ML20205C115

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Insp Rept 50-333/99-02 on 990125-0209.No Violations Noted. Major Areas Inspected:Evaluate Cause or Causes of 990114, Hydrogen Fire,Licensee Response to Event & Actions Taken to Understand Event & Prevent Recurrence
ML20205C115
Person / Time
Site: FitzPatrick Constellation icon.png
Issue date: 03/26/1999
From:
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20205C110 List:
References
50-333-99-02, 50-333-99-2, NUDOCS 9904010083
Download: ML20205C115 (29)


See also: IR 05000333/1999002

Text

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                          U.S. NUCLEAR REGULATORY COMMISSION
                                              REGION I
     Docket No:         50-333
     License No:        DPR-59
     Report No:        .50-333/99-02
     Licensee:          New York Power Authority
     Facility:          James A. FitzPatrick Nuclear Power Plant
     Location:          Post Office Box 41
                        Scriba, New York 13093
     Dates:             January 25 - February 9,1999
     Inspectors:       A. Della Greca, Senior Reactor Engineer
                        B. Norris, Resident inspector
                        D. Dempsey. 9eactor Engineer
                      ' C. Cahill, Reactor Engineer
     Approved by:       Laurence T. Doerflein, Chief
                        Engineering Programs Branch
                        Division of Reactor Safety
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 9904010083 990326
 gDR  ADOCK 05000333
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                                            EXECUTIVE SUMMARY
                                   Jtemes A. FitzPatrick Nuclear Power Plant
                                      NRC Inspection Report 50-333/98-07                                     !
      The primary objectives of this special team inspection, conducted during the period between
      January 25 and February 5,1999, were to evaluate the cause or causes of the January 14,
      1999, hydrogen fire, the licensee's response to the event, and the actions taken to understand         i

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      the event and prevent its recurrence.
      Operations

l e Overall, the conduct of operations personnel during the H2 fire event was good.

             Operations personnel were attentive, used good communications, and exhibited a
             proactive questioning attitude. However, their failure to complete a surveillance test

! procedure and secure the emergency diesel generators, resulted in leaving the

             emergency electrical system in an unanalyzed condition for 3.6 hours and the failure to
             meet the requirements of the FitzPatrick Technical Specification regarding procedure
             adherence. Based on the licensee's taking reasonable actions to address the violation
             and prevent its recurrence, this violation was not cited consistent with the guidance of

l Appendix C of the NRC Enforcement Policy. (NCV 50-333/99 02-01) (01.1)

                                                                                                             !
             The licensee also initiated action to evaluata :md correct an apparent discrepancy
             between Sections 7.3 and 7.4 of Administrative Procedure AP-02.06 regarding                     i
             procedure adherence guidance.
      e      During the hydrogen fire of January 14,1999, the licensee operated both pairs of
             emergency diesel generators (EDGs) unloaded with their respective tie breakers open
             for 3.6 hours. Operation of :he EDGs in this alignment placed the electrical system e,d
             the plant in an unanalyzed configuration that was not recognized by either the operating

l staff or by Engineering until approximate'y a week after the event. The consequences of l the licensee's actions were limited because of the short duration of the event and  !

             because the EDGc were available for manual loading on the emergency buses. Also the
             licensee's probability risk assessment model indicated a low core damage frequency
             value. Nonetheless, the licensee's decision to operate the plant in the above                   i
             configuration increased the probebility of a station blackout and decreased their ability to
             mitigate the consequences of an accident. (04.1]
      e      A design feature of the emergency electrical system permits leading only one EDG of the
             pair on the emergency bus if the associated tie breaker is open. The licensee did not
             take credit for this feature in their design and licensing bases of the plant. However, a
             relay race in the control circuitry could prevent the EDGs to function as intended.
             Therefore, this characteristic of the logic was considered a weakness of the design
             (O4.1)
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     *     The operator who manipulated the hydrogen system was generally familiar with the

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           system and the associated operatinc procedure as well as with the safety requirements
           for handling industrial / compressed p ases. The training module, however, had not
           specifically addressed the training recommendations of EPRI Report No. NP-5283-SR-A
           regarding consequences of component malfunctions at the hydrogen supply facility and
           the potential hazards of the hydrogen gas. (O5.1)
     Enaineerina
     e     The temporary modification prepared to provide hydrogen makeup to the main generator          i
           was acceptably prepared and implemented. (E1.1]
     e     The oxygen facility was in good physical condition and the tank was adequately sited.
           The operability determination prepared to justify the adequacy of the battery rooms air      i
           intake, located within the EPRI-specified unacceptable range, was reasonable. [E1.2)
                                                                                                         l
     e     The response of the technical support team tc the event was prompt and guidance was          i
           provided as needed. Engineering, however, did not recognize the effect of leaving the
           EDGs running unloaded and with the tie breaker open and were, therefore, not effective
           in preventing Operations from operating the emergency electrical buses in an
           unanalyzed condition. The licensee's evaluation of the event was ongoing, but planned
           and completed activities appeared comprehensive, detailed, systematic, and a good
           example of integrated departmental efforts. (E2.1]
     *     The use of a hydrogen delivery trailer as a third source of hydrogen did not conform to       )
                                                                                                        I

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           the design description for the facility in the UFSAR and did not meet all of the guidelines
           specified in EPRI Report NP-5283-SR-A, as specified in the UFSAR. The impact of such

l deviations on the design and operation of the system as well as on the severity of the fire

           event was being investigated by the licensee and the results of such review were still
           incomplete. This is an apparent violation pending completion of the effort by licensee,
           identification of corrective actions, and review by the NRC. (eel 50-333/99-02-03)
           (E8.1)
     *     The licensee's preliminary evaluation of the ability of a single diesel to accelerate and
           carry the design loads, in the event that the paralleling of a pair of emergency diesel
           generators failed to take place, indicated the potential overloading of the diesel. Also,
           the single EDG test conducted in December 1998 was not designed to demonstrate

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           single emergency diesel generator capability under accident conditiont,. The licensee
           planned to develop formal calculations but the issue was not a concern during this
           inspection because operatiori of the en ergency bus with a single diesel generator is not
           within the design basis of the plant. (El'.2]
     e     The licensee had not previously verifiet proper operation of the EDG pair loading
           sharing circuits. The licensee revised ihe testing procedure to verify proper circuit
           operation in the future. This minor violation was not subject to formal enforcement
           action.

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     Plant Support

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     o      The overall emergency preparedness response to the Hydrogen fire was good.

l Especially noteworthy was the ability to implement alternate locations for the emergency

            response facilities and still have them activated and functional within an hour. [P1.1]
     e      The training provided to the fire brigade to combat the hydrogen fire was appropriate. In
            addition, the quick request by the Fire Brigade Leader for off-site assistance was
            instrumental in minimizing the damage to other equipment in the area. [F5.1]              1
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                                                  TABLE OF CONTENTS                                                                                  I
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                                                                                                                                           PAGE
     . EXECUTIVE SUMMARY ....................................................ii
      TABLE OF CONTENTS . .....................................................v                                                                    3
                                                                                                                                                    I
      1. O P E RATI O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1  l
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      O1     Cond uct of 0pe ratio n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1            j
             O1.1 Operations Response to the Hydrogen Fire . . . . . . . . . . . . . . . . . . . . . . . . . 1                                       !
                                                                                                                                                      1
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      O.4    Operator Knowledge and Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                           4   1
             04.1 Emergency Diesel Generator Design Basis and Operation . . . . . . . . . . . . .                                                 4
                                                                                                                                                    i'
      05     Operator Training and Qualification . . . . . . . . . . . . . . . . . . . . . . . . .                        ...........8
             05.1 System Operating Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
      111. Engineering . . . . .  ................. .. ..................... ......                                                      .... 9
      E1     Conduct of Engineering . . . . . . . . . . . . . . . . .................. .... .. ..... 9
             E1.1   Makeup Hydrogen for Main Generator .                             ................. ...........                                9
             E1.2 Bulk Oxygen Tank Storage Siting . . .                              ..........................10
                                                                                                                                                     1
      E2     Engineering Support of Facilities and Equipment . . . . . . . . . . . . . . . . . . .........11                                          l
             E2.1    Engineering Support of the Hydrogen Fire Event and Root Cause Analysis .                                                    11
      E8     Miscellaneous Engineering issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,12
             E8.1 Post-fire Hydrogen Storage Facility inspection . . . . . .                                 ................12
             E8.2 Emergency Diesel Generator Capability . . . . . . . . . . . ...............13
             E8.3 Emergency Diesel Generator Load Sharing . . . . . . . . . . . . . . . . . . . . . . . . . 14                                       )
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      IV     Plant Support Activities .           ...        ................... .... ...                                 ....           ... 16
      P1     Conduct of EP Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                 ...     .. ...... 16
             P1.1    Implementation of Emergency Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
      F5     Fire Protection Staff Training and Qualification . . . . . . . . . . .................16                                                 l
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             F5.1   Firs Brigade Training Related to Flammable Gases . . . . . . . . . . . . . . . . . . . . 16
      V.     M anagement Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
      X1     Exit Meeting Summary . . . . . . . . . . . . . . . . . .              ..............                   ......... ... 17
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                                                 Report Details

