IR 05000354/1986052

Operational Team Insp Rept 50-354/86-52 on 861020-31. Violation Noted:Special Trailer Used for Storage of Radiographs Had Flooring Damage Caused by Excessive Moisture & Humidity

ML20207N135
Person / Time
Site:	Hope Creek
Issue date:	12/12/1986
From:	Norrholm L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20207N133	List: IR 05000354/1986052 ML20207N131 ML20207N134
References
50-354-86-52, NUDOCS 8701140007
Download: ML20207N135 (34)

Text

.

..

+

U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report N /86-52 Docket N License No. NPF-57 Licensee: Public Service Electric and Gas Company Facility: Hope Creek Generating Station Conducted: October 20, 1986 - October 31, 1986 Inspectors:

L. J. Norrholm, Chief, Reactor Projects Section 2B T. P. Johnson, Senior Resident Inspector, Peach Bottom A. J. Luptak, Senior Resident Inspector, FitzPatrick L. R. Plisco, Senior Resident Inspector, Susquehanna G. Napuda, Lead R tor Engineer G. A. Sly M t.telle, PNL l

\

Approved by: - M 4 L. J. bbrrfybim, Chief,ReactorProjects (dat6 Secti'on'2B Inspection Summary: Inspection on October 20-31, 1986 (Report No. 50-354/

86-52).

Areas Inspected: Special announced operational team inspection of Hope Creek Generating Station management controls over operational, surveillance, main-tenance, quality assurance, engineering support, design change, and safety re-view activities. The inspection involved 344 hours0.00398 days <br />0.0956 hours <br />5.687831e-4 weeks <br />1.30892e-4 months <br /> on site by four inspectors, a contractor, and team leade Results: One violation was identified relating to document storage. In addit-ion, the following strengths and weaknesses (requiring licensee attention and/

or written response) were evident. These strengths and weaknesses are discus-sed in detail in the attached inspection repor Strengths: (1) Control room operators were knowledgeable and in contro Shift briefings were effective, procedures were routinely used, alarm and event response were good, and safety perspective was evident. (2) Department inter-face activities were supported by multiple interdepartmental meetings at sev-eral levels. (3) The Inspection Order system is an effective management tool 990Il90007 t?e leC Ahoc PD orsoossy 7

.

..

.

for surveillance and preventive maintenance scheduling. Non-Technical Specifi-cation preventive maintenance appears well developed. (4) The Quality Assur-ance program is complete and effective. Audits are timely and use technical specialist (5) The Work Control Group is a useful technique for preparing work activities with a minimal impact on control room operators. (6) Onsite Safety Review and SORC are qualified, inquisitive, timely, and demonstrate good safety perspectiv Weaknesses: (1) An excessive number of control room overhead annunciators are illuminated and some will not reflash on receipt of a new alarm input (Detail 3.3). (2) A number of administrative implementation problems were found in tagging, temporary modifications, log keeping, the surveillance overdue list, EMIT tags, and the LCO log index (Details 3.1,3.5,4.2.3,5.3,7.4). (3)

Operator accessibility to plant areas is hampered by unnecessarily locked doors and multiple key systems (Detail 3.4). (4) Document storage conditions and monitoring were inconsistent with the requirements of Regulatory Guide 1.8 (Detail 6.3). (5) Safety evaluations have been inconsistent in providing an explicit basis for unreviewed safety question determinations (Detail 7.1.3).

i

.

.

. .

.

OPERATIONAL TEAM INSPECTION HOPE CREEK GENERATING STATION TABLE OF CONTENTS Page 1.0 Scope......................................................... 4 2.0 Inspection Process............................................ 4-3.0 Operating Activities.......................................... 4 3.1 Shi f t Turnover and Log Entries. . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3.2- Controls for Paintenance and Surveillance................ 5 3.3 Con t rol Room Ann unci ato rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3.4 Key / Door Control......................................... 7 3.5 Safety Tagging........................................... 8 3.6 Procedure Usage......................................... 10 3.7 Independent Ve ri fi cation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.8 Observations During Plant Tours......................... 11 4.0 Maintenance Program.......................................... 12 4.1 Maintenance Management and Organization................. 12 4.2 Maintenance Procedures and Programs..................... 13 4.3 Review of Maintenance Work Activities................... 17 4.4 Primary Coolant Sources Outside Containment. . . . . . . . . . . . . 20 5.0 Surveillance Program......................................... 22 5.1 Surveillance Program Management......................... 22 5.2 Program Implementation.................................. 22 Observations............................................ 23 6.0 Quality Assurance............................................ 24 6.1 Organization and Program................................ 24 Implementation.......................................... 25 Conclusions............................................. 26 7.0 Management and Review........................................ 28 7.1 Engineering and Technical Support....................... 28 7.2 Station Operations Review Committee..................... 30 7.3 Nuclear Safety Review................................... 31 7.4 Tempo ra r y Modi fi cati o n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 7.5 Post-trip Reviews....................................... 32 8.0 Persons Contacted............................................ 33 9.0 Management Meeting........................................... 34

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

.

..

..

1.0 Scope Hope Creek Generating Station received its full power ~ license on July 25, 1986. To assess the facility's operational effectiveness, particularly as it applies to transition from the startup testing phase to normal opera-tion, NRC Region I conducted an' operational team inspection on October 20-31, 1986. The inspection focused on the adequacy of controls over operat-ional, surveillance testing, maintenance, quality assurance, engineering support, design change, and safety review activities by direct observat-ion, personnel interviews, and program review. Particular emphasis was placed on interfaces among the various groups responsible for planning,

'

accomplishment, and review, and on plant management oversight and review of these activities. In addition, an evaluation was made of plant read-iness to make the transition from startup testing to operational statu .0 Inspection Process The inspection team, consisting of a team leader, four inspectors, and a contractor, observed operational and turnover activities on all three shift Interviews were conducted with the General Manager - Hope Creek Operations, department heads, and the onsite QA manager. Comprehensive tours of the facility were conducted to observe operational, maintenance, surveillance, and quality assurance activities, and to assess plant equip-ment condition and housekeeping. The NRC senior resident and resident inspectors were not formally part of the team, but interacted frequently with the team regarding the conduct and findings of the inspectio .0 Operating Activities The inspection team observed control room activities including shift turn-overs and briefings on all three shifts encompassing 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of contin-uous shift coverage. The inspection included: randomly interviewing operators and supervisors; reviewing the operating staff (SNSS, NSS, NCO)

and turnover Tags; and examining operation and design reference material available in tne control room. Additional reviews were made of: the LC0 logs; standing orders; annunciator response books; as well as the perform-ance of normal, surveillance, and startup testing operations to ensure compliance with procedural guidanc The control room contained all the reference material necessary for safe plant operation (e.g., administrative, normal, abnormal, emergency proce-dures; P& ids; and electrical drawings). Interviews with the operators revealed that they were knowledgeable of the material in content and usag Overall, the Hope Creek operating staff was well informed, knowledgeable, and professional in the execution of facility operations. The operators demonstrated an awareness of plant status and ability to use available procedures and reference materia . - _ _

.

..

.

Detailed discussion of the areas reviewed is provided belo .1 Shift Turnover and Log Entries s

'

Review of OP-AP.ZZ-110(Q) - Rev.4, Use and Development of Operating Logs, and the operational narrative logs indicated that the logs were both inconsistent shift to shift and lacked detail. For example, the inspection team identified occasions in which a power reduction occur-red or a component operated improperly, and no entry was mad During the inspection, as the plant entered and exited a number of LCOs, the operating staff response was inconsistent. For example, when the maintenance staff reported that a main steam line radiation monitor had failed a channel check due to a typographical error in the surveillance procedure, the operating staff declared the channel inoperable and were preparing to shut down the reactor. Technical Specifications indicated that they were only required to trip the channel within one (1) hour. On another occasion, when the "A" core spray check valve failed to reseat following a HPCI surveillance, no mention of it was made in the logs, even though it took approximately one (1) hour to reseat the valve by draining off the upstream pres-sure. Technical Specifications indicated that an LC0 was entered, due to primary containment isolation failure. In each instance, the situation did not violate a Technical Specification action statement, but in one case an LCO was declared and in the other case it was no During a review of the licensee's Technical Specification Action Statement log, a deficiency was noted in that approximately four act-ion statements were not cleared from the index when no Action State-ment Log Sheet existed in the log. This indicates a lack of adminis-trative controls over, or lack of use of, the Technical Specification Action Statement Lo .2 Controls for Maintenance and Surveillance Currently, Hope Creek maintains an additional two (2) SR0s and two (2) R0s above the Technical Specification minimum staffing require-ment to assist in the control of maintenance and surveillance task One (1) SR0 and one (1) R0 per shift are assigned to the Work Control Group (WCG) to process maintenance and surveillance work orders. The other SRO acts as the work order process control clerk in the control room and has no operational duties except supervisor relief and Techn-ical Specification assistanc The second R0 is assigned to the field to assist in field operations, secondary verifications, and tag hangin The system maintains control over the flow of activities in a very effective manner. A licensed SR0 reviews and approves all work re-quests without the additional responsibility of maintaining facility operation . _ - -- . -- _ -

-. _ _ . . , _ _ .

