ML20207L915

Forwards Schedule of Corrective Actions Being Taken to Resolve Issues Raised by Insp Rept 50-346/83-16 Re Conformance W/App R.Remaining Noncompliances Will Be Resolved by Sixth Refueling Outage

ML20207L915
Person / Time
Site:	Davis Besse
Issue date:	11/07/1986
From:	Williams J TOLEDO EDISON CO.
To:	Paperiello C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
References
1-678, TAC-56864, NUDOCS 8701130034
Download: ML20207L915 (48)

Text

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TOLEDO EDISON JOE WiLUAMS, JR.

Docket No. 50-346 w,va,m e w (413]249 2300 License No. NPF-3 14 ' S1 2 " "

serial No. 1-678 November 7, 1986 Mr. C. J. Paperiello, Director Division of Reactor Safety United States Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Elleyn, IL 60137

Dear Mr. Paperiello:

On September 5, 1985, the Toledo Edison Company received the Nuclear Regulatory Commission's (NRC) Inspection Report (IR) No. 50-346/83-16 (Log No. 1-1024) which documented the results of the special safety inspections conducted at the Davis-Besse Nuclear Power Station, Unit No. 1 on July 11-13 and July 25-29, 1983. The intent of the inspection was to assess the Davis-Besse conformance with 10CFR50, Appendix R (Section III.G, J, O and L), including the exemptions approved by the NRC. Within IR 83-016, no reference is made to 10CFR2.201, " Notice of Violation." Consequently, Toledo Edison is not required to provide a written explanation or state-ment with regard to corrective steps taken or to be taken and when compli-ance will be achieved.

Toledo Edison, however, is committed to resolve the issues raised by IR 83-016 and agreed to provide a response prior to restart from the current outage in a telephone conversation on October 1, 1985 with Messrs.

L. Reyes and N. Jackiw of the NRC Region III office. Attachment 1 provides such a response in the form of a status of Toledo Edison efforts to resolve the noncompliances identified by IR 83-16. Many of these noncom-plisnces have been closed by subsequent NRC Region III followup inspec-

,$, tions and Attachment I references these follow-up inspections as g

NO appropriate.

1 Of the 19 noncompliances identified by IR 83-16, Toledo Edison considers

$o '.1 noncompliances to be closed. The resolutions of the remaining 8 open a noncompliances involved procedure revisions, physical modifications and/or

@ exemptions and have scheduled completion dates of no later than the sixth g

refueling outage. The specific schedule for resolution of each open noncoupliance is presented in Attachment 1. However, the exemptions,

& which were requested in Toledo Edison letter dated March 6, 1986 (Serial No. 1255), will require NRC approval. Toledo Edison assumes action by the

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THE TOLEDO ED! SON COMPANY EO.50N PLAZA 300 MADISON AVENUE TOLEDO. OHG 43652 e HOV 10 W -

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.Dockat Ns.~50-346 '

l> 'Licznaa No. NPF-3 Serial No. 1-678' November 7, 1986 i

Page 2 NRC to approve the requested exemptions prior to the scheduled completion

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of,the' physical modifications. Consequently,' Toledo Edison expects

. Davis-Besse to be in full compliance with the fire protection requirements

'of 10CFR50,. Appendix A (General Design Criteria 3) and Appendix R, by the end.of the sixth refueling outage, contingent upon NRC approval of the requested exemptions..

The schedule to achieve full compliance, however, may be affected if the NRC.does not approve the requested exemptions prior to the sixth refueling outage or denies any of the requested exemptions such that additional extensive physical modifications and/or procedure revisions would be required. In letter dated April 8, 1986, the NRC requested that Toledo Edison resubmit the requested exemptions and include a discussion of the applicable special circumstances in accordance with 10CFR50.12. Toledo Edison will resubmit the previously requested exemptior - by December 31, 1986 :h2 order to support their approval by the NRC prioc to the sixth refueling outage.

It should also be noted that the installation of certain physical modifi-cations discussed.in the Davis-Besse Appendix R Compliance Assessment Report (CAR) and reiterated in Attachment 1 may result in procedure revisions. These procedure revisions are considered to be part of th'e

. physical modifications and will be completed to support the completion schedule for the physical modifications (i.e., prior to the end of the . sixth refueling outage) . Those procedure revisions identified by the CAR and not associated with physical modifications will be completed prior to plant restart from the current outage. Toledo Edison believes that this' clarification of the completion schedule is consistent with its commitments in letter dated June 3, 1986 (Serial No. 1253).

As a status, Attachment ILdescribes certain fire protection activities completed or scheduled to be completed at Davis-Besse. Attachment 1, however, does not detail the past and present good faith efforts taken by Toledo Edison or the mitigating circumstances associated with the noncom-pliances. Such a response would be made by Toledo Edison if the NRC issues a Notice of Violation and takes additional enforcement action regarding IR 83-16.

In letter dated October 13, 1986 (Serial No. 1-674), Toledo Edison provid-ed a-response to the Davis-Desse Study Group Report dated May 30, 1986 (Log No. 1-1394). This letter. states that.the responses to Study Group Report Items III.A.4 and III.E.4 involve mostly fire protection issues and would be more appropriately cddresse.1 in the response to IR 83-16.

Attachment 2 provides the status of c:tivities addressed by Study Group Report Items III.A.4 and III.E.4.

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'Dockst No. 50-346 s- Licanza No. NPF-3 S riel N3. 1-678 November 7, 1986  ;

6. -Page 3 Attcchment 3 also provides a list of, references used in Attachments 1 and 2.

Previous meetings with the NRC regarding the status of the Davis-Besse Fire Protection Program have proven to be extremely beneficial. Toledo Edison would be pleased to discuss the status of the Davis-Besse fire-protection efforts with representatives of the NRC. Please feel free to contact Mr. R. F. Peters at 419-249-2366 if such a meeting or additional discussions are desired.

Very truly yours, 0:?:v=

ML:p1f cc: DB-1 NRC Resident. Inspector i

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v . Dock;t N2. 50-346 Liccn32 No. NPF-3 Serial'No. 1-678

-.- November 7, 1986 Attachment i  !

ATTACHMENT 1 CURRENT STATUS OF CORRECTIVE ACTIONS ASSOCIATED WITH THE NONCOMPLIANCES IDENTIFIED IN IR 83-16 1

a' Dock 3t No. 50-346 <

License No. NPF-3 Serial No. 1-678 e- November 7, 1986 Attachment l' INTRODUCTION In a telephone conversation on October 1,.1985 with NRC Region III repre-sentatives,-Toledo Edison committed to provide a response to the noncom-pliances. identified :in IR 83-16 prior to plant restart from the current outage. This attachment satisfies that commitment. Many of the IR 83-16 noncompliances have been closed by NRC Region III follow-up inspections and this attachment references these follow-up inspections as appropriate.

At this time, Toledo Edison considers 11 of the 19 noncompliances to be

. closed and the remaining 8 to be open.

The following is a aummary of the status for each of the noncompliances.

IR 83-16 Actions to be Taken Noncompliance Status Procedure Rev. Modification Exemption 01A Open X- X X 01B Open X X X 02 Open - -

X

03. Open - -

X 05 Open -

X X 07 Closed - - -

11 Open X X -

13 Closed - - -

15 Open X X -

22A Closed - - -

22B Open X X -

22C Closed s 22D Closed - - -

.22E Closed - - -

22F Closed - - -  ;

22G Closed - - -

22H Closed. - - -

22I closed - - -

22J Closed - - -

The resolutions of the 8 open noncompliances involve procedure revisions, physical modifications and/or exemptions and have scheduled completion dates no later than the sixth refueling outage. The specific schedule for t- resolution of each noncompliance is presented in this attachment. However, the exemptions requested in Toledo Edison letter dated March 6, 1986

-(Serial No. 1255) will require NRC approval. Toledo Edison assumes action by the NRC to approve the requested exemptions prior to the scheduled

. completion of the physical modifications. Consequently, Toledo Edison

, expects Davis-Besse to be in full compliance with the fire protection requirements of 10CFR50, Appendix A (General Design Criteria 3) and Appendix R, by the end of the sixth refueling outage, contingent upon NRC approval of the requested exemptions.

The following is the current status for each of the IR 83-16 noncompliances.