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      Summary of Plant Status

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      During the period between January 25 and February 5,1999, the NRC conducted a special
      team inspection at the James A FitzPatrick Nuclear Power Plant as a result of a hydrogen fire     ,
esvent on January 14,1999. The objectives of the inspection were to
evaluate the cause or l

! causes of the fire; assess the fire damage and its impact to safety-related structures, I

      components, and systems; determine the response of protective equipment (if any); and
      evaluate the licensee's response to the event and their actions to understand the event and       ;

i prevant its recurrence. The plant remained at or near full power throughout the inspection .

      period.                                                                                            I
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                                                 1. Operations                                          I
     .01      Conduct of Operations
      01.1 Operations Response tcpe Hydroaen Fire                                                       I
                                                                                                        I
        a.     Insoection Scooe
              On January 14,1999, a fire started in the control cabinet of the hydrogen (H2 ) addition
              system at the James A. FitzPatrick Nuclear Power Plant. The facility entered the
               Emergency Plan and requested offsite fire department assistance. A detailed description  I
              of the event and a time line are included as Attachment 3 to this report.
              The team evaluated the response of the operations personnel during the H      2 fire. The
              evaluation included observations of activities in the control room and in plant by the
              resident inspectors during the event, discussions with the operations crew and station
              management, and a review of applicable portions of the Technical Specification (TS) and
              plant procedures,
       b.     Observations and Findinas                                                                  ,
                                                                                                        !

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              When the control room operators received the report of the H2 fire, their actions were
              quick and decisive. They promptly sounded the site alann, announced the emergency,
              and dispatched the fire brigade to the scene of the fire. After the Fire Brigade Leader
             . (FBL) reported the magnitude of the fire, the Shift Manager (SM) directed the evacuation
              of the general area and all buildings near the H2 tank-farm. In accordance with the
              Emergency Plan, the SM assumed the duties of Emergency Director and declared an
              Unusual Evant, the lowest of four possible emergency action levels (EALs). The team
              independently reviewed the EALs and considered the classification to be appropriate.
              The Control Room Supervisor (CRS) conducted a precautionary brief of the shift

l personnel, including concems of a reactor scram and/or a loss of offsite power, in l addition, a reactor operator was directed to continuously monitor the reactor parameters '

              during the fire. Overall, the conduct of the operating staff during the event was very
              good. Operations personnel were attentive, knowledgeable of procedural requirements,
              used good communications, and exhibited a proactive questioning attitude.

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   Due to the proximity of the 115KV switchyard to the H2tank-farm, the FBL requested
   that the switchyard be de-energized for the safety of the fire fighters. Two 115KV
   electrical lines supply offsite ac power to the plant's emergency buses. The CRS
   r3 viewed the precautions associated with the loss of the offsite emergency ac power,
   briefed the operators, and directed that the 115KV switchyard be de-energized. The
   team considered the actions of the CRS to be proactive in anticipating the "what if"
   scenarios related to the loss of 115KV power.
   Section 3.9.B of the FitzPatrick TS requires that all four emergency diesel generators
   (EDGs) and both 115KV lines remain operable during power operation. If one or both
   the 115KV line3 are not available, limiting condition for operation (TS Section 3.9.9.2)
   allows the reactor to remain in operation for up to seven days, provided that all EDGs
   and emergency core cooling systems are operable. TS Surveillance Requirement
   (TSSR) 4.9.B.5 states that, if the emergency ac power supply is degraded, the
   availability of the operable EDGs shall be demonstrated by manual starting and force
   paralleling each set of EDGs.
   The surveillance test procedure developed by the licensee to meet the requirements of
   the above section of the TSSR is ST-9D, "EOG,115KV Reserve Power, Station Battery,
   or ESW [ emergency service water] System inoperable Test." Section 1.1.2 of this            '
   procedure stated, in part, that, "If both reserve [115 KV offsite power] sources ... are
   inoperable, then the following is per'ormed: Subsection 8.1 and 8.2 (EDG Test) within 1     j
   hour and at least once per 24 hours thereafter."
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   The steps of subsections 8.1 and 8.2 for testing the availability of the 'A and C' and the
   'B and D' EDGs, respectively, required manually starting the EDGs, verifying that the
   forced-parallel tie-breakers automatically close, manually opening the tie-breakers, and
   stopping the EDGs and returning them to the standby condition. Specifically,
   subsections 8.1.7, for the 'A and C' EDGs, and 8.2.7, for the 'B and D' EDGs, directed
   that the control switches for the EDGs be placed in "STOP."
   Within one hour from the de-energization of the 115KV switchyard, the CRS initiated
   action to test the EDGs. If properly implemented, as required by the TSSR, the
   procedure would have permitted the sequential verification of the availability of the two
   sets of EDGs and their subsequent placement in the standby Mode. Instead, as a
   precaution, the SM directed the operating staff not to complete sections 8.1 and 8.2 of
   the procedure and leave all four EDGs running unloaded, with the respective tie-
   breakers open. The four EDGs were left rJnning in that condition for 3.6 hours. The
   licensee's failure to complete the steps of the procedure subsections and return the
   EDGs to the standby mode immediately following the opening of the tie breakers resulted
   in placing the plant in an unanalyzed condition for the period when the EDGs were left
   running. The licensee discovered the condition a week later, as described further in
   section 04.1 of this report.
   In failing to complete the steps of the surveillance test procedure, the licensee failed to
   meet the conditions of section 8.8(A) of the Technical Specification which requires that
   written procedures be established and implemented. if the conditions did not permit the
   use of the procedure as written, the licensee could have alternatively implemented the
   procedure change process, as allowed by TS sections 6.8(B) and (C) for permanent and