__ - .. _._ _ .- _. _ _ _ _ .-- -

,

L

..

,x

!-

_

,

3.3 Control Room Annunciators

,

Hope _ Creek has approximately 450 active overhead annunciators in the

! control room. Each annunciator typically'has several (>8) alarm in-i- put Ten percent (46) are local panel alarms. Two percent (10)

have been identified as having invalid signals (eight continuously energized,-2 de-energized). A number.of other alarms.had been found 4 to have invalid signals but had not been so marked on the panel.

i During the team inspection, the reactor was at 50-75% power and the

control board annunciator panels displayed approximately 50 energized annunciator Observations and discussions with the operators indicated an overall understanding of each energized annunciator, with timely response to i new alarms. However, a number of concerns are discussed belo Operators were continuously responding to a number of periodic nuis-t ance alarms. The cause was identified as invalid signals or alarms

! caused by setpoints being too close to operating conditions. An

]- example was the Radiation Monitoring Alarm. This.particular alarm j had been marked as having some bad input signals and the operators 4- would have to silence the alarm then go to a back panel to verify the signal. This verification action was not always performed in a

timely fashion if at all.

'

Ten (10) annunciators had been marked by the licensee as having in-valid input signals. Discussions and review of an annunciator audit

. revealed more than 10 annunciators which were suspected as having invalid signals but which had not been identified by the operator aid L (red tape cross hatch). Most of the suspect signals were as a result of the vibration testing progra At the current operating condition of 70% power, approximately 50 alarms were energized. The underlying cause. appears to have origin- 1 ated from the annunciator reduction program, in which Hope Creek went from greater than 1600 overhead annunciators down to 450 annuncia-

tors. The consolidation of multiple annunciators, as well as plant operating design, has dictated that a number of annunciators will L

'

always be energized. For instance, the condensate.demineralizer annunciator will always be energized because one (1) demineralizer is

! always unused in the present mode of operation.

!-

It was also observed that, once an alarmed annunciator had been ac-

knowledged and the initiating signal clears subsequent to alarm ac-l_ knowledgement, the annunciator would de-energize and not backflash.

L

, A sampling of the alarm response guides was performed to examine con-

,

tent, completeness, and consistency in format. During this review, l it was found that the alarm response guides lacked responses for some

!

!

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

-

.

..

.

annunciators in the control room. Overhead window box E3 contained alarm windows that did not have alarm response procedures. The win-dows are E3-C1 thru C5, E3-01 thru D4, and E3-El thru E4. These alarms are all " motor control center MOVs under test" related win-dows, and are a result of a recent modification. The inspector dis-cussed this with the operators and licensee engineers. The licensee was aware of this deficiency and has a program underway to prepare these missing alarm response procedure Plant management is actively pursuing resolutions to the above annunc-1ator problems. Observations and discussions with the operators re-vealed that they are knowledgeable, alert, and attentive to plant conditions. When questioned about each alarm, operators demonstrated knowledge of the annunciators' statu .4 Key / Door Control Key and door control has been subdivided by the licensee into three (3) areas of control: operations, radiation protection, and secu-rit Each control group is responsible for the keys assigned to them, with no group capable of accessing all doors within the facil-ity. The only exceptions appeared to be the senior shift supervisor and senior security supervisor who have master keys to all security, operations, and radiation protection door The procedures for key control for both operations and radiation pro-tection were spot checked for procedural compliance. While the facil-ity appears to be adhering to procedural direction, a number of acces-sibility concerns were identifie The reactor and equipment operators do not have keys to doors which could be significant due to being classified as radiation or security door For example, radiation protection controls the keys for both the torus and RHR pipe chase room. Both rooms are classified as rad-iation areas (not high radiation areas), but need to be accessible by operations staff during routine surveillance and valve lineup test-ing.

l The inspectors located doors which were: locked but not latched, l locked but another door to same area not locked, identified as radia-tion area doors but not locked, identified as operations doors but operations could not open them with the standard key rin Each department appears to have a number of locks but no single master key exist For instance, during a plant tour, an inspector observed that the operations department controls a number of doors in the UPS and battery room areas which can not be opened with the master key issued to operations personnel. No operator aid is pro-vided on the door or lock to identify which key is to be used for i

!

l

_ _

_ - _ _ . --

_ . - -

.

..

.,

entry. At some doors the operator was unable to gain entry even after trying a number of key In addition, there is no observable designation as to which doors are controlled by which departmen In summary, while it appears that each individual department is ad-hering to its own set of procedures, there is a lack of overall plant coordination regarding the established managerial policy on total site key and door control. Concerns over this apparent inconsistent policy could have a detrimental effect on plant safety due to lack of operator access to critical areas during emergencie .5 Safety Tagging The inspectors reviewed the current practices at Hope Creek for com-pliance to administrative procedures: SA-AP.ZZ-015(Q),(Station Safety Tagging Program); and OP-AP.ZZ-103(Q)-Rev.3, (Tagging Request and Inquiry System Use, Management, and Audits (TRIS)). Licensed operators, management, and TRIS programmers were interviewed, and the tagging requests were reviewed to determine programmatic complianc TRIS is a computerized tagging and information data base system which was designed to maintain the current status on all blocking valves, relays, and breakers within the Hope Creek complex. This system will eventually be able to track all valves and electrical components (operations, chemistry, etc.) in the facility. Additionally, TRIS will be able to provide current system configuration and standard tagging requests for routine maintenance and inspection The inspectors identified a number of instances in which TRIS tagging information was wrong, incomplete, or not current to plant configura-tio Examples were: 1) tags which appeared in the field but were not in TRIS, 2) tags which TRIS showed as being in the field and no tag existed, and 3) tags which TRIS showed as being in the field and the work order had been closed out. All of these problems were attri-buted, by operational staff, to a paperwork time delay and TRIS up-dating.

! In discussions with the TRIS computer programmer it was identified

that TRIS generated 27 computer pages of blocked or tagged compon-

! ents, of which, it was estimated, 15 pages were attributed to spare l

breaker This situation is a hold-over from late construction and the licensee is reviewing the need for continued tagging of spare l breakers.

l During control room observation on October 25, 1986, the inspector ( noted that an I&C technician was utilizing a key, with caution tags

! attached to it, during performance of a surveillanc The I&C techni-

'

cian stated that he realized where the tags belonged, but the key operated all of the switches on the panel. The technician removed the caution tags (2) and placed them on the switches intended by the tags. One other tagged key was observed on the other divisional l

l l

[

'

.

4 %

..

.

panel. The caution tags (C0000365, C0000368) had been hung February 28, 1986 to warn against placing the turbine stop valve RPS test switch in the test position. The Senior Nuclear Shift Supervisor (SNSS) stated that this practice was not acceptable. The tags were verified to be on the switches, and the SNSS stated they would evaluate if the tags could be cleared. In addition, it appears that one tag had been previously cleared, but not the remaining thre During control room and plant tours, the inspector noted that caution tags are being utilized to give operators information that may be of permanent or long term application. Three examples include:

--

Caution tag #C000579 on 1 EG-HV 25178, SACS heat exchanger by-pass valve. The tag states that the valve should be closed to maximize flow; however, the valve was noted to be open on'

October 21, 198 Caution tag #C000016 (April 16, 1985) on the breaker for th'e core spray suction valve 1 BE-HV-F001B states that the breaker should not be closed until the control room switch is in the s

close positio s

--

Caution tag #C000236 on fire protection panel 10C671 for hand switch HS 3447-1 states that if depressed it will dump one mill s ton gallons of foa The inspector discussed these specific items and the generic use of caution tags with licensee engineer The methodology for managing and auditing TRIS is presented in OP-AP.ZZ-103(Q)-Rev.3. According to the procedure, Hope Creek will per-form daily, monthly, and quarterly audits "... to maintain TRIS com-ponent statuses as accurate and current as possible." Administra-tively and procedurally the program appears to be well conceived, but some concerns were identified. First, a TRIS computer printout of the RCIC system was taken into the field to verify system lineu The inspector found tags which were not in the field but identified in TRIS. Second, the inspector found valves on the computer printout which were marked "NA". These valve positions could not be validated because TRIS did not track the position. Third, with over 50% of the tagged components being spare breakers, the' audits have a potential to be biased towards non-functional components. The audit system does utilize a sample size increment feature when discrepancies are' ~

identifie The Hope Creek tagging system has the potential for becoming a very valuable tool for the effective and efficient control of system /com- ~

ponent status and should be considered a strength-to the overall

<

%

_ - -- - -

.

