Assistant Plant -

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Manager Operations. The Asristant Plant t +y - Operations agreed with the  !

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Inspectors' assessment that the corrective actions were untimely given the continued

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problems with tegout program anplementation between November 1995 and

Septemtr - 1997. In response to the inspector concoms, the licensee revised the .

i scheduloc ccs-Of -n date for the corrective actions in CR 19610-371 from April 1998 l

to November 15,1997. .

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The inspectors reviewed the CR extension request forms for the corrective actions in

CR 19610 371 and noted that the forms spec 6Aed that no NRC commitments were

irrpacted by the extensions. The inspectors noted that the licensee's response to Notice

of Violation No.50-461/96009-04 specified that corrective actions involving training

described in CR 196-10 371 would be taken to avoid further violation. The inspectors

determined that the inability to track corrective actions involving responses to NRC ,

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violations a weakness in the licensee's commitment tracking system.

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The inspectors noted that even though CR 196-10-371 was assigned to the operations '

department, the common cause analysis involved a multi-disciplinary review by

departments which utilized the tagout program. The corrective actions were designed to

improve the performance of each of the effected departments. However, departments

, which expec'.sd to receive training on the lagout process were not consulted prior to the

l extension of corrective actions. The inspectors considered the lack of communication

between departments prior to the extension of corrective actions a weakness 1.- the

implementation of the corrective action program.

! Procedure CPS 1016.01, " CPS Condition Reports," Section 8.10.1, requires that

justification for changes to corrective action due dates be provided to the CR owner's

director for approval and that if the CR is greater than 1 year old, correctise action review

board (CARB) concurrence is also required. The inspectors noted that the corrective

actions for CR 1-9610 371 were extended beyond the 1 year date without concurrence

from the CARB _ The conective action program manager stated that although the

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requirement is not explicitly stated, management expected directors to obtain CARB

concurrence li the CR is to be extended beyond one year. The inspectors considered the

lack of appropriate guidance and management expectations for corrective action

extensions beyond the 1 year date a weakness in the implementation of the corrective .

- action program.

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c. Canciunions

one violation was identined for the failure to implement corrective actions to proverd the I

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recurrence of tagging denciencies. t+m.: was focused on plant start-up and did i

not implement conective actions to improve the quality of the tagout program. Several  !

weaknesses with tiec corrective action program implementation were idenoned including ]'

ror,t cause analyses which did not determine why previous correcuve action were

ineffective, a lack of QA involvement in the tagout process, a lack of ranmunication i

between departments prior to extending corrective actions, and extending CRs beyond l

one year without appropriate reviews.

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> The failure to track corrective actions involving responses to NRC violations was a l

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weakness in the licensee's commitment tracking system.  !

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08 Miesellaneous Operations issues

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08.1 (Closed) Nouco of Violation 50-461/96004-01a' incorrect informah provided in

emergency operating procedures (EOPs). The licensee determined that this violation

occurred due to a lack of understanding the physical operation of the analog trip medule ,

during initial development of the EOPs. The licensee corrected the inaccurate

information in the affected EOPs and validated tint the informah provided was coirect.

The inspectors considered the currective actions appropriate for this issue.

08.2 iOpen) Notice of Violation 50-461/96009-01: Failure to provide adequate procedural

guidance dudng restoration of the Division i Nuclear System Protective System (NSPS).

In October 1996, the licensee performed an outage on the Division i NSPS system. In

order to keep the RT system in service during the outage, Outboard Containment  ;

Isolah Valve / Pump suction Valve 1G33 F004 was maintained open by removing power i

to the valve and disabling the low suction pressure / flow pump trip protection for the

operating RT pumps. During restoration from the bus outage, operators noticed that tlw i

i Division 1 NSPS bus restoration checklist, Procedure CPS 3509.01C001, cautioned that

various safety system actuations may result during the restoration of the NSPS system.  :

However, the operators did tM4 assess the possible impacts on any specific equipment

listed in the checklist prior M Morming the restoration. Men the operators restored

power, Valve 1G33-F004 c;osed ttoe to a pre-existing contamment isolation signal which

! resulted in a loss of suction to the operating RT pumps. The pumps did not trip because ,

the procedure had not instructed that the pump trip protection be restored prior to ,

restoring power to the suction valve. The failure to assess possible equipment impacts

during the rePtoration process contributod to an in service failure of the "C" RT pump.