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v Dockst Ns. 50-346 Licznas No.-NPF-3 ,

Serial No. 1-678- '

. November 7, 1986 Attachment 1 Noncompliance The alternate shutdown capability did-not meet the 83-016-01A acceptance criteria for achieving and maintaining hot '

standby, achieving cold shutdown within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />,

'being independent of the fire area, accommodating loss of offsite power, providing direct readings of the process variables necessary to perform and control the reactor shutdown functions, and having.

procedures in effect to implement the safe shutdown capability (83-16-OlA).

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Toledo Edison developed and submitted the Davis-Besse Appendix R Compliance Assessment Report (CAR), Revi-sion 1, to the NRC in letter dated June 3, 1986 (Serial No. 1253). The CAR provides a compliance ,

assessment of Davis-Besse's safe shutdown systems, components, circuits and associated circuits (Appendix R,~

Sections'III.G), emergency lighting (Appendix R,

'Section III.J) and reactor coolant pump oil collection system (Appendix R,Section III.0). The CAR also presents the evaluation for alternative shutdown capability as required by Appendix R, Sections III.G and III.L.

Proposed resolutions of identified deficiencies in Davis-Besse's compliance with Appendix R are presented in the CAR and include procedure revisions, physical modifications and specific exemptions from Appendix R requirements.

The following specific concerns cited in IR 83-16, Paragraph 4.a (1) and the proposed resolution docu-mented in the CAR are as follows:

IR 83-16-01A

a. It did not consider the effect of a fire.

Assumptions of initial conditions such as the capability of automatic control features were not consistent with the existence of a postulated fire in the control room or esble spreading room.

Thus, various designated procedural actions could not be implemented without procedural modifica-tions. For example, auxiliary feedwater flow to the steam generators will provide decay heat removal for hot shutdown and the decay heat removal system for cold shutdown. The use of the 3

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v Dock 2t No. 50-346 License'No. NPF-3 Serial No. 1-678

. ' November 7,-1986.

Attachment 1 steam generators requires either MS101 and FW612 l i

or MS100 and FW601 valves to close plus either MS106 and AF3870 or MS107, AF599, and AF3872 valves to open. A fire could affect the automat-ic operation of these valves.

CAR Resolution The CAR documents the analysis of the components ,

and associated circuits necessary for decay heat  !

removal using the auxiliary feedwater and decay- )

heat removal systems. The CAR analysis indicates  !

that valves, FW601 and FW612 are not necessary to  !

achieve safe shutdown in the event of a fire.

Additionally, valves MS100, MS107, AF599 and AF3872 have no outstanding modifications, proce-dure revisions or exemption requests and are.

currently considered to.be.in compliance with Appendix R. However, the CAR does specify certain procedure revisions, one physical modifi-cation and three exemption requests for Fire Areas A, DA and EE addressing valves AF3870, MS106 and MS107.

IR 83-16-01A

b. It did not consider-the possible effects of i interaction between associated circuits of concern. Protection from spurious or maloperations of associated circuits caused by a fire may require the addition of isolation, transfer switches or other equipment.

CAR Resolution Section 5 of the CAR documents the associated circuits analysis for common power sources, i spurious actuations and common enclosures. This analysis includes an evaluation of the noncon-formances with Appendix R,Section III.G and planned resolutions which include the installa-tion of isolation (transfer) switches.

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s Dock t N2. 50-346 Licsnaa No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 IR 83-16-01A

c. It failed to delineate specific actions or shutdown methods unique to the availability or unavailability of offsite power for 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.

Instead emergency operating procedure EP _1;02.02,

" Station Blackout" had to be utilized in conjunc-tion with AB 1203.12, but the station blackout procedure did not address the effects of a fire on implementation of the procedure.

CAR Resolution The analysis performed in the CAR considered the possibility of a loss of offsite AC power in conjunction with a fire. The systems necessary to satisfy the protective functions to safely shutdown the plant in the event of a fire were identified through a review of Emergency Proce-dure EP 1202.02, " Station Blackout." A list of components for each of these safe shutdown systems included those components required to assure essential power to safe shutdown compo-nents in the event of a loss of offsite power.

Required operator actions, including those necessary to cope with a loss of offsite power based on the CAR analysis, will be addressed in procedures AB 1203.02, " Serious Station Fire

Procedure," and AB 1203.26, " Serious Control Room Fire."

Currently, procedure AB 1203.02 specifically addresses automatic and operator actions with and without a loss of offsite power. Operator actions without a loss of offsite power include tripping all source breakers to Buses "A" and "B", thereby resulting, in effect, in the same condition as a loss of offsite power. This operator action would be taken if cafety systems are adversely affected by fire and the fire is extremely serious.

Procedure AB 1203.26 also currently addresses the availability of offsite power. As with procedure AB 1203.02, the operator is directed by procedure AB 1203.26 to trip all source breakers to Buses "A" and "B" as determined necessary by the Shift Supervisor.

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l Dockst No. 50-346

- Licznsa No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 IR 83-16-01A

d. The station staff did not agree with some proce-

- dure requirements. Procedure AB 1203.12, Section 4.2 states, "The objective of this procedure is to place the plant in a shutdown condition with the reactor decay heat dependent on the minimum amount of equipment...". At a meeting with plant personnel on July 27, 1983 the licensee's staff verbally indicated that the pressurizer heaters were not included in'the minimum amount of equipment. However, the control room evacuation procedure required use of the pressurizer heaters and the control for the heaters were electrically independent of the control room or cable spreading room. The procedures did not delineate methods of maintain-ing hot standby without pressurizer heaters nor did the procedures identify the provision to immediately proceed to cold shutdown, given a control room or cable spreading room fire.

4 CAR Resolution The CAR analysis does not consider the essential pressurizer heaters as necessary to achieve and

, maintain hot standby. Procedure AB 1203.02,

" Serious Station Fire Procedure," specifies that if there is a loss of all pressurizer heaters because of a fire, the operator is to proceed to cold shutdown. This operator action is required with either offsite power available or unavailable.

Procedure AB 1203.26, " Serious Control Room j Fire," does not require the use of the pressur-

izer heaters in the operators guidelines to achieve and maintain hot standby. Additionally, Section 4.0 of procedure AB 1203.26 provides operator guidelines for cooldown to cold shutdown.

L i IR 83-16-01A

e. The licensee did not provided the capability of achieving cold shutdown conditions independent of l the control room or cable spreading room.

Additionally, during the July 27 meeting, the licensee indicated that cold shutdown conditions could not be achieved in 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> assuming a loss of offsite power.

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. D;ckst No. 50-346 Licsnto No. NPF-3 Serial No. 1-678

- November 7, 1986-Attachment 1 CAR Resolution In letter dated August 20, 1984 (Log No. 1586),

the NRC granted an exemption from Appendix R to obviate the need for the capability to achieve cold shutdown within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. This portion of noncompliance 83-16-01A was closed by an NRC Region III follow-up inspection documented in IR 85-028, dated November 22, 1985, (Log No. 1-1280).

IR 83-016-01A

f. The instrumentation at the auxiliary shutdown panel did not provide complete process monitoring function. The panel lacked source range flux monitoring capability. Monitoring of core flux is needed to provide a direct indication of the reactor shutdown condition. The reactor coolant temperacures, in conjunction with the reactor coolant system p_rescure, are necessary parame-ters for plant cooldown and control. The plant control elements which rely on accurate reactor coolant temperature indication are natural circulation, subcooling and pressurized thermal shock concerns. The panels lacked instrumenta-tion for reactor coolant cold leg temperature and the range for reactor coolant hot leg temperature was inadequate.

CAR Resolution In response to the NRC Region III inspection leading to noncompliance 83-16-01A, Toledo Edison committed in letter dated September 13, 1986, (Serial No. 986) to take interim action to compensate for the absence of source range flux, cold leg and wide range hot leg temperature, and the potential isolation of the reactor coolant system (RCS) pressure instrument. These interim measures, including procedure revisions and physical modifications, were verified as complete by an NRC Region III follow-up inspection as documented in IR 83-16. As discussed in the CAR, a source range monitor will be installed at the alternative shutdown panel and a redundant source of RCS pressure indication will be installed at a local panel. Additionally, digital readouts of RCS cold leg and hot leg temperature will be installed at a local panel.