.

g..7

.

operational progra Continual internal reviews and system upgrades will maintain and improve the program's effectiveness in controlling the tagging proces .6 Procedure Usage As part of the continuous shift observation, the inspection team ob-served a. number of startup, normal, and surveillance evolution Prior to and following each planned or unplanned evolution a thorough briefing was conducted. The on-shift senior supervisor directed this

.

'

briefing in a professional manner and ensured that all operational and safety concerns were addressed prior to any actions. During the actual performance of a test or evolution, the operating staff com-municated and worked together as a team, and adhered to the proce-dures. In the case where a startup test was being performed, the operational staff referred to both the operational and startup proce-dures and discussed the differences prior to execution, with the senior shift supervisor maintaining overall test and plant contro .7 Independent Verification During this inspection, the inspector observed a surveillance test (0P-IS.BC-104(Q) Rev.1, Residual Heat Removal System "D" Inservice Valve Test) from the control room and in plant. The surveillance required a number of independent verifications to be performed. Dis-cussion with the operators indicated that two (2) methods could be used for the execution of the independent verification functio Either a licensed operator would provide the secondary verification after the equipment operator aligned or checked the system, or the

-

next shift would review and check the alignment. Additionally, the inspectors observed a number of work orders for which a portion had to be independently verified. The observations indicated that the verification had been performed properl One concern in this area was identified during the inspection. While on a plant tour, an inspector located a fuse which required indepen-dent verification, but documentation had not been signed by-the second verifier. A follow-up with operations staff indicated that the sit-uation could have been caused by the tag being developed using TRIS for the individual component and not for the system with which it was associate If this were the case, TRIS would not have identified the need for independent verification. If the tag had been developed using TRIS, for the system, as opposed to the individual component, the need for independent verification would have been indicated by TRIS and it would have been more difficult to miss the verification requiremen Generally, the independent verification program appears to be pro-perly implemented, with responsible supervisory and operations per-sonnel cognizant of both the intent and requirements of the progra .

..

.

3.8 Observations During Plant Tours During a control room tour, the inspector noted that the Containment Hydrogen /0xygen Analyzers accident monitoring instruments were not indicating the expected oxygen concentration. Both detectors were selected to the low range scale (0-10%) and were indicating approxi-mately 6% oxygen concentration inside containment, but the contain-ment was not inerted and the readings would normally be expected to be approximately twenty-one percent. Based on this inconsistent in-dication, the inspector questioned the operability of these detec-tors. Although Technical Specification Special Test Exception 3.1 allowed operation of the unit without inerting the primary contain-ment, Technical Specification 3.6.6.2 required operability of the monitoring instrument The licensee provided a safety evaluation, dated June 27, 1986, which documented the results of an evaluation performed to verify the oper-ability of the hydrogen / oxygen analyzer system. As stated in the FSAR, the analyzer has a dual range capability of 0-10% and 0-30% by volume. Although the analyzers have the capability of utilizing either scale, only one can be utilized at a particular calibratio For example, the safety evaluation states that, if the analyzer is calibrated using the 5% calibration gas, the analyzer must utilize the 0-10% scale for measurement. The licensee also stated that, should there be a need to analyze containment gas for concentrations greater than 10%, the analyzer could be recalibrated without needing access to the containment. The inspector noted that the safety eval-uation was not complete since it did not actually address the fact that the meters could not be read at greater than 5% although the 0-10% scale was selected. The adequacy of safety evaluations is fur-ther discussed in section 7.1.3. Based on this information, the lic-ensee considered the system operable. The inspector reviewed the associated Technical Manual (10855-J359Q-25) and held further dis-cussions with the responsible engineers. Based on further review, the inspector verified that the indication of 6% was as expected due to the calibration method utill:ed. Because of the reagent gas used, both the hydrogen and oxygen 0 tectors can only monitor concentrat-ions of up to 5%. The ininect r discussed with the licensee the acceptability of this m(i cor g limitation and the availability of additional gases needed co e n orm calibration at the higher scale Review of FSAR Section 6.2.5.3.5 determined that the oxygen concen-tration would not exceed 5% until 39 days post-LOCA (assuming satis-factory recombiner operation), with an initial containment oxygen concentration of 4%. The licensee stated that the alternate reagent and calibration gases could be obtained within the required time, although they were not currently staged. The inspector recommended to the licensee that precautions be placed in the emergency operating procedures concerning the unreliability of any readings over 5%.

- .- ,

.

.

..

.

Additional observations during the inspection were made in the area of fire protection. During a plant tour with a senior shift opera-tor, five to six fire doors were found to be in the non-latched pos-ition. The problems consisted of one door that would not latch an other doors where-the door knob came off. In addition, observation of the fire extinguishers throughout the facility showed an inconsis-tency in. inspection frequency. The recorded inspection tags showed inspections occurring on a monthly, bimonthly, and quarterly fre-quency. In the Work Control Group work area a fire extinguisher was inspected on April 8, 1986 with the next inspection on October 27, 1986. Discussions with operations staff indicated that the inspect-ions were to have been performed on a monthly basis by site protect-io The licensee was addressing these items and had completed inspection of all fire extinguishers by the end of this inspectio .0 Maintenance Program The inspectors reviewed station administrative controls, conducted inter-views with maintenance and planning personnel, and observed work in pro-gress to ascertain whether the licensee is implementing an effective pro-gram relating to maintenance activities. The review included the mainten-ance organization, maintenance procedures and programs, observation of work activities, and effectiveness of the station leakage reduction pro-gra .1 Maintenance Management and Organization Station administrative procedure, SA-AP.ZZ-009(Q), Control of Station Maintenance, describes the program for maintenance of all station structures, systems, and components including identifying, planning, establishing priorities, authorizing, scheduling, assigning, perform-ing and documenting the activities. The Maintenance Manager is res-ponsible for the mechanical maintenance, electrical maintenance, and instrumentation and controls areas. The Maintenance Manager is sup-ported by a well qualified staff and directed by detailed procedure The Work Order Tracking System (WOTS) is the computerized system util-ized to initiate, track, and document all maintenance activities per-formed. The system is capable of providing adequate status reports for effective management oversight of the program. The Maintenance Department procedures ensure adequacy of job preplanning, proper classification of work activities, proper controls over procedures, drawings and manuals, and proper documentation of work activities performed. The licensee's program has established written procedures for initiating requests for routine and emergency maintenance. The criteria and responsibilities for review and approval of work orders have been well established. The administrative procedures also estab-lish an effective station retest program and a trending and monitor-ing program. Detailed procedures have been implemented for the equip-ment control process and the preventive maintenance progra . _ _ _ - - - , __ _ _ _ . _ . . - _ . .

.

.

..

.

Inspector review of the maintenance procedures found them to be very thorough and complet .2 Maintenance Procedures and Programs 4. Planning and Scheduling of Work Orders After initiation and approval by the appropriate department head, work orders are received by the Station Planning and Scheduling Department either by computer printer or manual initiation. The work order is then delivered to the appro-priate discipline Lead Planner (i.e., mechanical or elect-rical). The Lead Planner reviews the Work Order to deter-mine the job priority and, after evaluation of the problem description, the work order is assigned to a planner. The assigned planner reviews the work order for content comple-teness and assembles the work package. The work package includes the work order repair parts list, Radiation Work Permit (RWP), tagging request, applicable procedures, a retest package, and any additional drawings, forms or ven-dor information required for the jo Preparation of the work package is to also include a field verification of the work area where necessar The planner coordinates closely with the appropriate department in the planning proces If the activity involves work within a Radiological Control Area (RCA) boundary, the work package is submitted to the Radiation Protection Planner to process the RWP reques Following completion of the planning, the work packages are sent to the appropriate discipline schedulers, where sched-uling requirements are determined. If the activity re-quires scheduling, the scheduler utilized a computer sched-uling system to generate a specific schedule for the work activity on the Master Schedul When the schedule indicates a work activity is ready to be worked, the responsible Lead Planner reviews the package and assigns it to the applicable supervisor for wor One notable strength was apparent during the review of man-agement controls over maintenance activities, namely, per-iodic planning meeting discussions. The licensee manage-ment team holds a planning meeting daily to discuss various upcoming scheduled activities. As part of this meeting, a list of LC0 Action Statements that are in effect, including the required action, responsible department, and potential affect on scheduled activities, is discussed. This discus-sion, at the senior plant management level, ensures a sound awareness of technical specification requirements and cur-rent work activities. The daily management meeting also discusses the status of temporary modifications, deficiency

.

