ML20213E378

Forwards All Documents Re 830225 Manual Scram Event at Plant,Per 830310 Congressional Subcommittee Request.Div of Human Factors Safety Comments Also Included

ML20213E378
Person / Time
Site:	05000000, Salem
Issue date:	03/11/1983
From:	Thompson H Office of Nuclear Reactor Regulation
To:	Lainas G Office of Nuclear Reactor Regulation
Shared Package
ML20213E339	List: ML20213E336 ML20213E343 ML20213E369 ML20213E378 ML20213E398 ML20213E402 ML20213E721 ML20213E743 ML20214H045 ML20214H430 ML20214Q607 ML20214Q637 ML20214Q718 ML20214Q745 ML20215G157 ML20215G165
References
FOIA-87-152 NUDOCS 8303300057
Download: ML20213E378 (114)

Text

{{#Wiki_filter:' a March 11,1983 w MEMORANDlM FOR: Gus Lainas Assistant Director for Operating Reactors Division of Licensing FRfN: Hugh Thompson, Director Division of Hisian Factors Safety SU8 JECT: CONGRESSIONAL SU8COMITTEE REQUESTS In response to your repest on this subject dated March 10, 1983 I have enclosed copies of all dociments relative to the Salem event of February 25,1983 which include DHFS generated cassents. Any questions on these documents should be addressed to R. G. Ramirez of my staff (exesnsion 28106), %1Je n W Hugh Thompson, Director Division of Human Factors Safety

Enclosures:

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1 v TABLE OF CONTENTS 1. General Conclusions of March 4,1983 Visit To Salem Site. -2. Conclusions on O'perator Training and Procedures. - 3. Input to Region I Salem Restart Report. 4 Information Paper omSalem Restart Action Plan. 5. SalemRestartReiert. 6. Staffs Comments on Salem Restart, 7. Information Paper on Salem Restart Status Report. 'i ~ as e e O 4 ,r...~. ,ar-r- -= e---w*- --ee- -= - =--we-w w $ w

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T poy 2.O T II. SPIC;FIC FINDINGS AND CONCLUSIONS ~ l 1. "anual Backup cf aI ematic scrams Jt I6 h L. ot planc practice to in=ediately back up automatic scram with manual scran. 'b. This is based on Owner's Group Guidelines.[4. be. codem*4) c. Plant charges 5 procedures to direct-operators to initiate manual reactor. trip based on "any valid fir.st out overhead -e: annunciater and/or indication on the "one RP-4 Status Panel" that a Reactor Trip Signal exist. This does not assure an ice.ediate manual reactor trip. 2. Adequacy of ATn'S Instructions a. The operators question the appropriateness (validity) of tripping turbine w/o Rx trip (loss of heat sink) b. Practice is not to follow steps in the order prescribed in the procedures. c. Based on items 1 and 2, there is a need for the plant to re-evaluate the basis for the trip procedures. (c.1) The staff will review the results of the re-evaluation e DR. AFT

i ~ ~ ~ ~ ~ ^MM AY "I o. g3pf d. Train operators on new procedure (s) (clarify priority cf steps) Train operators on basis for the turbine trip in the ATWS procedure, e. f. Revised procedure EI-I-4.3 dated March 2,1983 is unacceptable. There are a number of substantitive charges necessary 3. Operator Perfomance a. Operators do not understand whether the reactor first out annunciators are demand signals" of "confimatory indicaters". b. The first out an'nunciators are not being used to deter: sine cause of trip. c. Operators believed there could be different set points for the annun-ciators and the reactor trip demand signals. d. The operators do not know what conditions cause the red reactor trip indicator on IRP4 " Status ?anel" (RPS mimic) to light (demand /confim). e. Inspite of indications available, the operators did not believe they had an ATWS until after testing of SSPS (RPS) approximately 30 minutes subsequent to the 25th February event. f. At least one operator did not understand that first out reactor trip reacter annunciation (SG'JLL) was equivilant to two or three channels of SGWL Le to trip. DRAFT'

~ " "^ ggg F484 *N g. At lease one operator's judgment of the validity of the first at 'annunciater (SGWLLLL'L) was biased by previc'us cecurrence of Nuisance alarms on this panel. h. Given the operators training, and " general experience", they believed it necessary to verify the reactor trip demand signal prior to taking any action. Verification was r cwiQ:.aut t beyond ~ the procedural requirements and may have delayed implementation of the imediate actions of the E0P procedure, en February 25. 1. The indications,.available in the Control Room were sufficient to imediately identify a failure to scram. j. The reactor trip procedures were adequate to (=ediately identify a failure to scram. k. Following the loss of the 4160V bus and associated equip =ent, there was a real need for the operators to detamine the plant status during the 22 February event. For the first 20 sec:nds, there were no reactor trip demand signals present. Based on this determination of plant

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status, the operator decided to manually initiate a reactor scram. at about the same time that the automatic protection system detected SGWLLL. Based on the event initiators and the need to evaluate the plant status, the operators performance was logic ~al' and reasonable. 4 i 1. Based on the cperators training and their perceived need for verify the first reactor trip demand signal by detemining overall plant DRAFT ~

U W YI pay SoE S" 9 Or status, their respense tire to evaluate the plant status t the 25 February, 1983 event. w e s ecaw w. Liv, in Recomended corrective acticns being prepared. e e m 9 4 e e e 9 e O we $ e e + 0 e e i DRAFT

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CO*;CLUSIONS ON OPERATOR TRAINING AND PROCEDURES ~[ 1. Although complete failure of the automatic trip system was not recognized int.ediately for either the February 22 of F'ebruary 25 i event, manual reactor trips were initiated and therefore the plant was safely shutdown in both cases. 2. The licensees revised procedure that directs manual scram follow up ~ of an automatic trip is unacceptable, because it requires the operators to verify the trip signel prior to acting. 3. The Control Room indicators are adequate to identify and respond to these events. Howsver,'the operators do not uriderstand all the control room indication.s and do not trust all their control room indications. 4 The operators do not take immediate action based on reactor trip annun-ciators, and are not directed to do so by their procedures. 5. The time taken to determir.e One overall plant status and initiate a manual scram (20 to 30 seconds) during both 22 and 25 February events ~~ is a reasonable time for performing the verification tasks directed by the existing procedures. 6. The time taken by the operators after the event of the 25th February to recognize that a failure of the automatic trip system had actually occurred was excessive (1/2 to I hour) because of a lack of understanding of the Solid State Protection System design and operation and the associated indicators. I

.o. v Recommendation: Prior to cestart the licensee should evaluate the RPS circuitry to identify the annunciators that will clearly indicate that RPS trip logic has been met and UV coils should have been deenergized. Procedures should be developed that clearly direct the operators to take corrective action without evaluation or confirmation when those annunciators are received. Licensed operators shot 1d review the procedures prior to startup or prior to assuming licensed juties and be briefed by the licensee management on the importance of following these procedures without hesitation. m o e D 0 6 4 e s. m

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c Regien I Salem Resta,rt Report Operat:r Response

..:erviews with operators on shift fo r the Februa ry 22 and 25, 1953 etents disclosed.the following: 1. In both events, ttui operators took 20-30 seconds to determine - the overall plant status and initiate a manual reactor trip. For the first event, th-is. evaluation was necessary due to the large number. of alarms and_ equipment and indicators lost 'with the electrical bus transfer f ailure. Fo r 'the second event, this to evaluation was not necessary due the presence of positive g indication e f a f ailure of the reactor ' protection system.

2. D'ri.g the first ' event af ter an operator was directed to nanually trip (scram) the rea t:r, the switch handle. as not

'~ operated correctly. .This may have contributed to the ggL operators failure to recognize that the automatic trip system had failed to trip the reactor prior to the manual trip,

3. husch C=nclusion:

~ ' Given the operators' understanding of the re, actor protection system and annunciators, their need to determine the everall,. plant status, and their procedures, the response of the oper'ato'rs. was af eguate to protect the reactor for both events. 9 9

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• E:4: Ade:;uacy cf Infcrmation Presented to the Operators at Salem 1 Easad on interviews with the operating staff during the February 22nd and Fs:ruary 25th events, a review of controls and displays provided in the con-trol room, limited to these two events, interviews with instrument and control

~ a-d maintenance technicians and a review of pertinent licensee documents, we f:und that adequate infomation was provided cperators to enable an imediate diagnosis of an~ ATUS event. However, during the February 25th event; due to a lack of understanding of.tg operation of some of the indicators and a general lack of confidence in the information presented by the overhead annunciator first-out panel, the operators

• were hesitant to take immdediate action to trip the reactor as recuired by the procedure, and instead, did a systaatic visual e.aluation of plant status.

_,Pjst infomation proviceo by the first-out panel is derived from the solid S. state protection systems (SSPS) logic and therefore is a direct indication that the SSPS logic has generated a deand si nal for the plant to trip. There 5 are several feedback indications in the contro.1 rocm which imediately identify whether the trip breakers have been de-energized. Two of these (i.e., the Reactor Trip-Turbine Trip and Turbine Trip-Reactor Trip) also located on the first-out panel have alarm signals derived from auxiliary contacts on the trip ' breakers. In addition, a " Reactor Trip" red indicator located at the end of the logic output in the SSPS mimic board also derives its input frem the reactor trip breakers. None of these positive feedback indicators were energized. ' The above discussed information is displayed within the main control area and cer.venient to operator usage.

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erators during the February 22nd eve t indicated a problem with' the canual

~ trip "J" handle control, which by design is r6 ovable. ,lhentEeSROcalled fer a manual trip, the control inadvertantly was pulled off the. board and had' te be reinserted to perforn the manual trip, Reco.r.endations : Frior to Restart: 1. Operators should receive trainin w the usef@ rest of information presented by the firs 55ut panel and the mimic boa [ improve their Mciirstanding of the infor,ation providedM v 2. Operators should be cautioned on the use of the manual trip "J" handle ~ control. 7 Lcngsr Ra,ga: 1. Operators should receive training to improve their understanding of the operation and design of the firs-cut panel and mimic boards with regard to which indications are demand signals and which are confirmatory indica-tions and to inform them of the general source of this information. 2. The "J" handle reactor trip control should either be made secure or the switch replaced. 6 O E A J s== = 'm_m-

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. ~. ~ p.i s s A l # J. %. ~ V . / o., -y p v INFCE% TION PA?ER SECY. n ?: : The Cennissier.ers F-c : William J. Dircks Executive Directer for Operatio.]s

5. _iect:

SALEM RESTART ACTICN PLAN Pur:cse: To provide tte Commissioners with a report en the current status of the invest'iqation of the ATWS events of February 22 and 25, 1983 at the Salem Nuclear Generating Station and an action plan for restart of Units 1 and 2. Otscussion: 'During a briefing on March 2,1983 concerning the Salem reactor-trip system. failure events, the Commissioners requested that the staff ptbvide its plan of action to resolve the issues l identified frcm the SEC investigation of the Salem events. i Enc 1csed is the Sale: Restart Action Plan which identifies the issues and the short and long-term actions needed to resolve those issues. For the short-term actions the staff intends. to ebtain specific ccmaitments frem the lic'ensee to complete those actions and the staff will fo11cwup their ccepletien prior to permitting restart of either Salem unit. For the long-term actions, the staff intends to negotiate an acceptable schedule f:r c; : eti:n Of th:se ac-icas, c:tain rt:assary ec. mit: ants. and fo11cwup their cc:pletten en the agreed upon schedule. William J. Dircks Executive Director for Operations 1

Enclosure:

-(1) Salem Restart Action Plan i i i s CONTACT: R. W. Starcstecki FTS a58-1230 I I 1 $1'.i'-t RES7 ant ACTION LIN

? i s Cgr.ents' 4 -

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t .urcose and Scc:e I. Iackcreund III. Issues 1 A. Ecui::ent Issues 1. Safety Classification of Breakers 2. Identification of Cause of Failure i 3. Verification Testing ~ ~ 4. ' Maintenance and Surveillance Precedures 5. Management Issues 1 1. ~ Operator Tranining M 3 i i 3 j r 3 l i 1 1 aP 4 r i 4 ,.. f. :, e s 7 sat.EM RESTART ACTICH PLAN ..-a w e- =, e, a t-gr ee e--s.en*w,--#,-we.,,.%.+. e,u+e-,,,4-~,.--%-.ut--m --.----m. m m3 --e w e w m - w 3,--v-- r-,--- erw w- - w,,,wwr---v---.w- --n..mw----

2. %sratin; Fr3caduras fcr Anti-i;s ad Transie.ts Witncut Scra.m (ATWs) v

1. :..st: :r irl s 3.

Ope"at0r R6570.958 7:s. rip Review 5. P.as er Equip:ent List ,.; r '.~ 5. W:rk-Order Precedures ..... i / 7. Ticaliness of Event Notification 8. Updating Vendor-Supplied Information 9. Involve:ent of QA Personnel with Other Station Departments 10. P:st Maintenance 0,perability Testing IV. Cenclusions Appendix A A;pendix 3 ..:,.-. / c.1 S SALDi RESTART ACTICN PUR a m .u-.

4 Aistract v ac-icn plan for~ restart of Ur.i,1 cf the Sale: Nucietr Generating Stati:n f s : resented based en the,NEC ir.vesti;atica ef. the even s of February 22 a.d 25, ;!!3, when there were failuras of the aute:atic reactor tr.ip sys' ten fo11cwing recei;t of valia signals frca the Rateter Protection Systan. "The manual trip sjs tm. as used to shut dcwn the reacters. It was determined that the failuras to trip were caused by. calfunction of the undervoltage trip attachments in / teth reacter-trip circuit breakers. A r. utter of issues have 'been identified, ar.d short-term actions proposed to resolve them prior to resumptien of cperation, as well as long-term actions needed following restart. The issues are categorized as equipment issues and =anagement issues. The equipment issues are (1) the safety classification of t..e circuit breakers, (2) verification testing of cperability, and (3) main-tanance and surveillance procedures. The management issues are (1) operating procedures, training, and response; (2) pesttrip review of. failure of the autecatic system; (3) the quality assurance and work order procedures; (4) timeliness of reporting; (5) updating vender-supplied dccumentation; and (6) pest /caintenance equipment. operability testing. 1 1 i i .,../ e 3 9 SALEM RESTART ACTICN PLAN .s.

Sat ir :ts.31r-Action Plan ~..

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.is s;;rt triefly descritis :na S.:: ac-icn plan to adcress and resolve a: i: tr.t and ca.aqinen ?r: 's.s i:5..-ified by the NRC inves~tigation of the s.s-s at Uni-1 cf the St[er N.:: tar Ganarating Station that resulted in f at,.u. e to trip the reacter. ine sa::nd event Occurred en Februarv 25, 1983 a-d,'.ed to the realicatien that a si.ilar event had occurred on February.22, .-*J. An SRC task force has been establisted to conduct a separate longer range-study of the brcader implications of the events. NRC long-term actions noted erein are those related only to Salem. The NRC task force will determine additional acticas needud for cther :perating plants. ~I. Backcround ~ Cn.:ebruary 25, 1983 an event occur id at Unit 1 of the Salem Nuclear Generating cf a valid trip signal fffs,ip circuit breakers failed to open following receipt 5 atica when the reactor-tr the.'.et:ter Protection Systan (RPS). The manual i trip system was used to shut d:wn t..a reactor. Subsequently, it was c:ncluded hy the licansee that the failure te trip was caused by a malfunction of the ut.darvoltage (UV) trip attach:ents in both reactor-trip ci.cuit breakers. These UV trip attachments trtnslate the electrical signal from the RPS to a echanical action that opens the cir:uit breaker. --*:!/g; 10 SALEM RESTART ACTICN.:LAN l

s: r s ry 2 5, *.5 3 3, a- ' 7 0 11: -Is ensite to su;;crt the resident inspect:rs

e 'ni-{ al #:11: ".: 1: :: ::.'t:$ preliminary infer-Iti:n.

As a result ine..iries, na li:tr. sis :sitr-i.ec that ::ta rea::Or-trip circui-

takers ha: si.ilarly 'li'ac :: : en u;cn receipt of a valid trip signal en t:ruary 22, lii3.

The 'tiiert aute atically trip en Febry.ary 22 was net s::;r.i:st by ne licansse unt'i :: e c:eputar prir.tcut of the"secuence of t.sn s as reext:{ned ir.

. e :stail en.:ebruary 25.

Further investigation of ..ase ever. s and the cir:u s ar:as leacing up to them revealed a number of 'ssues that require resc'utien by the licensee and/0r the NRC. This report i:an-ifies -h:se' issues a : the sr.:rt-term acticr.s pro;csed to resolve them

-ice to resur;tien of c;erati

n at Salem Unit'll and the long-term actions

. at are needet en a def'ned s:hedule folicwing restart. The licensee cet with NRC staff en February 28 and March 5,1983 to present tr.e results cf initial s.aluatiens related to the events. Based on licensee submittals of March 1 ar.d March 3,1983 and on the findings of the NRC task f:rce, the issues ay be cites:ri:ed as equipment issues and management issues. They are discussed in detail in Se:tien III of this report. II. Issues A.. Ecui: ment Issues Three of the issues relate to the affected equipment, that is, the reactor-trip circuit breakers ('n'esti..;h:use C3-50 circuit breakers). These issues are 1) 15 ale: L' nit 2 is present'y sF.td:-a for refueling is not presently scheduled i: resume ;crati:n be9:re Uni: 1. ..,f / e 11 SALEM RESTART ACTION PLAN

sais

lassifica.ica of.ne cir: i :rea%ars, 2) identificatien of the cause

'. s faticre, an: 3) verifi:sti:n tis-i..; cf the circuit treakers.

1. Infe:y Ciasif fica-ica cf Ersake s C.r' ; the initial SRC investiga-i:n f the February 25 eventh it was determined t a. ai tana ce was ccnduc.ed en -he Sale: Unit i react:r-trip circuit treakars i-Ja. gary 1552,1011cwing a f ailure of 0..e reaccor-trip circuit breaker to trip.:en receipt of an R?S sigr.a1 at Salem Unit 2 on January 6,1983. The .:rk :rders auth:ri:ing the January 1532..aintenance identified the. aint'enance as not safety related and not requiring quality assurance review. The reactor-trip :ircuit breakers c:ntain both a UV trip attach::ent and a shunt trip a. tach.ent, but only the UV trip atta:h=ent is cperated by an RPS trip signal. . s a result, it was not cleer on February 26, 1983 what portion, if any, of the reacter-trip circuit breakers was considered safety related by the licensee. Action / Evaluation Secticn 7.2.1.1 of the~ Salem Updated Final Safety Analysis Report (UFSAR), Revision 0, indidates that the Reacter Trip System includes the reactor-trip circuit breakers and thew trip attach =ent. The Westinghouse Solid State Logic Prctectica System Ceicription (WCAP-74SSL) also defines the scope of the syste as including the reacter-trip circuit breakers and the UV trip attach-cents. The UV trip attachment and the reactor-trip circuit breaker (not including actuation devices) are safety related equip =ent in that they are e.,./ /33 12 SALEM RESTART ACTICN PLAN i

as:s tial feat.res Of the F.aaet:r Tr's system, wnich is recesserv to prevent

- '-i;t:e the c:. sac.re cas of a desi n-asis event t.na:,cculd ' result in a:.:st:i ;

...e Offsite ex::scra gui ali..as set f:r:n in 1 C;R Part 100. The

s..

trip attach snt of the react:r-trip circuit breakars is n0t required by

ess..t NF.0 regulati:ns and, alth:t;n it is pr:vided to ;srfcra the canual tr': fur.cti:n, no credit is taken fer this design faa ure in tne safety analysis

'.a t tal reacter trip aisc a: cates the UV trip attach:en-). The licensee in a yarch 1, 1953 letter to NRO concurred in this position. Hence, the specific isste with regard to the safety classification of the reactor-trip circuit breakars is censidered resolved. Other issues concerning the mar.ner in which . e reacter-trip circuit breakers were treated frca a pr: cur-trent and main-

s ance standpoint at Salem.are addressed under Manage ant issues (Section III 3).