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Dock t Ns. 50-346 Liccnya No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 As stated in TED letter dated June 3, 1986 (Serial No. 1253), the physical modifications identified by the CAR are scheduled to be completed by the end of the sixth refueling outage and the procedure revisions identified by the CAR are scheduled to be completed prior to plant restart from the current outage. The necessary exemptions from certain requirements of Appendix R have been requested in Toledo Edison letter dated March 6, 1986 (Serial No. 1255).

Date When Full Compliance Will be Achieved Full. compliance will be achieved upon implementation of the procedure revisions and physical modifications committed in the CAR and NRC approval of the exemp-tions requested in Toledo Edison's letter dated March 6, 1986. The physical modifications are sched-uled to be completed by the end of the sixth refueling outage and the procedure revisions are scheduled to be completed prior to plant restart from the current outage.

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s. Dock t Ns. 50-346 Lic:nto Na. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 Noncompliance Failure to perform a spurious signal analysis for 83-16-61B motor-operated valves M02929, 2930, 2931 and 2932 in the service water discharge line, and failure to analyze for spurious signal actuation of the pressur-izer PORV and block valves, and the letdown cooler isolation valves (83-16-01B).

Response: Acceptance or Denial of the Alleged Noncompliance i Toledo Edison accepts the alleged noncompliance.

Corrective Action'Taken and Results Achieved The CAR documents the spurious. actuation analysis of safe shutdown circuits and associated circuits, including the service water valves, PORV and its block valve, and the letdown cooler isolation valves. No modifications, procedure revisions or exemption requests are outstanding for the spurious actuation concerns of the service water discharge line valves:

SW2929, 2930, 2931 and 2932. One of the service water discharge line valves is administratively controlled open and depowered in order to ensure service water discharge. Consequently, a fire would not result in a loss of service water due to spurious actuation of the valves.

However, the CAR does identify two procedure revisions (Fire Areas DD/FF and U) and one physical modification (Fire Area CC) to resolve the outstanding spurious actuatfun concerns regarding the PORV and its block valve (kC-2A and RC-11). The CAR also identifies two procedure revisions (Fire Areas D and DD/FF) to resolve the outstanding spurious actuation concerns regarding the letdown cooler isolation valves (MU 01A.P.;

MU 02A,B and MU 01).

As stated in Toledo Edison's letter dated June 3, 1986 (Serial No. 1253), the physical modifications commit-ted in the CAR will be completed prior to the end of the sixth refueling outage and the procedure revisions will be completed prior to plant restart from the current outage. However, those procedure revisions and modifications required for the PORV and its block valve will be resolved prior to plant restart for the current outage as documented in IR 85-028.

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. Dock 3t No. 50-346

~Liccn33 No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 Subsequent to IR 83-16, NRC Region III follow-up inspections documented in IR 85-028, dated November 22, 1985 (Log No. 1-1280), and IR 86-06, dated February 28, 1986 (Log No. 1-1342), have reviewed certain actions taken regarding this matter and have closed the noncompliance.

Date When Full Compliance Will be Achieved Full compliance will be achieved upon implementation of the aforementioned physical modifications and procedure revisions and approval of the exemption request by the NRC. The physical modifications will be completed by the end of the sixth refueling outage, and the procedure revisions will be completed prior to plant restart from the current outage. However, those procedure revisions and physical modifications re-quired for the PORV and its block valve will be resolved prior to plant restart from the current outage.

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D:ckst Ns. 50-346 License No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 Noncompliance The auxiliary shutdown panel fails to provide one 83-16-02 train of systems needed for hot standby free from fire damage. (83-16-02)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Actions Taken and Results Achieved Specifically,_IR 83-16, Paragraph 4.b addresses the potential loss of control and indication for the auxiliary feedwater pumps 1 and 2 at both the auxiliary shutdown panel and the control room due to a fire in Room 324, Fire Area R. The CAR documents the analysis performed for Fire Area R. The results of the analy-sis indicate that either Auxiliary Feedwater System-(AFWS) governor control valve required to regulate and control the speed of the associated turbine may be subject to fire-induced failure.

The recommended corrective action proposed in the CAR is to provide alternative shutdown capability by manually aligning and starting the Motor-Driven Feedwater Pump (MDFP). The MDFP has been installed during this current outage and is physically and electrically independent of Fire Area R. Procedure AB 1203.02, " Serious Station Fire Procedure," will be revised to manually align and start the MDFP and,'as

.necessary, to manually operate the applicable governor valve locally in fire areas other.than Fire Area R.

Monitoring instrumentation for the AFWS pumps or the MDFP, such as discharge pressure and flow, are not uecessary to achieve a safe shutdown in the event of a fire. The'MDFP would be utilized after the normal and auxiliary feedwater capabilities are confirmed to be unavailable.

Additionally, an exemption was requested from Appendix R,Section III.G 3 to obviate the need for fixed fire suppression in Fire Area R. The exemption was re-quested in Toledo Edison's letter dated March 6, 1986, Serial 1255.

4 Date When Full Compliance Will be Achieved Full compliance will be achieved upon implementation of the procedure revision, scheduled to be completed prior to plant restart from the current outage, and l

NRC approval of the aforementioned exemption request.

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4 D:cket Ns. 50-346 License No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 ,

Noncompliance The auxiliary shutdown panei and transfer switch room 83-16-03 lacks a fixed fire suppression system. (83-16-03)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved The CAR documents the analysis performed for the auxiliary shutdown panel andLtransfer switch room, Fire Area R. The results of the analysis indicate that alternative shutdown capability is necessary for the Auxiliary Feedwater System and Service Water System. The provisions for this alternative shutdown capability are presented in Section 7 of the CAR and include a revision to procedure AB 1203.02, " Serious Station Fire Proecdure." This procedure revision is scheduled to be completed prior to plant restart from

the current outage. However, Fire Area R is not provided with a fixed fire suppression system. An exemption was requested from the requirements of Appendix R,Section III.G.3 to-obviate the need for the fixed fire suppression system in Toledo Edison letter dated March 6, 1986 (Serial 1255).

Date When Full Compliance Will be Achieved Full compliance will be achieved upon the NRC approval of the aforementioned exemption request and implemen-tation of the procedure revision scheduled to be completed prior to plant restart from the current outage.

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r Dockst Ns. 50-346

-License No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 Noncompliance Four areas of the plant did not have installed 83-16-05 emergency lighting units; three areas of the plant had inadequate lighting; and two of the six emergency lighting units tested failed the 8-hour discharge test. (83-16-05)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Section 6 of the CAR documents the results of the emergency lighting evaluation of Davis-Besse. Numer-ous modifications are proposed in the CAR in order to establish compliance with Appendix R, including the installation of additional battery-powered, self-con-tained lighting units and the redirection of certain existing lights. -Adc+tionally, an exemption from the requirements of Appendix R,Section III.J was request-ed to allow the use of existing hard-wired D.C powered emergency lights rather than battery-powered, self-contained lighting units. This exemption was request-j ed in Toledo Edison's letter dated March 6, 1986 (Serial No. 1255). As stated in Toledo Edison's letter dated June 3, 1986 (Serial No. 1253), the modifications committed in the CAR will be completed prior to the end of the sixth refueling outage.

The fire areas specified by IR 83-16 as having defi-cient emergency lighting and the resolution proposed

. in the CAR are summarized below:

Fire Zone Room CAR Resolution EE-4 500 Install additional battery-powered lighting units EE-3 501 Install additional battery-powered lighting units Access route to auxiliary The CAR does not ident-feedwater pump room and ify the specific routes 4160V switchgear rooms to reach an area for leading to manual control manual actions. However,

stations for the auxiliary in order to determine the feedwater pumps, adequacy of the emergency lighting, those fire area and rooms necessary for operation of safe shutdown equipment or access

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Dockst No. 50-346 Licensi Ns. NPF-3 Serial No. 1-678

-November 7.-1986 Attachment 1 Fire Zone 1 Room CAR Resolution or egress thereto were identified and documented in the CAR. Proposed resolution of deficient emergency lighting.in

' fire areas and rooms is documented in Section 6 of the CAR.