..

.

reports, out-of-calibration reports, work orders, and de-sign change requests. A daily schedule development meeting is held with shop supervisors and the planning department to evaluate, in detail, the upcoming work day schedul LC0's are also discussed at this meeting, as well as the status of priority work items, priority design changes, parts restraints, and startup testing. A 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> and seven day schedule are discusse In addition, a detailed shift turnover meeting is held with each shift, prior to taking the shift, which discusses current plant conditions, sched-uled work activities, an overview of the most significant problems, and upcoming evolution Inspector observation of these meetings found that control and planning of routine activities is a strength. The do-cuments distributed at the meetings were a comprehensive description of all ongoing activities and plant status, and included a list of current LC0's. All of the meetings ob-served were well organized, punctual, professionally con-ducted, set the tone for the day's activities, and were an efficient and effective method for conveying a large amount of information to many peopl .2.2 Preventive Maintenance Program The inspector reviewed station procedure SA-AP.ZZ-010(Q),

Station Preventive Maintenance Program, and interviewed persorniel involved with development and implen;entation of the Preventive Maintenance (PM) program to verify that a written program for safety-related structures, systems and components has been established and to ascertain the status of implementatio The PM program is implemented using the Inspection Order (IO) system, which develops the master schedule and informs the responsible department of the details of the particular task to be performed. The 10 system is capable of provid-ing completion status reports and overdue reports for man-agement oversight, and automatically schedules activities and initiates the activity work order for each task when required. The Technical Engineering Group is responsible for reviewing the adequacy of the PM program and evaluating equipment performance to determine any recommended changes to the program (See Detail 4.2.4). The Technical Engineer-ing Group is also responsible for maintaining the 10 system and issuing the 10 system generated work orders and 10 status reports. The station department heads are respon-sible for evaluating the plant equipment under their juris-diction to determine the PM requirements and frequencies and establishing approved procedures for performance of

- - . .

.

..

i

'

.

safety-related PM activities. Vendor recommendations, reg-ulatory requirements, and operating experience were all considered in the program development. Documentation of completed PM activities is performed by normal processing of the associated W0, and updating of the WO/IO data bas An extensive lubrication control system has also been estab-lishe The inspector reviewed the associated procedures, master PM schedules, outstanding and overdue reports, completed PM work orders, and several safety related PM procedure The PM program development has been completed for safety-related systems and is still being developed for the bal-i, ance of plant systems. The program was found to be quite extensive, especially considering the limited operating experience of the station, and should be adequate to optim-ize equipment reliability and performanc . Equipment Malfunction Identification Tagging System Station Administrative procedure SA-AP.ZZ-009(Q), Control of Station Maintenance, establishes a program to identify and tag malfunctioning equipment in the plant. The Equip-ment Malfunction Identification Tagging System (EMITS) is utilized to notify other plant personnel that a malfunction has been identified and the necessary documentation has been submitted to initiate corrective action. The purpose

'

is to eliminate initiation of duplicate work orders, and to alert operations personnel of component deficiencies. An individual who identifies an equipment malfunction in the plant is to fill out an EMITS tag, and have a work order initiated. The work order has a data filed block which is

to include the EMITS number. The EMITS tag is to be re-moved when the corrective maintenance is completed and re-

-

moval is documented by initialing the EMITS block on the work orde The inspector conducted a tour of the plant on October 21,

, 1986 and selected six EMITS tags at random in order to de-l termine the status of the associated corrective actio Of the six tags, three (Tag No's 024351, 017511 and 07512)

were found to have the corrective maintenance completed, but the EMIT tags had not be.t removed as required by the station procedure. One of the associated work orders (WO #8507010075) was completed in July 1985. Of the three re-maining tags, one work order had been cancelled on

,

October 13, 1986 and the work was completed on a duplicate work order, one was on hold in scheduling, and the third work order number could not be located by the licensee in l

. . . _ _ _ . _- - - -. . -

,

...

.

the data bas In summary, of the six randomly selected EMITS tags, only one could be verified to be a current equipment deficiency. The use of this tagging system can be an effective tool, but based on the inspector's sample, the program does not appear to be adequately implemente The condition of having EMIT tags hanging on non-deficient equipment can have an adverse impact on the purpose of this program. The inspector discussed the noted deficiencies with station maintenance personnel who initiated corrective action for the specific deficiencie .2.4 Trending of System and Component Failures A review of the station performance and reliability monitor-ing program was conducted to determine if a program has been established for reviewing completed corrective mainten-ance records to assess the adequacy of the preventive main-tenance program, to identify repetitive failures of parts and components, and to identify design deficiencies. Stat-ion Administrative Procedure SA-AP.ZZ-048(Q), Station Per-formance and Reliability Monitoring, establishes the pro-gram and the analytical methods used to implement monitor-ing and trending of plant process data to identify degrad-ing unit efficiency or component performance, establish the cause, and recommend corrective actions. The program is composed of monitoring operating performance parameters, identification and tracking of component failures, monitor-ing of Technical Specification surveillance results, incor-poration of industry operating experience lessons learned, reporting of performance and reliability statistics, and identifying the need for predictive maintenance. The Techn-ical Manager is responsible for oversight of the progra Technical Engineering procedure TE-PR.ZZ-005(Z), Monitoring of System and Component Failures, provides the specific instructions for identifying plant systems and components that exhibit repetitive failure The licensee's program requires a weekly review of recently initiated and completed work orders to detect system and component failures. If a failure occurs, an Investigation Request is initiated to include a description of the fail-ure, cause of the failure, and corrective action take In addition, if the identified failure is NPRDS reportable, a failure report is prepared. The Senior Performance and Reliability Supervisor is tasked to examine the history of equipment failures identified in the WO reviews, by utili-zation of the Work Order Tracking System (WOTS). Several other identification methods are utilized, such as reviews of deviation reports and surveillance test results, and close interface with maintenance and operations personne .

l l

..

.

The procedure states that, if a piece of equipment has suf-fered two failures in the previous twelve months, or three failures in the 5 previous years, a root cause investiga-tion is to be initiated. The root cause investigations are performed by the responsible System Engineer. System and equipment failures identified in the evaluations are also ,

subject to calculation of a mean-time-between-failure for comparison with industry data. The Performance and Reliab-ility Supervisor prepares a monthly report to station man-agement discussing plant performance, trends identified, ani recommendation The inspector reviewed the associated procedures, inter-viewed responsible engineers, and reviewed the current fail-ure data files and monthly report. Since the amount of failure data is limited, due to the short operating history of the plant, it was not possible to evaluate the adequacy of the program implementation. Although some failure re-ports have been generated, no root cause investigations or meen-time-between-events calculations have been initiate The system is currently manually tracked and evaluated, and the inspector expressed concern that, after a few operating years, the effectiveness of the data review would be im-paired. The supervisor stated that the potential use of computer-aided system was being evaluated. The inspector also noted that the current data form would not lend itself to analysis of similar component failures which occur in different systems since the vendor and part numbers are not annotated. Several minor procedural problems were also noted, which the supervisor stated would be evaluated pri-to the next revisio In summary, the trending and evaluation program that is established should effectively identify repetitive equip-ment failures and initiate the required evaluations and necessary corrective action, and is considered a strengt .3 Review of Maintenance Work Activities 4. Review of Completed Work Order Packages The inspector reviewed a sample of recently completed, safe-ty-related Work Orders (WO) for evidence of proper planning and conduct of work, and QA/QC inspection involvement. The handling and processing of WO's was discussed with the Main-tenance Manager, Station Planning Manager, shift personnel, and the work control center. The inspector reviewed the WO's to determine if the administrative procedures estab-lished in procedure SA-AP.ZZ-009(Q) had been followed.

l l

l

..

... . , . __

_ - - - - _ _ . -.