The licensee has made a ccamitment to install new UV trip attachmenti on all four Unit 1 circuit breakers prior to restart and to verify that the new c'r:uit breakers have been properly serviced and tested. 2. Identification of Cause of Failure The licensee's' initial-determination of the cause of the failure of the rescter-trip circuit breakers (as d cumented in a March 1,1983 letter) was

t. at there was binding sad; excessive friction of the vertical latch lever of

t. e UV trip attachment due to a lack of proper lubricati:n.

This conclusion was concurred in by Westinghouse representatives and was based en visual 1 spection of the UV trip attachment, in place testing ;erformed after the failures, and previcus Westinghouse experience. Because of the icportance of .. s. cfg3 13 SALEM RESTART ACTION PLAN

.e it:::r rt; circui

rea.ers a..d 'sV trip a ach ents, h:-ever, the NRC s af f is :-t:are: a ::re stru::ure: 1:; ca:h to res 1ving this item.

A;;endix

:s s : ':s s.r e 'G.C e f f:rt at: ir. '..:es ne exten cf ince;er. tant esting to

-:e ::r.1 by 5:.C. L':e see

.ica - Shcrt Ter:

The li:ir.see niil provice UV and shunt trip attachments to the NF.C fdr exam-instic.. ar.d i.vestigation. N?.C A:-ica - Sh:rt Term NRC c:.du:ted an initial investigation of the cause of the UV trip attachment ~ failures by visual examination of the devices by qualified personnel and de-termir.ed hev the devices, were maintair.ed (See Appendix A). NRC Action - Lena Term nRC will conduct laboratory. testing and examination of the failed attachments to datermine the precise cause of failure, if possible. Test and examination results will be used as a,,pasis for future maintenance surveillance and/or requi a ents for the UV tryp attach:ents. i 14 SALEM RESTART AC.TI S PLAN e,.g.,: l

o. 3. ' erification Testinc

- Augus-20,1952, :ne rea:ter-trip circuit brsaker :n Unit 2 f ailed to

tra a during surveillance testi..g. A UV trio attach er.t was replaced en

. is cir:uit breaker, the circuit breaker was reinstalled, and subsequent

straintenance testing established

perability.

Similarly, 6n January 5 _I53, a rea:: r trip c::urred at Sale: Unit 2 due to a 10 -1:w steam generator i level, but ene reactor-trip circuit treaker failed to cpen. The licensee

.cluded that the' circuit breaker failure was due to binding from dirt and

rresten in the UV trip attach:ent. The UV trip attach ent en the Unit 2 circuit breaker, as well as the UV trip attachdent en all Unit I reactor-trip

'rcuit breakers, was cleaned, lubricated and readjusted under supervisien. of a %'estinghouse representative.

Since the circuit breakers again failed 6n February 22 and 25, adequacy of the veri-fication testing to ensure circuit treaker operability is an issue. Verification testing following reactor-trip circuit breaker maintenance or initial installation should be sufficiently c::prehensive to provide reasonable assurance that the circuit breaker will a function as needed. r_icensee Action - Short Term The licensee has prcposed a pregram to verify proper operation of the reactor-trip circuit breakers prior to returning them to service. The program will involve 1) preinstallation testing of UV trip attachments 25 times by the .andor and ten times after installation, and 2) response time testing of the circuit breakers. i i k t 15 SALE.9 RESTART ACTION PUJi ~2/05/53 u -,- -

Liin..see A:ti:n - Lene Ter-A*.-.:c;. - t iicansse has n:t yet pre;; sed a 10 ;-tar: ; :gran, the NRC staff

r

;:res a.. Extsr.sive ts.:h test of a reactor-trip circui. breaker and UV and s..u tri; a tach: arts as an in.egra ad unit.

The tes. is to involve cycling (a :.a1 of 2000 cycles) under simulated envircr.: ental servies.c:nditions to ta ar-f r.e,if a preparly matr.tained circuit breaker and its attach.ents can cpara e for an extenced nutter of cycles. NRC A:tien - Short Term SEC will verify c: pletion of the licensee's shcrt-tarm precperational tes. ting program. NRC Action - Lona Term NRC will review the licensee's long-term operational verification progre n for the reactor-tri.p circuit breakers to assure that the folicwing points are ~ included: 1. a sufficient nutber.cfjcycles is included to provide statistically meaning-ful results. 2.' the test exercises both UV and shunt trip attachments, as well as the circuit breakers. 16 SALE.u. RESTART ACTION PLAN . -.c. c.f e : ui. u-

I. the test is cenducted unde. e..virer. ental ccaditicas similar to those see :y -he circui-breakers. 1 s.'fficient delay time is ir.ciudad 'cetween cycles to alicw return to steady-s a:e conditicas. uti.ter.ance z..d Sureei11ance Pr:cedures rire :ne investicatica, it was determined that no specific maintenance u preceicre existed to cc.. duct preventive or corrective maintenance on the reactor-trip circuit breakers. The maintenanci ccnducted in January 19S3 was no: perfer:ed in accordanca with the latest Westinghouse recc=mendations,. which were centained in Vestinghouse Technical Bulletin NSD-74-1, as amendid by technical dats letter NSG-74-2. Additionally, no program of preventive caintenance had been conducted on these circuit breakers since original install- - ation. With respect to surveillance testing, the licensee conducted a functional test ' of one of the two reactor-trip circuit breakers every month, so each circut,t breaker was tested once every two conths. The surveillance tests, which involved tripping a circuit: breaker by use of the UV trip attachment, met the technical specification reduirerents. The licensee also operated the circuit breakers weekly by exercising the shunt trip a'ttachment. In view of the number of reactor-trip circuit breaker failures at Sales, it appears that the periodic surveillance testing was ineffective in assuring reactor-trip circuit breaker cperability. l l l l l 17 SALEM RESTART ACTICN PLAN 03/C5/:--: i

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...,..,, _ a.... : 2. :. a. - {i..:...: ..:c.e. r $ s. :. :.~. :...:.x.:j\\.. ~ s s.:. c s. tc-.. .2 The *: ice,see has de'.'elCped a specific prEvar.tive Cainterance ph0Ce:Ure for use -j..-..j.

6. - e..s k. =.. c.

r :.w I <:.-.. c. a.. i e .ar..:, .6 6.. .. E C.. e n. ), v.6. :, c.g s,i w...... y i,.::r:: rates all a;;iicable ve'.dcr. ai..te.ance rec:- e. dations,' apprcpriate quality assurance (QA) rec,uire ents, and post caintenance testing. The iicar.see has pr: posed conthly testing of th'e main reactor-trip circuit breakers by use of the UV trip attachtsnt and

• eekly testing of the reactor-trip '

circuit breakers by use of the shunt trip attachment. Licensee Action - Lono Term The licensee will incorporate results of long-term verification testing of the reactor-trip ci.rcuit breaker into maintenance and surveillance programs. lG Action - Short Term ~ N:. will raview the revised caintinance procedures and c;erational verification prc;-a-to resolve the ceficiencies noted in Appendix 2. The licensee's pr: posed surveillance test require:ents en the circuit breakers will also be r s. i e', e d. 4 ,_g... 3,..a. e.... s., .8 SALEh. P.c.s_i m i.su..a w/..r. r .m c-,. r _,-..,-~,.-..,-err, e e.-- e w s r

=.,. . ~:. { . ki D. I g-e I B s.... ....a .-a.....**

z... a '... s. 6. a.

] 4.. =. $ =. =. ' t.....e-a. '..h.3. 3.J. .s .4......*e.. :..... o r *..>i. 1.t. # e a ..c ...=...s(..,... ....a t2 .. t.. a.. a.... ...a..,..,

s.. e...e.,.y

,.,a. 6,.,..: ,.:en,.oin.s o - ......i e - a:;'icati:n, et:.). NRC ili also assure that results f long.-term verification ss;in; cf the reacter-trip circuit breakers are i.':Orp: rated::into maintenance ..., s. <. t. e....3.....

s.,.. r.. #..*. *. -<-4..',- ', r =. q.e. n. './, 1 n,.e c.'. c n re qu'e r a.-

..s .e .c.w a sr..s, and lifetimes. p.s evaluat' ens will be conce :ed by the Franklin Research Car. tar (FRC) and the

,r::,ghaven National Labcratory (3NL).

4 I t f I l 4 2 i i d c y.s,. -. g n, T n. C..tn, 3, n. d. ,9 .n.t. n:. s ii s 2. .;.u v:/ca I ,n -,,--,.c,-.,,n,.e,,,. ,,,-,n,m-,,--. -r..-- s r,.

m 1. t a:s..ent Issess itsidenaxamina-icaOf.tecir:bastar.:ssass:izta: witn the avents ir.ve; vin; reac r-trip cir:uit traakars, cartain issues have been identified relative :: proceduras, training, etc. that are r.ot solely related to the react:r-trip circuit breakers. The extent to which such;. issues icpact e r.er systems, c: penents er c; era-icns at the Sais: facili y needs to be extrined. These are catag0rized as eanagament isstas. They are j ?. 0;erator training effectiveness relative to the RPS and associated indicators l.Z. Operating procedures for ATVS and reactor trips d.E. Operator response 4. - Posttrip review 5. Issues relate ( to the Master Equipment List associated with the licensee's QA program 5. Work order procedures' 7. Timeliness of 10 CFR 50.72 reporting 8. Updating vendor-supplied documentation 9. Involvement of QA with other station departments 10. Pest maintenanta. equipment cperability testir.g Th se issues are discussed in the Sections below. - ~ ~... /. e/n. 20 SALEM RESTART ACTION PLAN 5 yg y g ru g.. .i.....,.......y.gi g..- a - - -' -

{ l 3

e a :r Trai-i v

.- E.is-s c:.:u:.Ed by NEC wi.h the lica.se: 0;arat:rs who -are enshift

r' ; the c.o even s 'ntica e a lack of f amiliari y with tne func-iens of the a-..--ica,:rs and indica :rs as scciated wi-h 2.PS.

The interviaws also revaaled t a

ne c;aratcrs 5.h: were enshift during the February 25 event did not s::;-i e -ha. a.alfunction cf the F.?S had cccurred until approxicately 30 ri.. es af ter the event.

Specifically, the cparators interviewed were not a:1s :: describe whether the reactor-trip-indicator light (red) en the F.PS '.i : status ;ar,el indicated a demand or confirmation of a breaker trip. .-.a. views also indicated that at least scme operators quest-ioned the validity Of a..unciato,_3 until they could be confirmed by independent indication. -. tr- ...s....'.o s gr -- ,..u.. _- - - _.g... u.=.........s..n-.~., ~...,--m g._; a .....a j .,.a::.u.a'r-st-;4iM_'*# ; %'h 6#-4Druai:y-.2-2 :..d 2-3 TVcat:.. : 5 20 *

• M : ~ t%d a

-- ' '--- ** -ca1 s + 's...>..-..... h- - 5.1 ^ '. '.... '.-. -u:'---'-- ^- ..s e e r-s 3 c.r.a.t.ad by._the.tect;d.r.s. - Eased -cn a review of calibration testing incidents e in 1952, where the reactor trip annunciator was actuated by a spurious signal tut no reactor trip cccurred, ' g=-"+ "=' - tr:t:-r: c:::- ' : .:. ta'.;Lh is ediate action to trip the react:gc:ntribut d '-the o to verify reac' tor trip annunciators. This s not 25,1953.jas discussed %3 ased en annunciator indicauen,,- b ~ alcre on February -'estino conducted by the licensee in respenlse'to NRC questioning co firmed tN I 2. -,at short-duration - ;uri::c signals (less,*.han 10 milliseconds) co 1d produce L - 9 =J. h W i % Ng k (*N5 nce.s ve r f c n,.(, y -lk d af<t d, a. 21 sal.EM RESTART ACTION PLAN

0 ( t I a sa: r rip an..u.ics-ica --ith u. tripping tha react:r. Initial foliewus of s.'e Of.-is ss-i.; i.:ici as tr.atsthe systa-is fu.:ti-:ni. as designsh, s:ui-in;.rio si;..ais Of re than 10 :: 12 mi'.lisacents to actuate the rea:::r ri; :ir:ui. treakers. I. any event, it is a;;arent that training in the areas cf theI RPS and tss::ia ed indt a-i:ns and alar:s is warranted. f),. L :ensee Action - Shert Ter: qfw W( -J . a r *+ 1 e i ' W" The licensee has made a cc :ittent to ccnduct additional training on th...?S ar.d associated indications and alaras and to review the.:ebruary 22 and 25 /f events with all c;erators. \\spirb(b) Eb NM e.re. Md# T u,3 c,,jt rmg,,,) > g +g y w,4 4,,,;,, g,f,,4 L. ensee Action - Leno utrm c ,h .cssu g i:nf. c;hni:p.. RPS training and associated gihe licensee will p :.i.d: dd.t subjectgn the operator qualificatien and requalificatien program. l. n:.C Actic6Short Term

4. -, A L I.. - %

cv d u'.t will-{v-r:tfy the adequacy and ccepletion of recedial training prict to Unit N:.: 1 estart X

a. ~ L o uil L b

d.ddress rJ m i L p_.pS o.0 0 l 3 % a t w/- i-5 u n w,

4. t'<M u ms ~

I ,1,. o[s $ Q$ 0 re-c.> T!% #M j s I AP s '2.) e \\a cteu. t s ta Le udtt%.t95. ff (2. C.,Y.t u ~l on) 5% ,y a c_ w.,a a ; f + u he m a s : ur M d'us F Fa 22 SALEli RESTA?,T ACTION PLAN .f.-: /3 3

,N f of horr u+ cm i ,w -t lyt -> # l> C 9( _J 7 !.:d A:ti:n - ler.c Tern s: iil raview 1:..;-ter trair.ing pr:gra: changes. f i f* 'E. C:eratine Pre:6dursi for Antici:Eted Transients 'n'i... cut icram (ATVS). anc.:.eatter Trics q ; --.4.,3 f i Ir.terviews with cc.. trol reem cperat:rJ Nere conducted by NRC staff, and a review of the cperating procedureV.cr ATVS and reactor trip (~i. ave revealed tna. O the cperaters do not take im:sdiate action to_initia a a manual tri g .tue vr. ltased on reactgI,,-grip "first-out" annunciators, s-fQ .'.ey sere not esrected g

1. .o ce s o by 'M--.:::. p rec e dure # S ; r n u n n

n.. '. r:

M ut: :t' ' #r *>2 - T

= :-;c.t.. ; :. nnu:M/

.e4<<-- -:- :d =d the. n..tr.i. d5 ::: c,.. ;.. c... -e-cperatore. St.:r :x:d geestioned the appropriateness of the ATWS precedure's F C 'Q" t-Ario the turbine. vithout first verifying that the reactor had tripped, 4 since that results 'in a ioss of heat sin] G.icr -c.'.G=. cica nu-cd,i'.'. '.af kH+r-r a t : d.5Etond.Sft.g) ~ Licensee Action - Short Terd The licehsee has ade a. aitment t. revise tn ATVS a'-d rea:-b rip 4 cedures to arrect 'eficier. 'es iden ied fr:m h. reviek All operators

.. h e. procedures prior to. it 1 restart.

will be train.e r: s(?2/T-Iu S. ,) 1 e hru.itnr N C ? r: Ccbr& hl r 7$ si rt $ rq em.u I 1 ( v i Off i om w k m 3, /-it rt; A.! by r/f d// ho f o ('Ca r", k .~. m c ay' <s. ~]v m!7only ra nke pousse e.,.:s n i -c k. ,t.vs l remrinig knylt. n1/sr-ml/iple anbo/ n d., r. r. t TG i ll n

• 76 Iribe.ft O

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a. perwve need lo e va! ads g

copnn. \\ pin!.sh!w fnm u n ta l ru m in d'h @n s, t 23 SALEM RESTART ACTICN FLAN ....f.- : / ~e -a

~ w K iT.!;O 22 5 r<. u *= 5

n..e. =, -

L, c, : A. sts ...L c.tre: L t. ~. .:..:e e.. s.- e c.:. e. g..: - .. c 4e

- -.i...