00 345 This fire zone contains the local indication of the Condensate Storage Tank (CST) level. Based on CST level, the suction of the auxiliary feedwater pumps (AFWP) is realigned, automatically or manually if automatic control circuits are lost, to.the Service Water System.' The minimum CST level specified by the Technical Specifications has been determined to be sufficient to provide the AFWP for more than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />.

Hence, it is not necessary to monitor the local CST level indication prior to-beginning cooldown to cold shutdown and Procedures AB1203.26, " Serious Control Room Fire", and AB 1203.02,

" Serious Station Fire Procedure", will be so revised prior to plant restart from the current outage. Therefore, 8-hour battery powered emergency lighting units are not required for this fire zone.

EE-3 501 As documented in V-9 404 IR 83-16, the Senior D-17 303 Resident Inspector has verified that the emergency lighting units in these rooms have been properly redirected.

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-* ' Dock t No.'50-346 Lican;s No. NPF-3 Serial No. 1-678-

.. November 7,'1986

. Attachment 1 Fire Zone Room Resolution J-1 318 Batteries for emergency R-1 324 lighting units in these rooms were replaced.

Documentation to this effect was reviewed by an NRC Region III inspector during a follow-up inspection as discussed in IR 85-028.

Date When Full Compliance Will be Achieved Full compliance will be achieved upon implementation of the modifications committed in the CAR which are scheduled to be completed prior to the end of the sixth refueling outage and upon NRC approval of_the exemption request submitted in Toledo Edison's letter dated March 6, 1986.

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_, Docket N2. 50-346 License No.-NPF-3 Serial No. 1-678 November'7, 1986 Attachment 1 Noncompliance The reactor coolant pump oil collection systems are 83-16-07 not large enough to hold the entire lubricating oil systems inventory (83-16-07).

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved In letter dated September 13, 1983 (Serial 986),

Toledo Edison submitted a preliminary review of the reactor coolant pump oil collection system. Toledo Edison committed therein to submit an exemption request subsequent to a determination that the as-built conditions would ensure the proper drainage of any overflow such that it would not present a fire hazard.

In letter dated September 30, 1983 (Serial No. 991), i TED requested such an exemption from Appendix R, l Section III.0 to obviate the need for the oil collec- ,

tion system to hold the entire lubricating oil system l inventory. The NRC approved the exemption request in j letter dated August 20, 1984 (Log No. 1586). This  :

noncompliance was closed by an NRC Region III followup inspection as documented in IR 85-028, dated November 22, 1985 (Log 1-1280).

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli- ,

ance was closed by an NRC Region III follow-up inspec-tion as documented in IR 85-028, dated l; November 22, 1985. j l

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- .; Dockct No. 50-346 License No. NPF-3 Serial No. 1-678

.. ' November 7, 1986

-Attachment 1 Noncompliance Lack of a 1-hour fire barrier in various conduits and 83-16 junction boxes in Rooms 314 and 328 (missing wrapping.

and partial wrapping) (83-16-11).

Response: Acceptance or Denial of the Alleged Noncompliance

.ToledofEdison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Room 314 is in Fire Area DJ, and Room 328 is in Fire Area T. As documented in the CAR, these fire areas were analyzed and proposed modifications and procedure revisions were determined necessary to bring Fire Areas DJ and T into compliance with 10CFR50, Appendix R.

However, no outstanding fire barrier modifications for Fire Area T are identified by Revision-1 of the CAR and one circuit (IPBE 1234A) located in Fire Area DJ was identified to require a fire barrier (CAR Section 4.DJ, Note 12). As stated in Toledo Edison letter dated June 3, 1986 (Serial No.-1253), the physical modifications will be completed prior to the end of the sixth refueling outage'and the procedure revisions will be completed prior to plant restart from the current outage.

The followfng specific concerns were cited in Paragraphs 4h '

and 8b of IR 83-16:

a. In Fire Area T, Conduits 36010C, 37452A, 37450B, 47342B, 37474A and 37035A were without fire barriers that totally enclosed the equipment.

b. In various locations,. temperature and flow monitoring instrumentation was not protected by a fire barrier.

c. Junction boxes JB 3715, JB 3716 and JB 3718 were not protected by a fire barrier.

d. In Fire Area T, conduits 36011A, 36203A and 36111A containing the power cables for the CCW pumps were not protected by a fire barrier.

e. Conduits located in Room 53 and needed for the operation of Service Water System va.' ,o SW-2929, SW-2930, SW-2031 and SW-2032 were found to have worn Kaowool wrapping and, in one case, the

! Kaowool wrapping for Conduit 30526 was incomplete.

17

.- Dock t Na. 50-346 Lic;nra N3. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 As a result of the CAR analysis, the following resolutions have been developed for these specific concerns cited in IR 83-16, Paragraphs 4h and 8b:

a. Conduit Resolutions 47342B Does not contain circuits required to satisfy Appendix R.

37035A No physical modifications or 37452A procedure revisions are necessary since their fire-induced failure would be inconsequential.

37450B No physical modifications or procedure revisions are necessary since its redundant train is accredited for safe shutdown.

36010C Has been verified to be wrapped with a fire barrier during NRC Region III fol-low-up inspection as docu-mented in IR 84-10, dated July 5, 1984 (Log 1-988).

37474A Will not be wrapped with a fire barrier but a revision to procedure AD 1203.02,

" Serious Station Fire Proce-dure," will be made to establish temporary component cooling water pump room ventilation as an alternative shutdown capability.

b. The numerous monitoring instruments considered as safe shutdown components are listed in Appendix A of the CAR. Section C of the CAR describes the physical modifications, procedure revisions, and/or exe:nptions necessary to establish compli-ance with Appendix R.

c. Junction boxes JB3715, JB3716 and JB3718 have been wrapped and so verified by an NRC Region III follow-up inspection documented in IR 84-10, dated July 5, 1984 (Serial 1-988).

18

- .. . Dock;t Na. 50-346'.

Lic;nac Ns. NPF-3 Serial No. 1-678

.y . November 7, 1986 Attachment.1'

d. The component cooling water pumps (CCWP) as well

~

as their power circuits contained in conduits 36111A, 36203A and 36011A are located in Fire Area T. In letter dated November 23, 1982 (Log-No. 1138), the NRC granted an exemption from Appendix R to obviate the need for one-hour fire barriers for components in Fire Area T. These conduits are considered to be part of the CCWP and are addressed by this approved exemption.

e. Room 53 is located in Fire Area II. For a fire in this area, one of the Service Water System

! valves, SW-2929, 2930, 2931 or 2932, must be open to ensure service water discharge. One of these valves is administrative 1y controlled open and I depowered. Consequently, a fire in this area would not affect'the safe shutdown function of

. the valves, and their related conduits and raceways do not require a fire barrier, i Date When Full Compliance will be Achieved As stated on Toledo Edison letter dated June 3, 1986 (Serial No. 1253), the physical modifica-tions will be completed by the end of-the sixth refueling outage and the procedure revisions will be completed prior to plant restart from the current outage.

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. Dock:t No. 50-346 Lic n s No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment-1 Noncompliance Failure to establish a fire watch after finding 83-16-13 inoperable fire dampers (83-16-13)

Response Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Once Toledo ~ Edison management became' aware of the fire damper failures as a result of the demonstration tests performed on July 27, 1983 during the NRC Region III inspection, corrective action was taken to' return the fire barrier to an operable status as discussed in LER 83-41, dated August 26, 1983. Surveillance Test

Procedure ST 5016.11. " Fire Protection System Barrier Surveillance Test," was revised on August 26, 1983 to more clearly indicate the administrative steps to be taken in order to establish a fire watch when a' fire damper is found not to be operable. As stated in IR 83-16, Part II, the inspector verified that Procedure ST 5016.11 had been revised and its implementation was observed by the inspector.on September 8, 1983 and found to be acceptable. As discussed in IR 86-06 dated February 28,.1986 (Log 1-1342), this failure to establish a fire watch was viewed as an isolated personnel error and is considered closed.

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli-ance was closed by the NRC Region III in-IR 86-06 dated February 28, 1986.