.

..

.

For all of the 20 WO's sampled, procedural controls for authorization and documentation were verified to have been adequately followed. Where QC involvement was required, acceptance criteria were noted and visual inspection was conducted, as applicable, in such areas as torque applicat-ion, electrical termination and crimping, housekeeping, material accountability, and internal component cleanlin-ess. In all cases, each WO clearly documented the problem and job description, quality requirements, and the actual work accomplished. The completed WO's included: mainten-ance procedures adequate for the scope of the maintenance performed; the required administrative approvals; documenta-tion of functional testing and calibration prior to return-ing the equipment to service; identification of measuring and test equipment used and calibration status; and docu-mentation of parts and materials utilize No unacceptable conditions were noted and the performance of the work activities was well documente . Observation of Maintenance Activities The inspectors observed portions of selected safety-related corrective maintenance activities to ascertain that these maintenance activities were being conducted in accordance with approved administrative and maintenance procedures, Technical Specifications, and appropriate vendor document During the observation, the inspector verified that: the required administrative approvals and tagouts were obtained prior to initiating the work; approved procedures were be-ing used; the procedures used were adequate to control the activity; activities were being accomplished by qualified personnel; radiological controls were properly implemented; and replacement parts were properly certifie On October 27, 1986, the inspector observed portions of the activities performed under WO 8610260062, concerning the RCIC steam admission valve (1FCHVF045) repacking. The prob-lems identified on the work order included: an observed packing leak (See Detail 4.4), the packing gland was bot-tomed out, and the packing gland appeared cocked. The in-spector reviewed the complete work package and found it acceptable and properly documented. The technicians inter-viewed were very knowledgeable about the assigned tas During observation of the physical packing removal, the inspector noted that a small amount of steam was leaking out of the packing while packing rings were removed. The inspector questioned the responsible supervisor concerning the status of the steam system; the supervisor was unsure if the system had been adequately depressurized, drained, and vented. Further reviews and discussions determined

- --

___ _ _ __

. __ -

-

,

..

19

.

that the system had been isolated from the reactor by only

,

a single isolation valve, and the system had not been drained or depressurized. The station safety tagging pro-gram, as described in administrative procedure SA-AP.ZZ-015(Q), states that the supervisor in charge of an activity is to verify that all necessary tests have been made to ensure that no pressure, or unsafe condition exits prior to starting the work. The licensee stated that a conscious decision had been made to use single valve isolation, due to the undesirability of cycling the isolation valve inside containment, and that system depressurization was not poss-ible due to the system alignment. Additionally, the work-ers had a surface pyrometer at the job site to sense piping and room temperatures, and the pre-job briefing had stress-ed the point that the maintenance technician could backseat the steam admission valve manually if necessary. The in-spector acknowledged the licensee's comments, but stated that the situation could have better controlled by opening (backseating) the steam admission valves to allow a vent path to be established. The additional effort needed to ensure that the single valve used for isolation was fully seated was not performed during preparation for the jo Special instructions were not included in the work package to describe the need for system depressurizatio Although the work was eventually successfully performed, the detailed job planning necessary to effectively imple-ment a maintenance program was not evident during the pre-paration portion of this evolutio On October 25, 1986, during an inspection of the interior of instrument cabinets, the inspector noted a reject tag attached to the total flow indication for the "B" Contain-ment Atmosphere Control Hydrogen Recombiner. The tag, writ-ten June 23, 1986, indicated that this instrument was out of calibration. The inspector also noted a tag indicating a temporary modification was in place. This temporary modi-fication indicated that the meter for the total flow of the

"B" Hydrogen Recombiner was replaced with the meter for the

"B" Hydrogen Recombiner inlet flow. A safety evaluation concluded that, for a non-inerted containment, the total flow would be equal the inlet flow and the recombiner was operable without inlet flow indicatio The inspector questioned the operability of the total flow instrument based on the reject tag. Instrument and Control technicians informed the inspector that the total flow in-strument had been satisfactorily calibrated on October 23, 1986 and the inlet flow meter was still inoperabl Fur-ther review by the licensee determined that, on September 5,1986, the operable total flow meter had been replaced

._ _

. -- .

.

..

.

with a new meter which was meant-to replace the inlet flow meter. This left the inlet flow meter still out of calib-ratio In addition, the work order specified retest re-quirements for performing a channel calibration of the Hy-drogen Recombiner instrumentation. This retest was not performed until October 23, 1986, when a review of the open work order discovered it. Upon questioning by the inspec-tor, the licensee concluded that the total flow instrument was operable. This was based upon satisfactory completion of a device calibration performed on the flow instrument prior to installation even though they.had failed to per-form the channel calibration. The inspector, based on the results of the channel calibration performed on October 23, 1986, agreed that the total flow instrument was operable, however, these events demonstrate a poor maintenance con-trol practic .4 Primary Coolant Sources Outside Containment Technical Specification 6.8.4 states that a program be established, implemented, and maintained to reduce leakage from those portions of systems outside containment that could contain highly radioactive fluids during a serious transient or accident to as low as practical levels. The systems include HPCI, Core Spray, RHR, RCIC, Containment Hydrogen Recombiner, 2H /0 2 analyzer, Post-Accident Sampling, and Control Rod Drive Hydraulics. The program is to include preventive maintenance, periodic visual inspections, and service pressure leak tests for each syste Station Administrative procedure SA-AP.ZZ-051(Q), " Leakage Reduction Program," describes the program for reducing the leakage from systems outside containment that could contain highly radioactive fluids fol-lowing an accident. The procedure establishes the responsibilities

'

for implementing the program, and defines the scope of the program, which was found to be consistent with the Technical Specifications and the FSAR. The program was verified to include periodic visual examinations during system operation, periodic inservice leakage tests, and a corrective action program to correct identified leakage problem The inspector reviewed the combined leakrate data sheet for the leak-age reduction program, which recorded the individual leakage rates from the periodic inspections and the combined leakage. Although the Technical Specifications do not specify acceptance criteria, the lic-ensee's procedure states that the total combined as-left leakrate is not to exceed 10 GPM. The inspector discussed the acceptance crit-eria with the licensee, and was informed that the total leakage limit was determined from FSAR Section 15.6.5.5.1, which assumes that total leakage from ESF components outside the primary containment is 10 GPM for accident analysis purposes. The licensee also informed the in-spector that several of the quarterly leakage tests required by the

'

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

.

..

.

procedure were missed in the third quarter of 1986, but were satis-factorily performed in the fourth quarter without any changes in leak rates. The licensee stated that the inservice leak' tests have been entered in the I0 program for future schedulin The leakage reduction program also includes several design features to aid in detection of gross leakage within the reactor buildin One design feature is temperature monitoring instrumentation in high temperature system equipment areas and ventilation ducts, which pro-vides alarms and system isolation signals. Another design feature is instrumentation which monitors the cycling of the reactor building floor drain and. equipment drain sumps, which also provides control room alarm During control -room panel walkdowns on October 25, 1986, the inspec-tor noted that the "Rx BLDG SUMP LEAK HIGH" alarm was almost contin-uously lighted throughout the entire shift. Additionally, the

" REACTOR BLDG SUMP LVL HI/LO" alarm annunciated intermittentl Fur-ther review by the licensee following inquires from the inspector-found that the leak alarm was signalled by a timer timing out as one of the sump pumps was energized. A work order was initiated (WO 8610290433) to investigate, and it was determined on October 29 that a sump pump check valve was stuck open. The valve was repaired and system retests verified proper system operation and the alarm clear-ed. The licensee initiated another work order (WO 8610300439)-to perform a calibration of the low level switches. The licensee has also initiated design change requests to add a run hour meter to assist in trending of leakage rates and to install spring assist for the check valve internal During a tour of the reactor building on October 26, 1986, the in-spector identified a steam leak from the RCIC steam admission valve (F045). The inspector was looking for a possible leak due to the

. abnormally high temperatures noted in the RCIC room by several other NRC inspector Following identification of the leak, the licensee

initiated a work order to replace the valve packing. (See Detail l 4.3.2).

I-

The temperature in the RCIC room did not appear to have reached the i room cooler automatic start setpoint, since the inspector verified that the temperature detector for the "B" room cooler had been cali- '

brated on August 19, 1986 (The "A" loop cooler was out service).