The licensee's violation sosponse dated April 9,1997, stated that

Procedure CPS 3509.01C001, " Division l NSPS Bus Outage Checklist,* was revisea to

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include a caution statement regarding the possible repositioning of valves during

restoration of NSPS. The inspectors reviewed the checklist and determined that no

caution statement had been placed in the procedure. A review of the corrective action

plan associated with this event determined that the corrective actions for this violation .

were not approved until May 6,1997, and procedure CPS 3509.01C001 was not i

scheduled to be revised until February 15,1998. The inspectors reviewed a listing of .

deferred procedure reviews and determined.that those procedures used during the

outage or subsequent plant start up had been revised or were in the review process.

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Through docuulons whh the licensee, the inspectors loamed that the information

otadained in the No6ce of Violation response was in enor due to miscommunications {

! between plant staff and the failure of mana0ement to fully review a documord before  ;

soneng N to the NRC. Speci6caty, the licensing staN amumed that the corredive i

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actions for this everd had been completed since the due dates in *he conocHvo action

j plan were blank. Neither licensing or plant management verined the wr-( A, of the ,

adions prior to sending a letter to the NRC stating that Clinton Power Station was in full l

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compliance with NRC regulations. Licensing personnelinitiated CR 1-97-09 077 to i

documord this occurrence and initiated an effort to ensure that the information provided in

) other letters to the NRC was conect. The licensee planned to lesus a revised ,

NOV responso. This hem will remain open pendmg review of the licensee's revised

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response, j

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! 10 CFR Part 50.9 states, in part, that information provided to the Commission by a  ;

! licenses shall be complete and accurate in all material respects. The failure to provide

complete and accurate information in response to Notice of Violation i

i No. 50-461/96009-01 was considered a violation of 10 CFR Part 50.9

l (VlO 80 441/97019-43).

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On August 22,1997, operations was restoring from another Division i outage by ,

! performing procedure CPS 3514.01C005, "4160V Bus 1 A1 Outage," Revision 2, in *

I parallel with procedure CPS 3509.01C001. Procedure CPS 3514.01C005 directed that *

i power be motored to Valve 1G33-F004. Since the operators had not yet reached the

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step in procedure CPS 3509.0W01 which reset the RT isolation logic, Valve 1G33-F004

shut due to a pre-existing containment isolation signal when power was restored and ,

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suction was lost to the operating RT pump. The operators manually tripped the pump

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upon noticing that the suction valve had repositioned itself and prevented any possible *

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pump damage.

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The inspectors review of this event detern ied that the licensee's failure to promptly take

the conective actions committed to in 1;wir April 9,19g7, letter to the NRC resulted in  ;

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procedures CPS 350g.01C001 and 3514.010005 remaining inadequate. These

procedural inadequacies resuhed in a second inadvertent isolation of the RT system on

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, August 22. The failure to promptly correct information provided in bus outage restoration

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procedures to prevent an additional inadvertent isolatio.1 of the reactor weiter cleanup

. system was considered an additional example of a violation of 10 CFR Part 50,

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Appendix B, Criterion XVI (VIO 80441/97019 02b).

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08.3 (Closed) Notice of Violation 50-461/96009-02: Failure to_ maintain temperature log

required by technical specifications during testing of t;1e reactor core isolation cooling

system. The licensee determined that this violation was caused by human error.

! Specsfically, the line assistant shift supervisor overlooked the requirement to initiate a ,

suppressir n pool temperature log when performing a test which would add heat to the

suppression pool. The inspectors considered the licensee's corrective actions for this

event appropriate.

-

08.4 (Closed) Notice of Violation 50-461/96009-03: Failure to perform required quarterly shifts F

, to maintain active license status. The inspectors reviewed the 1997 Licensed Operator  :

'

Watch Standing Record of Completion f6rms for two senior reactor operators (SRos) and I

found that one SRO had credited performing one shift as the Shift Resource Manager ,

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.u. .a. _ - - _ _ _ _ _ _ , . . . _ _ . -

._ . _ ___. _ __ ____ _ _ _ _ _ _ _____

t

(SRM) towards completion of his watch standing requirements. The inspectors brought

this error to the attention of operations management who then initiated CR 1-97-09110.

Further review by operations determined tint the SRO had completad the required

quarterty shifts and that the information provided on the watch standing form appeared to

be a documentation error, An operations department review of Uconsed Operator Watch

Standing Records of Completion for all remaining operators identified three additional

examples where SROs had credited watches performed as the SRM towards maintaining

their proficiency. Operations verified that sll three operators had performed the required

number of watches however, the inspectors considered this to be fortuitous.

08.5 (Closed 1 Violation 50-461/96009-04: Inadequate corrective actions for safety tagging

errors involving protected area illumination. Protected ares illumination adjacent to the

service building was inadvertently de-energized on July 25,1996, when the licensee

opened Standby Ughting Cabinet 159, Circuit M. NRC Violation 50-461/96009-04 was

initiated due to fallms to implement corrective actions to prevent a second inadvertent

loss of service building lighting when Standby Ughting Cabinet 159, Circuit M was

de-energized on September 9,1996.