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, _ . _ . _ . . _ _ _ . , , _ . . _ , . . . _ . . . . . . , , _ _ . . , , , , _ . , . . _ - - _ _ , . - _ _ _ _ . _ _ , . _ _ . _ _ , . . _ _ . _ . . . _ _ . . . ~ . _ _ _ _ - - _

. Dock 2t No. 50-346 License No. NPF-3 Serial No. 1-678

.. November 7, 1986 Attachment 1 Noncompliance Failure to control modifications to fire doors (83-16-15) 83-16-15 Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved As a result of the NRC Region III inspection leading to IR 83-16, Toledo Edison evaluated the fire resis-tive capabilities of Security Doors 320, 321, 322, 323, 427 and 428 and of pressure doors 215, 601 and 602. Two additional security doors, 332 and 605, were later evaluated. These security and pressure doors were considered to be 3-hour fire barriers at the time of the NRC inspection.

Based on this evaluation, these security and pressure doors were declared inoperable and fire watches were established in accordance with Technical Specifi-cation 3.7.10. Toledo Edison committed in LER 83-069 dated April 26, 1984 to consider replacing the doors with new UL-listed fire doors and associated UL-listed hardware, modifying existing doors to comply with UL and NFPA requirements, or preparing an exemption request.

Toledo Edison has completed its review of the actions necessary to resolve the fire resistive capability of these security and pressure doors. For Door 215, an exemption from Appendix R to obviate the need for a 3-hour fire barrier was granted in NRC letter dated August 20, 1984 (Log No. 1586).

Doors 601 and 602 were evaluated and are not required to be 3-hour fire barriers as documented in Revision 7 of the FHAR. Fire Doors 601 and 602 separate Fire Areas DH and HH. Both of these fire areas contain Train 1 components that were analyzed to assure protection from fire damage. Appendix R requires a 3-hour fire barrier to separate redundant train components, not components of an identical train.

Since Fire Areas DH and HH both contain Train 1 protected components, Doors 601 and 602 do not sepa-rate redundant components and need not be 3-hour fire barriers.

21

Dock;t Na. 50-346 Lic nis No. NPF-3 Serial No. 1-678

, November 7, 1986 Attachment 1 The remaining eight security doors were inspected by Underwriter's Laboratory. Based on the results of this inspection, Toledo Edison will replace these eight security doors (Doors 320, 321, 322, 323, 332, 427, 428 and 605) with UL-approved, 3-hour fire doors.

This physical modification is scheduled to be complet-ed by the fifth refueling outage.

To control modifications and maintenance on fire doors, administrative procedures now direct Mainte-nance Work Orders affecting fire doors to be reviewed by the fire protection coordinator and require an operability inspection by Surveillance Test Procedure ST 5016.17. " Fire Door Inspection." A new maintenance procedure will be developed to further establish inspection criteria.

Date When Full Compliance will be Achieved Full compliance will be achieved upon the development of a new maintenance procedure and the installation of the aforementioned fire doors. The maintenance procedure is scheduled for development by December 31, 1986 and the installation of the fire doors is sched-uled for completion by the fifth refueling outage.

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.. Dockst Ns. 50-346 Lic:nga Ns. NPF-3 Serial No. 1-678

. ~ November 7, 1986 Attachment 1 Noncompliance Failure to develop and implement adequate surveillance 83-16-22A. test procedures for fire pump testing (83-16-22A)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Surveillance Test ST 5016.08, " Electric Fire Pump Annual Flow Test," was revised to specify a " shut-off" test, to measure the pump vibration at peak load conditions and to develop a fire pump characteristic curve. Surveillance Test ST 5016.12, " Diesel Fire Pump Annual Flow Test," was also revised to specify a

" shut-off" test, to measure pump speed (rpm) and flow to 150 percent of rated capacity at 65 percent of rated head, to measure pump vibration at peak load conditions and to develop a fire pump characteristic curve. This noncompliance has been closed by NRC Region III follow-up inspections documented in IR 85-028, dated November 22, 1985 (Log No. 1-1280), and IR 86-006, dated February 28, 1986 (Log No. 1-1342).

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli-ance has been closed by NRC Region III follow-up inspections as documented in IR 85-028 and IR-86-006.

23 l

. Dock:t Ns. 50-346 License No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 Noncompliance Failure to develop and implement adequate surveillance 86-13-22B test procedures for fire protection system valves operability (86-13-22B)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Toledo Edison has evaluated its program for providing supervision of fire protection system valves. This program will be revised by December 31, 1986 to inspect locked valves on a monthly basis and unlocked valves on weekly basis.

Date When Full Compliance will be Achieved Full compliance will be achieved upon revising the program for supervising fire protection system valves, which is scheduled for completion by December 31, 1986.

1 1

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, Dockst Ns. 50-346 Licence No. NPF-3 Serial No.'l-678

.. November 7, 1986 Attachment 1 Noncompliance . Failure to develop and implement adequate surveillance 83-16-22C test procedures for automatic sprinkler systems (83-16-22C)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison denies the alleged noncomp1'.ance.

Basis for Denial IR 83-16 Paragraph 14C etated that the test results of Surveillance Test Procedure ST 5016.07, " Fire Protection System Automatic Sprinkler System," did not verify simulation of the actuation of the most remote sprinkler head by opening the inspector's test valve.

An NRC Region III followup inspection was performed and determined that the surveillance of the inspec-tor's test valve was conducted and had been conducted since at least 1981. This followup inspection closed this noncompliance and is documented by IR 85-028 dated November 22, 1985 (Log No. 1-1280).

Date When Full Compliance will be Achieved Full compliance has been in effect at Davis-Besse prior to and since NRC Region III inspection leading to IR 83-16. This noncompliance was closed by NRC <

Region III in IR 83-28 dated November 22, 1985.

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., Dockst No. 50-346 Licenso No. NPF-3 Serial No. 1-678

.. . November 7, 1986 Attachment 1 Noncompliance. Failure to develop and implement adequate surveillance 83-16-22D test procedures for fire detectors (83-16-22D)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved IR 83-16, Paragraph 14.d states Surveillance Test Procedures ST 5016.06, " Fire Detector Functional Test," did not specify measurement of sensitivity, periodic cleaning and adjustment of photo-electric fire-detectors and specifies an unsafe practice in the use of an "open flame" to test fire detectors.. An NRC Region III followup inspection determined that the aforementioned procedure allows use of a Maintenance Work Order in conjunction with the performance of the test to document and correct any deficiencies such as cleaning or adjustment and that the reference to an "open flame" was removed from the procedure. It should be noted that the open flame referenced in the procedure was never used at any time to test the detectors at Davis-Besse. An NRC Region III follow-up inspection closed the noncompliance as documented in IR 85-028 dated November 22, 1985 (Log No. 1-1280).

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli-ance was closed by the NRC Region III follow-up inspection in IR-85-28 dated November 22, 1985.

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D;ck:t Ns. 50-346 Licin2 No. NPF-3 Serial No. 1-678 i November 7, 1986 Attachment 1

~

Noncompliance Failure to develop and implement adequate surveillance 83-16-22E test procedures for the emergency lighting units (83-16-22E)-

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Periodic Test Procedure PT 5112.01, " Emergency Light-ing System Test," was revised to include quarterly surveillance of emergency lighting units, an 8-hour discharge test and the lighting unit's manufacturer recommendations for periodic replacement of the batteries. This noncompliance was closed by an NRC Region III followup inspection documented in IR 85-028, dated November 22, 1985 (Log No. 1-1280).

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli-ance was closed by NRC Region III followup inspection in IR 85-028, dated November 22, 1985.

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Dockat Ns.~ 50-346

'*~

License No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment.1--

Noncompliance Failure to develop adequate procedures controlling 83-16-22F physical examinations for fire brigade members (83-16-22F)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Procedure AD 1810.00, " Fire Protection Program,"

requires fire brigade members to complete the respira-tory protection plan in accordance with Procedure HP 1605.02, " Respiratory Equipment." This procedure requires each individual certified to wear respiratory protection equipment, including fire brigade members, to have an initial physical examination with an annual spirometer test. Thereafter, a physician will annual-ly review each certified individual's medical status.

The resolution of this noncompliance was reviewed by an NRC Region III inspector and found acceptable as documented in IR 85-28, dated November 22, 1985 (Log No. 1-1280).