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        temporary changes, respectively, in an emergency, i.e., when actions are required to
        protect the public health and safety, and there was not sufficient time to implement the
        change process, the licensee can invoke the latitude allowed by 10CFR50.54(x). The
        licensee did not implement the procedure change process and did nct invoke the latitude
        allowed by 10 CFR 50.54(x).
        The requirements of 10 CFR 50.54(x) regarding procedure adherence were included and
        paraphrased in section 7.4 of the licensee's administrative procedure AP-2.06,
        " Procedure Use and Adherence." During discussions with the SM regarding the concern
        that not completing the surveillance test procedure was not consistent with the
        requirements of TS 6.8(A), the team determined that another section (7.3) of procedure
        AP-2.06 also addressed procedure adherence. This section, which states, in part, that,
        "In an emergency, operations personnel are authorized to depart from procedures where
        necessary to protect personnel, the public, or prevent damage to the facility..." is derived
        from section 5 of ANSI Standard 18.7 -1972 which is referenced in section 6.8 (A) 1. of
        the FitzPatrick TS. The team believed that section 7.3 of AP-2.06 might allow some
        latitude which is in addition to that allowed by 10 CFR 50.54(x) and section 7.4 of the
        same procedure. The team discussed this concern with the licensee who indicated that
        they would evaluate the guidance provided in the two sections and determine whether a
        procedure revision or a Technical Specification amendment was required to render the
        two documents consistent. On March 23,1999, they formalized this understanding by
        initiating a commitment action item, ACT-99-40532, with a completion schedule of April
        30,1999.
        The licensee's failure to complete the surveillance procedure step and placement of the
        electrical system in an unanalyzed condition constituted a violation of the Technical
        Specification (TS) section 6.8(A) requirements regarding procedure implementation.
        However, because: (1) the violation was not willful; (2) no previous examples of similar
        violations were identified by the team; (3) the licensee issued a night order and revised
        applicable operating and surveillance procedures to caution against future operations of
        the di9sels in the unanalyzed condition; (4) the licensee initiated action to provide
        training to the operating and technical staff regarding the issue; and (5) the licensee
        initiated an action item to evaluate the discrepancy between the guidance of AP-02.06
        and the requirements of the FitzPatrick TS and 10 CFR 50.54(x) regarding procedure
        implementation; this violation is not being cited in accordance with the guidance of
        Appendix C of the NRC Enforcement Policy. (NCV 50-244/99-02-01)
     c. Conclusion
        Overall, the conduct of operations personnel during the H2 fire event was good.
        Operations personnel were attentive, used good communications, and exhibited a
        proactive questioning attitude. However, their failure to complete a surveillance test
        procedure and secure the emergency diesel generators, resulted in leaving the
        emergency electrical system in an unanalyzed condition for 3.6 hours and the failure to
        meet the requlrements of the FitzPatrick Technical Specification regarding procedure
        adherence. Based on the licensee's taking reasonable actions to address the violation
        and prevent its recurrence, this violation was not cited consistent with the guidance of
        Appendix C of the NRC Enforcement Policy.

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           The licensee also initiated action to evaluate and correct an apparent discrepancy
           between Sections 7.3 and 7.4 of Administrative Procedure AP-02.06 regarding
           procedure adherence guidance.
     O.4   Operator Knowledge and Performance

i 04.1 Emeroency Diesel Generator Desian Basis and Operation

       a.  Inspection Scope (93702)
           During the January 14,1999, hydrogen fire at FitzPatrick, the licensee operated the two       I
           pairs of emergency diesel generators (EDGs) unloaded and unparalleled for 3.6 hours.          ]
           The team assessed the acceptability of the EDGs operating in this mode and its impact
           on the operability of the emergency buses. The assessment included reviews of the
           FitzPatrick technical specifications, Updated Final Safety Analysis Report, emergency
           power system logic diagrams, and operating and surveillance procedures, The team also
           reviewed applicable portions of the EDG load calculations and discussed the event with
           licensee operators and engineers,
      b.   Observations and Findinas
           Desian and Licensino Basis
           The design of the FitzPatrick onsite 4 KV emergency power system consists of two
           independent and redundant emergency buses (Division I bus 10500 and Division 11 bus
           10600). Each bus is supplied by a pair of EDGs that operate in parallel to meet the
           minimum emergency load requirements. Each EDG, rated to carry a continuous load of
           2600kW, has sufficient capacity to supply power to the loads needed (less than 1400kW)
           to safely shut down the reactor following a transient involving a loss of offsite power
           (LOOP). The EDGs also have sufficient capacity that, as a pair (5200 kW), can supply
           the engineering safeguards feature (ESF) loads needed (approximately 4000 kW) to
           shutdown the reactor, maintain safe shutdown conditions, and mitigate the
           consequences of a loss of coolant accident (LOCA) coincident with a LOOP.
           Each pair of EDGs is supplied with three circuit breakers, one to tie the output of the
           generators together and the other two to connect the output of the individual generators
           to the emergency bus. On a s' art demand signal, both pairs of EDGs start automatically.
           When they reach 200 revolutions per minute (rpm), the tie circuit breakers close and          ;
                                                                                                         '
           force-parallel the outputs of the generator pairs while the engines are still t celerating if
           normal voltage is present on the emergency buses, the EDG output break , remain
           open and the EDGs continue to run, in their standby mode, unloaded and .. parallel. If
           voltage is not present on the buses, the system logic causes all loads (except the 600
           Vac emergency substations) to be stripped from tneir respective buses, the EDG output
           breakers to close, and the ESF loads to be connected to their buses according to a pre-

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        programmed start sequence. If either EDG fails to start or the associated tie breaker
        fails to close, only one EDG is allowed to supply the emergency bus. In this case, if a

l LOCA signal is present, one of the two residual heat removal (RHR) pumps is inhibited '

        from starting.

i l The FitzPatrick safety analyses assume that one pair of EDGs is available, as a ! minimum, to supply the associated emergency bus,

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        Event Descriotion

! As described in Section 01.1 of this report, during the January 14,1999, hydrogen fire,

        the operators de-energized both 115KV offsite power lines at the request of the fire          l
        brigade. This action resulted in the operators entering TS limiting condition for operation
        (LCO) 3.9.B.2 for unavailability of both reserve (115 KV) station transformers. This
        condition required that operators verify the ability of both EDG pairs to manually start and  !
        force parallel per TS 4.9.B.5 and surveillance procedure ST-9D, "EDG,115KV, Reserve           !

l Power, Station Battery or ESW System inoperability Test." Following the successful l demonstration of the EDGs availability, as a precautionary measure, the SM decided to

        leave the EDGs running unloaded. Tie breakers 10504 and 10604 had been opened per              i
        ST-9D procedure steps 8.1.6 and 8.2.6, respectively. The decision not to secure the           i
        EDGs was noted in the remarks section of the surveillance procedure. The EDGs were
        secured after 3.6 hours of operation. Later in the day, after the fire was out and the
        115KV lines were restored, the licensee performed a regularly scheduled monthly
        surveillance test of the Division 11 EDGs. During this test the output breaker (10312) of
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       the "D" EDG failed to close. Operators performed the correct compensatory measures            i
                                                                                                     '
        for this occurrence.
        Emeroency Diesel Generator Control Loaic
        Following the event, on January 21,1990, the licensee informed the NRC that a later
       review of the emergency diesel generator protective scheme indicated the possibility that
       one or more of the EDGs may have failed to energize the emergency buses in the event
       of a main generator trip with the 115KV supply out of service. The licensee's original
       concern was thst, with the EDGs running, a loss of the main generator would result in the
        EDG output breakers closing on to the emergency bus. However, because the tie                 l
        breakers were open, the EDGs would be unsynchronized and the simultaneous closure
       of the output breakers of each EDG pair could result in the loss of one or more EDGs on
       overcurrent. Subsequent review of the breaker control logic by the licensee determined
       that their original concern was unfounded and that only one EDG would load on each
       bus.
                                                                                                     J
       To verify the licensee's conclusions, the team reviewed the EDG load breaker control          l

l logic. The inspectors determined that the automatic closing circuit included two parallel I l - paths, one for the condition when the tie breaker is closed (normal condition following a . l LOCA/ LOOP start signal), and one for the condition when the tie breaker is open (failed  !