7R 197-02-141 was initiated on February 17,1997, to perform a root cause analysis in

response to Notice of Violation No.50-461/96009-04 dated February 11,1997. The

inspectors noted that even though the original deficiency was reported to the licensee in

an exit meeting on Novamber 3,1996, the licensee did not initiate a root cause analysis

to determine the root causes and corrective actions until February 11,1997. The

t inspectors considered that delaying the initiation of a root cause analysis until receipt of a

'

Notice of Violation a poor corrective action program practice in that the potential existed

for recurrence of the deficiency between the initial identification and formal notification by

the NRC.

The inspectors noted that CR 197-02-141 narrowly addressed the specific technical

aspects of the loss of security lighting and did not address causes for why corrective

actions were not adequate to preclude recurrence. Consequently, corrective actions

were not sufficiently broad enough to prevent recurrence of a third loss of service building

lighting on July 7,1997, involving Standby Ughting Cabinet if9, Circuit M. The July 7,

1997, loss of lighting occurred during a Division ll outage when operators de-energized

the 4160 VAC 181 Bus which in tum de-energized Standby Ughting Cabinet 159,

Circuit M.

The licensee initiated CR 197-07-044 to perform an additional root c.ause analysis of the

loss of security lighting provided by Standby Ughting Cabinet 159, Circuit M. The

licensee determined the root cause to be " human error, inadequate corrective actions as

a result of tunnel vision, and not familiar with the task of schematic changes."

Specifically, corrective actions in response to CR 197-02-141 were inadequate in that

only the electrical schematics and not the operations procedures were revised to include

the provision that outside lighting was impnted by Standby Ughting Cabinet 159,

Circuit M. Contributing factors included a lack of sensitivity concoming the impact of a

loss of outdoor lighting, inadequate procedures, and a lack of identification on breakers

that interrupt power to outdoor lighting. The inspectors noted that the root cause from

CR 197 02-141 identified the deficient technicalissues, but did not determine why the

corrective action program failed to prevent the third occurrence of the loss of service

building security lighting within a 1 year period.

11

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?

In addition, the inspectors reviewed CRs 1-96-07 066 (July 26,1996) and 196-09-013

(September 6,1996) which also involved the inadvertent de-energization of Standby

I

Lighting Cabinet ib9, Cirwit M, and noted several deficiencies:

CR 1.96 07 066

An action item was identified for security to determine how breakers that supply security

related lighting should be identified and for coadnation with the engineering department

to determine power supplies for lighting circuits of concom. The item was reassigned

from the security department to the ongineering department on September 5,1997,

without any corrective actions having been taken. In addition, an item to determine how

breakers that supply security related lighting should be identified was not completed and

the verification process which closed the CR did not identify the omission. These were

examples of the ineffectiveness of the licensee's corrective action program.

CR-109-013

CR 196-09-013 was closed to CR 1-96-07-066 on October 17,1993. However, an action

item assigned by the shift supervisor on the day of discovery was not transferred. The

item involved a request for the security departmert to provide a listing of effected outside

lighting to the work control team for future tagout use. The failure to ensure all

recommended corrective actions were complete was an additional example of the

ineffectiveness of the licensee's corrective action program.

Root Cause Analyses

The inspectors noted that CR 197-07-044 resolved the technicalissues associated with

the loss of security lighting. However, neither CR 1-97-02-141 nor CR 1-07-07-044

addressed why previous corrective actions were ineffective in preventing recurrence.

Specifically, CRs 197-02-141 and 1-97-07-044 did not determine why recommended

corrective actions specified in CR 1-96-07-066 (determine how breakers that supply

security related lighting should be identified), and CR 196-09-013 (security provide a

listing of effected outside lighting to the work control team for future tagout use) were not

implemented even though the NRC violation pertained to the licensee's failure to

implement corrective actions.

CR 197-07-044 did not datermine why the corrective actions implemented from the root

cause analysis performed via CR 1-97-02-141 did not preclude recurrence. The

inspectors determined that the licensee's root causa analyses were of poor quality it? ' hat

they did not address the failure to inplement corrective actions. The failure to implement

corrective actions to preclude the recurrence of a third loss of service building security

lighting is an additional example of a violation of 10 CFR Part 50, Appendix B,

Criterion XVI (VIO 50-461/97019-02c). Corrective actions for VIO 50-461/96009-04 will

be assessed during the review of VIO 50-461/97019-02c. Therefore,

VIO 50-461/96009-04 is closed.

