ML20199A877
| 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: |
| 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
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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
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NRC inspection Report No. 50-461/97019(DRP)
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This inspection included aspects of licensee operations, er#::t.ii, maintenance, and plant
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support. The repori covers a 6 week period of resident inspection.
Operations
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The plant manager declared a site wide stand down on September 11,1997, due to an
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Increase in personnel errors. (Section 01.1)
' One violation was identified due to a line assn mt shift supervisor failing to property
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direct and monitor the activities of the reactor ogators such that a drain down of the
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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
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operator tralnee system reviews during a reactor vessel level drain down evolution was
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
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recurrence of eleven near m!ss tagging events. (Section 01.3)
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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
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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
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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
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weakness in the licensee's commitment tracking system. (Sections 01.3 and 08.6)
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One violation was identified due to the failure to provide complete and accurate
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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
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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)
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
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quality in that tlwy did not determine why corrective actions were untimeh, not
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implemented, or ineffective. The delay in initiation of root cause analyses and
' 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
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One violation was identiflod for the failure to provide guidance whleh was commensurate
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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
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
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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Three discrepancies with the Updated Safety Analysis Report were identified involving
alarm set points, omission of sensitivity studies, and the detection capability of radiation
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monitors. (Section E8.1)
Plant Sunbort
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Several weaknesses with the implementation of the corrective action program were noted
inclu#ng: the completica of root cause analyses which did not determine why previous
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corrective actions were ineffective, poor integration of quality assurance (QA) findings, a
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
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
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site wide stand down due to a % crease in personnel errors.
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L Oseratiena
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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
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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
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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.
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01.2 Operator Inattention Results in Drain Down of Reactor Vassel Below Adinlnieti As Limit
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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,
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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
Ictdown rate or final reactor vessel level was not specified by the LASS nor was the lack
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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
licensed operator trainee regarding another plant system. The system review created a
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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
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go inches on the shutdown range should have taken less than ten minutes.
Approximately 30 minutes after beginning the drain down, the 'A' RO checked his panel
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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.
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Operations persornel initiated condition report (CR) 1 g7 Og 133 to document this event
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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
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questioned the Assistant Plan *,":.+;+:- Operations as to the actions taken to correct
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the performance of the "8" RO. -The Assistant Plard Y: +;+:- Operations stated that the
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"B" RO was not accourdable for the event since he was not responsible for manipulating
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the controls _ associated with reactor vessellevel. The inspectors disagreed with this
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reasoning since the "8" RO was also responsible for monitoring panels within his watch
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area, including instrumentation for the shutdown range reactor water level. On
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- October 8, the Assistant Plant Manager Operations acknowledged the inspectors'
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assessment on operator performance.
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During the licensee's fact finding review for this event, the inspectors loamed that the
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operators had the opportunity to activate a performance monitoring system alarm which
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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
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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
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also responsible for monitoring cathode rey tubes (CRTs), indkators, annunciators and
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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
controlling and operating equipment and systems from the main control room in a safe
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and competent manner. The failure to property direct, monitor, and control activities
associated with lowering the reactor vessel level was considered a violation of Technical
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Specification 5.4.1 (VIO 80 441/97019-01).
c.
Conclusions
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
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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
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Inspection Scope (71707 and 62707)
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The inspectors reviewed the effectiveness of corrective actions to improve the
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implementation of the tegout program following the initiation of numerous CRs.
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b.
Observations and Findinns
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Between July 14,1997, and September 10,1997, the inspectors noted that several CRs
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were initiated by the facility to document deficiencies associated with all aspoots of the
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tagout program including: (1) inadequate preparation - CR 1 97 07 139, (2) tagging the
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wrong component CR 197-07 257,(3) issuance of a tagout without approval
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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,
(6) inadvertent release of a tegout prior to completing work - CR 197-09-057,
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(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.
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The inspectors expanded the scope of the review to include deficiencies between
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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
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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).
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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
above. The inspectors noted that the tagout deficiencies identified throughout 1997 were
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repetitive of the deficiencies reviewed in CR 19610 371.
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.
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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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program even though there continued ta be signlAcant ;wf:r':-, weaknesses. The
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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.
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10 CFR Part So, Appendix B, CrHerts XVI, requires, in part, that measures be established
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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
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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
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with tegout program implementation continued to be pervasive throughout the
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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
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Septemtr - 1997. In response to the inspector concoms, the licensee revised the
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scheduloc ccs-Of -n date for the corrective actions in CR 19610-371 from April 1998
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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
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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
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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.
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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
requirement is not explicitly stated, management expected directors to obtain CARB
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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
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- action program.
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c.
Canciunions
one violation was identined for the failure to implement corrective actions to proverd the
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recurrence of tagging denciencies. t+m.: was focused on plant start-up and did
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not implement conective actions to improve the quality of the tagout program. Several
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weaknesses with tiec corrective action program implementation were idenoned including
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ror,t cause analyses which did not determine why previous correcuve action were
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ineffective, a lack of QA involvement in the tagout process, a lack of ranmunication
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between departments prior to extending corrective actions, and extending CRs beyond
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one year without appropriate reviews.