       force paralleling). The team identified no concerns with the breaker " normal" closing         j
       path. However, they did observe the following weakness in the closing circuit for the         j
       open tie condition.
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     As stated above, if the tie breaker is open only one EDG is allowed to load on the
     emergency bus. This is accomplished through an auxiliary circuit that evaluates the
     readiness of each EDG (in the EDG pair) and allows the loading of only the first EDG to
     reach readiness. Specifically, with the tie breaker open, when the output voltage of each
     EDG ( e.g., B and D) reaches its pre-established setpoint (90%), it energizes the
     associated voltage relay (27B and 27D, respectively). The first of the two relays to
     energize (e.g.,27B) energizes, in turn, an auxiliary relay (27XB). A contact from this
     relay, after a 0.8 second time delay, permits closure of the associated EDG ("B") load
     breaker. A second contact from the same auxiliary relay blocks the energization of the
     other auxiliary relay (27XD) and the closure of the associated EDG ("D") load breaker.
     Note that, although the example refers to EDGs B and D, the same is applicable to
     EDGs A and C.
     In the above description, the ability of the circuit to perform its function is based on the
     assumption that the two EDGs will not reach the voltage setpoint at the same instant. In
     fact several milliseconds (dependent on the response time of the individual relay) would
     suffice to make the circuit operate as intended. However, should the two voltage relays
     reach their setpoint at the same time, both auxiliary relays (27XB and 27XD) would
     continue to cycle off and on (energize and de-energize) until one relay fails or slows
     down sufficiently to allow the other relay to accomplish its intended function (close the
     associated EDG output breaker).
     Given the independence of the EDG starting circuits cnd the fact that the tie breaker
     would have to fail to close for the condition to exist, the team did not believe the above
     scenario to be likely to occur normally. As a result, the team believed this circuit
     characteristic to be a weakness rather than a deficiency of the design. During the event,
     however, the opening of the tie breakers rendered the condition likely to occur.
     During the event, the EDGs were started manually and, according to procedure ST-9D,
     they were not loaded on the bus. When the EDG output voltages reached their

I

     respective setpoints, the voltage relays energized, but no breaker actuation occurred
     because the emergency buses were powered by the normal supply. Later, when the
     licensee opened the tie circuit breakers, both auxiliary relays (27XB and 27XD) were

l armed (ready to energize), waiting for a loss of the normal power to occur. Had that ,

     occurred, both auxiliary relays (27XB and 27XD) would have energized concurrently and

l

     their cycling would have begun.                                                              l
     As the licensee concluded, the circuit would have not allowed the simultaneous loading
     of the unsynchronized EDG pairs on the emergency buses and, hence, the potential loss
     on overcurrent of both emergency buses. However, the loading of a single EDG on the          !
     each emergency bus would have been highly dependent on the individual response time
     of the relays involved and potentially might have not occurred without manual
     intervention by the operating staff. The licensee recognized the existence of a relay

'

     " race,". but believed that one of the relays would have energized and prevented the other
     from actuating, thereby allowing a single EDG to load on each emergency bus.                 ;
                                                                                                  l
                                                                                                  l
                                                                                                  l

I

. .

                                                7
   The team reviewed the design logic and confirmed that, during LOCA load sequencing,
   closure of only one EDG output breaker inhibits the automatic start of one of the two
   RHR pumps. The team also confirmed through a review of surveillance procedure ST-
   9C, " Emergency Ac Power Load Sequencing and 4KV Emergency Power System
   Voltage Relays Instrument Functional Test," that this logic feature had been tested
   satisfactorily in December 1998.
   Assessment of the Event
   As stated previously, the onsite emergency power system includes two emergency
   buses, each designed to be powered by two EDGs operating in parallel. This design
   represents the analyzed configuration of the plant electrical system and satisfies the
   single failure criterion. With the tie circuit breakers intentionally left open, if the logic
   performed as intended, only one EDG would load on each bus. This configuration is not
   within the design basis of the plant, was not analyzed by the licensee, and does not
   satisfy the single failure criterion. Licensee operations and engineering personnel did
   not recognize the implications of their decision to open the tie breakers until a week later,
   during their analysis of the event.
   During the event, the unit remained in operation and continued to supply the design
   loads. Therefore, no adverse effect was experienced by the plant. However, because of
   the fire fighting activities in the proximity of the switchyard, the probability for a loss of the
   main generator increased and with it the temporary loss of all ac power. Complicating
   factors were provided by: (1) the relay race that could have prevented all EDGs from
   loading on the emergency buses; (2) one EDG load breaker that failed to close when
   tested following the event; and (3) the ability of one EDG to accelerate the loads
   scheduled to be sequenced on the bus (see Section E8.1). The consequences of the
   licensee's decision were mitigated by the short duration of the event, the availability of at
   least three EDGs for immediate manual loading on the emergency buses, and the
   availability of the offsite sources to power the buses within a short time.
   Risk Analysis
   A turbine trip with the power conversion system available has the highest initiating
   frequency of 3.45 times per year. This transient was used by the licensee in their
   evaluation of the incident. As stated above, even if it is assumed no automatic loading of
   the diesel generators, they were available for manual start and loading. The same was
   true for both offsite power sources.                                                               I
   in the event of a station blackout (SBO), caused by a load rejection and failure of the            -
                                                                                                      I
   onsite as well as of the offsite sources, the facility would rely on the high pressure core
   injection, the reactor core isolation cooling, and the automatic depressurization systems.
   The facility can cope for eight hours with this equipment and the de power supply
   system. In addition, it would take five more nours before core uncovering. The
   lic3nsee's probability risk assessment (PRA) shows that the limiting case for a SBO is
                                                                                                      !
                                                                                                       i
                                                                                                      l
                                                                                                       l
                                                                                                      J
  . .
                                                        8                                                ;
            bounded by a large break LOCA and a portion of the intermediate break LOCAs. Using           3
            the licensee's PRA model, the total probability for these LOCAs is 1.8E-7. This value
            indicates that the risk of the H2 event was low. This value would have been even lower if

l the model had considered recovery of the ac sources in a timely manner, as would have

            beers expected.

l

        c.  Conclusions

l i '

            During the hydrogen fire of January 14,1999, the licensee operated both pairs of
            emergency diesel generators (EDGs) unloaded with their respective tie breakers open
            for 3.6 hours. Operation of the EDGs in this alignment placed the electrical system and

,

            the plant in an unanalyzed configuration that was not recognized by either the operating     j

l staff or by Engineering until approximately a week after the event. The consequences of l the licensee's actions were limited because of the short duration of the event and l because the EDGs were available for manual loading on the emergency buses. Also the

            licensee's probability risk assessment modelindicated a low core damage frequency
            value. Nonetheless, the licensee's decision to operate the plant in the above

l configuration increased the probability of a station blackout and decreased their ability to !

            mitigate the consequences of an accident.

'

            A design feature of the emergency electrical system permits loading only one EDG of the

l pair on the emergency bus if the associated tie breaker is open. The licensee did not

            take credit for this feature in their design and licensing bases of the plant. Therefore,
            this characteristic of the logic was considered a weakness of the design, not a
            deficiency. However, a relay race in the control circuitry could prevent the EDGs to
            function as intended.
      05    Operator Training and Qualification                                                           l
      05.1 System Ooeratina Procedures
        a.  Insoection Scooe (93704)
                                                                                                         ,
            The team interviewed the operator who manipulated the hydrogen system at the time of
            hydrogen fire, reviewed the system training module and material safety data sheet for
            hydrogen, and compared the licensee's training module to the training guidelines
            provided in the applicable Electric Power Research Institute (EPRI) Report to assess the
            adequacy of the licensee's hydrogen system train.. g.

, b. Observations and Findinas

            The team found that the licensee's hydrogen addition system training module, SDLP-
            89A, adequately addressed the basic operation of the system, particularly the portion of
            the system located downstream of the hydrogen farm. The training module, however,
            did not fully address all of the training areas recommended in section 6.3 of EPRI Report
,
            No. NP-5283-SR-A, Guidelines for Permanent BWR [ Boiling Water Reactor) Hydrogen
            Water Chemistry Installations - 1987 Revision. For instance, module SDLP-89A did not
            address the consequences of component malfunctions at the hydrogen supply facility
            and the potential hazards of the hydrogen gas.