08.6 (Closed) Notice of Violation 50-461/96009-05: Failure to follow procedure during diesel

generator over speed trip testing. The u 7,ensee stated that the violation occurred due to

persennel error. The inspectors deterT nedi that the violation likely occurred due to the

licensee's previous policy on procedural adherence which allowed procedures to be used

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as guidanos documento and allowed procedures to be changed using the " noting out"

F process. Since this violation occurred, the licensee has initiated sigrW6 cant corrective

actions regarding procedure adherence and the ' noting out" process in no longer allowed,

l

The licensee's corrective actions stated that Procedure CPS 3882.01, " Diesel Generator

Over Speed Trip Test," had been revised to allow the use of varying styles of

techo notors. The inspectors review of this procedure determined that the procedure -

speci6ed the use of a Monarch Portable Tachometer instead of varying styles c *

techometers. The licensee initiated CR 1-g7-09-278 to document the discrerat and

= oiscovered that the corrective action plan for this violation had been changed aph.av the

use of the Monarch Portable Tachometer during future performances of

pro:edure CPS 3882.01. The decision not to revise the above procedure to reflect the ,

use of varying styles of techometers as stated in the violation response was not clearty

i communicated to the NRC prior to revising the procedure. The inspectors reviewed the

, licensee's remaining corrective actions and considered thera appropriate.

e

! The licensee stated that a letter would be sont to the NRC revising their commitment on

,

the use of techometers. This is an additional exampe a problem with the licensee's

i tracking of corrective actions for NRC violations.

i ll. Maintenance

.-

M1 Conduct of Maintenance

M1.1 fttDeral Comments (62707 and 61726)

!' . The inspectors observed or reviewed the following maintenance and surveillance

activities:

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MWR D7770g Leakage and Set point Testing of Safety Relief Valve 1821-F047C

! MWR D81492 Troubleshooting Locked in Alarm on Fire Protection Pa91

1H13U723

i MWR D75794 Failure Analysis of Division i 12 cylinder engine heat exchanger

.

PEMSXM003 Grease Lower Bearing of Division lil Shutdown Service Water

Pump Motor

- M1.2  !)fety Relief Valve Testino (62707)

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The inspectors monitored portions of the as-found testing of recently removed main

steam safety relief valves. Work documents, vendor manuals and applicable procedures

, were of the proper revision and documentation requiring signing or initialing was current

based on the work progress. ' The analysis required by the ASME code to test these

4

particular valves with nitrogen (vice the actual working fluid [ steam]) was also reviewed

, and appropriate for use. A member of QA was observad at the job site monitoring

performance.

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M1.3 : Over creasina of Division ill Shutdown Service VVater Pumo Motor Bearina

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s. Inspec%n Scope (62707)

On September 18,1997, engineenng initiated CR 1-g7-09 232 to document the presence

of excessive grease under the Division til Shutdown Service Water (8X) Pump Lower

Motor Bearing. The inspectors reviewed the details associated with and the actions

taken in response to the CR.

b. Observations and Findmas

Procedure CPS 1501.02, " Conduct of Maintenance," Revision 18, Step 2.2.24, lists the

lub icction of equipment as a toolbox skPI (I o. a toolbox skill is a standard industry -

practice that does not normally require a job step, instructions, or an approved procedure

to be in hand while performing the skill). The inspectors reviewed preventive

maintenance task PEMSXM003 for grossing the lower motor bearing and found that job

Step 3 stated " lube lower motor bearing using grease spmfied by MS-01.00." No other

work instructions were given. The inspectors determined that the guidance given in

PEMSXM003 was inadequate in that it was not commensurate with the knowledge, skills, .

and abilities of the electricians performing the task. Specifically, the over grossing -

occurred because the electricians did not know that vendor manual K28288-003,

" Bingham-Willamette Vertical Pumps," required the removal of a motor drain plug when

applying new grosse to the lower motor bearing such that ti,e old grease could be

expelled.

in order to determine the condition of the pump motor windings, the engineering

department initiated a maintenance work request to megger the motor. The initial

megger readings indicated no major fault was present in the motor and there was nr.

reduction in the resistance of the motor windings. The inspectors were concemed

however that additional plant equipment may be degraded due to over grossing during

the performance of past maintenance activities. The licensee informed the inspectors

that actions were being taken to address the possibility of over grossing other plant

equipment.