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The failure to track corrective actions involving responses to NRC violations was a
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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
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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
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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
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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
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resulted in a loss of suction to the operating RT pumps. The pumps did not trip because
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the procedure had not instructed that the pump trip protection be restored prior to
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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
include a caution statement regarding the possible repositioning of valves during
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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
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were not approved until May 6,1997, and procedure CPS 3509.01C001 was not
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scheduled to be revised until February 15,1998. The inspectors reviewed a listing of
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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
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otadained in the No6ce of Violation response was in enor due to miscommunications
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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
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actions for this everd had been completed since the due dates in *he conocHvo action
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plan were blank. Neither licensing or plant management verined the wr-( A, of the
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adions prior to sending a letter to the NRC stating that Clinton Power Station was in full
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compliance with NRC regulations. Licensing personnelinitiated CR 1-97-09 077 to
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documord this occurrence and initiated an effort to ensure that the information provided in
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other letters to the NRC was conect. The licensee planned to lesus a revised
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NOV responso. This hem will remain open pendmg review of the licensee's revised
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response,
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10 CFR Part 50.9 states, in part, that information provided to the Commission by a
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licenses shall be complete and accurate in all material respects. The failure to provide
complete and accurate information in response to Notice of Violation
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No. 50-461/96009-01 was considered a violation of 10 CFR Part 50.9
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(VlO 80 441/97019-43).
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On August 22,1997, operations was restoring from another Division i outage by
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performing procedure CPS 3514.01C005, "4160V Bus 1 A1 Outage," Revision 2, in
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parallel with procedure CPS 3509.01C001. Procedure CPS 3514.01C005 directed that
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power be motored to Valve 1G33-F004. Since the operators had not yet reached the
step in procedure CPS 3509.0W01 which reset the RT isolation logic, Valve 1G33-F004
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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.
1
The inspectors review of this event detern ied that the licensee's failure to promptly take
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the conective actions committed to in 1;wir April 9,19g7, letter to the NRC resulted in
procedures CPS 350g.01C001 and 3514.010005 remaining inadequate. These
i
procedural inadequacies resuhed in a second inadvertent isolation of the RT system on
August 22. The failure to promptly correct information provided in bus outage restoration
r
,
!
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,
.
Appendix B, Criterion XVI (VIO 80441/97019 02b).
'
08.3 (Closed) Notice of Violation 50-461/96009-02: Failure to_ maintain temperature log
4
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
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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
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found that one SRO had credited performing one shift as the Shift Resource Manager
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(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
inspectors considered that delaying the initiation of a root cause analysis until receipt of a
t
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.
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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 ned that the violation likely occurred due to the
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licensee's previous policy on procedural adherence which allowed procedures to be used
12
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as guidanos documento and allowed procedures to be changed using the " noting out"
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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,
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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
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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
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use of varying styles of techometers as stated in the violation response was not clearty
communicated to the NRC prior to revising the procedure. The inspectors reviewed the
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licensee's remaining corrective actions and considered thera appropriate.
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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
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tracking of corrective actions for NRC violations.
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ll. Maintenance
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M1
Conduct of Maintenance
M1.1 fttDeral Comments (62707 and 61726)
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. The inspectors observed or reviewed the following maintenance and surveillance
activities:
MWR D7770g
Leakage and Set point Testing of Safety Relief Valve 1821-F047C
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MWR D81492
Troubleshooting Locked in Alarm on Fire Protection Pa91
1H13U723
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MWR D75794
Failure Analysis of Division i 12 cylinder engine heat exchanger
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PEMSXM003
Grease Lower Bearing of Division lil Shutdown Service Water
Pump Motor
- M1.2
!)fety Relief Valve Testino (62707)
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
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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
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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
skills.
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c.
20clusions
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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.
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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.
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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
16
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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
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deficiencies during the review of GL 96-06.
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IV. Pisnt Support
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R1
Radiological Protection and Chemistry (RP8,C) Controls
R1.1
Continued Poor Radworker Performance issues
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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
166 CRs involving, in part, inadequate control of radioactive material (50), inadequate
4
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
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significant CRs, which required a root cause analysis, were initiated in response to
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NRC violations; however, root cause analyses had not been initiated based on a review
L
of deficient conditions by the RP or QA organizations,
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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
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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
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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
of deficient conditions.
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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
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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
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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
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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
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
Corrective Action Review Board
CR
Condition Report-
Cathode Ray Tube
Division of Reactor Projects)
Eme ;,ency Diesel Generator
Emergency Operating Procedures
L. ASS
Line Assistant Shift Supervisor
NSPS
Nuclear System Protection System
OSO
Operations Standing Order
Public Document Room
Quality Assurance
Reactor Operator
Reactor Water Cleanup System
Shift Resource Manager
Senior Reactor Operator
Shutdown Service Water
Updated Safety Analysis Report
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