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. c.]

t. 4 < ; (; a<. L is c! +, e valv.J: 4' ove ll plok 5 hs. 4 ~

2. T h. (ace m nu?

re v,% +L. ba.us fo < A. Aras p,.c.-<v,e sr&G N o$ P A cide. Tu lii.h? o f ~%. o(~v h r s' S-4 p a,s. s i f O ff W )" e y /) '83 es a O b b (roc.d wr% } Mc YJ 3<.p id

• ^

, w. _, :. e-- el e ~ c h m e e_. ,,$ll Gj:< r t-bx hv o. s u s./ ~!!.< h. c s*.o ,gvo k) p,.g.4,,., e3

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1 b a (+%.g ( \\ cm !,Ju,y qT l t't: f*

== O o 66 6 0 e e

e r_e:e see Acticn - Len Term % + l a e r i u d-s u f ec :cIu rd 'c '.< c. ~ p fe e ikk L lris U ni5 '2. g i s c e J..--e k4 r d ru'. >. U s..1 2

p an% c,v c s ; Q p p.e d c m _

g ci e r.'. U u d 2. mh ri, .:: %:ien - Shor: Term o N:: will. review the licensee's revised procedures a d bui[ [ce A'Rd5 M/3, ad r edu. predrD 6 r<s+<.d e! E ti~.l.y. prter" N:.: A:ti:n - L:nc Term M9 C ch0 *paccr fa ch f'*5C~ * $ b' *I" ' b *Y my(m a 4 4 k (.O s u.g % o><. O n e n $ro *p kip 2.4 c:erator Res:ense +<d*d P rec < '""- #'""' II" "A

• ck T5 L

.terviews with operators on shift for the February 22 and 25,1953 events ^deMd-F""

cisclosed the followingi a m4 .L l A g. In both events, the operators teck. 2.1 to 30 seconds to determine the / wi cverall plant status and initiate a manual reactor trip. For the f* c.ed A event, this evaluation time was necessary because of the large t.. ::er of 4o alar:s and scuipment,.and indicators lost with the electrical 5 s transfer oM r** 4 failure and was nearly identical to the time it teck for th.PS Eespond. C*ustu;.. 3 Fct the second event, the evaluatierp' began when the reactor trip annunciator actuated and - " -' " = .i that a reactor trip was necessary based a on plant paracete%,This time coul d have been shcrtened had the operators recognized that vi 1d trip was cal led for by RPS. _ jy g,,4 - twe. L y c. L Yk =A L 1 d f'. e<Ju A*. dd u W i,,,,,,4 del ~ ] nuanc:sse de < - u"r~% ,u q1%ser-tex 1 e,uac4 m 9.ess a d.<s. uw ua - of & g k u k O N o* 's $, ?@ci Juf.<-.6,.u etc+du{ k % cc,dal room. De y b$ *E p,.t a.h,-,,1 ntuda m & ? W & d"P' % 1I gefeh p reds.jusN*mtb1" 't$ oh{u'E*. '!O "'"A'*'I) g igg,d,k qu hTW S eve 9k o.h &k O. Or& * / * #' Mhdi NIidble. ik ? 95,l e ph a cc h, C. a.a.rw r f """ pssw<l

e.

vAc.ded SAL:i RESTART ACTION ?LAN J

g/33 24

C j f?

ring.he first sven, af ar a.. cperator was directed to manually trip

's: ras) tne rea:::r, .t s-i :h F.andle was r.: Operated c:rrectly. (fhis a.v nave c:n.r.butad 0.ne ::s a;o@'f ailer.$ t o n.= ~. s.. :.. e *s.' e- +. *..w. s. s au ::atic trip sys s, had fails:.o trip Ina reacter pii:r to the canual g ~N* AIld.fi e 4. Ie'.f 44 ha t- ~ u d' * ','d 4. !. spite of the ;0siti'.s indication of the reactor protection system f ailure curing the sec0nc event, the operators did not understand or trust the incicaticas. Because cf this the cparators unnecessarily 'r reevaluated plant status. The cperators manually tripped the reacto because of their evaluation of the plant status, and not p '-=-i'y :: :M N gf}m-4.-M recognition of,the fa,iluge of the realtor protection system. 4I p UdtgJ. 4 es~%-er W s L<. [< n. p.ps tw:6s concluded tnat, gi.ven the operators' understanding of the reactor pro-tection systemje$f annunciators, theirs.need to determine the overall plant states, and.thei precadures, the resp 6nse of the operators was prompt and adequate to prct ct thg reactor for bo{h events.4 Use.oc Pc"5 kW A u:.. ' ;.; 4.s February 22 event, the c: erat' ors indicated a problem with '& ra W. aL o " dandle which 'y d=e'r e *=-av = bi d Wnen the dRO called for 4 a.anual trip, the control *jinadvertently was pulled off the boa 9d and had to se rainserted to perform the can6al trip. ~6ece u,ce o E -R. N ea.e comcch/d' Mee.ltc. blp N 25 SALEM RESTART ACTION PLAN

y/. e /..a-

.i:e,$ se * : tion - Short Term v re.u ? ~ C; era crs.e.c-ric be cautier.ac :. tr.e use cf the ca.ual trip "J" handie cc.trci. The } icensee should evaluate the need to perma.ently sec'$re the"J" j f

.ica see Acticn - teno Term

[ Ner.e. pest rio Review The licensee did not determine that there had been a failure to trip on February-22 until the computer printcut of the sequence of events was reevaluated on . struary 26, as a result of NRC inquiries. Although the licensee conducted a review of each, trip, there was no formal procedure for conducting a systematic review. By letter dated Ma'rch 1,1933, the licensee made a commitment to develcp a posttrip and safety injection review procedure. The procedure will specify the review and cccymentatien necessary to determine the cause of the eva. a.d whether equipment functic..ed as desi,gned. Other key elements of a pos.-trip ) review procedure are 1) necessary management autheri:ation ford restart, 2 requirements were completed, and 4) folicwup review by safety committees. d l 25 SALEM RESTART ACTICN PLAN -,v .-,.y y , ~.. -., ,,7 n---

t

• :5 ses *:tica - 55:rt Ter v

~ s l':er.sie -1'. I c'ivelc? E..d issue ;;sttrip a..d ;:st sa'aty-ir.je:.ica review

::E:ures ar.d train all C;traticns Ospar. ent parsenns) en t,.e require:ents pri:r to Unit I restart.

' ': e r.r s s Acti n - Lcr,c Ter T. e licensee will evaluate the affectiveness of the above precedure. N:.C A:tica - Short Term tiR; will review the licensee's pesttrip and safety injection procedures. ~ li:.C Action - Lono Term. !ic r.e. 5. P.astar Ec'uiement tist The licensee maintains a.-Qilist that identifies activities, structures, ccm-penar. s, and systems to which the Operational Quality Assurance (QA) Program applies. A Master Equipment List (MEL) is used by the licensee as the source-d::urent for determining the safety classificatien of individual equipment. T.e F.EL is inteqded to be a cc prehensive lisi of all station equipment and P i.:.!c-27 SALEM RESTART ACTION PLAN

L l i ~ o i 6.. #es ea:n its: as n safety related er safety related. 'rl hen preparing s#-;t t :e -:-k :-ders, the "EL is :ensulted to cetermine if CA ccverace of - s. : r.: is ns:sssary. Licensee ar.d NRC review identified three ;r:blans a s s ::' a.a: with -he "IL. These pr031 ems are,1) the accuracy and cc pleteness c' t. i ::::: ant, 2) issuan:e as a n:n :ntrolled documen, and-3) lack of unda-s Inding cf its pr:per use. 7 e P.IL was darived frc: a c:nstruction progra: document called Project Directive 7 (?:-7) and was pr:vided to station personnel by the Engineering Department' as a sf aren:e d::urant in July 1931. The MEL, however, was not issued as a c:ntr:11ed decu: ant, therefore verification of its accuracy and cc:pleteness 0.- i ssuan:e was not assured, and it was not updated in the plant as necessary. TP.e rate or-trip circuit breakers and the RPS were not included in the MEL'. Ir. addition, sete personnel-were not familiar with how to use the MEL for dater-ining the classification of a particular piece of equipment. Maintenance pers:n..a1 acknowledged that reference was cade to PD-7 cn occasion during the Janua y - February IcS3 period. Licer.see Action - Short Term 1. Verify the MEL is coe.slete and accurate with respect to e:argency core c:: ling (ECCS), RPS, auxiliary feedwater,, ar.d containment isolation syste:s. 2. Ir.dectrinate appropriate personnel in the purpose and use of the MEL. . : e..- 23 SALEM RESTART ACTION PLAN ..r*- gg,9 w

L'ce.see

• ct':n - Lcno Term e lice..see -ill ve,rify the ccmplectness and accuracy of the MEL and reissue it as a cent :lled c:cc:ent.

!; 01ctic.. - Sh:rt Term N C will ;crf rm sampling review of the 1 EL on the above systems. N:C Action - Lono Term !G.C will confirm completion of the licensee's long-term action. 5. Work Order Procedures - The review identified that the personnel preparing maintenance work orders W re not complying with instructions contained in the station administrative procedures. Specifically, for the work performed on the reactor-trip circuit breakar in January 1983, the engineering department was not consulted to .erify safety classification, and an erroneous nonsafety determination was ade. Such consultatictr-ty required if equipment is not listed in the MEL. Tnere was, therefore, no independent review within the maintenance organization, a.d the Quality Assurance Department was not involved in the work. Historically. -here was no requitecent for QA personnel to be involved in the processing of work orders. I I i i l 29 SALEli RESTART ACTION PLAN 03/CS/53

~. 1 i i 1 ':e see Acticn - $5cri Tern s.i:a.sse has 1:s a ::r.;tes t.:- have the QA CE;artner.t review ali nonsafety ra'.a ed w:rs ts uirements pr;,;r te, narting w:rk, and ;c it;ierent a program 1.d training to ensure that werk ortsrs are preparly classified. _i:2.see Acticn - Lonc Ters The licensee will review-wcrk c.-ders written since issuance of the MEL for

:;er classificaticn and will evaluate safety consequences of those found i: properly classified.

'o.C Action - Short Ters NP.C will review licensee's work order classification program. s ' 7. Timeliness of Event Notification ~ Cn three occasions between January 30 and February 25, 1983, the licensee. notified NRC of significant ever.ts belatedly. In each case, the notification as approximately 30 minut,e.s late. Two of these repo: ts were for the February 22 and 25 events. Furtherrore, in the February 22 event, the first notifi-cation did not contain known significant informatica regarding actuation of engineered safety features and c;ening of the power cperated relief valves. s i i. t ~ 1 l i 03/03/83 30 SALEM RESTART ACTION PLIN 4 -w -e- --,.-,,w.+s .w e.. ,,,,eemow..w+,,r-,se--,-,,,, -n,- e-,-,.

---

+,,--,r-

~.--,n.-r--- - - - - - - - - -, -,, ~ - - - -,

This ac:(.ic..a1 inf:r ati:n was ;r:vided a;;rexicataly 40 minutes later. The .:-if t:a-i: :r::s:.rs esse ty the liiansse warrants furtar evaluation as to , e pri ri y assig. st f r SEC no.ification. Lics.see *:tien - Sh:rt Term T.e it:a.sae will res:phasi:e re;crtir.; racuirensnts with all shift and on-call a..sgena.t parscar,el and will reevaluate notificaticn priorities. S:.0 ;.ction .NRC will confirm that licensee's short-term action is completed.' 8. U:datinc Vender Sucolied Information As a result of the February 25, 1983 event and NRC IE Bulletin 83-01, the. licensee indicated not being aware of the existence of two Westinghouse technical service bulletins that.provided preventive maintenance recommendations for the reacter-trip circuit breakers. The two documents in question were published by Westinghouse in 1974. The licensee has requested documentation for all Westincheuse equip:ent antf'.4111 i,ncorporate this information into station dccumsnts. An NRC staff concern is whether a similar situation exists with respect to docucantation for other vendcr-supplied safety-related equipment. ' and how the licensee will maintain vendor-supplied information current in the future. f i 31 SALEM RESTART ACTION PLAN ..,i .2,:- e

== ,w

L':s.sse A:-f:n - Short Ter.- v T..a licanses has 1:e a certit:En

a prograr :: c; a:e existing d::: 5..tation

.. safety ecuiprsnt an: to ensure trat vender d:c. r.antation is ur.dsr a :entrolle:

sys ea. Licensee Action - Lena Term The licensee will ec plete the above program. NRC Action - Shcrt Term None NRC Action - Lono Term, NRC will verify the adequacy of licensee's program. 9. Involve.?.eht of OA-Personnel With Other Station Decartments The Quality Assurance Depac.tcent did not review maintenance work orders asse-ciated with repair of the reactor-trip circuit breakers in January 1983 because the work was not designated safety related. Further examination deter =ined that the QA Department does not review for proper determination of classification mp e m e d s 4 5 e .h m

ra.

-k c cirs casigra.ed ncasafEty related by other depart ants.

Discussicas . i-. s if car!!e irdcate that the QA Capartment has been. sc awhat isciated fec.. s ac '..'-iss cf ether cs;ar.:ents. - As a reivit cf prior decisions, the licensee had initiated s:sps in January 1953 : relt:a e te QA Department frca the cor; crate offices to the site and is a<i g stsps to increase QA Cepart ent involve:ent in othai station activi-ties. Lice..sse *ctica - Shcrt Term '~ The'licsasse has made *a ccamitment to instit0te a program to more fully integrata QA activities into the overall activities. Licensee Actica - Lono Term The licenses will cceplete the above QA integration program. 10. Fest =aintenance Ocerability Testina Past ;ractice at Salea for post:aintenance operability testing has varied. Such testir.; cay be specif ted by.the preparer of the maintenance work order or lef t to the discretien of maintenance personnel. For safety-related equipcent, generally, ;; cst:aintenance surveillance testing is done before returning the equip: sat to service. Additional functional postcaintenance and repair testing i 33 SALEM RESTART ACTION FLAN w ~

f' equi; ent, su:h as surveiliance testing, cay esd to te perfereed to dec:n-s, rate :;eretility as an. integral part cf the larger c:- s..ent or system in

.n :n t. rust functi:n. i Lice.sse A:tien - L nc Ters The licensee will review and revise precedures and practices as necessary to ensure -hat functional tasting of the everall c::penents er system is perforced to den:nstrate operability prior to returning the equip:ent to service following aintenance and repair. !4easures will be revised, as nefessary, to assure that cperations department persennel review the testirrg prict to returning such-equipment to service. NRC Acticn - Loncj Term NRC will review licensee's revised procedures and their implementation to assure that appropriate postmiintenance cperability testing is being accomplished before equipment is returned to service. c 9 34 SALE:4 RESTART ACT~0N PLAN 03/03/S3

ft. 5::1csions e issues ciscussed in tris rep:rt -fre identified duri.g a thercuch examirati:n

' t e streary 22 ar.d 25, *.352 ave..ts an: related :ircumsta. css by'NRC Regien

, t.e P.C Office cf Nu:iear React 'r Regulati n, and cc..ra:::t personnel. T e,ssues were develeped frc: exanination cf the infor ation revealed durir.g ._ a :.s intervisas, c:ce e..: reviews,'and meetings. Sc e acfion to resolve

.e issues in the shert ter: rust be :: pleted prior to the restart of either Sale: Sit 1 or Unit 2 Other c:re c eprehensive acticas. ust be cc pleted on a sche:ule for their cq:pletien agreed upon by the licensee and the NRC staff.

q ilev In the NRC staff' view, cc pletion of the short-ter actions identified is sufficient te. --rmt the safe restert of the Salems units. Althcugh there is a:reecent between NRC and the licensee on the issues and general corrective a:tiens, the short time alleved for preparation of this report has not permitted

e de. ailed discussiens with the licensee needed to obtain commitments to c::plete all the specific actions. The NRC staff will fo11cwup cc pletion of these actions and will document satisfactory cc pletion in inspection r'eports a..d/or safety evalations, as appropriate.

1 .- - <. : < = 3 35 SALEM RESTART ACTION PLAN .i...-

-*s-0 ~

• pendix A

E 5'.

7 5.: S?.C ST.A?F IWiESTIGATIC!i 0~ EVE.NTS AT SALEM t;U LEAR GENERATIt<G iL i...i b ~;ENTIFICATIO!i 0F CAUSE OF FAI8.URE S:!- l-v an. Initial.:indines !..itial i..spection of the UV trip attachment indicates a possiblity of cultiple c:ntributing causes of failure. Possible contributgrs are (1) dust and dirt; (2) '.tek of lubrication; (3) wear; (4)'more frequent operation than intended by design; (5) corrosion from improper lubrication in January 1983; and (6) r.icking of latch surfaces caused by vibration from repeated operation of the breaker. The contributors appear to be cumulative, with no one main cause. The initial investigation indicates that the failure was age related and that a new cevice would perform properly. Many surfaces of the latch mechanism are worn and the additional fri.ction tended to prevent proper operation. Proper lubrication throughout the life of the device might have prevented the wear' -hat can be seen on the sample. s t 38 SALEM RESTA?.T ACTIO!i PLA!i

) ^ e ~Pe es.s and exaninaticns pre;cssd t;rthe staff End its scntractor will a. a--. c cate.-.ine.ha caus e of f ailure and if --<',ihe ;rb bse[s ci-%'~ a--- j fei'.c ing se.ari:ss the initial findings and lis5s ? test i Ciscussica and Circumstances .7 A site visit was conducted en March 3.1933 by NRO and Franklin Research Car.ter personnel to inspect the type C5-50 circuit brea'<er undervoltage trip attachement in an effort.to determine the most prchable cause of failure The rsactor trip ctreuit breaker rocms for Units 1.and 2, each of which contain , cur u- :0 ctreuit breakars, were visually inspected and the following cbser-vaticas were made: 1. All four 03-50 Unit 1 circuit breakers and UV trip attachments were removed from the circuit breaker cabinets. The enclosures were generally c'iean and free of dust. The ambient temperature was between 85 and 95'F, with warm exhaust air frem inverter cabinets being directed at the 05-50 circuit breaker cabinets. The spacing between cabinets is approximately 3 feet. 2. All four 05-50 Unit-~f.; circuit breakers were also ir.spected. The UV trip attach =ents were removed, however. The circuit breaker cabinets centained a layer of loose dust approximately 1/15 inch thick. The a.bient temper-i ature was in the 70*F range. UV trip attachments are mounted on the top i i s 1 l i i w l P c.3/ce/23 39 SALEM RESTART ACTION PLAN

of the circuit-breaker platforn,,.to the rignt of the snunt trip attach:e..t, -hicn is several inches frc: t s'tette: cf the circuit treaker cati..st. I-erviews ere conducted with Mr.'setchum, an electrical maintenance superviscr, h ciscussed the circumstances cf ne removal of the circuit breakers that ' e e i,.volved with the incident en L' nit 1, and Mr. Leo Relard',' ancther electrical s_carviser,.who nad also worked en tne circuit breakers in questien in August 1932. The information received was that the circuit breakers and their UV trio attach ents had been operated frequently and had operated during surveill-ance tes-ing within a few days prier to the incident. A request was made to Salem managecent to provide ene of the UV trip attachments and a shunt trip attachment for. testing at Franklin Research Center (FRC). This request was cceplied with, and an investigation of these devices is now under way at FRC. Results of Initial Examination ~ Initial investigations indicated roughness in the cperation of the trip latch. There is seme dragging of the mechanism, and portions of the latch mechanism have cbvious signs of weW'.; Possible centributing facters to the failure to cperate are a lack of lubrication, vear, jarri-ng of the UV attachment as a resuit of circuit breaker operation and more frequent cperation of the UV trip a.tachment than was intended during design. It is postulated that under most industrial applications, the UV attachment would be used very infrecuently and ".2/CE/33 40 SALEH RESTART ACTION PL*N

4 . :ssiy would be c;erated only duri.; test secuences at :erhaps yeariv cr

:.;er i..terval s.

Theref: e, i. i..Lstrial applice-icns,'it would cpe'ra e

.ly a 'a.

. ices, per.a;s 20 cr IO ycles during its li'etire, and sculd no ta a n:r:11 rip;ing eschanisc f:r, the breaker. Mcwaver, in its use at Sales a.: cther nuclear pcwer plants, it is the pr.imc tripping devifce for the circuit breaker, and is therefore called up:n to cperate on the crder"of 50 tices :er

. aar.