10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings,"

states, in part, that activities affecting quality shall be prescribed by documented

instructions and procedures appropriate to the circumstances. The failure to provide

appropriate instructions and procedures regarding the proper lubrication of the Division Ill

SX Pump lower motor bearing which were commensurate with the knowledge, skills, and

bailouts of the electricians is considered a violation of 10 CFR Part 50, Appendix B,

Criterion V (VIO 50461/g7019-04),

in addition to the example discussed above, two additional examples of the failure to

provide guidance commensurate with the knowledge, skills, and abilities of electrical

maintenance personnel performing tool box skills were identified.

'

Inspection Report No. 50-461/g7020 documents the lack of procedural guidance for

soldering main control room noon indicating lights. in June 1997, the performance of

work on the reserve auxiliary transformer was delayed due to the failure to provide

. guidance on prope,1y meggering this type of transformer. The inspectors were concemed

that knowledge and training regarding toolbox skills may be lacking since electrical

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maintenance personnel have experience:I problems padorming certain toolbox skills ,

without additional procedural guidance. The inspectors discussed this issue with the  ;

electrical maintenanne supervisor and were told that the maintenance department was

exploring possible training defHencies and procedural inadequacies regarding toolbox

'

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skills. -

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c. 20clusions

One violation was identified for the failure to provide guidance appropriate to the

circumstances which was commensurate with the knowledge, skills, and abilities of

electrical maintenance individuals performing the lubrication of the Division til SX Purep

lower motor bearing. This was the third example in 4 months where technicians were

unable to competently perform toolbox skills.

,

M8 Mieoellaneous Maintenance issues

.- M8.1 (Closed) Notice of Violation 50-461/g6003-01: Failure to remove injector settir.g Jack

following emergency diesel generator (EDG) maintenanos results in EDG overspeed.

The licensee determined that the injector setting Jack was not removed following

maintenance on the Division 11 EDG due to a maintenance technician failing to follow the

steps of procedure CPS 8207.06, Tmergency Diesel Engine Scheduled Maintenance."

Since this viv!ation was identified, the licensee has taken a number of corrective actions

to resolve procedure adherence deficiencies which were documented in numerous

NRC inspection reports. The licensee's corrective actions were considered appropriate.

M8.2 (C40*M) Notice of Violation 50-461/96004-01b and Licensee Event Report 96-004:

l Inadequate job preparation for work in switchyard results in reactor scram. Following this

event, the licensee implemented several procedural enhancements to improve the

planning and monitoring of work performed in the swit:hyard. The inspectors reviewud

the corrective actions for this event and considered them appropriate.

~

M8.3 (Closed) lnspection Follow-up Item 50 461/96004-02:- Dualindication on multiple pieces

of equipment following a reactor scram. Through the use of troubleshooting and testing,

maintenance and engi,wering personnel explained the reasons for the dual indication on

j several pieces of equipment. The inspectors reviewed the licensee's actions and had no

further concems.

M8.4 (Closed) Notice of Violation 50-461/97006-05: Inadequate freeze seals. This issue

' involved a lack of procedural guidance relating to installing two freeze seals oq a common

line and utilizing craftsmen who had not received formal training on this technology at the

site. The corrective actions involved a revision to Procedure CPS No. 8208.01, " Freeze

Seals," to incorporate lessons loamed and industry guidelines, training of site personnel

in the use and installation of freeze seals prior to implementing the process, and utilizing

only freeze seal vendors for this process prior to completing the two corrective actions.

The utility revised it's commitment pertaining to training in letter U-602843, dated

September 30,1997. In the revised response, the utility removed the date requirement

for completing the training but added a commitment to remove the freeze seal attribute

from the Task Certification Matrix (thus rendering the licensee unqualified to perform the

task) pending completion of a formal training program. The inspector also confirmed that

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freeze seats since the violation were installed by a vendor. The inspectors considered

'

the corrective actions for this issue appropriate.

111. Enoineerina

E8 Miscellaneous Engineering issues

E8.1 (Closed) LER 50-461/95-008: Design program deficiency results in potentially erroneous

indication and inoperable drywell floor drain sump monitoring system. On January 25,

1996, the licensee reported its identification of the failure to meet

Technical Specification 3.4.7, " Reactor Coolant System Leakage Detection

Instrumentation," due to the weir box indication and altemate floor drain sump monitoring

system (LD-027) being inoperable for greater than 30 days. The weir box monitoring

system was inoperable due to fouling and LD-027 was inoperable because flow rates

greater than 8 gpm resulted in anomalous indications of less than 8 gpm.

In response to the deficiency, the licensee implemented a modification which clamped the

indication for LD-027 at 8 gpm (Technical Specification allowable value is 5 pm)

whenever the flow rate exceeded 8 gpm and performed reviews of other modifications to

determine if a similar configuration existed. The licensee's review did not identify any

additional concems. Following the September 5,1996, recirculation pump sea; failure

event, the licennee implemented modifications to increase the indicating range of LD-027

to 64 gpm and installed an additional leak detection system (LD-028) utilizing a differential

pressure transmitter in addition to sump pump run times.