Date When Full Compliance will be Achieved Full compliance has been achieved and this noncompli-ance was closed by an NRC Region III follow-up inspec-tion in IR 85-28, dated November 22, 1985.

28

Docket No 50-346

• - Licen;3 No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 Noncompliance Failure to develop adequate administrative procedures 83-16-22G requiring fire prevention and use of fire protection equipment for personnel performing fire watch duty (83-16-22G)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Administrative procedure AD 1828.19, " Fire Protection Qualification Program," was revised to include the minimum instructions contractors and onsite personnel are to receive to qualify as a fire watch for open flame, welding, grinding and cutting operations.

These instructions consist of both classroom training and practical training in the use of fire extinguish-ers. Fire watch requalification is required on an annual basis. Additionally, a second type of fire watch, called the " Fire Barrier Watch," was incorpo-rated into the procedures to monitor potentially degraded fire dampers, barriers and other items that potentially degrade the adequacy of the fire protec-tion program. Procedure AD 1844.07, "Open Flame, Welding, Cutting and Grinding Permits," also includes the responsibility for the fire watch to remain _at the work area for a minimum of thirty minutes after the work activity is completed in order to check for smoldering fires.

This noncompliance was closed by an NRC Region III follow-up inspectiop documented in IR 85-028, dated November 22, 1985, (Co'g- No. 1-1280)

! Date When Full Compliance will be Achieved I Full compliance has been achieved and this nonconfor-mance has been closed by NRC follow-up inspection in IR 85-028, dated November 22, 1985.

29 I

Dock;t N3.30-346 License No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 1 Noncompliance Failure to develop adequate admin'istrative procedures 83-16-22H identifying the duties and responsibilities of the off site fire department when responding to a site fire (83-16-22H)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved In October 1983, Toledo Edison initiated a revision to the Emergency Plan that would require the off-site fire department to function under the direction of the Davis-Besse Fire Brigade when responding to a site fire. The Emergency Plan Modification Request was submitted to the NRC Region III in Toledo Edison letter dated November 16, 1983 (Serial No. 1-390).

This modification is currently incorporated in Rev. 10 of the Emergency Plan. This noncompliance was closed by an NRC Region III followup inspection documented in IR 85-28, dated November 22, 1985 (Log No. 1-1280).

Date When Full Compliance will be Achieved Full compliance has been achieved and the noncompli-ance has been closed by IR 85-28, dated November 28, 1985.

30

Dockst'No. 50-346

~~-

Licsnso Ns. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 Noncom'pliance Failure'to4 adhere to staffing qualification requirements-83-16-22I~ for fire protection program implementation (83-16-221)

Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and.Results Achieved Aa documented in IR 85-28, dated November 22, 1985 (Log No. 1-1280),'and IR 86-06, dated February 28, 1986 (Log No. 1-1342), NRC Region III has conducted

!- followup inspections which have closed this noncom-

, pliance. The followup inspections determined that Davis-Besse had a sufficient number of qualified personnel responsible for implementation of the fire protection program, that the fire protection coordina-tors had academic and work experience which satisfied NRC guidelines, and that the fire protection engineer 1

was adequately qualified and devoted full time to fire  !

protection activities. Since the time of the i- followup inspection, the fire protection organization has been supplemented with full-time Toledo Edison and contractor personnel who have previous fire

protection experience or other technical expertise

• I necessary to conduct their assigned tasks.

i i Date When Full Compliance will be Achieved i Full compliance has been achieved and this noncompli- ,

j ance has been closed by NRC Region III in IR 85-28, dated November 22, 1985, and IR 86-06, dated February 28, i 1986.

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Dock t No.-50-346 Licznsa Ns. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 1 Noncompliance Inadequate test procedure ST 5016.11.1 failed to 83-16-22J indicate only one attempt is allowed to close the damper in determining operability (83-16-22J)

-Response: Acceptance or Denial of the Alleged Noncompliance Toledo Edison accepts the alleged noncompliance.

Corrective Action Taken and Results Achieved Surveillance Test Procedure ST 5016.11 " Fire Protec-tion System Barrier Surveillance Test," was revised on August 26, 1983 and requires testing of the fire damper from the installed position and allowing the damper to close unassisted. The damper is required to be cleaned after the first functional test, and a subsequent functional test is then required to verify the cleaning had not affected the damper's operabili-ty. The procedure further requires the Shift Supervi-sor to be immediately notified of inoperable fire dampers in order to establish continuous fire watches.

On September 8, 1983, an NRC Region III inspector verified that Procedure ST 5016.11 had been revised and found its implementation acceptable. This noncom-i pliance was closed in IR 86-06, dated February 28, 1986 (Log 1-1342).

Date When Full Compliance will be Achieved a Full compliaace has been achieved and this noncompli-ance was closed in IR 86-06, dated February 28, 1986.

i 32 J

es

=Dockst No. 50-346

?"- Licenno Ns. NPF-3

' Serial No. 1-678 November 7, 1986 Attachment 2 ATTACHMENT 2 CURRENT STATUS OF CORRECTIVE ACTIONS ASSOCIATED WITH STUDY GROUP REPORT ITEMS III.A.4 AND II.E.4 I

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, Dockat No. 50-346 Licens2 No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 2 INTRODUCTION In letter dated October 13, 1986 (Serial No. 1-674), Toledo Edison provid-ed a response to the Davis-Besse Study Group Report dated May 30, 1936 (Log No. 1-1394). This letter, however, states that the responses to Items III.A.4 and III.E.4 would be provided as a portion of the response to Inspection Report No. 50-346/83016, dated August 30, 1984 (Log No. 1-1024).

This attachment provides the response to those two items.

I 2

... : Dockst'Ns. 50-346

- Licsnas Ns. NPF-3

' Serial No. I-678

. -November 7, 1986 Attachment 2' Study Group Report. Continuing problems with fire and ventilation Item III.A.4 boundary doors closing / latching mechanisms. As of the time of this review, the licensee does not appear to have resolved these problems. See LERs 81-07, 81-42, 82-03, 82-16, 82-31, 82-43, 82-57,-83-06, 83-21, 85-14 and DVRs84-044, 85-087,85-095 and 85-116.

t

,[ Response Toledo Edison has reviewed numerous Licensee Event Reports (LERs) regarding the closing / latching mecha-nisms of fire and ventilation boundary doors. The

, scope of this review includes those LERs and Deviation Reports (DVR) identified by the Study Group Report.

The corrective actions specified by the LERs identi-fied in the Study Group Report have been completed and are considered by Toledo Edison to be closed.

The majority of the LERs regarding closing / latching mechanisms addressed in the Study Group Report involve fire doors. LERs 81-07 and 82-16 involve Doors 306 and 108, respectively, wt.ich are not fire doors.

These doors are not subject to the same surveillance and maintenance programs al fire doors. Additionally, the cause of the event 1 eating to LER 85-014 and associated DVR 85-087 was not related to a problem with the closing / latching mechanisms. Toledo Edison considers the corrective actions taken regarding these doors, as discussed in the LERs, to be adequate.

Toledo Edison, however, will continue to review reports documenting conditions adverse to quality, including LERs, for failure trends and potential root causes resulting in failures of "Q"-designated equipment.

The majority of fire doors at Davis-Besse are hollow-metal types. While there are a few solid-metal fire doors at Davis-Besse, these are for specialized purposes in addition to being fire barriers (such as containment hatch entry) and the review of the LERs has not established a history of closing / latching mechanism failures for solid metal fire doors.

Toledo Edison has completed an inspection of the 130 hollow-metal fire doors at Davis-Besse against the requirements of National Fire Protection Association (NFPA) Code 80, " Standard for Fire Doors and Windows,"

1976. The inspection included a verification of the closing / latching mechanisms as well as other function-al requirements. Of the 130 inspected fire doors, only two fire doors satisfied the inspection accep-tance criteria. While closing / latching mechanism 3

l Dock;t N2. 50-346 Liccn a Ns. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 2 failures were noted, the ilnepection identified two basic types of fire door problems: 1) physical damage to the door and; 2) failure to satisfy the maximum clearance between the door and the frame. Those doors not satisfying the inspection acceptance criteria were declared inoperable pending an evaluation of the inspection data. Compensatory measures have been established in accordance with the Technical Specifications.

An evaluation of the inspection data will be conducted by Toledo Edison and a member of the NFPA 80 board.