o

 . .
                                                    9
          The team's interview of the operator determined that he was familiar with the system and

l

          the system operating procedure, including manipulation precautions. The operator had
          also received general industrial / compressed gas safety training. However, consistent
          witn the content of the training module, he had not been given specific training on the   j
          hazards of hydrogen. Because the licensee's root cause analysis had not been              j
          completed, the team was unable to ascertain whether the training of the operator           l
          contributed to or could have prevented the hydrogen fire event.                           {
                                                                                                    l
       c. Conclusions                                                                               !
                                                                                                    i
          The operator who manipulated the hydrogen system was generally familiar with the
          system and the associated operating procedure as well as with the safety requirements
                                                                                                    I
          for handling industrial / compressed gases. The training module, however, had not
          specifically addressed the training recommendations of EPRI Report No. NP-5283-SR-A
          regarding consequences of component malfunctions at the hydrogen supply facility and
          the potential hazards of the hydrogen gas.
                                            Ill. Enaineering
     E1   Conduct of Engineering
     E1.1 M.jgtu;
             a    Hydroaen for Main Generator
       a. Inspection Scope (64704)
          The team reviewed and physically inspected a temporary modification installed to
          provide makeup hydrogen to the main generator. The inspection addressed the quality        l
          of the design as well as the adequacy of the fire protection program with respect to the
          handling of high pressure hydrogen cylinders.
       b. Observations and Findinos
                                                                                                     :
          The fire on January 14,1999, disabled the normal hydrogen supply to the main
          generator. To maintain plant operation, the licensee initiated Temporary Modification No.
          99-006, Alternate Hydrogen Makeup to the Main Generator. The team found that the
          modification and the supporting procedural changes had been acceptably completed.
          During the physicalinspection of the modification, the team found that three discharged
          hydrogen cylinders had been stored at elevation 272 of the turbine building. The
          cylinders, although discharged, contained hydrogen at a residual pressure of
          approximately 65 psig. Discussions with the licensee determined that the area had been
          evaluated (JDED-97-0370) and approved fc7 storage of acetylene. However, the
          licensee had not prepared a safety evaluation for the storage of hydrogen in this area

l and had not obtained a combustion control permit (CCP), as required by section 8.1.1 of

          procedure AP-14.04, " Combustible and Flammable Material Contiol." As stated in this

l i section of the procedure, a CCP is required for the use of a flammable gas in any

          quantity in nonsafety-related areas.
 . .
                                                       10
            Because the cylinders contained on'y residual hydrogen and had been stored in the area
            for approximately only two days, they represented only limited hazard. Furthermore,
            when the team notified the licensee of the discrepancy, they promptly removed the
            cylinders. The failure to properly control combustibles, as required by plant procedure
           'AP-14.04, constitutes a violation of minor significance of 10 CFR 50, Appendix B,
            Criterion V, and is not subject to formal enforcement action.
      c.    Conclusions
            The temporary modification prepared to provide hydrogen makeup to the main generator
            was acceptably prepared and implemented.
     E1.2 Bulk Oxvoen Tank Storaae Sitina
      a.    Insoection Scooe (93704)
            The team conducted a physical inspection of the oxygen tank storage facility and
            reviewed the siting design criteria to determine whether the design of the facility
            conformed to the licensing commitments and regulatory requirements.
      b.    Observations and Findinos
            The oxygen storage facility consists of a 3000-gallon liquid oxygen cryogenic tank,
            ambient air vaporizers, and a pressure / temperature control station. The facility is located
            approximately 130 feet West of the diesel generator building. The team found the
            physical condition of the facility to be satisfactory.                                         ,

l

            Section 9.20.3 of the updated final safety analysis report (UFSAR) states that the facility   j
            is designed and constructed in accordance with EPRI Report No. NP-5283-SR-A,
            Guidelines for Permanent BWR Hydrogen Water Chemistry Installations - 1987 Revision.          i

L

            The team compared the siting of the facility to the requirements in the EPRI report.
            They found that the licensee could not show that all of the safety-related air intakes were   j

'

            located at an acceptable distance from the oxygen tank in accordance with figure 4-8 of
            the report.

, The licensee conducted a survey of the facility and found that the battery rooms air l intake fell within the unacceptable range specified in figure 4-8. To document and track  ; l the discrepancy, the licensee initiated DER-99-00172. They also prepared an operability l determination (JDED-99-0038) and found the condition acceptable. The licensee based '

            this determinat!on on the fact that the air intakes were approximately 500 feet from the
            oxygen storage tank, on the opposite side of the turbine building, and that the building
            shielding would prevent tne development of an oxygen enriched environment. The team

j found this determination to be reasonable. L

u

v9 ,
                                                     11
      c.  pgnclusions
          The team concluded that the oxygen facility was in good physical condition and that the
          tank was adequately sited. The nperability determination prepared to justify the
          adequacy of the battery rooms e intake, located within the EPRl-specified unacceptable
          range, was reasonable.
     E2   Engineering Support of Feds'.ies and Equipment
     E2.1 Enaineerina Sucoort of the Hydroaen Fire Event and Root Cause Analysis
      a.' Insoection Scope (93794)
          The team evaluated the involvement of the engineering staff in the resolution of the fire
          event and the root cause analysis prepared to evaluate underlying design and -
          performance issues and to initiate appropriate corrective actions.
       b. Cbservations and Findinas
          Based on concems with the size of the fire and potential exposure of the old
          administration building to the effects of the fire, as stated in section P1.1 of this report,
          the Emergency Director ordered the Miocation of the Technical Support Center to the
          main library. The response of engineering personnel was prompt and relocation of the
          facility took place in an orderly and timely manner. Engineering monitored the event and
          provided the needed guidance. However, as also stated in section O4.1, they were
          unaware of the consequences of operating the EDGs unloaded and with the tie circuit
          breaker open. Therefore, they were not effective in preventing Operations from
          operating the emergency electrical buses in an unanalyzed condition.
          Regarding the analysis of the event, the licensee promptly assembled three multi-
          discipline teams, one to evaluete the root cause of the event, one to assess the plant        '
          response, and one to address recovery from the eunt. By the end of the inspection the
          efforts of all three teams were ongoing and incomplete. The NRC inspection team,
          nonetheless, reviewed tha methodology and status of the root cause analysis. The team
          determined that the licensee had nearly completed their collection of evidente and the
          development of potential scenarios leading to fire initiation. The licensee p;anned to

< construct from these a credible scenario by systematically comparing the effects of the

          gathered evidence to those postulated in the various scenarios. The licensee also
          planned to support their conclusions with metallurgical analyses of the failed
          components.
          The team's review of the ongoing and completed activities found them to be
          comprehensive, detailed, systematic, and a good example of integrated departmental
          efforts. The team also found that the results of the investigation were integrated in the
          repair and redesign of the new hydrogen supply facility. The NRC inspectors will review
          the results of the completed investigation at a later date. (IFl 50-333/99-02-02)

t

 -

F= -

      :,
  3
                                                          12
          c.   Conclusions
               The response of the technical support team in the event was prompt and guidance was
               provided as needed. Engineering, however, did not recognize the effect of leaving the
               EDGs running unloaded and with the tie breaker open and were, therefore, not effective
               in preventing OMrations from operating ihe emergency electrical buses in an
               unanalyzed conostion. The licensee's evaluation of the event was ongoing, but planned
               and completed activities appeared comprehensive, detailed, systematic, and a good
               example of integrated deparlental efforts.
         E8    Miscellaneous Engineering issues
         E8.1  Post-fire Hydrooen Storaae Facility Insoection
           a.  Inspection Scope (93704)
               The team inspected the hydrogen storage facility to determine the extent of the damage
               caused by the fire. The team also reviewed the system design and installation and
               interviewed operators to evaluate whether the design and operation of the facility
               conformed to the 8Leensing comm tments and regulatory requirements.                             j
                                                                                                               l
           b.  Observations and Findinas                                                                       ,
                                                                                                               I
               The hydrogen storage facility includes two high pressure gas storage banks, a pressure
               control station, an excess flow control check valve and a gas discharge stanchion. This
               equipment is located on a concrete foundation, enclosed by a fence and surrounded with
               vehicle guard posts. Each of the two high pressure gas storage banks contains 15
               storage vessels. Adjacent to this installation and perpendicular to the longitudinal
               direction of the storage vessels, a hydrogen delivery trailer was apparently being used         :
               as a third source of hydrogen, w confirmed by the licensee.
               The team's review of the post-fire condition of the installation found that most of the         l
               damage was confined to the pressure control station, where the fire apparently initiated.
               The panel, housing two piessure controllers and a number of valves and pressure
               gauges (see Attachment 2), had received extensive damage, with fallen components at
               the bottom of the panel, broken pipe joints, and burst pipes and components. The
               flames and intense heat emanating from the panel had burned two large holes in the
               chain-link fence surrounding the installation and damaged the suppert structure of the
               storage bank closest to the panel. The delivery trailer also was damaged and one of the
               t;res was destroyed by the Re. The storage bank farthest from the fire appeared to be
              _ generally sound as did most of the storage vessels in the storage bank closest to the fire.
               To address the design of the hydrogen system, the team reviewed the UFSAR as well as
               portions of the modification package that installed the system in its current configuration,
               No. JAF-SE-87-087. Tht., team found that neither the UFSAR, nor the safety evaluation
               of the modified facility specifically addressed operation of the system with a hydragen
               delivery trailer acting as a third bank. This mode of operation was also not addrused in
              'the hydrogen addition system training module SDLP-89A. The team discussed the
               observation with the system engineer and other licensee personnel and found that the

L

,
                                                                                             _
                                                                                                            .-

-.