This wcule mean that at its current age, in 1953, there would have ' een b p:ssibly '.00 to 500 trip cperations of.his device. Oring the initial investigation, it was noted that the shunt trip attach. ment has been operated ence every seven~ days since hugust 1952, rather than at 1:nger intervals. This means that the ~ circuit breaker is tripped and clo~ sed e.ery seven days. This causes jarring of the entire mechanism of the circuit breaker and its attached relays and coils due to the normal operation of the breaker. This cay or cly not be significant, but it should be noted that the L.' attachment. stayed energized during these trips, and its latch mechanism was jarred semewhat by operation of the circuit breaker. This possibly added to the friction built up in_the latch mechanism from normal operation by causing the latch cechanism to just slightly nick the surface that it rides on and thereby tend to prevent operation. Further investigation will try to determine w. ether this is indeed a~pr0blem. It appears from initial inspection of the cavice that wear and roughness of nating surfaces in the trip latch are present. Fr:per lubricatien might have prevented the current situation or could have - reduced the roughness to the point where proper operaticn could occur. t 4 t i i t i i ? l l .,/cu e-41 SALEM RESTART ACTION PLAN i .c,.+,e- ...... ~. +. - -- +-,.---r

---

a-

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

ur..ar investigati:n will a a ;; i: r determine wnether the CRC-2-25. lubricatin; i a.d : leaning s; ray 1:ded :: : t c;e sting pr:ble: by eitner causing c:rr:sion

- rie:ving all resid;al 1:.:r':Eti:n frc: initial c nst uction ar.d pcssible

akir.: cf cust ar.d cirt.

1;; ears that fr:m the tics of initial construction

f the uv trip a a:hrents

antil January of 1953, no lubricatien procadures ad

een perfer.ed, and tha.., in January of 1953, lubricatien~precedures were u,ts aren by the.aintanar:e ;erscnnel and a L'estingh use technician.

At. -his tice, the CR 25 lubricant cleaner was sprayed en all four UV trip a,tachments asscciated with the Unit 1 circuit breakar. This lubricant is taing precured by FRC f:r tes-ing purposes. t.ist cf Investications to te ;erferred Sv NRC Contractor (.FRC) 1. The first test will bs. to perform various deenergizations and energizations of the UV trip attachment and monitor the device under various conditions. * ~ 2. The second test will be to disassemble the latch mechanism to observe the 5 surfaces of the various ; arts of the latch and to photograph these surfaces through a microsc pe to determine the various levels of wear on these.. surfaces. ) ~. 3. The third test is toistarcine the effects of CRC-2-25 spray on the various types of metals used in this devices. An attempt will be made to s use metals other than th:se in the actual attachment. If possible, the chemical consistency of this spray will be determined from the manufacturer. 'b N 4 4 c,.:/c..s 42 SALEM RESTART ACTIdit PWI

x.- ? \\ \\ s \\d i i 3: .a Tc ;-:ca. that the sar:le UV trip at apsent is' .'dtntical to all such f aiem ca 'ess, a visual ir.s;tetica cf all asistir.g Salar.'Ur.it l'a-d 2 UV trip attach-e-c.s ill be perferrid. This can take place a: Salam,.sith no' cists'serely esecad. The inspection can be' ade with the cavices counted en tae circuit f reakers er icose. These inspecticns should beic0r.e as soca es possible,'and T;;adday,. March S, 1953 is recca: ended. ...i If for-her tests are required they will be bued on the results of these init'fal tests. All< tests will be nondestructive such that the device can.be,

.: sed for further, testing and returned to the u-ility.

t Additienal Test ti ce Conducted bv the Licensee. as Revised by NRC Staff f. Th'is tIst will require the use of a spare circuit brsaker. The UV trip and shunt trip attachments Will be counted on the breab.d ud the breaker will be cperated repeatedly to/j'etermine the _effect on the, shunt'and UV trip attachmer.ts. It is surmised thht shile the attachments are, energized 'and the breaker trips . and closes a number, of _tices, additiaral frictiongf the trip latch may occur from the vibration. i This test is described in de;tsil in the( following section. I + r. 4,f u. i ( f, l5 W ~ p s' y' sq f-s iij j s r, I' i r- / '( N '4 3 ( 1 / s ( n s g g /, ) l l m .>f s. s, 1. , e I 4 f,' s .y; c.

/.-

g i .o r >. c ( m s . o s s \\ y e .s ' y. t t '{, [ 4 g 3

• f i

x. t' ' ' 43 (ALEM RESTART ACTICH PLAN .. i..r.a , bn.. - k.. a,. .n-. .~w-e + - - - - ~ ~ ' - - ~c - ' - - ~ ~ ~ ~ ' - - - ' ' * ~ ' ~ ' ' ~ ~ '

REVISE:' SU:VEILLANCE C.: :E1CTCR-TRIP CIRCU:T ERE* KER OPERATION AND ~ ~ . i:... iCAiiCN T E571t.] e licensse pr:pssed 'the f 011: sing incriass: s.rveilla ce cf reactor-trip cir:vit breaker Operatic..: ~ P.ain and bypass breaksrs will be shu.- -tri: ped week y. 2. Main breakers will ta UV-tripped mon.hly. T..e acceptability of this revised surveillance of react:r-tr-ip circuit breaker c eratica has been evalcated by HRC staff. Eased on an analysis c:nducte.d by 5.:.C staff, which considered reactor-trip systam unavailability, reactor-tr'ip circuit breaker failure ratas, and test intervals, the follcwing conclusions .are drawn. First, the proposed test of each reacter-trip circuit breaker UV trip attach: ant once every 30 days is acceptable. Secer.d, the proposed test of th2 shunt trip attachment once.every seven days is c:nsidered to be excessive cd eiay impact en the reliability of tile reactor trip system by increasing the -

u.ential for a single-failure.

During testing, a single failur'e in the logic mt'on of the reactor trip system could prevent an aut::atic SCRAM. Thus, it ei Nec: mended that the sbont trip attachment be tested en the sar.e schedule u *a UV trip attachment;#that is, ence every 30 days. e expS S e h 4 .g w. O e W I ..,../w . -. m- .m

C i s cus s ien T e acceptability of the pec : sed test intervals f:: tr.e res: cc-trip circuit

b. eakars was based en NRC staff review of reactcr-trip circuit breaker failure rate ci a cbtai:ed frc Licensee Evant Reports (LERs). Tne Ep5 unavailability

cal cf 3 x 10 * (used in bc-h NUREG-0450, " Anticipated Transients Withcut Sc. a for Light Vater Reactcrs," ar.d by.the ATW5 Task Fcrce and Staerir.g Grcuo i.. the cevelopment of the prcposed ATWS Rule).cas used in evaluating the licensee's proposed test intervals. In additien, the f=11

wing censiderations ere inco'rporated into the MC staff recce.mandation:

1. The shunt trip attachment providas a diverse means of tripping the reactor-trip circuit breaker, which is electrically independent of the UV trip attachment. The UV trip attachment is supplied by a 48-V de source and is deenergized-to trip. The shunt trip attach:ent is supplied by a 125-V de source and is energized to trip. 2. The shunt trip at_tachment is an energize-to-actuate device and is not " fail safe" in that a loss of power will not cause a trip. However, the shunt trip is pcwered. from a reliable Class 1E battery-backed source. 3. Since the shunt trip attachhent is an energize-to-actuate device, i't is not subject to the constant. heating effects that the continucusly energized UV trip attachment experiences. The heating effects may contribute to the higher f ailure rate of the UV trip attach ent. m c:.e 3 45 SALEM RESTAP.T ACTION PLAN s. .____._._,m_ J

t 1 T.e ce:hanical construc-i:n of the shunt trip attachment is less c::piex ..an that cf the UV trip attachfant. The shunt trip attach:ent d:es not rsiy en the su::essful Operaticn of the c: plex latching techanis that ' his been detersined to be the'scurce cf the majority of'the failures of the UV trip attachten. 5. -The majority of the electrical circuit breakers used in the high voltage. electrical distributien system have de powered energize-to actuate shunt trip attachments. These circuit breakers are used for manual, as well as aute:atic, trip functions for load shedding and p:wer switching. Relia.. bility of energite-to-actuate shunt trips' in similar applications throughout the nuclear power industry has been shown to be significantly higher than for devices that are constantly energized. n The licensaft s revising g acader o require the operator to manually .) i 5. . trip the reactor ic t iowing indication of an automatic reactor trip. Thus, on any trip signal, diverse means will be used to trip the circuit reakers. s 7. Over 70% of the known reactor-trip circuit breaker failures were caused by UV trip attachmentifailures. S. M st of the concerns relating to the events at Salem on February 22 and 25, 1983 are related to the operation of the UV trip attachment. During the events at Salem, the shunt trip attachment functioned properly. 4 f 46 SALEM ?.ESTART ACTION ?LAN ,.. r. e,r -. ca

Va.-ificatica Tastinc

is ra::: s.ced -hat a bench tes. La pericr:st :n :..5 CE-5G reac Or-trip circui: braaker.

The pur;ose of the test will t~e :: cy::e the 03-50 with the L.' trip ar.d shunt trip attach: ants in place fcr a te:ai f 2000 cycles to-caterni..e if any adverse effects can be icentified a..d, if there are no adverse affects, sh:w tha a properly maintahsd treaker a.d its subc :penents can c;erate fcr an extended nutter of cycles. The breakar will be tripped, with. each cycle being alternated with the UV and shunt trips. The ambient te.cerature sr.cuid be 100*F to simulate the expected service a.virc-ent, and the cir'cuit breaker should be cycled no more often than cace avery 30 minutes to allcw for return to steady-state conditions. The results of each circuit breaker operation will be d cumented and a visual check made. Additional details for this type of test will be provided at-a later time. 47 SA!.EH RESTART ACTION ?LAN n.,/r. :/33

O O 1 AcCsndix B INITIAL NE.C STAFF REVIEW 0: LICE';5EE's Mt.I;;TE.i;n;CE PROCEDURE. AND ?R:.,r:...o a.hAL YERI?icATION pp.;;aA 4 ';:: staff reviewed the licensee's maintenance procedure, Sale.Y. Generating Ita-ica Maincanance Capartment Man 11 !'aintsnance Procedure M3Q-2, Revision 1.~ -is dccument includes a precedure for verifying preper cperation of the UV - '? attachment and testing of the UV trip attachment coil following replacement.

.:' staff also reviewed the licensee's propcsad reactor-trip circuit breaker c.aratienal verification pregram, which references Procedure !43Q-2.

The fclicwing ccaments and r,eccamandatiens ',,ere made concerning these documents: 1. The maintenance procedure does not specify whether the maintenance and testing described are applicable to both the main and bypass breakers. It should specify that it does. 2. The maintenance pr,ocedure should specify required actions to be taken.in the event any acceptable tolerances, as identified in Enclosure 7 of > M3Q-2, are not met. 3. The frequency of all caintenance and test.ing specified in the procedure, with the exception of the verification tasting identified following UV trip attachment replacement, should be specified. e c3fggj33 48 SALEM RESTART ACTION PLA!!

- e ;r:: sic.re sh: Id te.:dified.to rsquirs cleani..g 0f the entire circuit

6 tier r::2, t..e s val of all f:ur circuit creakers ar.d cleaning of

,re.:sti..s s by vacuuni.g, a.d. citaning of the treaksrs d.: ring every reheling cutage. = f ac-i:n 9.7.2.1 of Precedure M3Q-2 specifies that the UV" trip attachment is to be cleaned wi-h a standard scivent. The precedure shculd specify

he exact solvent to be'used.

HRC will request FRC and ENL to determine the acequacy of the prc;csed solver.t and any pctential adverse effects frem i s use. (This evaluation need not it co:pleted prict to plant startup). Section 9.7.2.2 specifies the cc: position of the lubricant to be applied to specific points,of the UV trip attachment. This specification should - state whether the mechanism is to be lubricated each time maintenance is performed. NRC will request FRC and BNL to determine the adequacy of the iubricant and the points of application specified, as well as the frequency of lubrication. Any UV trip attachment. that does not successfully complete the 25 consecutive cycles of testing to ife performed by Westinghouse should not be accepted cr-installed by the licensee. Section 9.7.4.15 specifies the testing to be performed en the UV trip a-tachment coil following its replacement. The maintena.ce procedure 49 SM.EM RESTART ACTION PLAN .. f g3 '#~' "~ ^

• 5 :..c te ravisad t 'recuire that,all replacecent UV tri s'.::sssfully :: ? ete 25 c:rsectiive. Cycles of testi3g ;p a tachments l

rier o installation 3-r.e piant and start of the ten test cycle s;ecified in tr.a caintenance

.

:scure.

The tire between each of the ten tests shcule de specified. h:.; ac::: ends 30 minutes for the reasons specified in Ac:endix A. NRC-s aff telieve the increase in test cycles, and the accepiance criteria s:scified if any f ailures cccur during this testing, are reasonable and s.5: ele te in::rporated into maintenance procedure M3Q-2. 9. Technical Department Frecedures N:s. IIC-13.1.011 and IIC-13.1.010, referenced by the licensee, should be revi~ewed and thair acceptability de ermined oy NRC staff. c. F011cwine revision of the mIintenance procedure and the associated proposed reacter-trip circuit breaker operational verification pregram to incorporate the ab:ve cc :ents and recc mendations. NRC staff will reevaluate the documents a-d pr: vide ancther. report that will include the results of the NRC centractor's evaluations and will dqcument the final NRC evaluation and conclusions concerning the acsquacy of the maintenance procedure and preoperaticnal verification Prec.ran.

c. f;; 33 50 SALEM RESTART ACTION PLAN

fu s lOO Q /U ' r r be ra r. '5 ' Document Nace: SALEM "nESTiRT Fl? ORT $ 2. % u, N. Requestor's ID: e 10A%'E g$ hof,u,j fo Devbr '- ~- Author.s Na:e: Don Fisher /'Jalt 011u. Document Concents: ~ PLEASE RE1 URN TdIS SHEET VdEN YOU SUBMIT REVISIONS M 9 9 e 6 9 4 gas e99

• 9 h

9 9 sub e, 9 4 I

= =

P e e b - O -e e s O 4 e D e e M* M-Y

l[ ~% Conter.ts Abstract I. Purcose and Scoce II. Backcround III. Issues A. Eouioment Issues - 1. Safety Classification of Breakers 2. Identiff' cation of Cause of Failure 3. Verification Testing'. 4. Maintenance and Surveillance Procedures B. Manacement Issues 1. Operati g Procedures for Anticipated Transients Without Scram (ATWS) and ?.eac or Trips. 2. C;erator Response 3. "p-ra.:r T.aining 4. Post-Trip ' Review 5. Master Equipment Lis.t 6. Work-Order Procedures ~ 7-Timeliness of Event Notification 8. Updating Vendor-Supplied Information 9. Involvement of QA Personnel with Other Station Departments 10. Post Hair.tenance Operability Testing IV. Conclusions Appendix A Appendix B Sale. Restart Report 1

~ Ab'stract A report for assuring the readiness of Unit 1 of the Salem Nuclear Generat-ing Station for restart is presented based on the NRC evaluation of the events of February 22 and 25,1983, when there were failures of the automatic reactor trip system following receipt of valid signals from the Reactor Protection System. The manual trip system was used to shut down the reactor. It was determined that the -failures to automatically trip were caused by malfunction ( of the undervoltage trip attachments in both reactor-trip circuit breakers. A number of issues have been identified as having contributed to causing the events. Sh' ort-term actions have been identified to resolve them prior to resumption of operation, as.well as long-term actions needed following restart. The issues are categorized as " equipment issues" and " management issues." The equipment issues are (1) the safety classification of the circuit breakers,. (2) verification testing of operability, and (3) maintenance and surveillance procedures. The management issues are (1) operating procedures, training, and response; (2) post-trip review of failure of the automatic system; (3) the quality assurance and work order procedures; (4) timeliness of reporting; (5) updating vendor-supplied, documentation; and (6) post-maintenance. equipment operability testing. Ttie 4taff has reviewed the proposed corrective actions and has determined that they are appropriate and acceptable, c Salem Restart Raport 2

Salem Restart Report 1. purpose and Scoce This report briefly describes the NRC actions to address and resolve equipment and management issues identified by the NRC evaluation of the two events at Uni.t 1 of the Salem Nuclear Generating Station that resulted in failure of the reactor to trip automatically upon a valid signal. The second event occurred on February 25, 1983 and led to the realization that a similar event had occur-red on February 22, 1983. Based upon NRC evaluation, the cause of the failure has been identified and is attributible to the lack of proper attention given to a device in the breaker assembly. Replacement of such devices with neW ones and conducting proper test _s and surveillances, in conjunctidn with resolution of related issues, provides reasonable assurance that Salem Unit 1 can be restarted. An NRC task force has been established to conduct a separate longer range study of the broader implications of the events. NRC long-term actions noted herein are those related only to Salem. The NRC task force will determine generic actions needed for other facilities. For the Salem facility, longer term actions developed by tMisitask force may supersede or cocplement some of the long-term actions identified herein. II. Backcround On February 25, 1983 an event occurred at Unit 1 of the Salem Nuclear Generat- ' g Statien whan the ?s:: r-t*': :' : it bre'akers 'ti'ed to autcmatically open folic'..ing.scai;;.cf a.a:ic ria signal fr:m :ne Reactor Fratection System (RpS). The manual trip system was used to shut down the reactor. Subsequently, it war concluded by the licensee that the failure to trip was caused by a malfunction of the undervoltage (UV) trip attachments in both reac :r-trip circuit :reakers. These UV trip atta:n=ents translate the electrical signal from the RPS to a mechanical action that opens. the circuit breaker. On Febru.ary 26,1983,.an NRC team was onsi.te to conduct initial. followup an,d to collect preliminary information'. As a result of NRC inquiries, the licensee determined that both reactor-trip circuit breakers had similarly failed to open upon receipt of a valid. trip signal on February 22, 1983. The failure to auto-matically trip on February 22 was not recognized by the licensee until the com-puter printout of the sequence of events was reexamined in mo're detail on February 26. Further evaluation of these events and the circumstances leading up to them revealed a number of issues that require resolution by the licensee and/or the NRC. This report identi.fies those issues and the short-term actions proposed to resolve them prior to resumption of operation at Salem Unit 1* and the long-term actions that are needed on a defined schedule following restart. The short-term actions requir d for Unit 1 will also be implemented on Unit 2 prior to restart of Unit 2.

• Salem Unit 2 is presently shut down for refueling and is not presently scheduled to resume operation before Unit 1.