This evaluation will be completed by December 31, 1986. Based on the results of this evaluation, certain fire doors may be returned to an operable status and the remaining inoperable fire doors will be scheduled for rework. Compensatory measures in accordance with the Technical Specifications will remain in effect, as necessary, until the fire doors are returned to an operable. status.

To minimize future fire door failures, fire doors are inspected under Surveillance Test Procedure ST 5016.17

" Fire Door Inspection." A new maintenance procedure will be developed by December 31, 1986 to further establish inspection criteria. This matter will be addressed in a future revision to LER 86-027.

4

Dockat No. 50-346 License No. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 2 Study Group Report During the LER/DVR review, over 300 procedure viola-Item III.E. tions have been identified. This appears to be a significant number of violations. The areas that indicate the most concern are:

Item 4 Fire Protection, 19 incidents for fire doors open, 31 incidents of improperly sealed fire barrier penetra-tions, eight incidents of inadequate fire watch, and 13 incidents of equipment inoperable.

Response: Each of the individual areas of concern is addressed by a separate response.

a. 19 Incidents of Fire Doors Open Toledo Edison has reviewed numerous Licensee Event Reports (LER) regarding open fire doors, including those identified by Attachment C of the Study Group Report. The underlying cause for the majority of these incidents was personnel error due to blocking open a fire door without establishing a fire watch in accordance with the Technical Specifications. The corrective actions specified by these LERs include the installation of signs on fire doors, revisions to procedures and General Orientation Training, and personnel counseling and disciplinary actions. These corrective actions have been completed and are consid-ered closed.

As discussed in response to Study Group Report Item III.A.4, the fire doors are undergoing an opera-bility evaluation and, the majority of the fire doors are considered inoperable and are addressed by fire watches. As a result, there has been no recent LER regarding blocked open fire doors without compensatory measures taken in accordance with the Technical Specifications.

Upon returning the fire doors to an operable status, Toledo Edison believes that the current General Orientation Training, procedures and personnel atten-tiveness will be sufficient to minimize these inci-dents in the future. Toledo Edison, however, will continue to review reports documenting conditions adverse to quality, including LERs, for trends and potential root causes resulting in failures of "Q-designated" equipment.

b. 31 Incidents of Improperly Sealed Fire Barrier Penetrations l

Toledo Edison has reviewed numerous Licensee Event Reports (LERs) regarding improperly sealed fire 5

Dock;t No. 50-346 Licnn o N;. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 2 barrier penetrations. The reviewed LERs included those identified by Attachment C of the Study Group Report (LERs80-008, 81-022,81-046, 81-068,81-072, 82-036 and 83-058). The corrective actions specified by these LERs identified in Attachment C have been completed and are considered closed. However, Toledo Edison has determined from this review that the underlying causes of the majority of these LERs are attributed to personnel errors and procedure and construction deficiencies.

Resolution of the penetration construction deficien-cies has most recently been addressed in Toledo Edison's letter dated July 10, 1986 (Serial No. 1285).

As discussed therein, Toledo Edison has previously provided the NRC with detailed test documentation supporting the Davis-Besse fire barrier penetration seal configuration in letter dated June 25, 1986 (Serial No. 1267) and is currently implementing a program to verify the adequacy of the installed Davis-Besse penetration seals. This verification program includes the 1) replacement of 100% of the boot penetration seals, 2) a verification of the as-built installations versus the tested configura-tions for the penetration seals, and 3) the perfor-mance of a surveillance test to ensure the degradation of penetration seals, other than boot seals, is within the acceptance criteria.

Currently, boot penetration seals necessary for fire barrier requirements are being expeditionely replaced in order to complete as many as possible prior to restart from the current outage. Those boot penetration seals necessary to satisfy only flood barrier requirements have been installed.

For penetration seals other than boot seals, LER 86-034 discusses the status of the ongoing penetration verification program which, at that time, identified 65 penetration seals to be inoperable. The verification of the remaining penetration seals is continuing and is expected to be completed by December 31, 1986. At this time, those penetration seals not verified have been administrative 1y declared inoperable. Appropri-ace fire watches are currently established for those penetration seals determined to be and declared to be inoperable and will remain in effect until the seals are returned to an operable status.

Resolution of the personnel errors and procedure i deficiencies as a cause for improperly sealed fire barrier penetrations includes a revision to a proce-dure and the establishment of a penetration seal

. Dockat N3. 50-346 License Ns. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 2 configuration management program. Surveillance Tent Procedure 5016.11, " Fire Protection System Barrier Surveillance Test," addresses the periodic visual verification of penetrations and has been revised to more clearly indicate the administrative steps to be taken in order to establish a fire watch when a fire barrier penetration is inoperable.

The penetration seal configuration management program is currently being implemented. The program will include the development of design basis documents and procedures to control those documents and the instal-lation and repair of penetration seals. The design documents will include penetration drawings and a penetration schedule identifying the penetrations by unique plant identification number and specifying their location, seal material and configuration.

The development of a definitive schedule to complete the penetration seal configuration management program is pending the completion of the ongoing surveillance of the penetration seals, which is scheduled for comple-tion by December 31, 1986. Toledo Edison, however, anticipates the program to be implemented by the end of the fifth refueling outage.

c. 8 Incidents of Inadequate Fire Watch Toledo Edison has reviewed numerous Licensee Event Reports (LERs) regarding the failure to"estiblish.a fire watch. The reviewed LERs included those identi-fled by Attachment C of the Study Group Report (LERs79-115, 81-65, 82-48 and 83-67). The corrective actions specified by these LERs have been completed and are considered closed.

It should be noted that IR 83-16 also identifies as a noncompliance (83-16-13) an instance when fire watches were not established. Resolution of this matter included revising a surveillance test procedure to more clearly indicate the administrative steps to be taken when a fire barrier is found inoperable. This noncompliance was closed by an NRC Region III followup inspection which viewed the failure to establish a fire watch as an isolated personnel error. Toledo Edison concurs with the view of the NRC Region III inspection and, based on the review of the aforemen-tioned LERs, determined that there is no single cause of the previous incidents.

7

. Dockst Ns. 50-346

' License No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 2 i

Currently, roving and continuous fire watches have been established due to fire barrier evaluations at Davis-Besse. These fire watches will remain in effect, as necessary, until acceptable. fire barriers have been established. Toledo Edison believes that the current administrative procedures and training for personnel responsible to establish fire watches are adequate to preclude instances of this type in the future.

Toledo Edison, however, considers any instance of failing to establish a fire watch to be unacceptable.

A. revision to administrative procedure AD 1810.04,

'" Administrative Controls for Fire Detection Systems and Fire Boundaries (Dampers, Doors, and Barriers),"

will be issued by December 31, 1986 to identify the fire _ barriers by unique plant identification numbers and to distinguish those fire barriers that require continuous versus roving fire watches. In the inter-im, the fire barriers have been identified to the Davis-Besse Operations Department in memorandum.

d. 13 Incidents of Equipment Inoperable Based on the number of instances specified by the Study Group Report, Toledo Edison believes the NRC is referring to the fire protection equipment other than fire barriers (i.e. walls, doors, dampers and penetrations).

Toledo Edison has reviewed numerous Licensee Event Reports (LER)~regarding inoperable fire protection equipment other than fire barriers. The reviewed LERs included those identified by Attachment C of the  !

Special Group Report (LERs79-127, 79-134,80-021, 80-026,80-070, 82-056,83-025 and 83-033). The corrective actions specified by these LERs have been completed and are considered closed.

The review of these LERs did not identify a pattern of identical or similar equipment failure. Toledo Edison believes that the failures were isolated incidents and ,

were adequately resolved by the specified corrective  :

actions and that additional actions are not necessary.

In letter dated October 13, 1986 (Serial No. 1-674)

Toledo Edison provided a response to the Davis-Besse Study Group Report dated May 30, 1986 (Log No. 1-1394).

That letter describes the substantial changes and enhancements made to the equipment maintenance program at Davis-Besse. The discussions in the letter are applicable to fire protection equipment.