Since the leakage reduction program is dependent on special design features and periodic visual inspections, including operator tours,

'

further management attention appears necessary to ensure effective implementation of this program. Although the RCIC room cooler did not reach its automatic start'setpoint, the adequacy of periodic oper-ator tours was not evident since the NRC inspector identified the

,

'

high temperature system steam leak. In addition, ineffective follow-up to a control room alarm condition made the reactor building sump L

f i

i

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

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

.-

..

.

alarm incapable of alerting the operators to an abnormal conditio The effectiveness of two of the leak reduction program features was not adequately demonstrated during this review. The adequacy of the program will be further reviewed during routine following to TMI Action Item III. D.1. .0 Surveillance Program The inspector reviewed the surveillance program and controls, interviewed personnel responsible for administering the program, and reviewed records to verify proper implementation of the progra .1 Surveillance Program Management The licensee's surveillance program is implemented through Station Administrative Procedure, SA-AP.ZZ-010(Q), " Station Preventive Main-tenance Program". This procedure provides the guidelines for imple-menting the preventive maintenance program which includes Technical Specification surveillance tests, calibration of safety related and non-safety related instrumentation, inspections, and other routine

~

maintenance items which reduce the need for corrective maintenanc An Inspection Order (IO) System is used to identify, schedule, and track these activities. The 10 system does not track tasks performed on an interval of less than seven (7) day The 10 system is a computerized system which automatically generates a work order for each task. These computerized work orders are then issued to the responsible department prior to the task's due dat The work orders are then scheduled by the responsible depart ant or the planning department to assure completion of the task. 'he i Tech-nical Engineering Group is responsible for maintaining the 10 system and weekly provides separate status reports of items due in the next two weeks, items which are outstandirig (i.e., past their due date but not overdue), and overdue item .2 Program Implementation The inspector reviewed the licensee's program to ensure the required surveillance tests for Technical Specification (TS) and other safety related components are completed. The licensee maintains a matrix which cross references the TS surveillance requirement by paragraph, the 10 number, the frequency, the responsible department, and the applicable procedure. Surveillance tests not covered by the I0 sys-tem are completed by applicable logs or contained within specified procedures. The inspector verified that specific TS surveillance requirements were contained in the matrix and the logs. The inspec-tor also verified the completion of selected surveillance require-ments and that surveillance requirements specified by TS action state-ments for inoperable equipment were being performe .

, ..

.

The inspector also reviewed the licensee's program for controlling non-TS safety related instruments. These instruments are also con-tained in the 10 system. A list of instruments used to satisfy sur-veillance acceptance criteria was generated by the responsible depart-ment and used to assure these instruments are routinely tested and calibrated. The licensee also calibrates or tests all testable safe-ty related instrumentation. The inspector selected various instru-ments and verified their inclusion in the 10 progra The licensee program for the control of both TS and non-TS safety related instruments appears to be effective and comprehensiv The inspector reviewed the Operations and Instrument and Controls (I&C) Department methods for controlling and scheduling of 10s. I&C utilizes personal computers for tracking Work Orders and has adequate measures for reviewing and updating the 10 system. The Operations Department utilizes a manual system which projects the next 2 weeks of surveillance requirements and a daily tickler file to implement the program. In addition, sorts of the 10 by mode are used to verify requirements are met prior to mode changes and to assure the tests are done while in each mode for an extended tim The inspector's review of the licensee's surveillance procedures found them to be detailed and well written, providing sufficient guidelines te the technicians or operators. A review of selected completed surveillance procedures found all required data entered and within toleranc .3 Observations The licensee's program is very extensive and currently contains appro-ximately nine thousand I0s. This system allows considerable flexi-bility in data retrieval and tracking and has the ability to be a very effective management too The computerized system ensures a work order is generated but still relies upon the responsible department to implement it. The outstand-ing and overdue lists can be used to assure the requirements are be-ing met. However, in reviewing the overdue list, the inspector noted approximately fifteen (15) regulatory required surveillance tests listed as overdue, with five of these items being greater than one month overdu The inspector verified that these surveillance tests had either been completed or were not, in fact, over their required frequenc Based on the listing of these items as overdue, the inspector ques-tioned the effectiveness of the overdue list as a management tool for assuring the required surveillances are completed on time. In addit-ion, it was noted that the 10 system will permit only 1 open work order for each item, therefore if an item is not recognized by the 10

.

..

.

system as being completed, it will not automatically generate a work order the next time this item is du The inspectors also observed portions of the surveillance procedures listed below to verify that the test instrumentation was properly calibrated, approved procedures were used, the work was performed by qualified personnel, limiting conditions for operation were met, and the system was correctly restored following the testin OP.ST.ZZ-001 - Power Distribution Lineup,Re OP.ST.SF-003 - Reactor Protection System Manual Scram Test, Re OP.ST.KK-001 - Main Steam Isolation Valve Sealing System Functional Test, Re OP.IS.BC-004 - Residual Heat Removal Subsystem "0" Valves -

Inservice Test, Re No violations were note .0 Quality Assurance Tours were conducted of the plant and support facilities such as the main warehouse, station storeroom, records vault, records file room, records processing rooms, radiographic storage trailer, engineering and procure-ment offices, and physical locations of QA/QC personne Ongoing activities, including QA/QC, were observed and discussion / inter-views were held with various levels of personnel. Several purchase orders were reviewed and the storage / location of those procured items examine .1 Organization and Program The Manager - Station QA (SQA), Manager - QA Programs and Audits (QAPA), and the Manager - QA Engineering and Procurement (QAEP) re-port to the General Manager Nuclear Quality Assurance who reports directly to the Vice President - Nuclea Each of these three man-agers is the head of a divisio The Station Quality Assurance Division includes: a Quality Control Section that is responsible for conducting inspections (first level overview) of selected work done at the plant and some first level surveillance of activities as time permits; an Operation /Statian Sur-

, veillance Section that monitors (second level overview) ongoing plant activities in areas such as chemistry, control room and TS surveill-ances/ instrument calibrations; and, a Service Surveillance Section that monitors ongoing activities in areas such as document control /

records, fire protection and contractor wor The Programs and Audits Division includes; a QA Program Section that is responsible for reviewing various licensee administrative proce-dures, manuals, etc; an Audits Section that conducts all internal

_

.

..

.

!

l and external audits; and, a Training and Analysis Section that pro- l vides QA type Training, performs the quality elements trending analy-sis, and prepares reports such as training, status, et The Engineering and Procurement Division includes: a QA Engineering Section responsible for the review of engineering documents such as procurement item classifications, weld procedures, and equipment spec-ification; a Procurement Control Section that is responsible for ven-dor control; and, a Materials Compliance Section responsible for re-ceiving inspection and first level overview of warehouse activitie .2 Implementation Work instructions / procedures contain QC inspection / hold / witness points and it was noted that approximately 6500 Inspection Hold Points (IHPs) and 950 Inspection Notification Points (INPs) were per-formed this year to date by the QC Section. Six IHPs and eight INPs had been waive The number of Maintenance Work Procedures implement-ed exceeded 10,500. The sectin has also initiated a surveillance effort of I&C, maintenance and construction type activities on an as time permits basi A quarterly QA surveillance schedule is developed and addresses funct-ional areas such as chemistry, document control, fire protection, operations and the installation and testing of equipment and part One or more checklists have been developed, are used, and reports are written for each functional area surveilled. Unscheduled (i.e., mom-ent of opportunity) surveillances do not require check lists. Sur-veillance reports normally identify any specific procedural steps that were observed or witnessed and/or include the checklist use A biennial audit schedule (1985-1986) has been developed and is per-iodically updated. The approximately 80 audits are evenly spaced throughout the cycle and only minor adjustments have been made in their scheduled date. The new biennial schedule is in preparatio The assigned lead auditor reviews applicable documents, procedures, previous audits, the performance history of the functional area to be audited, and then develops the audit checklist. Non-QA Department personnel are often included in audit teams to provide specific techn-ical expertise when it is unavailable within the departmen The QA Engineering Section has assigned an individual to a core group of engineers who review purchase requisitions and determine item classification, technical and program requirements, etc. , to be applied to the purchase order. This group also determines the func-tion of component individual parts so as to properly assign each a safety or non safety related classification that is then entered into a computerized data bas .

..

.