Salem Restart Report 3 .i J.A m- -.Ah-.J1------

=. The li:ensee met with NRC staff on February 28 and March 5,1983 to present the results of initial evaluations related to the events. Based on licensee sub-mittals of March 1 and March 8,1983 and on the findings of the NRC evaluation of the Salem events, the issues are categorized as equipment issues and manage-cent issues. They are discussed in detail in Section. III of this report. III. Issues A. Ecutoment Issues Thre.e of the issues relate to,t'he affected equipment, that is, the reactor-trip circuit breakers (Westinghouse 08-50 circuit breakers). These issues are 1)' safety classification of the circuit bretkers,'2) -identification of the cause i I- / . of the failure, and 3), verification testing of the circuit breakers. l - 1. Safety Classification i e Breakers Duiing the initial NRC evaluation of the February 25 event, it was determined that maintenance was conducted on the Salem Un' 1 reactor-trip circuit breakers in January 1983, following,a failure of one reactor-trip circuit breaker to trip upon receipt of an D6 signal at Salem Unit 2 on January 6,1983. The werk orders authorizing the January 1983 maintenance identified the maintenance as not safety related and not requiring quality assurance review. The reactor-trip circuit breakers contain both a UV trip attachment'and a shunt trip attacn-i ment, but only the UV trip attachment is operated by an RPS trip signal. As a result, it was not clear on February 26, 1983 what portion, if any, of the j reacter-trip circuit. breakers was considered safety related by the licensee. - Action / Evaluation This issue has been resolved. Section 7.2.1.1 of the Salem Updated Final Safety l Analysis Report (UFSAR), Revisicn 0, indicates that the Reactor Trip System includes the reactor-trip circuit breakers ano the UV trip attachment. The Westinghouse Solid $ tate Logic Protection System Oesc'ription (WCAP-7488L) also ~ ~ defines the scope.of the system as including the reactor-trip circuit breakers and.the UV trip, attachments. The UV trip' attachment and the reactor-trip circuit breaker are safety-related equipment in that they a're essential features j of the Reactor Trip System, which is necessary to prevent or mitigate the con-sequences of a design-basis event that could result in exceeding the offsite exposure guide, lines set forth.in 10 CFR Part 100. The shunt trip attachment of the reactor-trip circuit breakers is not required by present NRC regulations i and, although it is provided to perform the manual trip function, no credit is taken for this design feature in the safety analysis (a manual reactor trip also actuates'the UV trip attachment). The licensee in a March.1, 1983 letter to i NRC ccacurred in this understanding. Hence, the specific issue with regard to the safety classification of the reactor-trip circuit breakers is consioered j r'esolvad. Other issues concerning the manner in which the reactor-trip circuit breakers were treated from a procurement and maintenance standpoint at Salem are addressed urider Managenent issues (Section III B). The licensee has made a commitment to" install new UV trip attachments on all four Unit 1 circuit breakers prior to restart.nd to verify that the new circuit breakers have been prooerly serviced and tested. 2 i j Salem Restart Report 4 __,.,py,,--.c.igy.-9,n.,pwy ,9, ym y,- 7,.,.p. ym.,em pe m.9m w-v, s-g, gwww

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~ 2. Identification of Cause of Failure The licensee's initial determination of the cause of the failure of the N.s reactor-trip circuit breakers (as documented in a March 1,1983 letter) was that there was blading and excessive friction of the vertical latch lever of the _UV trip attachment due to a lack of proper lubrication. This conclusion was concurred in by Westinghouse representatives and wasJased on visual inspection of the UV trip attachment, in place testiTig performed after the failures, and previous Westinghouse experience..Because of the importance of the reactor-trip circuit breakers and UV trip attachments, however, the NRC staff has prepared a more structured approach to resolving this item. The NRC has conducted an initial determination of the cause of the failure based on inspection of the failed trip attachments and interviews with cognizant maintenance personnel on how the devices were maintained. The. inspection indicates that theie were possibly multiple contributing causes of failure. Possible contributors are (1) dust and dirt; (2) lack of lubrication; (3) wear; (4) more frequent operation than intended by design; (5) corrosion from improper lubrication in January 1983; and (6) nicking of latch surfaces caused by vibration from repeated operation of the breaker. The contributors, appear to be cumulativeryith no one main cause. The initial investigation indicates that the failure was a~ge related and that a new device would perform properly. Many surfaces of the latch mechanism are worn and the additional friction tended to prevent proper operation. Proper lubrication throughout the life of the device might have prevented the wear that can be seen on the sample. .These initial findings. confirm that the UV trip attachment failed from binding and excessive fricticn. A laboratory testing and ex' mination program will a attempt to determine the precise cause of failure, if possible. Appendix A describes the NRC inspection effort and extent of additional examination and tesd..; :: be c:re by NF.C. NRC Action - Short Term NRC conducted an initial investigation of the cause of the UV trip. attachment ' failures by visual examination of che de' vices by qualiffeif personnel and de- ~ termined how the devices were maintained (See Appendix A). NRC Action - Long Term NRC will conduct laboratory testing and examination of the failed attachments to determine the precise cause of failure, if possible. Test and exainination results will be used as a basis for future maintenance surveillance and/or requirements for the UV trip attachinents. 3.- Verification Testing On August 20, 1982, one reactor-trip circuit breaker on Unit 2 failed to operate during surveillance testing. A UV trip attachment was replaced on this circuit breaker, the circuit breaker was reinstalled, and subsequent post maintenance testing established operability. Similarly, on January 6,1983, a reactor trip occurred a{ Salem Unit 2 due to a low-low steam generator level, but one Salem Restart Report 5

'A .<- e - [ ~ reactor-trip ci cuit breaker failed to coen. The license concluded that the circuit breaker failure was due to binding from dirt and corrosion in the UV trip attachment., The UV trip attachment on the Unit 2 circuit breaker, as well as the UV trip attachment on all Unit 1 reactor-trip circuit breakers, was cleaned, lubricated.and readjusted under supervision of a Westinghouse representative. Since the circuit breakers again failed on February 22 and 25, adequacy of the verification testing to ensure circuit breaker operability is an issue. Verification testing following reactor-trip circuit breaker maint-enance or initial installation should be sufficiently comprehensive to provide reasonable assurance that the circuit breaker will function as needed. Licensee Action - Short Term The licensee has proposed a program to verify proper operation of the reactor- . trip circuit breakers prior to returning them to service. The program will involve preinstallation testing of UV trip attachments 25 times by the vendor. After installation on the trip breakers, the UV trip attachment and trip breaker will be tested. ten.more times. Following this testing, a time resconse test of the breaker actuated through.the RPS will be performed. This iss,'s is sufficiently resolved to permit restart of the plant pending a commitment to develop cnd implement a pVogram comparable to that described under Long Term. Licensee Action - Long Term Althoughthelicenseehasnotyetproposedalong-termprogram,theNRCstaff proposes an extensive bench test of a reactor-trip circuit breaker and UV and shunt trip attach. rents as as.* integrated unit. T'e test is to involve cycling (a total of 2000 cyclet) uncer simulatea environmentai service concitions to determine if a properly maintained circuit breaker and its attachments can operate for an extende'd number of cycles. The testing should be performed by the licensee or appropriate industry owners group or vendor. NRC Action - Short Term ~* NRC will verify satisfactory comple' tion of the licensee's short-term preope'ra-tional testing pr.ogram. NRC Action - Long Term NRC will review the licensee's long-term operational verification program for the reactor-trip circuit breakers to assure that the following points are included: 1. a sufficient number of cycles.is included to provide statistically meaning-ful results. '2. the test exercises both UV and shunt trip attachments (not simultane,cusly), as well as the circuit breakars. 3. the test is conducted under environmental conditions similar to those seen by the circuit breakers. . Salem Restart Report 6 ,e . ~...

4 sufficient delay time is included between cycles to allow return to' steady-state conditions. 4. Maintenance and Surveillance' procedures During the investigation, it was determined that no specific maintenance pro-cedure exis.ted to conduct preventive or corrective maintenance on the reactor-trip circuit breakers. The maintenance conducted in January 1983 was not per-formed in accordance with the latest Westinghouse recommendations, which were. contained in Westinghouse Technical Bulletin NSO-T4-1, as amended by technical data letter NSD-74-2. Additionally, no program of preventive maintenance had been conducted on these circuit breakers since original iristallation. With respect to surveillance testing, the licensee ' conducted a functional test of one of the two reactor-trip circuit breakers every month, so each circuit breaker was tested once every two months. The surveillance tests, which involved tripping a circuit breaker by use of the UV trip attachment, met the technical specification requirements. The licensee also operated the circuit breakers weekly by exercising the shunt trip attachment. In view of the number of reactor-trip circuit breaker failures at Salem, it appears that the periodic surveillance testing was-i.neffective in assuring reactor-trip circuit breaker operability. The' licensee has now developed a tr.aintenance procedu-e and preoperational verification program. The NRC staff inithl review of the procedures and pro-gram identified certain deficiencies (see Appendix B). This issue is unresolved pending further review. Licensee Action - Short" Term The licer ee has n:w devele:ed a s;ecific preventive maintenance procedure for use on t.ie reactor-trip circuit breakers (including the UV trip attachment), which is based on all applicable vendor maintenan'ce recommendations, appropriate quality assurance (QA) requirements, arid post maintenance testing. The. licensee has proposed monthly testing.of the main reactor-trip circuit break' rs by use of the UV trip' attachment and wiekly testing of the react'or-e trip circuit breakers by use of the shunt trip attachment. Licensee Action - Long Term The NRC intends to require that.ne licensee incorporate results of a long-term verification testing of the reactor-trip circuit breaker into maintenance and surveillance programs. In July 1982, the licensee had embarked on a managed maintenance program to. thoroughly review and update the preventive maintenance program for certain systems and components. The licensee should centinue this program and complete it in a timely manner. NRC Action - Short Terin The NRC staff has completed an initial review of the surve!' lance and mainte-nance program and its procedures. Certain deficiencies have been identified Salem Restart Report 7

(see Apoendix B). The licensee will be required to compit,te action necessary te resolve t..e identified deficiencies prior to restart. With regard to the licensee's managed maintenance program described above, the NRC staff will verify prior to restart that the licensee's program also includes the reactor trip. system, emergency core cooling systems (including activation systems) actuation systems, the auxiliary feedwater system, and centainment isolation systems. The licensee's propa:ed surveillance test requirements on the circuit breakers ~ will also be reviewed. NRC Action - Long Term NRC will evaluate the Ficensee's proposed lubrication requirements for the UV trip attachments (i.e., type of lubricant, frequency of' lubrication, points of application, etc.). NRC will also assure that results of long-term verifica-tion testing of the reactor-trip circuit breakers are adequately ine'orporated Into maintenance and surveillance programs to determine testing frequency, ~ inspection requirements, and lifetimes. The evaluations will.be co'nducted with the ass.istance of the Frank,lin Research Center (FRC) and the Brookhaven National 1.aboratory (BNL). B. Manacement Issues Based on examination of the circumstances associated with the events involving react:r rip ci.rcuit breakers, certain issues have been identified relative to procedures, training, etc. that ars not solely related to the reactor-trip cir-cuit breakers. The extent to which such issues impact other systems, components or cer1.i:9s at tr.e Salem facility needs to be examined. These are categorized as management issues. They are 1. Operat'ing procedures for ATWS and' reactor trips 2. Operator response 3.' Operatcr training effectiveness relative to-the RPS and associat,ed indicators 4. Post-trip review 5. Issues related to the Master Equipment t.ist associated with the licensee's QA program 6. Work order procedures l 7. Timeliness of 10 CFR 50.72 reporting 8. Updating vendor-supplied documentation 9. Involvement of QA with other station departments 10. Post maintenance equipment ope'rability testing These issues are discussed in the secticns below. ./ Salem Restart Report 8

t 1. Creratina procedure for Anticicated Transients With:ut Scram (ATJS) a c Reactor Trios

• terviews with control room operators were conducted by NRC staff, a'n Pa'-

n review of the operating procedure for ATWS and reactor trip (EI-4.3) have revealed that a) the operators do not take immediate action to initiate a manual trip based on reactor-trip "first-out" annunciators, b) they were not directed to do so by the procedure; however, the procedure did require a manual trip if an automatic reactor trip did not occur. The procedure required only evaluation of reactor power level remaining high and/or multjple control rods failing to insert, c) at least one operator questioned the appropriateness of the ATWS procedure's step to trip the turbine, without first verifying that the reactor had tripped, since_that results in a loss. of heat sink, and d) the revised procedure dated March A', 1983, would not aave substantially changed the operators' response dug to a perceived need to evaluate plant status from control room indications. i Licensee Action - Shott Term 1. The licensee shall identify the indic'itions in the control room that provide positive indV::ation., without operator analysis or verification, that an automatic reactor trip demand.is present. 2. The licensee must revise procedures to direct the. operators to insert a manual trip whenever positive indicatfon of an automatic trip demarid is present without delaying to evaluate the overall plant status. be licensee must review the :: asis for t.e ATnS procedure steps and order 3. of priority in light of the operators' concern, revise the procedure as necessary, and brief the coerators on the basis for the' procedural steps t c i ;.:-ta.ca of pr::ac rai c: :liance. ~~ 4. All operators must be trained on the revised procedures prior to restart of Unit 1. Licensee Action - Lo'no Term Incorporate any procedural changes for Unit 1 into Unit 2 procedures and ' retrain Unit 2 operators on revised procedures prior to Unit 2 restart. NRC Action - Short Term 40 \\. NRC will review the licensee?s revised procedures and basis for the procedural ';% C steps and order of priority. J.M NRC Action - Long Term i ~.< NRC will incorporate review of ATVS basis into the review of the Westinghouse I 'd ' Owners Group, Emergency Operating Procedure Guidelines review. Salem Restart Report 9

2. Ocerator Ras::ense v Interviews with operators on 'shif t for the February 22 and 25,1983 events and with I&C and maintenance personnel disclosed the following: a. In both events, the operators took 20 to 30 seconds to determine the overall plant status and initiate a manual reactor trip. For the first event, this evaluation time was necessary because of the large number of alarms and equipment and indicators lost with the electrical bus transfer failure and was nearly identical to the time it took for the plant condi-tions to degradscausing the RPS to respond. For the second event, the 4 evaluation of the plant status began when the reactor trip annunciator actuated and the evalgation determined that a reactor trip was in fact necessary based on plant parameters and RPS indicators. This time could have been shortened had the operators recognized that a valid trip was called for by the RPS. b. Information provided in the control' room (i.e., first out panel alarms, illuminated RPS displays, and safety grade instruments) is adequate to immediately identify an ATWS event. I&E and maintenance personnal indicated that the~'fWst out panel and the RPS logic are highly reliab,le. During the ff rst event, after.an operator was directed to manually trip c. (scram) the reactor, the switch handle.was not operated correctly. When the SRO called for a manual trip, threontrol inacvertentTyg pulled off H i the board and had to be reinserted to perform the manual trip. Because of the near coincident automatic trip signal, this may have contributed to tne operator's fai. lure to recognize.that the automatic trip system had called for a trip and had failed to trip the reactor prior to tt)e manual trip. gg% d. .In spi of the positive indication of the reactor rotection s stem ~~ failure during the second. event, the. operators h,i. under.st detr trust a 9 the l'ndications..Because of,this* the operators unnecessarily reevaluated plant status. The operators man'ually, tripped the reactor in responsa to their evaluation of the p.lant status,and RPS indicators and not due to recogni' tion > 7 the failure of the ' reactor protection sy' stem. e The NRC staff concluded that, given the operators' understanding of the reactor D1Mfi s protection system, their lacksof confidence in 'the annunciators, their'pe,rcei.ved N need determine t(e overall p'latt status, and their use of procedures, the f the operatgrs was prompQ adequate to\\p,rotect the ' reactor for r N respons both events. Licensee Action - Short Term 1. Operators must be cautioned on thh use of the manual trip "J" handle control. Licensee Action"- Lono Term 1. The licensee should evaluate alternative means to permanently secure the "J" handle. Salem Restart Report 10

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3. Ocerator Trainino Interviews conducted by NRC with the licensed operators who were onshif t during the two events indicate a lack of familiarity with the functicos of the annuni-cators and indicators associated with RPS. The interviews also revealed that l the operators who were onshift during the February 25 event did not recognize that a malfunction of the RPS had occurred until approximate 1y' 30 minutes after the event. Specifically, the operators interviewed were not able to describe. whether the reactor-trip-indicator light (red) on the RPS mimic status panel indicated a demand or confirmation of a breaker trip. Interviews also indicated tnat at least seine operators questioned the validity of annuriciators until they could be confirmed by independent indication. Based on a review of calibration testing incidents in 1982, where the reactor trip annunicator was actuated by a signal but no reactor trip occurred, there may be instances that operators need to verify reactor 4. rip annunciators. This need to verify caused the operators not to take immediate action to trip the reactor based on annunicator indication alone on February 25, 1983 as discussed in management issues I and.2. Testing conducted by tTie li~censee in response to NRC questioning confirmed that short-duration signals (less than 10 milliseconds) could produce a reactor trip annunication without tripp,ing the reactor. Initial followup of review of this testing indicates that the system is functioning as designed, requiring trip signals of more than 10 to 12 milliseconds to actuate tne reactor-trip circuit-breakers. In any event, it is apparent that training in the areas of the RPS and associ-ated indications and alarms is warranted. This issue is unresolved.pending further review. g4 9 'p %phop recch3 M,, *3 d d c Licensee Action - Shcrt Term 4 The. licensee will conduct additional training n the RPS and associated indica-l ? tions and alarms (specif.ically whether these are de' mand or confirmatory and the b0i' use of this information), and to.' review the February 22 and 25 events with all s' operators. e c Licensee Action - Long Term The licensee will assure that RPS training and associated subjects in ~the operator qualification and requalification program address the areas of (1) logical function of the RPS and (2) operation of the RPS and associated indications. NRC Action - Short Term NRC will evaluate the adequacy and completion of remedial training prior to Unit 1 and Unit 2 restart. NRC Action-Long' Term NRC staff will audit the licensee's requalification program. Salem Restart Report 11

l t ^ 4. Post-Trio Review e The licensee did not determine that there had been.a failure to trip on February 22 until the computer printout of the sequence of events was reevalu-ated on February 26, as a result of NRC inquiries. Although the licensee con-ducted a review of each trip, there was no formal procedure for conducting a systematic review. By letter dated March 1, 1983, the licensee made a ccmmit-ment to develop a post trip and safety injection review procedure. The proce-dure will; specify the review and docurrentation necessary to determine the cause of the event and whether equipment functioned as designed. Other key elements of a post-trip review procedure are 1) necessary management authorization for restart, 2) debr'iefing of affected operators, 3) verification that reporting requirements were completed _, and 4) followup review by safety committees. Licensee Action - Short Term The licensee will develop and issue post-trip and post-safety-injection review procedures and train a,Il Cperations Department personnel on the requirements i .pr or to Unit 1 restart. Licensee Action - Long Tet_m The licensee will evaluate the effectiveness of the above procedure. NRC Action - Short Term. NRC will review the licensee's post-trip and safety injection procedures. 5. Master Ecuicment List The licensee mairtains a Q list that identifies'a:tivities, structures, c.m-ponents, and systems to wnich the Operational Quality Assurance (QA) Program applies. A Master Equipment List (MEL),is used by the licensee as the source document for determining the safety' classification of individual equipment. The MEL is intended to be a comprehensive list of all station equipment and identifies each item as nonsafety related or safety related. 'When preparing maintenance work orders, the MEL is consulted to determine if EA coverage of the work is necessary. Licensee and NRC review identified three problems associated with the MEL. These problems are, 1) the accuracy and completeness of the document, 2) issuance as a noncontrolled document, and 3) lack of understanding of its proper use. The MEL was derived from a construction program document called Project' Directive 7 (PD-7) and was provided.to station personnel by the Engineering Department as a reference document in July 1981. Prior to issuance of the MEL, the PD-7 was used as' the reference document. The MEL, however, was not issued as a controlled documeat, therefore verification of its accuracy and ccmplete-ness on issuance was not assured, and it was not updated in the plant as neces-sary. The reactor-trip circuit breakers and the RPS were not included in the HEL. In additio'n, some personnel were not familiar with how to use the MEL' for determining the classification of a particular piece of equipment. Maintenance personnel acknowledged that reference was made to PO-7 on occasion during the ~ January - February 1983 period. Salem Restart Report 12 4