8

Dockr,t No. 50-346 Lic:n:o N3. NPF-3 Serial No. 1-678 November 7, 1986 Attachment 3 ATTACHMENT 3 REFERENCES l

1

Dock;t N2. 50-346 Lic;nco No. NPF-3 Serial No. 1-678

. November 7, 1986 Attachment 3 These references are referred to in Attachments 1 and 2. The Toledo Edison Log and Serial numbers and abbreviations used in the attachments are included where applicable.

A. NRC Letters and Other Documents

1. U.S. Code of Federal Regulations. Title 10, Part 50, Appendix R.

2. NRC I.E Inspection Report 50-346/83-016, dated August 30, 1984, Log No. 1-1024 (IR 83-16).

3. NRC (A. DeAgazio) to Toledo Edison (R. P. Crouse) Letter,

" Exemption from Certain Requirements of Appendix R to 10CFR50,"

dated August 20, 1984, Log No. 1586.

4. NRC I.E. Inspection Report 50-346/86-028, dated November 22, 1984, Log No. 1-1280 (IR 85-028).

5. NRC I.E. Inspection Report 50-346/86-06, dated February 28, 1986, Log No. 1-1342 (IR 86-006).

6. NRC I.E. Inspection Report 50-346/84-10, dated July 5, 1984, Log No. 1-988 (IR 84-10).

7. Appendix A to the Branch Technical Position APCSB 9.5-1,

" Guidelines for Fire Protection for Nuclear Power Plants Docketed Prior to July 1, 1976," dated August 23, 1976.

8. U.S. Code of Federal Regulations, Title 10, Part 50, Appendix A, General Design Criterion 3.

9. NRC (R.W. Reid) to Toledo Edison (L. E. Roe) Letter, " License Amendment and Safety Evaluation Report," dated July 26, 1979, Log No. 409.

10. NRC to Toledo Edison (J. Williams) Letter, " Davis-Besse Study Group Report," dated May 30, 1986, Log No. 1-1394.

11. NRC (D. G. Eisenhut) to Toledo Edison (R. P. Crouse) Letter,

" Exemption from Certain Technical Requirements," dated November 23, 1982, Log. No. 1138.

B. Toledo Edison Letters and Other Documents

1. Davis-Besse Appendix R Compliance Assessment Report, Revision 1, dated March 6, 1986 (CAR).

2. Toledo Edison (J. Williams) to NRC (J. F. Stolz) Letter,

" Inspection Response," dated June 3, 1986, Serial No. 1253.

1

3. Toledo Edison (J. Williams) to NRC (J. F. Stolz) Letter, "Exemp-tion Requests," dated March 6, 1986, Serial No. 1255.

2

Dockst Na. 50-346 License No. NPF-3 Serial No. 1-678

, -November 7, 1986 Attachment 3

4. Toledo Edison (R. P. Crouse) to NRC (D. G. Eisenhut) Letter,

" Inspection Response," dated September 13, 1983, Serial No. 986.

5. Toledo Edison (R. P. Crouse) to NRC (D. G. Eisenhut) Letter,

" Exemption Requests," dated September 30, 1986, Serial No. 991.

6. Toledo Edison (R. P. Crouse) to NRC (J. G. Keppler) Letter,

" Completion Documents for Fire Protection Actions," dated November 16, 1983, Serial No. 1-390.

7. Davis-Besse Fire Hazard Analysis Report, Revision 7, dated March 6, 1986 (FRAR).

8. Davis-Besse Emergency Plan, Revision 10, dated August 7, 1986.

9. Toledo Edison (J. Williams) to NRC (C. E. Norelius) Letter,

" Response to Davis-Besse Study Group Report," dated October 13, 1986, Serial No. 1-674.

10. Toledo Edison (J. Williams) to NRC (J. F. Stolz) Letter, " Status of Fire Protection Program Activities," dated July 10, 1986, Serial No. 1285.

11. Toledo Edison (J. Williams) to NRC (J. F. Stolz) Letter, " Davis-Besse Penetration Seals," dated June 25, 1986, Serial No. 1267.

C. Toledo Edison Procedures

1. Emergency Procedure, EP 1202.02, " Station Blackout"

2. Abnormal Procedure, AB 1203.02, " Serious Station Fire Procedure."

3. Abnormal Procedure, AB 1203.26, " Serious Control Room Fire."

4. Surveillance Test Procedure, ST 5016.11. " Fire Protection System Barrier Surveillance Test."

5. Surveillance Test Procedure, ST 5016.08, " Electric Fire Pump Annual Flow Test."

6. Surveillance Test Procedure, ST 5016.12, " Diesel Fire Pump Annual Flow Test."

7. Surveillance Test Procedure, ST 5016.07, " Fire Protection System Automatic Sprinkler System."

8. Surveillance Test Procedure, ST 5016.06, " Fire Detector Function Test."

9. Periodic Test Procedure, PT 5112.01, " Emergency Lighting System Test."

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Dockst No. 50-346 -

Licanas Ns. NPF-3 Serial No.'l-678

, November 7, 1986 Attachment 3

10. Administrative Procedure, AD 1810.00, " Fire Protection Program."

'11. Health Physics Procedure,-HP 1605.02, " Respiratory Equipment."

12. Administrative Procedure, AD 1828.19, " Fire Protection Qualifi-cation Program."

13. Administrative Procedure, AD 1844.07, "Open Flame, Welding, Cutting and Grinding Permits."

14. Surveillance Test Procedure, ST 5016.17, " Fire Door Inspection."

15. Administrative Procedure, AD 1810.04, " Administrative Controls for Fire Detection Systems and Fire Boundaries (Dampers, Doors and Barriers."

D. Toledo Edison Licensee Event Reports (LERs) and Deviation Reports (DVRs).

2. Deviation Report,84-044, dated March 29, 1984.

2. Deviation Report,85-087, dated May 5, 1985.

, 3. Deviation Report.85-095, dated May 19, 1985.

4. Deviation Report.85-116, dated August 8, 1985.

5. Licensee Event Report,79-115, dated December 20, 1979.

, 6. Licensee Event Report,79-127, dated January 5, 1980.

l 7.- Licensee Event Report,79-134, dated January 24, 1980.

8. Licensee-Event Report,80-008, dated February 13,- 1980.

l 9. Licensee Event Report,80-021, dated April 10, 1980.

I 10. Licensee Event Report,80-026, dated April 25, 1980.

i

11. Licensee Event Report,80-070, dated April 10, 1981.

12. Licensee Event Report,81-007, dated February 20, 1981.

13. Licensee Event Report,81-022, dated May 4, 1981.

14. Licensee Event Report,81-042, dated August 20, 1981.

[

15. Licensee Event Report,81-046, dated December 18, 1981.

16. Licensee Event Report,81-065, dated November 10, 1981.

17. Licensee Event Report,81-068, dated March 15, 1982.

4

o Dockst No. 50-346 Lic:nra N3. NPF-3 Serial No. 1-678 0 November 7, 1986 Attachment 3

18. Licensee Event Report,81-072, dated January 8, 1982.

19. Licensee Event Report,82-003, dated February 5, 1982.

20. Licensee Event Report.81-016, dated April 29, 1982.

21. Licensee Event Report.82-031, dated September 28, 1982.

22. Licensee Event Report,82-036, dated September 7, 1982.

23. Licensee Event Report.82-043, dated September 29, 1982.

24. Licensee Event Report,82-048, dated October 14, 1982.

25. Licensee Event Report,82-056, dated December 2, 1982.

26. Licensee Event Report.82-057, dated July 6, 1984.

27 Licensee Event Report,83-003, dated February 16, 1983.

I

28. Licensee Event Report,83-006, dated February 25, 1983.

29. Licensee Event Report,83-021, dated May 31, 1983.

30. Licensee Event Report,83-025, dated September 22, 1983.

31. Licensee Event Report,83-034, dated September 22, 1983.

32. Licensee Event Report.83-041, dated August 26, 1983.

33. Licensee Event Report.83-058, dated November 18, 1983.

34. Licensee Event Report,83-067, dated December 29, 1983.

35. Licensee Event Report,83-069, dated April 26, 1984.

36. Licensee Event Report,85-014, dated July 12, 1985.

37. Licensee Event Report,86-017, dated April 30, 1986.

38. Licensee Event Report,86-027, dated July 31, 1986.

39. Licensee Event Report,86-034, dated September 5, 1986.

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