  .- .i
                                                           13
               trailer was being used to increase the hydrogen storage capacity. The increased
               capacity was required due to a larger than expected hydrogen demand. During the
               hydrogen fire, the trailer accounted for approximately 30% of the available hydrogen.
               Additionally, the proximity of the trailer to the fire resulted in the exposed side tires
               igniting and contributing to the total combustibic load.
               The team's review of UFSAR Section 9.20.3 also determined that the system was
               designed and constructed in accordance with EPRI Report No. NP-5283-SR-A,
               Guidelines for Permanent BWR Hydrogen Water Chemistry Installations - 1987 Revision.
               However, the installation did not meet all of the recommendation specified in the EPRI
               report. For instance, the hydrogen delivery f re. is a third source, had not been
               analyzed for a design-basis tornado (section 4.1.2.2) and was not enclosed in fenced
               area (section 4.1.1.2.2). Also, the facility did not incorporate security lighting to facilitate
               night surveillance (section 4.1.1.2.2) and the trailer discharge stanchion was not
               provided with e check valve (section 3.1.2.4). The licensee was evaluating the team's
               observations as part of the fire root cause determination and wrs considering them in the
               redesign of the hydrogen storage facility.
               Because the delivery trailer acted as a hydrogen source, the team was concerned that
               some of the piping and panel components might be exposed to a higher than planned
               pressure. The team discussed the pressure rating of the panel components, but
               because the panel was supplied by the vendor, the information was not immediately
               available. The licensee believed that the pressure rating of piping and components was
               well above that of the maximum pressure in the supply trailer. However, they did not
               believe that the vendor supplied portion of the system w as designed to the requirements
               of EPRI Report No. NP-5283-SR-A. A detailed review of the hydrogen control panel
               design was ongoing, as part of the fire root cause evaluation, and results were not
                                                                                                                l
               available by the end of the inspection.                                                          1
        c.     Conclusions
                                                                                                                i
               The use of a hydrogen delivery trailer as a third source of hydrogen did not conform to
               the design description for the facility in the UFSAR and did not meet all of the guidelines
               specified in EPRI Report NP-5283-SR-A for " Permanent BWR Hydrogen Water
               Chemistry Installations," as specified in the UFSAR. The impact of such deviations on
               the Gsign and operation of the system as well as on the severity of the fire event was
               being investigated by the licensee and the results of such review were still incomplete.         l
               This is an apparent violation pending completion of the effort by licensee, identification of
               corrective actions, and review by the NRC. (see r% item E2.1). (eel 50-333/99-02-03)
        E8.2 Emeroency Diesel Generator Capability                                                              l
                                                                                                                l
           a.  Insoection Scope (93702) .                                                                       l
              The team evaluated the ability of a single EDO to accelerate and carry accident loads in
              the event of a loss of the offsite sources while the tie breaker between a pair of EDGs
              was open.                                                                                         !
                                                                                                                l
                                                                                                                l

s

 -. ..
                                                        14
         b.   Qhservations and Findinas
              The design of the FitzPatrick emergency electrical buses allows the powering of the
              buses with a single EDG if the other EDG in the pair fails to start or if the tie breaker
              between each pair fails to close. In November 1998, the licensee evaluated the transient
              loading of a single EDG to determine whetner the loading was within the machino's
              capability. The licensee's preliminary calculations showed that with only one RHR pump
              operating, per design, the total steady state load was slightly below the 30-minute rating
              (3050 kW) of the diesel engine. Using reasonable rule of thumb assumptions, the
              licensee also preliminarily concluded that the transient load (i.e. the load during the first
              few seconds following closure of the motor supply breaker until the motor / pump is up to
              speed) was not within the capability of a single EDG. Specifically, peak transient loading
              due to the start of the last emergency core cooling pump (the core spray pump) wou!d be
              approximately 1300 kW above the continuous rating of the EDG.
              Limited single EDG testing was performed during the FitzPatrick pre-operational test
              peogram. These records were not available for review during the inspection. However,
             the team was informed that the tests may not have reflected actual emergency loads.
              More recently (December 1998), single EDG tests were conducted successfully under
              procedure ST-9C, " Emergency Ac Power Load Sequencing Test and 4KV Emergency
              Power Systems Voltage Relays instrument Functional fest" However, the test was
             designed only to verify proper logic system functionality, and significant design loaos
              (approximately 800 kW from the 600 Vac emergency substations) were secured during
             the test. Since the test did not reflect actual emergency loads, its value in demonstrating
              single EDG design capability was limited. The licensee planned to develop formal
             calculations in the future.
         c.  Conclusions
             The licensee's preliminary evaluation of the ability of a single diesel to accelerate and
             carry the design loads, in the event that the paralleling of a pair of emergency diesel
             gererators failed to take place, indicated the potential overloading of the diesel. Also,
             the single EDG test conducted in Decembe/1998 was not designed to demonstrate
             single emergency diesel generator capabi..iy under accident conditions. The I;censee
             planned to develop formal calculations, but the inspectors did not consider this issue is to
             be a concern during this inspection because operation of the emergency bus with a
             single diesel generator is not within the design basis of the plant.
       E8.3 Emeroency Diesel Generator Load Sharina
         a.  Jngpection Scope (93702)
             The team evaluated the ability of the EDG pairs to share the load following a design
             basis accident.
                                                                                                            I
                    _

t ..

                                                      15
    b.   Obsentations and Findinos
       ' The FitzPatrick onsite emergency system uses two sets of two EDGs in parallel to power
         the emergency buses. As stated in section E1.1 of this report, each diesel has a
         continuous rating of 2600 kW, whereas the calculated load on each of the two buses is
         approximately 4000 kW. Therefore, two diesels are required to provide sufficient power
         to power the dosQn accident loads. For proper parallel operation, a circuit must be
         provided that monitors the load of each EDG and signals the individual govemors to
         make necessary corrections in the control of the dieseis such that they share the load
         equally.
         The team discussed with the licensee the testing done to verify the ability of the diesels
         to properly share the load. The inspectors determined that no specific test had been
         developed to assure the integrity of the circuit interconnecting the two govemor
         controllers and that the individual EDG loads were not recorded during the LOCA/ LOOP
         test conducted each refueling outage. Discussions with the licensee determined that,-
         during monthly tests, adjustments were made to the diesel controls to properly load tha
         machines. However, during the monthly test, the EDGs are paralleled to the offsite
         system and the governor controllers do not operate in the same mode as when the
         diesel pairs operate independently from the system. Therefore, the monthly tests do not
         specifically verify the integrity of the interlocking circuit and the adjustments made do not
         assure the ability of the machines to share the bus load.
         Based on the above, the team discussed with the licensee the confidence they had
         regarding the ability of the diesel pairs to properly share the load. The licensee stated
         that, although the individual diesels loads were not specifically recorded during the
         refueling outage test, they were observed by the operators in the control room during the
         conduct of the tests. Therefore, they had no concern regarding the integrity of the load
         sharing circuit.
         Considering the size of the bus loads and the rating of each diesel, the team believed
         that a failure of the interlocking circuit would result in the overloading of one of the
         diesels with consequent supply breaker tripping. This event would attract the attentim of
         the operating staff. The licensee's review of recent tests identified no such occyrrence.
         Based on the licensee's review, the team concluded that sufficient confidence existed
         regarding the integrity of the load sharing circuit. Nonetheless, the licensee's failure to
         periodically verify the integrity of the govemor controller interlocking circuit is a violation
         of 10 CFR 50, Appendix B, Criterion XI, Test Control. This violation of the NRC
         requirements of minor significance and already corrected by the licensee is not subject to
         formal enforcement action. In response to the team's finding, the licensee immediately
         revised the test procedure to require recording of individual EDG loads during the
         refueling outage tests.
    c.   Conclusions                                                                                     ]
         The licensee had not previously verified proper operation of the EDG pair loading
         sharing circuits. The licensee revised the testing procedure to verify proper circuit
         operation in the future. This minor violation was not subject to formal enforcement
         action.
                                                                            _
  r ,
                                                                                                         !
                                                        16
                                                                                                         l
                                                IV. Plant Suonort
      'P1-    Conduct c,f EP Activities