~ Licensee Action - Short Term s. 1. Verify the MEL is c:mplete and accurate with respect to es.er'gency core cooling (ECCS), including actuation systems, RPS, auxiliary feedwater, and containment isolation systems. 2. Indoctrinate appropriate personne p the purpose and use of the MEL. Licensee Action - Long Term The licensee will verify the completeness and accuracy of thit MEL and reissue ~ it as a controlled document. NRC Action - Short Term / ~~ ~ . NRC.will perform sampling review.of the MEL on the above systems. NRC Action - Lono Term NRC will confirm completion of the licensee's long-term action.., 6. Work Order Procedures The review identified that the personnel preparing maintenance work orders were not complying with instructions contained-in the station administrative procedures. Specifically, for the work performed on the reactor-trip circuit breaker in January 1983, the.angineering department was not consulted to verify -~~ safety classification,,and an~ erroneous nonsafety determination was made. Such consultation is required if equipment is not listed in the MEL. There was, therefore, no independent review within the maintenance organization, and the . Cusif ty issurance Decartment was n:t involved in the work. Historically, there was no requirement for QA personnel to be involved in the review of work orders as they were processed to assure that appropriate steps were taken to assign classi,fication. ~ Licensee Action - Short Term ~ The licensee has made a ccmmitment to have the QA Department review all non-safety related work requirements prior to starting work, and to implement a program and training to ensure that work orders are properly classified. Licensee Action - Lono Term The licensee will review work orders written since issuance of the MEL for proper classification and will eval ~uate safety consequences of those found improperly classified. NRC Action - Short Term NRC will review *1icensee's work order classification program. /.. 2. Salem Restart Report 13

r ~~ 7.' Timeliness of Event Notification Cn three occasions between January 30 and February 25, 1933, the licensee s notified NRC of significant events belatedly. In each case, the notification was approximately 30 minutes late. Two of these reports were for the February 22 and 25 events. Furthermore, in the February 22 event, the first notif f-cation did not contain known significant information regarding actuation of engineered safety features and opening of the power operated relief valves. This additional information was provided approximately 40 minutes later. The notification procedure used by the licensee warrants further evaluation as to the priority assigned for NRC notification. ~ Licensee Action - Short Term A The licensee will reemphasize reporting requirements with all shift and on-call v management personnel and will reevaluate notification priorities. 5b. O7 NRC Action NRC will confirm that ITc'ahsee's short-term action is completed. 't :* 8. Uedating Vendor Sucolied Information As a result of the February 25, 1983 evenr and NRC IE Bulletin 83-01, the licensee indicated not being aware of the existence of two Westinghouse technical servi'ce bulletins that provided preventive maintenance recommenda-tions for the reactor-trip circuit breakers. The two documents in question were published by Westingnouse in 1974. The licensee has requested documenta-tion for all Westinghouse equipment and will incorporate this information into statien documents. An NF.C s:aff concern is whether a similar situation exists with respect to documentation for other vendor-supplied safety-related equip- ~~ ment and how the licensee will maintain vendor-supplied information current in the future. Licensee Action.- Short Term / t 12 The licensee has made a commitment to a program to update existing documentation i'M %. H on safety equipment and to ensure that vendor documentatfori is under a con-Q' trolled system. p ,A Licensee Action - Long Term The licenses will complete the above program in a, timely manner. NRC Action - Long Term NRC will perform inspections to verify the implementation of licensee's program. 9. Involvement of OA Personnel With Other Station Oeoartments The Quality Assurance Department did not review maintenance work orders asso-ciated with repair of the reactor-trip circuit breakers in January 1983 because Salem Restart Report 14

~ the work was not designated safety related. Further extaination determined that the QA Department does not review for proper determination of classifica-tion the work orders designated nonsafety related by other departments. Dis-cussions with the licensee indicate that the QA Department has been somewhat ~ isolated from the activities of other departments. As a result of prior decisions, the ifcensee had initiated steps in January 1983 to relocate the QA Department from the corporata offices in Newark, N.J'. to the site and is taking steps to increase QA Department involvement in other station activities. Licensee Action - Short Term ~ The licensee has made a commitment to' institute a program to more fully integrate QA activitie's into the overall activities. N I ---H 'c, S!4 Tet.. ? .? " Licensee Action - Lono Term The licensee will complete the above QA integration program. J NRC Action - Lono Term *~?j Monitor licensee's implementation of 'the above QA integration program.- 10. Post-thintenance Ooerability Testing-- Past practice at Salem for post maintenance cperability testing has varied. Such testing may be specified by the preparer of the maintenance work order or left to the. discretion of ma.*ntenance personnel. For safety related equipment, generally, post-maintenance surveillance testing is done before returning the equi; ent to servi:t. k:ditional functional post :raintenance and repair testin; of equipment, such as surveillance testing, may need to be performed to demon-strate operability as an integral part* of the larger component or system in ~ whi:h it must function. 1.icensee Action - l:ong Term - The licensee will review and revir procedures and practices as necessary to ensure that functional testing of Me overall components or system is performed to demonstrate operability prior to returning the equipment to service follow-ing maintenance and repair. Measures will be revised, as necessary, to assure

• that operations department personnel review the testing prior to returning such equipment to service.

NRC Action - Long Term NRC will review licensee's revised procedures and their implementation to assure that appropriate postmaintenance operability testing is being accomplished before equipment is returred to service. IV. Conclusions The issues discussed in this report were developed from examination of the infermation revealed during numerous interviews, document reviews, and meetings Salem Restart Report 15

conducted by fiRC staff and contractor perser.. el.with licensee representatives. Eased upon the staff's conclusion that the cause of the failures is attributed to the failure of the UV trip attachment to autcmatically trip the reactor and deficiencies in its maintenance and care, restart of Unit 1 should be permitted subject to the following: 1. Replaca.ent and operational verification of the UV trip, attachments; 2. Modification and implemen'tation of procedures 'asscciated with operator q.,,.1- -atponse to RPS trip signals; and, 7 ~ 3. Satisfactory resolution of those e%+r issues identified as "short-term" fn this report. "Lorig-term" issues involve more comprehensive action that do not have an immediate safety implication; furthermore, these long-term issues will be reconsidered in light of the results of the ganeric evaluations being conducted by an flRC Task Force. In the interim the staff intends to establish commitments for correc.tive actions and imple-mentation schedujo, and intends to, assume timely-implementation of these at the Salem facility. The staff also believef'tVat the long-term corrective actions related to the management issues at the Salem facility can be further evaluated as to com-pleteness and appifcability by an independent and more in-depth assessment. Accordingly, the Office of Inspection ar.d Enforcement is planning to perform a Performance Appraisal Team (PAT) inspectiFn of the licensee within the next few months. ~ Salem Restart Report 16 _ _ - _ _ _ _ - _ _ _ - _ _ _ _ _ - _ _ _. _ _ _ ~

Appendix A RESULTS OF NRC STAFF INVESTIGATION OF EVENTS AT SALEM NUCLEAR GENERATING STATION I. IDENTIFICATION OF CAUSE OF FAILURE Summary and Initial Findings Initial inspectlen of the UV trip attachment indicates a po'ssiblity of multiple contributing causes'of failure. Possible contributors are (1) dust and dirt; (2) 1ack of lubrication; (3) wear; (4) more frequent operation than intended by design; (5) corrosion from improper lubrication in January 1983; and (6) nick-ing of latch surfaces caused by vibration from repeated operation of the bres.ke r. The contributors appear to be cumulative, with no one main cause. The initial investigation indicates that the failure was age related and that a new device wo.uld perform properly. Many surfaces of the latch mechanism are worn and the additional friction tended to prevent preper operation. Proper lubrication throughout the life of the device might have prevented the wear that can be seen on the Ta.mple. The tests and examinations proposed by t'he staff and its contractor will ' attempt to determine the cause of failure.and if possible reproduce it. The following summarizes the initial findings and lists the proposed tests. Discussion and Circumstances A site visit was conducted on March 3,1983 by NRC and Franklin Research Center personnel to inspect the type 08-50 circuit breaker undervoltage trip attache-nent in an effort to determine the most cecbable cause of failure. The rea: Lor trip circuit breaker rooms for Units 1 and 2, each of which contain four 08-50 ' ~~ circuit breakers, were visually inspected and the fol. lowing observations were made: 1. . Al'1 'four 08-50 Unit.1 circuit breakers and.tN trip. attachments were -removed from the circuit breaker cabinets. The enclos'ures were generally clean and free of dust. The ambient temperature was be' tween 85 and 95*F, with warm exhaust air from inverter cabinets being directed at the 08-50 circuit breaker cabinets. The spacing between cabinets is approximately 3 feet. 2. All four 08-50 Unit 2 circuit breakers were also inspected. The UV trip attachments were removed, however. The circuit breaker cabinets contained a layer of loose dust approximately 1/16 inch thick. The ambient temper-ature was in the 70*F range. UV trip attachments are mounted on the top of the circuit-breaker platform, to the right of the shunt trip attachment, which is several inches from the bottom of the circuit breaker cabinet. Interviews were conducted with an electrical maintenance sucervisor who discussed. the~ circumstances of the removal of the circuit breakers that were involved with the incident on Unit 1, and an electrical supervisor who had also worked on the circuit breakers in question in August 1982. The information received Salem Restart Report 17

was that the circuit breakers and their UV trip attach. EM.s had been cperated frequently and had op'erated during surveillance testing within a few days prior to the incident'. A request was made to Salem management to provide one of the UV trip attach-ments and a shunt trip attachment for testing at Franklin Research Center (FRC). This request was complied with, and an investigation of these devices is now under way at.FRC. Results of Initial Examination Initial investigations indicated roughness in the opera-fon of the trip latch. There is see dragging of,_the mechanism, and portions of the latch mechanism have obvio'us signs of wear. Possible contributing factors to the failure to operate are a lack of lubrication, wear, jarring of the UV-attachment as a result of circuit breaker operation and more frequent operation of the UV trip attachment than was intended during design. It is postulated that under most industrial'applicatioDs, the UV attachment would be used very infrequently and probably would be operated only during test sequences a perhaps yearly or-longer intervals. Therefore, in industrial applications, it would op'erate only a few times, perhaps 2W6 30 cycles during its lifetice, and would not be a normal tripping mechanism for the breaker. However, in its use at Salem and other nuclear power plants, it is the prime tripping device for the' circuit breaker, and is therefore called upon to operate on the order of 50 times per year. This would mean that at its curren't age, in 1983, there would have been possibly 400 to 500 trip operations of this device. During the initial inve.stigation, it was noted tha$ the shunt trip attachment has been operated once every seven days since August 1952, rather than at longer intervals. This means that the circuit breaker is tripped and closed . every seven days. This causes jarring of the entire mechanism of the circuit breaker and its attached relays and coils due to the normal operation of the breaker. This may or may not be significant, but it.should be noted that the. UV attachment stayed energized during these trips, and its latch mechanism was jarred somewhat by operation of the circuit breaker. This possibly added to the friction built up in the. latch mechan. ism from normal operation by causing , the latch

• mechanism to ju' t slightly nick the surface that it rides on and s

thereby tend to prevent operation. Further investigation will try to determine whether this is indeed a problem. It appears from initial inspection of the device that wear and roughness of mating surfaces in the trip latch.are ~ present. Proper lubrication might have prevented the current situation or could have reduced the roughness to the point where proper operation could occur. ~ Further investigation will attempt to determine whether the CRC-2-26 lubricat-ing and cleaning spray added to the operating problem by either causing corrosion or removing all residual lubrication from initial construction and possible caking of dust and dirt. It a) pears that from the time of initial construction of the UV trip attachments up until January of 1983, no lubrica-tion procedures"had been performed, and then, in January of 1983, lubrication procedures were undertaken by the maintenance personnel and a Westinghouse technician. At this time, the CRC-2-26 lubricant cleaner was sprayed on all Salem Restart Report 18

four UV trip attach.ents associated w.ith the Unit 1 circuit breaker. This 'ubricant is being pr: cured by FRC for testing purposes. List of Investications To'Be Performed by HRC Contractor (FRC) 1. The first test will be to perform various deenergizations and energiza-tions of the UV trip attacncent and monitor the device under various conditions. 2. The second test will be to disassemble the latch mechanism to observe the surfaces of the various parts of the latch and to photograph these sur-faces through a microscope to determine the various levels of wear on-these surfaces. 3. The third test is-to determine the effects of CRC-2-26 spray on the various types of metals used in this devices. An attempt will be made to use metals other than those in the actual attachment. If possible, the chemical consistency of this spray will be determined from the ~ manufacturer. To prove that the sample-Ujf trip attachment is identical to all such Salem devices, a visual inspection of all existing S.alem Unit 1 and 2 UV trip attach-ments'will be performed. This can take place at Salem, with no disassembly needed. The inspection can be made with the devices mounted on the circuit breakers or loose. These inspections shocid be done as soon as possible, and Tuesday, March 8, 1983 is recommended. If further tests are reguired they will be based on the results of these initial tests. All tests will be nondestructive such that the device can be used for further testing and returned to the utility. Additional Test To Ee Conducted by the Licensee, as Revised by NRC Staff ~ This test wil1~ require the use of a spare circuit break'er. The UV trip and ~ shunt trip attachments will be mounted on the breaker, and the breaker will be operated repeatedly.to determine the effect on th,e shunt and UV trip attach-ments. It is. surmised that.while the attachments are' energized and the breaker trips and clcses a number of times, additional friction of the trip latch may occur from the vibration. This test is described in detail in.the following section. II. REVISED SURVEILLANCE OF REACTOR-TRIP CIRCUIT BREAKER OPERATION AND VERIFICATION TESTING The licensee proposed the following' increased surveillance of reactor-trip circuit breaker operation: 1. Main and bypass breakers will be shunt-tripped weekly. 2. Main breakers will be UV-tripped monthly. The acceptability of this revised surveillance of reactor-trip. circuit breaker operation has been evaluated by NRC staff. Based on an analysis conducted by NRC staff, which considered reactor-trip system unavailability, reactor-trip Salem Restart Report 19

e. circuit breaker failure rates, and test intervals, the foJ10 wing conclusions were drawn. First, the proposed test of each reactor-trip circuit breaker UV trip attachment once ewery 30 days is acceptable. Second, the proposed test of the shunt trip attachment once every seven days is considered to be excessive and may impact on the reliability of the reactor. trip syste'm by increasing the potential for a single failure. During testing, a single failure in the logic portion of the reactor trip system ceuld prevent an automatic SCRAM. Thus, it is recommended that the shunt trip attachment be tested on the same schedule as the UV trip attachment; that is, once every 30 days. It is also recommended that, the UV trip of the bypass breakers be tested prior to.rsstart and every ref,ueling thereafter. Discussion The acceptability of tBe proposed test intervals for the reactor-trip circuit breakers was based on NRC staff review of reactor-trip circuit breaker failure rate data obtained from Licensee' Event Reports (LERs). The generic RPS unavailability of 3 x.10 5 (used in both NUREG-0460, " Anticipated Transients Without Scram for Light Water Reactors," and by the ATWS, Task Force and Steering Group in the development of the proposed ATWS Rule) was used in evaluating the licensee T.hroposed test intervals. In addition, the following considerations were incorporated into the NRC staff recommendation: 1. The shunt trip attachment provides a diverse means of tripping the reactor-trip circuit breaker, which I's ' electrically independent of the UV trip attachment. The UV trip attachment is supplied by a 48-V de source and is deenergized,to trip. The shunt trip attachment is supplied by a 125-V de source and is energized to trip. 2. The shunt trip attachment is an energize-to-actuate device and is not "'sil safe" in th 3 M i :f ::wer M li rot cause 1 trip. However, the snunt trip is powerec from a reliaole Class 1E battery-backed source. 3. S'ince the shunt tiip itttachment is an-energize-to-actuate device, it is not subject to the constant heating effects that the continuously' energized UV trip attachment experiencest 7,he heating ef fects may contribute to the higher failure rate of the UV trip attachment.~ 4. The mechanical construction of the shunt trip attachment is less complex than that of the UV trip attachment. The shunt trip attachment does not rely on the successful operation of the complex latching mechanism that has been determined to be the source of the majority of the failures of the UV trip attachment. 5. The majority of the electrical' circuit breakers used in the high-voltage electrical distribution system have de powered energize-to-actuate shunt trip attachments. These circuit breakers are used for manual, as well as automatic, trip functions for load shedding and power switching. Relia-bility of energize-to-actuate shunt trips in similar applications through-out the nudlear power industry has been shown to be significantly higher than for devices that are constantly energized. Salem Restart Report 20

e 5. Over 70% of the kncwn reactor-trip circuit breaker failures were caused by UV trip attachment failbres.' 7. Most of the concerns relating to the events at Sale: on Fe:ruary 22 and 25, 1983 are related to the operation of the UV' tria attachment. During the events at Salem,. the shunt trip attachment functioned properly. ~ 8. The bypass breakers'are required to trip in response to a UV trip demand signal should this occur when the main breakers are being tested. Since the test frequency of the main breakers has been ir. creased, the bypass breakers should be tested to verify the capability to p'erform their backup safety function. Verification Testinq / ~ It is recommended that a bench test be performed on one 03-50 reactor-trip circuit breaker. The purpose of the test will be to cycle the 08-50 with the UV trip and shunt trig attachments in place for a total of 2000 cycles to ' determine if any adverse effects can be identified and, if there are no adverse effects, show that a properly maintained breaker and. its subcomponents can operate for an extended nymber of cycles. The breaker will be tripped, with each cycle being alternated with the UV and shunt trips. The ambient temperature should be 100 F to simulate the expected service environment, and the circuit breaker should be cycled no more of ten than once every 30 minutes to allow for return to steady-state conditions. The results of each circuit breaker operation will be documented and a visual check =ade. Additional details for this type of test will be provided at a later time. Salem Restart Report 21

y ~ ~~ A;;:endix 8 INITIAL NRC STAFF REVIEW OF LICENSEE'S MAltlTEt:ANCE ?RCCECURE AND PRECPERATIONAL VERIFICATION PRC3 RAM .RC staff reviewed the licensee's maintenance procedure, Salen Generating 5tation Main:enance Department Manual Maintenance Procedure M3Q-2, Revision 1. This document includes a procedure for verifying proper operation of the UV trip attachment and testing of the UV trip attachment coil folicwing replacement. NRC staf f also reviewed the licensee's proposed reactor-trip circuit breaker operational verification program, which refeFences Procedure 43Q-2. The following comments and recommendations were made cencerning these. dccuments: 1. The maintenance procedure does not specify whether the maintenance and testing described are applicable to both the main and bypass breakers. It should specify that it does. ~ 2. The maintenance procedure should specify required actions to be taken in the event any acceptable tolerances, as identified in Enclosure 7 of M3Q-2, are not met.-,: 3. The frequency of all ' maintenance and testing specified in the procedure, with the exception of the verification testing identified fo'. lowing UV trip attachment replacement, should tre specified. 1.' The peccedure should be mcdified to require cleaning of the entire circuit brasker room, the removal of all four circuit breakers and cleanitig of the esbinets by vacuuming, and cleaning of the breakers during every refueling outage. 5. Section 9.7.2.1 of Procedure M3Q-2 specifies that the UV trip attachment is to be cleaned with a standard solvent. The procedure should specify the. exact solvent to be used. NRC will request FRC and BNL to determine the adequacy of the proposed solvent and any' potential adverse effects from its use. (This evaluation, need not be completed prior to plant startup). 6. Section 9.7.2.2 specifies the composition of the lubricant to be applied to specific points of the UV trip attachment. This specification should state whether the mechanism is to be lubricated each time maintenance is perfo rmed. NRC will request FRC and BNL to determine the adequacy of the lubricant and the putnts of application specified, as well as the frequency of lubrication. 7. Any UV trip attachment that does not successfully complete the 25 con:ecutive cycles of testing to be performed by Westinghouse should not be accepted or installed by the licensee. 8. Section 9.7.4.15 specifies the testing to be performed on the UV trip attachment coil following its replacement. The maintenance procedure g: i i istam Restart Re; ort 22 l r L

sneuld be revised to require that all replacement UV trip attachments successfully cceplete 25 ccnsec0tive cycles of testilg prior to installation in the plant and start of the ten test cycle specified in the maintenance procedure. The time betneen each of*t.".e ten tests should be specified. NRC reccmmends 30 minutes for the reascns specified in Appendix A. NRC staff believe the increase in test cycles, and the acceptance criteria specified if any failures occur during this testing, are reasonable and should be incorporated into maintenance procedure M3Q-2. 9. Technical Department Procedures Nos. IIC-18.1.011 and TIC-18.1.010, referenced by the licensee, should be reviewed and their acceptability determined by NRC staff. Following revision of the maintenance procedure and the associated proposed reactor-trip circuit breaker operational verification program to incorporate the above comments and recommendations. NRC staff will reevaluate the documents and provide another report that will include the results of the NRC contractor's ' evaluations and will document the final NRC evaluation and conclusions concerning the adequacy of the maintenance procedure and preoperational verificatto,n program.. s t Salem Restart Report 23