The inspectors determined that the failure to ensure leak detection systems were

operable was a violation of Technical Specification 3.4.7. This licensee identified and

corrected violation is being treated as a non-cited violation, consistent with

Sectinn Vll.B.1 of the NRC Enforcement Policy. (NCV 50-461/97019-05)

During a myiew of the Updated Safety Analysis Report (USAR) the inspectors noted three

discrepar cies. First, USAR Section 5.2.5.1.1, " Detection of Leakage Within the Dr,well,"

specified that if the unidentified leakage increases to a total of 5 gpm, the detecting

instrumentation channels will trip and activate an alarm in the control room. However,

Technical Specification Bases 3.4.7 specified that an alarm would be generated in the

control room at 3.6 gpm and a large flow increase of 2 gpm in 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The inspectors

verified that the alarms actuate as described in the TS bases. The licensee initiated

CR 1-97-09-188 to correct the inconsistency.

Second, USAR 3ection 5.2.5.5.2, " Sensitivity and Response Times," specified that

sensitivity, including sensitivity tests and response time of the leak detection sys;em is

covered in Section 7.6, "All Other Instrumentation Systems Required for Safety."

However, Section 7.6 did not provide information on sensitivity and response time testing

of the leak detection system. The licensee stated that CR 1-97-09-188 would resolve the

inconsistency.

Third, USAR Section 1.8 specified that the sensitivity and response time of airbome

particulate and gaseous radiom ity monitors is not adequate to detect a leakage rate of

1 gpm in less than i hour. Hows 3r, TS Bases 3.4.7 specified that drywell atmospheric

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particulate and gaseous radioactivity monitoring systems are not capable of quantifying

leakage rates, but are sensitive enough to indicate increased leakage rates of 1 gpm

within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. The licensee stated that CR 1-g7-Og-164 would resolve the inconsistency.

E8.2 fClosed) Inspection Follow-up item 50-461/96009-06: Possible improper operation of

Division ll Emergency Diesel Generator synchronous check relay. Engineering personnel

~ performed an evaluation of the relay's f.ihir,ws,s and ensured that the relay was

property calibrated. The inspectors reviewed the work performed by the engir.::-ing

department and the licensee's conective actions. No further concoms were identified.

E8.3 fClosed) Unresolved item 50461/96011-06- Screen house water tight doors. This issue

concemed tour questions involving the access to the SX pump rooms dunng an intomal

flooding event and operability of water tight door seals.

First, Operations Standing Order (080) - 66, " Watertight Doors," aquired personnel to

be stationed at the screen house in the event of flooding but did not specify a location or

organization. The presumption was that the OSO directed the placement of operations

personnel when the real intent was the stationing of security personnel. Revision 2 to

OSO-066 stipulated that security force members are to be used to maintain control of the

vital area.

The second issue questions the ability of personnel to traverse the SX pump cubicles in

the event of intomal flooding. The inspectors reviewed a layout of the SX pump rooms

and flooding analysis NSLD 3C10-0485-001, and determined that personnel should be

able to traverse the SX pump room during an internal flooding event.

The third issue questions whether floodinJ in one cubicle being drained to another could

effect the operability of the electrical equipment in the second room. Calcelation

NSLD 3C10-0485-001 indicated that under the worst case pipe break concurrent with one

of the water tight doors between the cubicles being open or inoperable, only 5 inches of

water would accumulate in the center ("B") cubicle. Because the electrical cabinets are

approximately 10.5 inches at ove the floor, any flooding from neighboring cubicles-

causing electrical failures in cubicles with operable equipment is not credible.

- The fourth issues concems whether the SX room water tight doors would be operable

following the failure of a seal test. The licensee determined that flooding from pump

discharge piping failures would not cause pumps in the other two divisions to become

. inoperable rogamss of the position or condition of the water tight doors between them.

The operability of the door seals is only required when lake level reaches the 694 foot 4

elevation and the requirements of Proci. dure CPS 4303.02, " Abnormal Lake Level,"

becomes the goveming document.

t:8.4 (Chaed) LER 50-461/97-005: Containment penetrations susceptible to ther nally induced

over procurization. The LER involved notification to the NRC as part of the licensee's

response to Generic Letter 96-06," Assurance of Equipment Operability and Containment

Integrity During Design Basis Accident Conditions." The licensee determined that

nineteen penetrations were susceptible to thermal over pressurization.