>

      - P1.1 ~ Imolementation of Emeroency Plan
                                                                                                         )
         a.:  Insoection Scope
                                                                                                         i
                                                                                                         '
              The team reviewed the actions taken by the New York Power Authority to execute the
              Emergency Preparedness Plan and the associated Emergency Preparedness                      ,
              implementation Procedures..                                                                i
        : b.  Observations and Findinas
              Tne normal locations of the Technical Support Center (TSC) and Operations Support          ;
              Center (OSC) are in the Old Administration Building. This was one of the buildings
              evacuated due to the severity of the fire. Accordingly, the Emergency Director ordered
              that the TSC and OSC be relocated to attemate locations. The TSC was moved to the
              main library, and the OSC was moved to the cafeteria. The normal locations are pre-
              staged with the necessary telephone communications, procedures, and computers
              information to monitor plant parameters.
                                                                                                         1
              The emergency preparedness department facilitated the installation of adequate
              telephone lines and nee'Jed administrative and technical support in a timely manner.
              Both facilities were activated and functional within the required one hour. The team
              considered the effort to relocate the emergency response facilities in a short time frame,
              in the midst of an emergency, to be an example of a good Emergency Plan function.
              The licensee's overall emergency response to the event wa= good.
          c.  Conclusion
              The overall emergency preparedness response to the Hydrogen fire was good.
              Especially noteworthy was the ability to implement alternate locations for the emergency
              response facilities and still have them activated and functional within an hour.
       F5     Fire Protection Staff Training and Qualification
       F5.1   Fire Briaade Trainina Related to Flammable Gases
          a.   Inspection Scope
              The team reviewed the training provided by the licensee to the fire brigade with respcct
              to responding to a H2 fire.
w                                                                               _.

,: .

                                                                                                         l
                                                       17
     b.     Observations and Findinas
            The team determined that the training provided to the fire brigade included both
            classroom presentations and fighting of actual fires at the local fire fighting school. The
            subjects covered included, amongst othars, the general duties and responsibilities of the
            fire brigade, the chemistry of fires and methods of extinguishing a fire, the hazards of
            flammable liquids and gases, the strategy of combating the various types of fires, and the
            locations of the hazardous materials on site.
            The lesson plans were detailed and included a discussion of fire incidents. In the case of
            a gas fire, training lessons specified that it was not safe for a fire brigade to attempt to
            put out the fire. Rather, the fire brigade should wait for offsite assistance, unless
            immediate actions were needed to rescue personnel. Otherwise, the best strategy was
            to let the fire bum itself out. Water should be applied only to cool the containers and
            prevent tank failures which, in tum, could exasperate the condition and cause further
            damage.
            Overall, the inspectors considered the ability of the fire brigade to combat the H2 fire to
            be appropriate. In addition, the quick response by the FBL to request off-site assistance
            was instrumental in minimizing the damage to other equipment in the area.
                                                                                                         )
      c. -  Conclusion
            The inspectors considered the training provided to the fire brigade to combat the H2 fire
            to be appropriate. In addition, the quick response by the FBL to request off-site
            assistance was instrumental in minimizing the damage to other equipment in the area.
                                           V. Manaaement Meetinos
    X1      Exit Meeting Summary
    The team presented the inspection results to members of licensee management at the
    conclusion of the inspection in a telephone conference on February 9,1999. The licensee
    acknowledged the findings presented during the meeting.
    The licensee did not indicate that any of the information presented at the exit was proprietary.

. .

                                                  18-
                            PARTIAL LIST OF PERSONS CONTACTED
   James A FitzPatrick
   R. Baker             Maintenance Department
   W. Berzom            Manager Communications .
   G. Brownell          Licensing Engineer
   P. Brozenick         Operations Manager
   M. Bursztein        - Acting Electrical Engineering Supervisor
   M. Colomb            Site Executive Officer
   R. Converse          General Manager Maintenance                           I
   T. Dougherty         Engineering
   B. Drain             Acting Director Design Engineering
   F. Edler             Acting Maintenance Manager
   A. Ettinger          Nuclear Engineering (FP)                              i
   S. Kohr.             Design Engineering Mechanical Supervisor
   D. Lindsey -         General Manager, Operations
   J. Maurer            General Manager, Support Services
   R. Patch             Director Quality Assurance
   R. Plasse            Acting Licensing Manager
   M. Rastley           Operations Training Coordinator
   D. Ruddy             Director, Design Engineering
   P. Ryan              Control Room Supervisor
   T. Teifke            Security / Safety Manager
   G. Thomas            Manager D & A Engineering
   D. Wallace           Design Engineering Manager Support
   V.Walz               Assistant Operations Support Manager
   A. Zaremba           Licensing Manager                                    _,
                                                                                l
   NBL                                                                          !
   R. Barkley           Project Engineer
   L. Doerflein         Chief, Engineering Programs Branch, DRS                 l
   R. Rasmussen         Senior Resident inspector - FitzPatrick                 !
                                INSPECTION PROCEDURES USED
   IP 93702:    Prompt Onsite Response to Events at Operating Power Reactors
                                                                                <
                                                                                -
 .. .
                                              19
                        ITEMS OPENED, CLOSED AND DISCUSSED
       Opened
                                                                                             l
                                                                                             !
      ,50-333/99-02-01       NCV Failure to complete an EDG surveillance test procedure,     I
                                  resulting in the plant being in an unanalyzed condition.
       50-333/99-02-02.    'IFl   Review results of licensee investigation.                  1
       50-333/99-02-03       eel  Us of Hydrogen delivery trailer as third source did not
                                  conform to description in UFSAR.
                                                                                             I
       Closed
                                                                                             1
       50-333/99-02-01       NCV Failure to complete an EDG surveillance test procedure,   -
                                  resulting in the plant being in an unanalyzed condition.   1
       Discussed
                                                                                             i
                                                                                              1

i [ None

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                                                                J

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                                                  20
                                    LIST OF ACRONYMS USED
      A        Amperes                                           i
      AC or ac Attemating Current
      ASME     American Society of Mechanical Engineers
      BWR      Boiling Water Reactor
      CARB     Corrective Action Review Board
      CCP      Combustion Contro' Permit
      CFR      Code of Federal Regulations
      CR       Condition Report
      udS      Control Room Supervisor
      DBD      Design Basis Document
      DC or de Direct Current
      DCP      Design Change Package
      EAL      Emergency Action Level
                                                                '
      EDG      Emergency Diesel Generator
      EPRI     Electric Power Research Institute
      ESF      Engineered Safeguards Feature
      ESW      Emergency Service Water
      FBL      Fire Brigade Leader
      GL       Generic Letter
      H2       Hydrogen
      HP       Horsepower
      IEEE     Institute of Electrical and Electronic Engineers  l
      KV       Kilovolt
      KVA      Kilovolt-ampere
      kW       Kilowatt
      LCO      Limiting Condition of Operation                   l
     -LOCA     Loss of Coolant Accident
      LOOP     Loss of Offsite Power
      MWR      Maintenance Work Request
      NCV      Non-Cited Violation
      NRC      Nuclear Regulatory Commission
      NRR      Office of Nuclear Reactor Regulation
      OE       Operating Experience
      OSC      Operations Support Center
      OST      Operating Surveillance Test
      PM       Preventive Maintenance
      PRA      Probabiltj Risk Assessment
      QA       Quality Assurance
      RCS      Reactor Coolant System
      RHR      Residual heat removal
      rpm      revolutions per minute
      SBO      Station Blackout
      SM       Shift Manager
      TER      Temporary Evaluation Report
      TM       Temporary Modification
      TS       Technical Specification
      TSC      Technical Support Center
                                                                ,
 s , , e
                                                21
         TSSR  Technical Specification Surveillance Requirement
         UFSAR Updated Final Gafety Analysis Report
         Vac   Velts Altemating Current
         Vdc   Volts Direct Current
                                                                a