Kosurb} Spm $ f.%O3 (see Appendix B). The licensee will..be requiled to complete action necessary to resolve the identified deficienci'es prior to restart. ' With regard to the licensee's

• man'ged maintenance program described above, the a

NRC staf f will verify prior to restart that the licensee's program also includes the reactor trip system, emergency core cooling' systems (including activation systems) actuation systems, the auxiliary feedwater system, and containment isolation systems. The licensee's proposed surveillance test requirements on the circuit breakers will also be reviewed. NRC Action - Long Term NRC will evaluate the licensee's proposed lubrication requirements for the UV trip attachments (i.e., type of lubricant, frequency of lubrication, points of application,etc.). NRC will also assure that results of long-term verifica-tion testing of the reactor-trip circuit breakers are adequately iniorporated into maintenance and surveillance orograms to determine testing frequency, inspection requirements, and lifetimes. The evaluations will be conducted with the assistance of the Franklin Research Center (FRC) and the Brcokhaven National Labo'ratory (ENL). lp.i/m Op /.3 d. :'4"3 (2.re-9 '-o, pT* c'.4 h. O B. - " " - -:.. : n J s n c. die ~- Based on examination of the circumstances associated with the events involving reactor-trip circuit breakers, certain issues have been identified relative to procacures, training,/Me. that are not solely related to the reactor-trip cir-cuit oreakers. The exts t :: %h sc -:i3ses i pe.. W,o y a ;...o, w.,pummts p e@.+d. n ;;-; ::: ::te A d -p_.v-au t ' m t-m n'.. ,,.m.. 2 as~ 3:a-- i e gs. T e/ aregN ~ 1. Operating procedures forVAikS # reactor trip - L /.3 Operator response ~ 3 Operator training effectiveness relative to the RPS and associat,ed inoicators 4. Post-trip review 5. Issues related to the Master Equipment List associated with the licensee's QA program 6. Work order procedures 7. Timeliness of 10 CFR 50.72 reporting 8. Updating vendor-supplied documentation 9. Involvement of QA with other station departments 10. Post maintenance equipment operability testing These issues are discussed in the sections below. Salem Restart Report 6

-~' ( ri nticinated Tran'sients Without Scram (A WS) M 1. Oceratino Proced A -c=Mieac to r T ri ca p Interview's with control room operators were conducted by NRC staff, a'n P hw. review of the operating procedure f.or AWS and reactor trip (EI 4.3) have revealed that a) the operators do not take immediate action to initiate a manual trip based on reactor-trip "first-out" annunciators, b) they were not directed to do so by the procedure; however, the procedure did require a manual trip if an automatic reactor trip did not occur. The procedure required only evaluation of reactor power level remaining high and/or multiple control rods failing to insert, c) at least one operator questioned the appropriateness of the AWS procedure's step to tr.ip the turbine, without first verifying that the reactor had tripped, since that results in a loss, of heat sink, and d) the revised procedure dated March A', 1983, would not have substantially changed the h operators' response due to a perceived need to evaluate plant status from control room indications. Licensee Action - Short Term %,>< t u.u u w e> 1. gJhe licensee shaTl identify the indications in the control room that provide positive kdication, without operator analysis or verif.ication, that an automatic reactor trip demand,is present. %..(.: A ap.a . : }-j

2., Jhe licensee r.,a1ft revise procedures to direct the. operators to insert a manual trip whenever positive indication of an automatic trip demarid is present without delaying to evaluate the overall plant status, f.x W ' all.ryg.t.

3., @e licensee %_h:st review the basis for the ADS procedure steps and order of priority in light of the operators' concern, revise the procedure as necessary, and brief the operators on the basis for the procedural steps and im:ortance of precedural ecmpliance.

- u f../. .u m.,J,)- 4. fl> operators 'mtst be trained on the revised procedures prior to restart of Unit 1. Licensee Action - Lo'np Term f ,N'*"gn:*. SLO.s&ysAcorporate any procedural changes for Unit 1 into Unit 2 procedure .*l Ta M; Unit 2 operators on revised procedures prior to Unit 2 restart. NRC Action - Short Term g NRC will review thedic,ensess revised procedures and basis for the procedural ,' 6,f,,f 0%. steps and order of priority. '. U., ~ NRC Action - Long Term p.1,ea y 1". - NRC will ifwporate= review cf-AWbba:S Stethe review of the Westinghouse } \\' Owners Group, Emergency Operating Procedure Guidelines,ce:,*1ew, Salem Restart Report 9

~ Coerater Traia.inq Interviews conducted by f RC with the licensed operators who were onshift during the two events incicate a lack of familiarity with the functions of the annuni-cators and indicators associatad with RPS. The interviews also revealed that the operaters who were onshift during the February 25 event did not recognize that a malfuncticn of the R.:S nad occurred until approximately 30 minutes af ter the event. Spectfically, t. e operators interviewed were not able to describe whether the reactor-trip-indicator light (red) on the RPS mimic status panel indicated a demand or confirmation of a breaker trip. Interviews also indicated that at least some operators gestioned the validity of annunciators until they could be confirmed by indeoendant indication. I Based on a review or calioration1 0 (Testing incidents in 1982, wnere tne reTCt5r~ trip annunicator was actuated by a signal but no reactor trip-occurred, there may be instances that coerators J LJ1eed to verify reactor. trip an_nunciators) This need to verify caused the 'apergtors not to tar.s imceWi'a'te acf.fon to trip the reactor based on annunicator, indicatiori alone on February 25, 1983 as discussed in ues3 =Cf Terting conducted by the licensee in response to NRC questioning confirmed that short-duration signals (less than 10 milliseconds) could produce a reactor trip annunication without tr.ipsing the reactor. Initial followup of review of this testing indicates that the' system is functioning as designed, requiring trip signals of more than 10 to 12 milliseconds to' actuate the reactor-trip circuit breakers. In any event, it is apparent that training in the areas of the RPS and associ-ated indications and alarms is warranted. S39 < m., n,,-..u N a y -es-, Y s +.. -reviewp y d * &, <n IN. S u t. Licensee Action - Short Term y 'J,4 p -4,%. 3 g u- - - f/h'e. licensee wtf1 conduct, additional training /on the RPS and associated indica-tions and alarms (specif.fcally whether.these are demand or confirmatory and then i' use of this information), and to,' review the February 22 and 25 events with all operators.. Licensee Action - Long Tere ',x,jg Jtif M to Jtfe licensee wtT) assure that RPS training and associated subjects in 'the operator qualification and requalification program address the areas of (1) logical function o the RPS and (2) operation of the RPS and associated indications. J)4 {.% 2 ; *. r',M.to td*i A.4. w.pp'n 'q.' p3 ssl.n 6..on s,;*c% s o NRC Action 'Short Term NRC will evaluate the adequacy and completion of remedial training prior to Unit 1 and Unit 2 restart. NRC Action-Long Term NRC staff will audit the Itcensee's requalification program. O Saiem Res u re Report ,1r 1 0

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9 t A Ocerator Response Interviews with opgrators on shif t for the February 22 and 25,1983 events and with IAC and maintenance personnel disclosed the following: ./ a. ln both events, the operators took 20 to 30 seconds to determine the overs 11 plant status and initiate a manual reactor trip I:- t?; fi, n ll W N b iI bh: & t .(-i '. of md wes-6449 Dant 9:' t o th: tfn f; ;s V ea t @ nt con & ,h M e t H egm *f;:n W -4be-W t

p:S For the second event, the 9

evaluation of the plant status began when the reactor trip annunciator actuated and the evaluation determined that a reactor trip was in fact necessary based on phnt parameters and RPS indicators. This time could have been shortetted had the operators recognized that a valid trip was called for by the RPS. Information provided in the control room (i.e., first out panel alarms, I b. illuminated RPS -displays, and safety grade instruments) is adequate to immediately identify an AWS event. !&E and maintenance personnal irufcated that the.first out panel and the RPS logic are highly reliable. c. During the ff rst event, af ter an operator was directed to manually trip (scram) the reactor, the switch handle was not operated correctly. When the SRO called for a manual trip, threontrolhnadvertentIrwas, pulled off the board and had to be reinserted to perform the manual tr7 Secause of l the near coincident automatic trip signal, this may have contributed to the operator's failure to recogni24.that the automatic trip system had called for a trip and had f ailed to trip the reactor prior to the manual trip. 4',% <

• n,spita of the C:li".he f.ui:stien of tne reactor,fprotection s.

' d.. failure during the second. event, the. op9rators dic2:::t underst%ystemd 4r trustad SEE the indications. Because of this* the operators unnecessarily. reevaluated l plant status. The operators man'ually tripped the reactor in response to their evaluation of the p.lant status..and RPS indicators and not due to recognition of the failure of the ' reactor protection sy, stem. J The NRC staff concluded that,bqf confidence in the annunciators, their ' perce , given the operatqrs' understanding of the reactor DJfav' s pro action syste.9, their lac need determine \\the overall plant status, and their use of procedures, the s respons f the operitqrs was prom)t 4nd adequate to protect the reactor forN both events. .l.icensee Action - $hort Term e Ji'**6' N b'.."4 @ ",",, ",* d'* 2.> 4

n. u ac.

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1. A/perators must be cautioned on the use of the manual trip "J" handle

/' control, t.icensee Action Lono Term n, n:c. .e c e rv sh -evaluate alternative means to permanently secure the ,The licensee s 1. ,,J" handle... *.' J A. J.:,. '.. ~~~ !e s. I+: w. / Salem Restart Report ,,,AQ kf

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3.:1423.: $1 LIM RISTAAT STATUS Ai?CRT s -:sse: To previce. he Cc missionars with a report en the current status u of the. evaluation of the failure to av cmatically scram events of February 22 and 25,1983 at the Salem Nuclear Generating Station ar.d an actt:n plan for restart of Units 1 and 2. Ots:usiten: Ouring a briefing on Mar:h 2,1933 con:erning the talem reacter trip systen..fe}jlure events, the Ccamissioners req.ested that the staf f Or:vice.its :lta cf acticn to resolve the issues identiff e: fec: the NRC evaluatice of the Sale?. events. Inclosed is the Salem Restart status re;ces which identifies the iss;es and the sh:rt-and 1:ng-term a: tics.s e.teded to res:1ve th:te iss.es. Foa the s* rt-term 4::icns, 5e staf' f atteds to

atn :ecif': c:?-1: se s f r:m tr.s l':e*. tee :: c:.:less snose a::1:Ps, anc :he staf f will folicw w: :neir c: olett:n ;ri:e to ser.itting restart f either $41e. Unit.

F:e st;isfa:::ry resolu-i:n cf :Pe 1:ng-team 4::icas, tre staff it. ends te cavalop wi:n tra licensee an ac:tatable schedule for c:.;1etten of th:se acti:rs,

sin necessary co mitments, and follow v their cc. pletien on the agreed upon schedule.

William J. Oir:ks tie:utive Otract:r for C; era: tens

• !a:1clure:

Salem f.estart Status Report c;NTACT:,R. W. Starostocki

• Fi$ 111 '.213

0;ntat:s .t. i it: : :. :

n.+ r E

i:.': t : Issues 1. Saf t:y Classification of !riakers 2. Identifica:L:r. of Cause of Failure 3. Verifica'tien Testing 4 Maintenance and Surveillance Prc:edures i. C:e at:r Procedures. Training, and Reseense 1. 0:t 4 in; Ff::tdures for Antici:sted Transients Without Scram (ATWS) and Reacter Trips 2. 0;erator Training 3. C:t-ater Res;:nte 1 vate Is/ sues a 1 1.

st-Tat: Xaview I

2. Passer Equipment List 3. W:rk-Order Precedures 4 T'-siinass of Event Nctification :. : sting Ver.::r-Su; plied Infchmation 1 j 6. Inselvement of CA Personnel with C: hor 5:ation Capartments 7. Ecst. Maintenance Operability Testing 3 j IV.

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-ts' e::-: : 'e'1y descr' tis the h: as: l':e see acti:n

a dress and

-tss'.s i: t: t.: ar: tra;t est ist.es iter if'e: ::y.. e NRC evaluatica of tre 4.g s a . t; ; Of tre Sait N.: lear it erating 5:::1:n that resultec in 'at'. e Of vi sa:::r t: tri; aut:rati:tily u;:n a valid si;nal. Tpe see:nd l e.e.: :::.r-i: :n obruary 25, 1933 trd 's: :o the realt:atien that a similar t e. 4.: ra: :::ur id cr. F.e:ruary 22, '.153. Eased en NRC evaluati:n, a number of i

e tial c:.:rt:w::rs to failure have tatn identified. H wever, our injtial 3

e.'al'.asi:n in:icates that all of the potential c:ntrit6:ses to the failure were a;e-related and that a new device w:uld perform preperly. Therefore, replace-ent Of such devices wijh new devices and conducting prc;er eatntenance, testirs ar.d s;rveillance, in conjuncti:n with resolutten of related issues, p :vides reasonable assurance that Salem Unit 1 can be safely restarted and

grated.

a.. MC task f:rce has been established to conduct a se;arate longer range study

f the br:ader implicatt:3 of the events.

NRC long-term acticns identified e-ein a o a::lteable to 5flem but. ay have generic im:11 cations. The NRC task ':r:e will deter-ine generic actions needed for other f tcilities. Fce the Iale. facility, lenger term actions :evelo;ed by this task force eay supersede

r ::m:lement scme of the long-term actions identified herein.

i isc h e:. d s r :r,ary !!, ;ii3 an event :::ur se at Unit 1 of the Salem Nuclear Generat-e l

• v sta:1:n. hen the rea:::r-tris c' W basskers fai'ed : aut: atically :;in

':h :.' j re:et:: c f a v a '.t : set; s';nal frem sne Reae::r Protection System 4 t U3). .he an.11 trip system was. sed to shut d:wn the reactor. i

1. -Subst:uently, it was concluded by the licensee that the failure to trip was i

l

aused by a -alfunction of the undarvoltage (UV) rip attachments in both reactor-rip circuit breakers.

These UV trip attachments translate the sie:tri: 1 sig 41 fr:m the RPS to a e:hanical acticn that c: ens the circuit ,-eaker. On Fate:.ary P., 1933, an NRC team was onsite to c:nduct init.ial followup and to es11i:: ;rei'-trary inf:rmation. As a result of NRC tequiries, the licensee deter.irst r,a toth reactor-trip circuit breakers had si.ilarly failed to open w::n receipt cf a valid trip signal on February 22, 1983. l'he failure to auto-i

• : ati: ally tri; en February 22 was n:t recogni:ed by the licensee until the com-L i

.,tse prin*.

ut of the sequence of events was reexamined in more detail on February 26.

Further evaluaticn of these events and the circumstances leading up to the. revealed a nu-ber of iss;es that require resolution by the licensee i and/or the h!.0. This rep rt identifies those issues ar.d the short-term acticas t pr:p: sed to res:1ve them prior to resumption of cperation at Salem Unit l' and the leng ter-4::1:ns, hat are nested en a defined schedule (c11c41ng resttet. 1 The short-tars acticas required for Unit 1 will also be implemented on Unit 2 l t,rier to,res. art of Unit 2. 4 i 4 "a't Vnit 1 's ;reser:1y shut dc. fer refueling and is 9:t presently j

4:w'a: ::

as. e :;tratt:n :sf:*e Unit 1. t

'+ g i e :e let e '.:l sta## :n 4;_ vary 21 a : "t*:s j.1933 t: ; resent the

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'. e It'a e.t

s. 'ss.ts -ere ': grit' int an: :ats;;ri:ed as equi;:ent

'ss.es, :: eras:- :r::e:.-e, traint9g anc res: case is Les, and manag,emen: iss.es. .ey a-

's:;sst: 'r. da:411 in Se:ti:n !!! of this re::rt.