The Materials Compliance Section members are physically located at the main receiving warehouse and conduct the inspections and or re-view the documentation require Purchase requisitions are reviewed by discipline and QA engineer Appropriate requirements such as safety classification, QA category, certifications and technical specifications are verified to be part of, or added to, the purchase order. The determination of components and their parts, function, classification of these items based on function, and entry of that infornation into the permanent computer-ized data base is an ongoing functio .3 Conclusions The few hold / witness points waived indicate an active QC effor Personnel from the station QA surveillance section have maintained their ANSI N45.2.6 certifications and are used to preform inspections during work peaks. The conduct of QC surveillances in selected areas when work load permits is another indication of an active QC effor The QA surveillances are almost entirely observations of ongoing act-ivitie Records are reviewed only when a specific action needs to be verified such as the use of a current procedure. There is an al-most constant presence of QA surveillance personnel throughout the plant. This philosophy promotes the effectiveness and dynamic as-pects of this second level overview functio The audit checklists are comprehensive in nature and the observation of activities is emphasize Findings are followed up in an adequate and timely manner with no apparent backlog of open corrective act-ions. A majority of the audit reoorts reviewed indicated that non-QA Department personnel who were not associated with Hope Creek Station (i.e., Salem Station or engineering / support offices) were used to provide technical expertise in the audited are The Action Request system is used to track actions to correct ident-ified deficiencies, other than audit finding There were no overdue open items and only one item was more than six months old. The several Action Requests reviewed had corrections implemented in a timely and technically adequate manner. QA/QC and other personnel were found to be knowledgeable, competent and highly motivated. The QA/QC overview effort was assessed to be effective with only the fol-lowing minor weaknesses:

--

QA surveillance checklists did not address verifying fire exting-uisher inspection and closure of water tight doors

--

Monitoring of the records processing and storage facilities was not included in the QA surveillance responsibility assignments

.

.m

.

--

The location of-QC offices was further from the plant areas than those of other personnel less involved with day-to-day work activities

---

QA Engineering did not realize that the procurement (Purchase Order P-1-136272) of fire rated trailers was for storage of Qual-ity Program related records and should have had QA/QC involve-men During a. tour of the recently purchased trailers that are used to

-

store records waiting to be processed, it was identified that these records were stored in cardboard boxes which were stacked in rows on the floor of the trailer. Most of these records would be microfilmed and the radiographs would then be transferred to an offsite permanent storage facility. These trailers are designated as File Rooms per the provisions of NFPA No. 232-197 A tour of another trailer in which radiographs have been stored for a number of years identified that the humidity / temperature indicator had not been incorporated into the licensee calibration program after the trailer and contents had been turned over from the architect eng-ineer (Bechtel Corp.). Consequently, the indicator was overdue for-annual calibration. Also, moisture was evident on a section of the~

-

floor which had already' begun to deteriorate from the wetness. A number of radiographs were then examined but showed no sign of image or material deterioratio The stacking of cardboard boxes containing-records is contrary to NFPA No. 232-1975, Protection of Records. Chapter 34, Section 3.4.11 of this standard states in part, "All records shall be stored in fully enclosed steel containers... .If complete enclosure of certain records is impracticable, shelving having only the front open may be used.....". Regulatory Guide 1.88 endorses NFPA No. 232-1975 and is 2 commitment in FSAR Chapter 17.2.1.1.1.o. Additionally, 10~CFR 50, Appendix B, Criterion XVII states in part, " Consistent with applic-able regulatory requirements. . . . . . shall establish requirements con-cerning record retention, such as duration, location...."

I

'

The failure to calibrate the humidity / temperature indicator and moisture on the floor in the radiograph storage trailer is contrary to: ANSI N45.2.9-1974, Requirements for Collection, Storage, and Maintenance of Quality Assurance Records, that states, in part, " Preservation.... Provisions shall be made in the storage arrangement to prevent damage from condensation," and "5.6 Facility.... for stor-age of film.... humidity and temperature controls shall be provided to maintain environment...". Regulatory Guide 1.88 endorses ANSI N45.2.9 and is a commitment in FSAR Chapter 17.2.1.1.1.o. Addition-ally, 10 CFR 50, Appendix B, Criterion XVII states in part, " Consist-ent with applicable regulatory requirements .... shall establish re-quirements concerning record retention.....".

~ .

.-.

.

The above discrepancies are considered a violation (50-354/86-52-01).

The responsible licensee management representative initiated immed-iate corrective action, prior to the conclusion of this inspectio All records in the File Room trailers were transferred into enclosed steel cabinets. Also, the licensee stated that three or four individ-uals have been assigned to transfer the radiographs from the storage trailer to an onsite records vault, commencing November 3, 1986, and this transfer will be accomplished as expeditiously as adequate care and filing will permi During the review of the purchase order package for the file room trailers, it was noted that certification of these trailers meeting the two hour fire rating provisions of NFPA NO.232-1975 had not been requested or received. The licensee records management representa-tive immediately contacted the vendor and requested such certifica-tions. Pending review of documentation attesting to the fact that these trailers were fabricated to, and meet, the fire rating provis-ions, this item is unresolved. (86-52-02).

7.0 Management and Review 7.1 Engineering and Technical Support The Hope Creek Operations Technical Department is headed by a Techni-cal Manager and has groups which include reactor engineering, perform-ance and reliability monitoring, technical staff, design changes, and systems engineering. In addition, the Engineering and Plant Better-ment Department provides corporate support for the onsite Technical Department. The inspector reviewed station organization charts and division of responsibilities, station administrative procedures, and interviewed selected engineers in the organization. Detailed reviews of system engineering, design changes, event analysis, and operating experience feed back were performed. The Technical Department has some personnel shortages; however, the licensee has a staffing plan to fill these vacancie . Systems Engineering The licensee's Technical Department includes electrical /I&C sys-tems engineering and mechanical systems engineering. A group of responsible engineers are assigned the purview of specific plant systems. Systems engineers' responsibilities include re-view and cognizance of performance evaluations, corrective main-tenance, surveillance activities, operating procedures, operat-ing experience review, and major / minor modification The inspector reviewed the applicable programs and station admin-istrative procedures related to systems engineering. Discuss-ions were held with the system engineer responsible for RCIC,

__ ,

. . .

.

HPCI, Core Spray and RH The engineer was knowledgeable of system status and performance. On October 27, 1986, a system walkdown of RCIC was performed with the systems engineer. Com-ponents' inspected included piping, valves, instruments, motor control center, turbine, pump, and room coolers. Maintenance was in progress on RCIC valve F045 (steam supply valve) to repack it. (see detail 4.3.2 of this report).

7. Design Changes / Modifications Design changes and modifications for Hope Creek systems are con-trolled by station administrative procedure SA-AP.ZZ-008, " Stat-ion Design Changes, Tests and Experiments". The inspector re-viewed the procedure and discussed the overall program implemen-tation with applicable licensee engineers. The program was re-cently revised on October 22, 1986 to require major design changes to be performed by corporate engineering and minor de-sign changes to be performed by plant system engineer The design change process begins with initiation of a design change request (DCR). The DCR is reviewed by the cognizant sys-tem engineer to determine. if it is a major or minor modificat-ion. If a modification is warranted, a design change package (DCP) is generated. The DCP process includes a safety evalua-tion to determine if the change involves an unreviewed safety question. The SORC approves all safety related, fire protection or radiation protection DCPs prior to implementatio The inspector reviewed selected completed DCPs including #86-152 (control room fans time delay changes), #86-189 (RPS document change), and #86-529-(CRD hydraulic level switch trip unit re-placement). Items in the DCPs reviewed included adequate safety evaluations, design records documentation, drawing changes, post modification testing, SORC approval, and other items. The in-spector attended SORC meeting #86-281 (see detail 7.2). At this meeting several DCPs (T-MOD #476, #86-1269, and #86-1291) were SORC approve Within the scope of the review of design changes and modifica-tions, no unacceptable conditions were identifie . Safety Evaluations The inspectors reviewed a sample of 15 safety evaluations cond-ucted within the last year. Each of the selected evaluations was chosen on the basis that it did not involve or support a design change. Unlike design change safety evaluations, which are completed on an explicit form, these evaluations were pre-pared in a narrative forma .

.n

.