NRC Inspection Reports No. 50-461/97003 and No. 50-461/97015 document

NRC reviews and licensee initiated corrective actions. The inspectors determined that

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the licensee initiated g-Fepr't corrective actions in response to their identification of j

deficiencies during the review of GL 96-06.

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.

IV. Pisnt Support .

R1 Radiological Protection and Chemistry (RP8,C) Controls *

i R1.1 Continued Poor Radworker Performance issues  ;

'

a. inspection Scope f71750)

.

The inspectors reviewed CRs and QA audit and surveillence reports in order to assess ,

the licensee's corrective actions for continued poor radiation worker practices.

b. Observations and Findinas

On September 8,1997, the inspectors requested a summary print out of CRs involving

poor radiation worker practices between the period of September 1,1996, and

September 1,1997. The review determined that the licensee had initiated approximately

4 166 CRs involving, in part, inadequate control of radioactive material (50), inadequate

postings (19), improper dosimetry (15), and control of contamination bounderles (7). The

CRs were characterized as "other" (111), "close only" (52), and "significant" (3). The

I significant CRs, which required a root cause analysis, were initiated in response to

l NRC violations; however, root cause analyses had not been initiated based on a review

L of deficient conditions by the RP or QA organizations,

i

The inspectors s e owed the root cause ana!yses performed for the three significant

CRs 1-97-02-143,1-97-03-175, and 1-97T-237. The analyses did not address

I continued repetitive problems with radiation worker practices. CR 1-97-02-143 specifed

that a review of the CR data base was performed and most of the CRs were the result of

inattention to detail. The corrective actions involved a briefing to the facility control

department on contamination control. The corrective action plan for CR 1-97-03175 had

not yet received CARB approval. CR 1-97-07-237 specifed that there had been other

instances of improper postings, that the root cause was indeterminate, and that there

were no corrective actions to prevent recurrence.

The inspectors reviewed 17 QA surveillances performed between September 1,1996,

and September 1,1997. The inspectors noted that an increase in surveillance activity

occurred in July 1997 in response to continued radiction worker practice deficiencies.

The surveillance reports typically identified additional examples of frequently recurring

problems. However, an overall assessment of radiation worker practices for the facility

L was not provided by RP and QA did not provide an integrated assessment of its findings.

In addition, the surveillances did not assess in the aggregate the large number of CRs

being initiated which documented pervasive problems with implementation of good

radiation work practices. Consequently, QA and RP missed several opportunities to

provide management with an assessment on declining radiation worker performance.

During discussions with the QA manager, the inspectors noted that QA inspectors are not -

involved in the review of responses to CRs initiated by QA. In addition, QA inspectors are

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not required nor did they routinely verify the wT-C'.d actions of CRs initiated during

surveillances. The lack of QA involvement during the closure of CRs initiated by

QA inspectors was considered a weakness in the implementation of the corrective action

program.

The inspectors noted that no QA sudds had been performed in 1997 despite numerous .

'

examples of poor radiation worker practices. The next scheduled audit of the

RP program is in January 1996.

On September 9,1997, the interim RP manager was provided a copy of the same

summary listing of CRs provided to the inspectors. In response to his review of the

deficiencies, several corrective actions were initiated including an individual to greet

personnel entering the radiologically controlled area, a memorandum to all radiation

workers ra.T+ hee!99g their responsitulities and accountability measures, coordination >

'

with QA and outside organizations to perform assessment activities, and reenforcement

of management expectations during employee meetings with the vice president,

c. Conclusions

Several weaknesses with the implementation of the corrective action program were noted

including the completion of root cause analyses which did not determine why previous

corrective actions were ineffective, poor integration of QA findings, a lack of

QA involvement during the closure of CRs initiated by QA inspectors, and poor trending

i of deficient conditions.

L

R8 Miscellaneous RP&C lasues

R8.1 (Closed) Violations 50461/96009-09 and 97011-17: Failure to follow contamination

control procedures. The violations involved crossing a contamination control boundary

without proper protective clothing. Both examples were determined to be isolated cases

and actions were taken to counsel the individuals. The inspectors determined that the

licensee initiated appropriate corrective actions for these specifx: issues.

V. Mananoment Meetinos

,

X1 Exit Meeting Summary

The inspectors presented the inspection results to members of licensee management at the

conclusion of the inspection period on October 7,1997. The licensee acknowledged the findings

presented. The inspectors asked the licensee whether any materials examined during the

inspection should be considered proprietary. No proprietary information was identifici.

X3 Management Meeting Summary-

On September 26, Region til management met with lilinois Power management to discuss the

current status Westinghouse 4160V breakers, corrective action program improvements, and

possible enhancements in the preventive maintenance program.