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                                                                1

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                                                          22                                                            )
          ATTACHMENT 2 - J. A. FitzPatrick H2 Control System Cabinet                                                    l
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                                                                                              n_701
                  i                     i
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                                                              i                        I
                                                                                        JL        I
                                                                                                         truck ria
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              f                                  202
                              PI-1112                                                  PI-1111
                203
                                                    .
           ~{i                                                           g-                             Active Bank
                                          I           i
           _.
                            207                                            206
           -{                             208                                                             Reserve Bank
              p                I      @M                             i       i             l         I
              ]                                                                            l
                                                                                                                        i
            k210                                                                                 k212                    ,
                                                                                                                        .
                                                                                                                         1
                 PCV-215                                                                            PCV-216
                                                                                                  \
                                                                     Fi-1113
                                                                   209
             ~k.
                        211
                       i>< D                      I          O       i
                                                                                 213 _
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                                              .                 ,
                                      coes c               111
                                                       'h' EFV 112
                                                                                                           To the Plant

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                                                               23
                                                                                                                  I
                                                        ATTACHMENT 3
                                                                                                                  )
                                                                                                                  i
                                                                                                                  '
                                 HYDROGEN FIRE - DESCRIPTION OF THE EVENTS
           At 12:56 p.m., on January 14,1999, the FitzPatrick control room received a report of a iarge fire
           at the H2" tank-farm" located in the north-west corner of the property, inside of the protected        -
           area fence. The fire was reported by an operator who had been manipulating valves inside the
           H, tank-farm control cabinet in preparation for placino the H2 addition system in service, in
                                                                                                                  )
           accordance with an approved operating procedure. The Control Room Supervisor (CRS)                     I
           immediately dispatched the on-site fire brigade to the scene to investigate the fire; in addition,     ;
           buildings near the fire were evacuated. The fire brigade leader (FBL) determined that the fire
           was beyond the capability of the fire brigade and requested off-site assistance from local fire        !
           departments.                                                                                           I
           At 1:11 p.m., the Shift Manager (SM) entered the Emergency Plan, became the Emergency                  i
           Director (ED), and classified the fire as an Unusual Event. The ED activated the techrdcal             l
           support center (TSC) and operations support center (OSC). The required event notifications
           were made by NYPA to the county and state agencies, and to the NRC. Due to the proximity of
           Nine Mile Point Units 1 & 2, Niagara Mohawk also declared an Unusual Event.
           At 1:23 p.m., the FBL requested that the control room de-energize the 115KV switchyard due to
           the closeness o'the switchyard to the H 2tank-farm. The request was quickly reviewed by the
           control room staff and acted upon. The CRS briefed the crew on the potential affect on the plant
           if the main generator were to trip; i.e., the EDGs would be the only source of electrical power for
           the emergency buses. In addition, the CRS discussed the fact the plant was in an unusual
           configuration with respect to the electricallineup. He had the operators review the appropriate
           abnormal and emergency procedures for a reactor scram, a rapid power reduction, and a station
           blackout. All four EDGs were subsequently started and left running unloaded for approximately
           3.6 hours.
           At 1:37 p.m., the first off-site fire truck was allowed on-site and applied water to the fire; the FBL
           reported that extinguish:ng the fire was not viable. As additional off-site assistance arrived,
           more water hoses were used. At one point, eight hoses were spraying water onto the fire to
           maintain the H2 tanks cc:' 9nd to minimize the possibility of a tank failing. At 2:16 p.m., the FBL
           reported the fire was under control. At 7:45 p.m., following closure of several valves, the FBL
           reported that the fire was ou: and the H2 tank-farm was isolated. The 115KV switchyard was
           restored at 9:02 p.m. and the Unusual Event was exited at 9:05 p.m..
                                                       EVENT TIME-LINE
           January 14.1999-
                   12:56 p.m.       Control room received a report of a fire at the hydrogen tank-farm Fire
 i                                  brigade dispatched
                   1:02 p.m.        Sounded fire alarm. Fire brigade requested offsite assistance.
                                    Evacuated nearest buildings.
                   1:08 p.m.        Evacuated west side of site and calleo Mr additional offsite assistance

(' :,q , o

          Attachment 3                                  24
                 1:11 p.m.  Declared an Unusual Event. Technical Support Center (TSC) and
                            Operational Support Center (OSC) activated but relocated. The normal
                            location is in the Old Administration Building, which had been evacuated.
                 1:15 p.m.  Fire brigade reported that the hydrogen trailer was also on fire
                 1:17 p.m.  Control Room Supervisor (CRS) conducted a shift brief, including
                            reviewing procedures for a reactor scram or emergency power reduction,

! loss of 115KV offsite, and station blackout.

                 1:21 p.m.  First two offsite fire trucks arrived, escorted to fire scene by recurity

l 1:23 p.m. Fire brigade requested that the 115KV switchyard be de-energized

                 1:26 p.m.  First 115KV line de-energized (breaker 10022 opened)

l 1:28 p.m. Second 115KV line de-energized (breaker 10012 opened) !

                 1:29 p.m.  Entered Limiting Condition for Operation (LCO) for 115KV de-energized

l (TS 3.9.B.2)

                 1:30 p.m.  CRS held shift brief for 115KV de-energized and discussion to perform
                            the associated surveillance test (ST-9D) to test the EDGs. Shift Manager

l (SM) decision to leave the EDGs running unloaded (precautionary) with l the tie-breakers open. (ST-9D directs the EDGs be secured and retumed

                            to the standby condition.)                                                    ,
                 1:36 p.m.  Started A & C EDGs, opened tie-breaker 10504
                 1:37 p.m.  Water applied to the fire. Report from fire brigade that extinguishing the
                            fire was not a viable option.
                 1:39 p.m.  OSC staffed and operational
                 1:40 p.m.  Started B & D EDGs, opened tie-bredter 10604
                 1:55 p.m.  TSC staffed and operational
                 1:58 p.m.  Fire Brigade reported that the three hoses were being used on the fire.
                2:07 p.m.   SM directed that ST-9D be completed " SAT" with the EDGs uniraded.
                            SM directed the operators to review the normal operating preadure (OP-
                            22) with the intent of loading the EDGs.
                2:16 p.m.   Report from the fire brigade that the fire was under control with five hoses.
                 =2:30 p.m. With the fire under control, the SM decided to secure the EDGs, but left
                            them running while TSC evaluated the need to load EDGs prior to
                            securing them. TSC was concerned regarding oil and carbon buildup in
                            the exhaust system while the EDG were run unloaded for almost an hour.
                5:07 p.m.   Secured A & C EDGs
                5:08 p.m.   Secured B & D EDGs
                7:35 p.m.   Fire brigade suspended water spraying, but a two foot flame became
                            visib!e. They isolated that leak, and closed several other valves, including
                            the bottle isolation valves and the truck supply.
                7:45 p.m.   Report from the fire brigade that the fire was out and the hydrogen tank-
                            farm was isolated.
                8:00 p.rn.  Emergency Dirsctor formally declared the fire out.
                9:02 p.m.   The 115KV offsite lines were restored and the LCO was exited.
                9:05 p.m.   Exited the Unusual Event
                                                                                                           i
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