In reviewing the safety evaluations, the inspector found that many were brief, and did not always provide a stated basis for the conclusion that an unreviewed safety question did not exis The specific tests of 10 CFR 50.59 (e.g. potential for new accid-ent of malfunction, increased probability of occurrence, reduced margin of safety) were not always addressed to form a cogent rationale for the conclusio The licensee presented a draft of procedure SE-AP.ZZ-100(Q),

Safety Evaluation Preparation. Review of this procedure indi-cated that all necessary aspects of the 10 CFR 50.59 evaluation will be addressed and, further, the procedure will require that the safety evaluation set forth the basis and criteria used in the determinatio Adequacy of detail and basis in safety evaluations has been re-cognized as a concern by the licensee, and has been a previously expressed NRC finding (Reference NRC Inspection Report 50-354/

86-50). Appropriate corrective actions are underway to ensure that evaluations fully support the conclusion draw .2 Station Operations Review Committee

.The Station Operations Review Committee (SORC) functions to advise the General Manager - Hope Creek Operations on all matters related to nuclear safety. The SORC responsibilities, composition, meeting fre-quency and quorum, review process and authority, and records require-ments are delineated in Technical Specification 6.5.1 and implemented in procedure SA-AP.ZZ-04, "SORC", Rev. 4 dated February 4,1986. The inspector reviewed Technical Specification 6.5.1 and procedure SA-AP.ZZ-004. No unacceptable conditions were identifie The inspector attended SORC meeting #86-281 on October 29, 1986. The meeting was conducted in accordance with SA-AP.ZZ-004 and the compos-ition was adequate. Items reviewed at the a~eting included: NRC correspondence, LERs, revisions to administrative procedures, plant modifications and safety evaluations, and completed startup test pro-cedures. The inspector determined that the SORC reviews of the obser-ved items was adequate and no unacceptable conditions were identi-fle The inspector noted good questioning techniques and an adequate safe-ty perspective by members of the SORC. For example, LER #86-072 was not approved based on questions raised by SORC members. This LER deals with inoperability of one of the reactor building exhaust radia-tion monitors. The LER submitted to the SORC for concurrence and review was not adequate in that no root cause was determined and lic-ensee investigation was not complete. Thus, the SORC did not approve the LER. Overall, the inspector determined that the SORC is fulfill-ing and performing an adequate nuclear safety review of station activitie .

.-

.

7.3 Nuclear Safety Review The Hope Creek on-site Safety Review Group (SRG) is established to meet Technical Specification 6.5.2. for the performance of indepen-dent safety review and audit activitie The SRG consists of a qual-ified safety review engineer and three dedicated full time engineer SRG activities include the following:

--

reviews of procedures and plant ar'ivities

--

reviews of facility features, equipment and systems

--

reviews of operating experience information

--

surveillance of plant operations and maintenance activities

--

post scram /ESF actuation review

--

special projects and investigations

--

participation in the SORC The SRG is governed by the following administrative procedures:

--

M20-POP-01, Safety Review Group

--

M20-AP-01, Safety Review Group Recommendations

--

M20-AP-02, SRG Independent Review of Reactor Scram /ECCS Actuation Events The inspector verifies that the SRG is staffed as required by Techni-cal Specification 6.5.2.2. The inspector reviewed SRG activities by conducting interviews with SRG engineers, by reviewing the last 3 monthly SRG activity reports (July - September 1986) and by verifying SRG procedural implementation. The inspector noted that all of the unplanned scrams for 1986 had been reviewed by the SRG and the SRG had issued or was preparing a report. The inspector reviewed in de-tail post scram review report # HSR-PSR-86-08 dated September 29, 1986. This report reviews the scram that occurred due to low reactor water level on August 31, 1986. The inspector determined that the SRG post scram review report was timely, accurate and complete. The SRG determined that the root cause of a feedwater transient was in-duced by operator error. The SRG concurred with the 50RC review Overall, the SRG appears to be a licensee strength. Within the scope of the review of SRG activities, no unacceptable conditions were identifie .4 Temporary Modifications The inspector reviewed the licensee's program for the control of tem-porary modifications which refers to mechanical modifications, lifted leads, jumpers, and other electrical modification Station Administ-rative Procedure SA-AP.ZZ-013(Q), " Control of Temporary Modificat-ions," was examined. This procedure describes the processes of initi-ation and approval of Temporary Modification Requests (TMR's), instal-lation and removal of temporary modifications, and periodic evaluat-ions. The program was found to contain sufficient mechanism to assure safety evaluations are performed prior to installation of a temporary modification and administrative measures to prevent long

.

.

,

standing temporary modifications. However, several administrative deficiencies were noted. Two examples were found where both the in-staller and verification signatures were missing from the TMR, there-fore indicating that the temporary modifications were not in place '

-when in fact they were installed. Also, an example was noted of a copy of a TMR which remained in the temporary modification log after the temporary modification had been removed. These deficiencies in-dicate a lack of sufficient oversight and review of the temporary modification progra .5 Post Trip Reviews Unusual or unplanned events (including reactor trips / scrams) are re-viewed by the licensee in accordance with procedure SA-AP.ZZ-006 (Q), " Incident Report and Reportable Occurrence Program". The init- '

f al scram review is done by the operating shift (usually the STA) in accordance with OP-AP.ZZ-101. This review then becomes attached to the incident report revie Corrective actions are determined during the incident revie Immed-late corrective actions are recommended and approved by SORC prior to restar Longer term corrective actions are also recommended during incident review. Those corrective actions that are approved are tracked until completions utilizing the Commitment Tracking System (CTS).

In parallel with, or after, the plant incident report drafting and review, the independent onsite Safety Review Group (SRG) performs a post trip review. This scram /ECCS actuation review is further dis-cussed in detail 7.3 of this repo- This inspector reviewed the above mentioned implementing procedures for post trip / incident review, and discussions were held with lic-ensee engineers responsible for the conduct of these reviews. The inspector determined that the program is adequat The inspector selected one specific event to evaluate the licensee's post trip review of the incident. The incident reviewed was an auto-matic scram due to low reactor water level that occurred on August 31, 1986. The event occurred at 5% reactor power, during startup, when a high level transisent caused a trip of the operating reactor feed pump. Subsequently, the loss of feedwater resulted in the low level scram. This event was reviewed in NRC Inspection 50-354/86-4 The inspector determined that the licensee's evaluation of the August 31, 1986 scram event was adequate with one minor exceptio The inspector reviewed the OP-AP.ZZ-101 post trip review, the SA-AP.ZZ-06 incident report, LER 86-064 dated September 30, 1986, SRG report HSR-PSR-86-08 (see detail 7.3), and the SORC review including corrective actions. The root cause of the scram was determined to be personnel error based on operator actions that led up to the high

.

,

.

level reactor feed pump trip and subsequent inability of the opera-tors to reset the trip. Also, deficiencies in the licensed operator simulator training program were identified. The one minor exception to the otherwise adequate licensee review was the evaluation of the transient effect on reactor water level. The licensee's reports gave the lowest level as +9" based on LR-R608 (narrow range level 0" to

+60"). Further review by the inspector of the LR-R608 chart trace determined that level decreased below 0". The inspector questioned licensee engineers regarding this; and, review of the wide range chart traces LR-R623 A and B (-150" to +60") confirmed that level did go below 0". LR-R623A indicated a lowest level of -5" and LR-R6238 indicated a lowest level of -3". These indicated levels remained above the ECCS/PCIS set point of -38" and therefore above the top of active fue With the exception of the evaluation of the level transient during the August 31, 1986 scram, no unacceptable conditions were noted dur-ing the review of the licensee's post trip review progra .0 Persons Contacted J. Cicconi -

Planning Manager D. Cooley- -

Onsite Safety Review Engineer M. Farschon -

Power Ascension Manager S. Funsten -

I&C Engineer A. Giardino -

Manager - Station QA R. Griffith, Sr.-- Principal Engineer - QA C. Johnson -

General Manager - Nuclear QA P. Krishna -

Assistant to GM-Hope Creek R. Lovell -

Radiation Protection / Chemistry Manager C. McNeill, Jr. - Vice President - Nuclear P. Moeller -

Manager - Site Protection M. Murphy -

Senior Methods Analyst J. Nichols -

Technical Manager P. Opsal -

Systems Engineer B. Preston -

Manager - Licensing and Regulation E. Rush -

Senior I&C Supervisor R. Salvesen -

General Manager - Hope Creek Operations M. Shedlock -

Maintenance Engineer R. Tye -

Senior Fire Protection Supervisor C. Vondra -

Operating Engineer In addition, the inspection team interviewed operators, technicians and QA personnel, as necessary, to obtain information relative to the inspec-tio .

i

. l. -

.il

. . .

,

9.0 Management Meeting

,

'

On October 31, 1986,-an exit meeting was held with senior plant management to discuss the scope and findings of this inspection. During this inspec-tion, the NRC inspectors received no comments frora the licensee that any l of their inspection items or issues contained proprietary information.

!

,

!

! !

.

I

,

l l

,

I l

l t

l i

. ___4. . - . _ ..,- _ _ , . . . . . . - _ , . .