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PERSONS CONTACTED

Lic9nsea

J. Cook, Senior Vice President -

W. Romberg, Assistant Vice President

L Wigley, Manager - Nuclear Station Engineering Department

R. Phares, Manager - Nuclear Safety and Performance improvement

J. Palchak, Manager- Nuclear Training and Support

G. Daker, Manager - Quality Assurance

J. Gruber, Director- Corrective Action

J. Place, Director- Plant Radiation and Chemistry

R. Wood, Assistant Plant Manager- Maintenance

M. Lyon, Assistant Plant Manager Sperations

J. Hale, Director - Planning & Scheduling

W. Bousquet, Director - Plant Support and Services

M. Stickney, Supervisor - Regulatory Interface

C

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PERSONS CONTACTED

Licensee

J. Cook, Senior Vice President

W. Romberg, Assistant Vice President

L Wigley, Manager- Nuclear Station Engineering Department

R. Phares, Manager - Nuclear Safety and Performance improvement

J. Palchak, Manager - Nuclear Training and Support

G. Baker, Manager - Quality Assurance

J. Gruber, Director- Corrective Action

J. Place, Director - Plant Radiation and Chemistry

R. Wood, Assistant Plant Manager- Maintenance-

M. Lyon, Assistant Plant Manager- Operations 1

J. Hale, Director- Planning & Scheduling

W. Bousquet, Director- Plant Support and Services

M. Stickney, Supervisor - Regulatory Interface

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WSPECTION PROCEDURES USED

IP G1726: Surveillance Observations

IP G2707: Maintenance Observation

IP 71707: Plant Operhtions

IP 71750: Plant Support

IP 92700: Onsite Follow up of Written Reports of Nonroutine Events at Power Reactor

Facilities

IP 92901: Follow up - Operations

IP 92902: Follow up - Engineering

IP 92903: Follow up - Maintenance

IP 92904: Follow up - Plant Support

ITEMS OPENE9 CLOSED, AND DISCUSSED

Opened

50-461/97019-01 NOV Failure to provide proper oversight and control for reactor

vessel level manipulations.

50-461/97019-02(a,b,c) NOV Failure to promptly identify and correct conditions adverse

to quality.

50-461/97019-03 NOV Failure to provide complete and accurate information to the

commission.

50-461/97019-04 NOV Failure to provide instruction commensurate with the

knowledge, skills, and abilities of technicians for greasing

the Division 111 SX pump motor.

50-461/97019-05 NCV Failure to ensure leak detection systems were operable in

accordance with TS 3.4.7.

Closed

50-461/96003-01 NOV Failure to remove injector setting Jack following diesel

generator maintenance.

50-461/96004-01a NOV incorrect information in EOPs.

50-461/96004-01b NOV Inadequate job preparation for work in switchyard.

50-461/96009-02 NOV Failure to maintain suppression pool temperature log during

RCIC testing.

50-461/96009-03 NOV Failure to perform required quarterly shifts to maintain

. active license status.

50-461/96009-04 NOV Inadequate corrective actions for safety tagging errors

involving protected area illumination.

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50-461/96009-05 NOV Failure to follow procedure during diesel over speed trip

testing.

50-461/97006-05 NOV Inadequate freeze seals.

50-461/97009-09 NOV Failure to follow contamination control procedures.

50-461/97011-17 NOV Failure to follow contamination control procedures.

50-461/97019-05 NCV Failure to ensure leak detection systems were operable in

accordance with TS 3.4.7.

00-461/95-008 LER Design program deficiency results in potentially erroneous

indication and inoperable drywell floor drain sump

monitoring system.

50-461/96-004 LER Inadequate job preparation for work in switchyard.

50-461/97-005 LER Assurance of Equipment Operability and Containment

Integrity During Design Basis Accident Conditions.

50-461/96004-02 IFl Dual Indication on Equipment.

50-461/96009-06 IFl Operation of EDG Sync check relays.

50-461/96011-06 URI Operability of screen house water tight doors.

Discussed

50-461/96009-01 NOV Inadequate guidance in DIV 1 NSPS Bus outage checklist.

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LIST OF ACRONYMS

CARB Corrective Action Review Board

CR Condition Report-

CRT Cathode Ray Tube

DRP Division of Reactor Projects)

EDG Eme ;,ency Diesel Generator

EOPs Emergency Operating Procedures

L. ASS Line Assistant Shift Supervisor

NSPS Nuclear System Protection System

OSO Operations Standing Order

PDR Public Document Room

QA Quality Assurance

RO Reactor Operator

RT Reactor Water Cleanup System

SRM Shift Resource Manager

SRO Senior Reactor Operator

SX Shutdown Service Water

USAR Updated Safety Analysis Report

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