I . I. Isl.as A. !:.': ta.t its.es i nree :f the its.'es state to the affected equi;mant, that is, the reac*o9-trip i i cir: Lit breakers Caestinghrase 03-50 ' circuit breakers). Theseissuesare1) l safety classift:::i:n o of the failure, and 3) f., the circuit breakers, 2) identification of the cause verification testing of the, circuit breakers. 1. Safety Classif'estien of Breakers Curin; the initial EC evaluation of the February 25 event, it was determined that 24tatenance.as cerMted on the Salem Unit 1 reactor-trip ci,rcuit 5 t'reakers in January 1923. To11cwing a f ailure of one reacter-trip circuit treaker to trip us:n receipt of an RPS signal'at Salem Unit 2 on January 6, j 1933. The work, cr:ers av h:rt:ing the January 1933 maintenance identtfind the i maintenance as net safety related and not requiring quality assurance review. As a result, it was r:: clear en February 26, 1983 what portion, if any, of the l react: -trip c'r: wit 5 sakers was considered safety related by the licensee. re rea:::r-tet; :'r:;it.treakers c:ntain :sth a 'JV trip attachtent and a shunt i tri; atta:r en, t;: :rfy the UV trip attachment is operated ey an RPS trip l l signal. [ { ,,, t ::1 :n,'iv a l u s t' :r ) This issue has :st res:1ved. Section 7.2.1.1 of the Salem U; dated Final j Safety Ar.alysis Re;:r (UFSAR), Revision 0, indicates that the Reactor Trip tyste, ' :'.'. css s' e sa:::r-trip circuit breakers and the UV trip attachment. ? s ',.es ' ;-:vse 1:1'd 5:::e Legic 7ectaction Syste'a Description (WCAP-745al) l t '. s ta'i.es tr.: 5:::e :f the system as including the rea:ter trip circuit i tres.ers and *r. U',' tri; atta:htents. The UV trip attacheent and the ta:::r trts cir:ut; tretier are safety-related equipment in that they are essertial features :f is Reactor Trip System, which is necessary to prevent or titi; :s the c:nse:;en:es of a design-basis event that cculd result in exceegtag the ef' site ex;osure guidelines set forth in 10 CFR Part 100. The i shunt trip attacr en: of the reactor-trip circuit breakers in the Westinghouse . design is r.ot required by present MC regulations to be safety g-ade and, alth:vgh it is previded to perform the manual trip function, no credit is taken f:r :.t s design 'et:;re in the safety analysis (a manual reactor trip also actuate s tr.s O'.' trt: attachment). The Itcensee in a March 1,1983 letter to. i,t.C :: :;rraf ir : 's understanding. Hence, the 1;ecific issue with regard to t.te safety :lassif t:sti:n of the reacter-trip circuit breakers is considered resc1ved. Otrer issues concerning the manner in which the reacter-trip circuit

rea' e't' tre irla st "r:m a procura ent and maintenance standpoint at Sale'n i

l

\\ t a-a a::-esse:. :t- "t a ;t t r. i s s.e t,',! a::1:9 :!: !). "'.e li:e see cas a:e a

-- : c ; :: < su

.i : ': a.u: n u : a'i ':..'-'

t : t:

ii.e s :-t:r ::

ista-: at: u.e- *

at : e e4 :<-:vt: :ria),e s.a.e :eer

-:: a ;, i n ~. t ::: 4: usta:.

I.

e C f':au: :f Cause of "at h e ae :er.see's 'attial ceter inati:n :/ :ne ca'.H of tre f athre of the et:u r-tric cts:uit treake's (as d::. e9te: in a March 1, 1933 le:ter) was su, tre're 'as :in:t,7 a.d az:essive det: ion of ne verti:4.1 latch lever of she 'JV ri; atuch e,t due to a lack :f pr:;er lubrication.

This conclusion .as :ca:.fra: in by 'n'estingnouse representatives and was based en visual' ins;e::t:n of the. '.'V trip at.tachment, in-place testing perfor ad af ter the failures, and previ:us Kestinghouse experience. The NAC has c:nductsd an initial determination of the cause of the failure cased en inspection of the failed UV rip attachments and interviews with cognizant maintenance p rsonnel on has the devices were maintained. The inspec ton indicates that there were ;ossibly multiple contributing causes of failure. Possible centr.ibisters are (1) dust and dirt; (2) lack of lubrication; requen# ceratic than intended by design;

5) corrosion (3) wear; (t.) m:re d

fr m ie:re;er lubrication in: January 1933; and (6) nicking f l(atch surfaces caused by vibratien fr:m repeated c;eration of the treaker. The contributors 4:: tar :: te cumulative, with.no cne main cause. The initial investigation indicates that the failure was age related and that a new device would perform

r::e*1y.

Ffany surfaces of the latch mechanism are worn and the additional fe':st:9 tar:td : ;'aven ;-0:er : tra 1:n. Pec;er lutrication throt.$hout :ne li's Of the device -*;d have preve ud the wear that can te seen en the sa.;1e. "nese initial findings indicate that the UV trip attachment failed from cincing ~" and excessive friction. However, in addition to the potential contributors cited ab:ve, it is ;:ssible that othe UV trip attachment or breaker prcblems may have caused the Salen failures. Because of the importance of the reactor-tris circuit treake's and UV trip attach ents, hewever, the NRC staff has pre-sared a m:re struc.. red an; roach u resolving this itet, inerefore, a 't::raury test.ing and examinatic. ; :gra funded by NEC will atte st to deter-i a the pre:ise cause of fath e. A;pendix A describes the initial NRC to:e::icn effort afd extent of addittenal examination and testing to be d:ne

y NA.

.' NRC Aetica - Short form NRC c:nducted 'an initial evaluatien of the cause of the UV trip attachment failures which included visual exami ation of the devices by qualified pers:nce) a.c determining new the de,1ces were maintained (see A;;encis A for desatis). !ased on this, we cenclude that cperation with new devices, in

ri.n:,1cn,,ith prec;erational testing and periodic surveillance, is ac:estable.

@C a:ti'c3 - (c 0 Te' i '3C.ill c:rdu:t.lah:ratory testi ; and examinatten of the failed attach ents u :sur-* a ?e :PI:ise cause o' 'ture, if possible. We anticipate that i .:,,,......,n....

i i .'.ni, : e., : :n ake :..e res.'(s t11 :o as tilasle :s :: :*i

: : n -a.* :

, v.e ; t e ' : tap. ': :e.

': 'd':1:':- esti :

e 4.;.s- ::. 'i!2. : 9e ta:::r tri: :t-: wit breaker en Unit 2 fatted to I

n tit :. d ; s..eii'at:e tes 't;.

A JV trip atta: -ai,.,as reinstalled on l L . ts c' :.': :*etier af te" an;14:ir,g :.te c:il, tre cir:vit breaker was -ti stalle:, 1 d s'.tse:We-. cts rair. t ance testing established opera:ility, l ] 5t,ilarly, :r..'av.ary 6, '133, a ret::sr trip c::urred.at Salem Unit 2 due to a 1: -lew 5:st ge9 era ce tevel, but c e reactor-trip circuit breaker failed to r

en.

I..e '.i:t.ses c:n:'uced tha: :na circuit breaker fat ture was due to

• l

inging f r:. cirt.and :ctroi.!:n in the UV trip atta:hment.

The UV trip attach- .-ent on the Unit 2 circuit breaker, as well as the UV trip attachment on all Unit 1 react:r tri; ciri.'it breakers, was cleaned, lubricated and readjusted i under supervision of a Westinghouse representative. Since the circuit breakers again f ailed :n February 22 and 25, adequacy of the verification testin to 1 ensure etreutt breaker-;;erability is an issue. Verifice. ton testing f 11owing ) reacter tri: cir:uit breaker eaintenance or initial installation should be l sufficient'y c:m;rehensig.c.o provide reasonable assurance that the circuit 1 I breaker *t'.1 function as reh. ed. Licensee a::iti - Shset Tern The licensee ens ;rc;osed a pr: gram to verify pr:Ser operation of the reactor-t in c'r:u's bastkers :rd:r to returning them to service. The program will

• vche : t'a s;tasi:r. testi9g :f '.'s tri; atta:n e.:s 25 ti es by the vender.

l Af ter !ssiat:icn en t>l tri: trea'.ars, the UV tris attacament and trip ( lreaker 111 :s tested ten c:re times. Once initial adjustments have :een per-t fsr.e:, a y dail;re in sie 25 :y:'e er 10 cycle its:s will ::nstitute a failure

( tne ;-1; asse sty and it.vestigati:n of the cause of failure and NRC l

- n'otificaster will be required, ro11cwin this testing, 4 ' time response.est of t the breaker at:Wated through the RPS wil be performed. This issue is sufft-ciently resc1ved to permit restart :f the plant pending a commitment to develop sed 1 sle e a :r:;rs.. :: : arable :: that described under Long Term. ,d=3, s e t 4 ::' : '. 9e "e.. l l s'th:w;8 tra 'iceesee nas not yet pe :ssed a leng-term program, the NRC staff i

s',teves an entsesiva bench test of a reactor-trip circuit breaker and UV and-shunt trip a tachments as an integrated unit is indicated.

The test would .' involve cycite.g (a total of 2000 cycles: 1000 trips by UV trip attach-ent and i 4 1000 trips by shunt trip atta:n ent under simulated environmental service l l .condittent to determir.e if a proper y maintained circuit breaker and its i

• .tacP-ents ein operate for an extended number of cycles.

The purpose of this

est, will :t to determi e if there are ac:umulated ef fects which will af(ect l

r:;er breaker c;eration.,

If these tests point to specific deficiencies in

?:: sets :

'r. ne it.se;ral asse-bly, farther test'ng or design mcdifications -ay :e ine'ctied. The tes*,ing wculd be performed by the licensee or appropriate intustry c. reas group or vendor. We anticipate co plation of this program with-h six -dr. l. J

s. o '?" - !*;*." t s,

• • • .a*i la,'Ift:t:Py :: :* at':n of,ne li:e'see's sh:-t to*

ree;sra-v : s* tes,1 ; :r: ira.

'7* Ac;8:r, '.: ; "e - ' C t'i et. fat t e li:enses,: esta:lish a 1:ng,sr,:;eratica,a1 verificati:r,

:j:a d:P t s -et:t:r-tri; cir:uit :reat,e s and will assure that the f:t..13; ;:'r,ts 4 e tecluced' 1.

4 suf f t: tent cw-:er of cycles is tecluced to provide statist,1cally

sar,tagful results.

2. the test exer:isestoth UV and shunt trip attachments (not simultatecusly), as well as the circuit breakers. 3, the tes, is conducted under environmental conditions similar to those, seen by the :tecuit breakers. .A. 4 safficti". delay the,is inc1wfed between cycles to allow return to stency state c:nditions. 5. test :r:cedures ars acceptance criteria will give reasonable assurance of u,:cve='rI ;::ssibit deficiencies in the integral breaker assembly and 1 divicit sc.tets. 1, Pt i it i :e a c fu*veillance 8 ;teturet

. ia; t.s d.estt;ati:n,

't aan : stir-dred t*at no s:e:1fic maintenan:e pro- ,,,:j:are esisted to c:r.c.ct :reventive er c:Practive estatenance on the reactor-Tric cir:uit, breakers, The maintenance conducted in January 1983 was not per-f:=, ed in at::rtan:e with the latest 'destinghouse recom endations, which were contained in 'destinghouse Technical Bulletta N$0 741, as amended by technical f a ta l e tte r *;13 74'2, Additlenally, no program of preventive maintenance had teen c:r. ducted en trese circuit breakers since original instal 14 fon, W th res:e:S t,: surveillance testhi, the 1(cer,see conducted a functional test af cne of ? t'as reac,or-trip cirewit breakers every e: nth, so each circuit

resker was tested ence every two m:nths.

The surveillance tests, which invc1ved t,r':pir.g a circuit breaker by use of the UV trip attachment, met the techni:a1 s;scification ruuirements. The licenset also operated the circuit breakers wes'ely by exercising the stunt trip attachment. In view of the nu.ber of rea: tor tria circuit breaker fattures.at talem, it appears that the periodic suntillance testing was ineffectivt in detecting reactor trip circuit breaker failures. Se it:anses ran n:w devole;ed a maintrnasce procedure and prec;easticial ' v e ri fi cat,t ca pr: gram. The NAC staff initial review of the procedures and pro-gra. iter.it#f ed :ertain deficiencies (see Appendix 0), j

e .':5 tit 1;;': - I':a: i-n

• • t

:t stt si

:6.e'::e: a I:e:' f': :re<t t',e ateteaa.:e ;r::s:ure f:r

n a. 4::(. i c a:

rt.d. : tt.ars (inc19:4 ng, 4 UV tri: tita: ent), .:s :

s t a

• ::r *. ':

e 'a ::,r.-aintenance re::?.entaticns,

P *s :4s4:

1:: ::a's;6 :.ailty ass.*t :e (3) t:wiet ents, a*.g ;:s: atntengn:, :agging, e :t see ns : :::14: *:.tr'y testing of the ain reacter-trip c'ecuit

-st; eas ty.!e of tre.".' trip Lt,1:h*ent and weekly *,esting cf the reactor-

• :' a:w's :reake's :).se :f t, e s'unt trip.at.a:.' ent.,,'de do not agree l

in 1;;en:'s 5. interval of the shunt trip assacheent as further .1 - 5 ; e w e e '. y t e s, f r a l

'::.sse:

i '.f e e s e e A c t f e n - t.:nc Te rm t ir. '.;; will require that the Itcensee incorporate results of a long term ,erif t:a,1cn testte; of the ras:ter trip circuit breaker into maintenance and sWrveillar.ca pr:gra l.,Thi.s action should be cce.pleted within two months of

. plett:n of long term testing.

t SNet'"ea,""N s:: 1::'en - s i e ' M siste has c::Pieted an tr.t tal review of the surveillance and mainte-

• arce ;asgra. and its precedures.

Certain deficiencies have been identified (see A::sadia B). The licenses will be required to :c.?;lete action necessary

res:1ve t e ider*,tfied def t:iencies prior to restart.

.l' r at;te: i: ine 'ite"Ite's ra 4;t: raintenan:e 3r: gram described above, the

• ;; itsf f.i*.1 vert'y ;rter to restart tonat the licensee's program also 9:1.:ss

=a ast::: gri: sys,em, 4 ergency ::ae c: clin; systats (includine 4

'.1:i:

systems), t..e a.s t',tary f ae:.ater system, anc containment isolation ~4/s'.e?s. MC Ac,1:n - t,cao "er9 '.;.- af') e.a' sate t e l':ansen's ; ::: sed lubrication recuire ents for the W ': it.t: e=ts ('.e., ty:e :' 16: ' cant, f requency of lubrication, ;oints of a: '!:: ttn. etc.). ' M aill 41sc assure that results of Icng-term vertfica-ti:n test,tn; cf tre res:::r tr's circuit treakers are adequately incarporated ' te -state ince a f sweveillance sregrams to determine testing frequency. tr.s:e:tien accuire sa.ts, 49c 11f atires. it e evaluat':ns wi'.) he concucted with the assistance of the Frank 1tn Research , er. tar (74-) and the Bromeaven flational t,aboratory (BNL). O nts' : Pr::e:".rtLJ:aatt:r **4 tnino u4ad Creater 9escenst !are: :=, sia at':n of t=e :'a:'. stances associated with the events involving ratet:r tri: circ 6f t treakars, certain issues have been identifitd relative to ar:*e".res, traint g, and :erator res;:nse, that are not solely related to the at t :,:* ta': cffc'.'t : eiksal. "re/ 4"o i .1. ':aalt,' g pr::e:.res f:P reacter *, rip and AiW1 S f... I

i t I 2

• l*L;:* t*1* ** *; s'de**,t vt'lf t,* elative t; the U$ a d gg ge:ign:

• ~~~'

.. 4. g.,.. ; }.

• lf1*:" "ll:**.le

"?ste iss.es are c'icalle: in sne le:tians sel:a.

• s *ai '{ *-::ehre #:* Ret:::* "ri: a*: 19ti-f:ated "ategie,ss ',.":>sut d

5:*i i;.5i i

-urvte i.n

nte:1

c= o: erat: i were c:neu:ted ny g. iuff, ane a

-a,iew cf the :: era *,ing ;rocedure fcr ATWS and reanor t,rts (!!-4.3) have j re. salad int, a) tne cpera,:rs co not take ir, mediate action te initiate J i

a.. 41 *,rt; tased,on reactqn-trip "first-out" annunciatcrs, b) they were not i

directed to do so by the procedure; however, the procedure did require a vaanval. trip if an aut::ttic rea*ctor trip did not occur. The procedure required only evaluation of reactor pcwor level re.aining high and/or multiple control rods failir.g to insert,'c) at least one c;erator questioned the a;prcpriateness of l the ATWS pro:edure s st4p to trip the turbine, without first verifying that the reac', r had trt;;ed, since that results in a loss of heat sink, and d) the re.'ised precit.re. dated $.:ch 2, 1983, would not have substantially changed the c:erators' res: case he t:M per:tived need to evaluate plant status from 'l c:ntac1 re:. trcicat, tens. l t a ti:n $5ert form 1.*eentge c t 1. The tR: -111 re:uire the licentet to identify the indicat. ions in the con-l s ert f t Ati:*., trat*jce petitive indication, =tthcut c;sratar analysis or l tr:1 r::, t*at :r:v i 9 aut:-ttic reac. tor trip comand is present.. 1 2. "se G*.t',i re:wi e ske li:entee to revise 3*:ce6fes to direct the t c;erturn ta insert a unual trip whenever positive ir.dicatica of an.aut:= l .utic trip de-ard is present without delaying to evaluate the overall ~ '

• L a-

/ kdod j p l a n t, t u t u s'. 3. The in: n111 retuire the Itcentee to review the basis for the ATV3 proca= hre sti:s ans :rder of priority in light of the c:erators' concern, j re< tie t e ;r::ecure at necessary, and bedet the c;srators on the basis h fer tr.s pr::ehral steps asd i=;crtance of peacedural c: pliance. t 4 f r.e tM: wt11 require that all cserators be trained on the revised procedsres orter to restart of Unit 1. i t,8cente, Action l.cno for9 The fmC will re;utre the Itcentee to incorporate any procedural changes for j Mt 1 te,ts '.3tt 2 proc 6hres and retrain Unit 2 operaters on rettled prece-l dures prior to Ur,it, 2 restart. BCatica=15tetfor9 c t.;;,,111' re. tt, the adewacy of Itcensee's revised procchrts 4*,4 basis for tre 'sesce ural tie:S and crear of ;rio'ity. t t... f,.... L i

l* 'b g -J f - e Y =** '.,.( , /V.'.?s.*s.e. i l* 4.! ce d.~%1'=== &, y ~ l..... h, %. ;'=; & .l.'. l).An,,e.1).'en l

1. 1*

,: ; *e== g . :..

• t.
• e.

e 1:::.1:y :' *, e i.'e s tir;.:.t e ".. t es 3r:.;, ~r e a;e.:y C:e ra- ' * ; * * : : t,'. e 3. ' : e ' ' e 1. l. C:t t s:

• • t'P'

/ l te.'s.s :: :.::sc t/ N:.; wi',h *he licensed c: era,ces,ho ere enshif t during

e t.: eser.,s ' c': ate a inch of fa.~.111&rity wi 5 the furctions of the annunt-

-s t 1 :icas:-s ass::tated with R75.

The interviees also revealed that tre ::t a,:rs #.: we=e :1thif*, during the Febr';ary 25 event cid not reccgnt:e, tr.4, a alfunc:t:n cf,he R75 had occurred unst) a;;roxi ately 30 minutes'atter $;e:tf tcally[, the operators interviewed were not able to describe ,na e.ar.. whethe the reacter-tri.2-indicator light (red) on the RPS mimic status panel is:1:a:ac a de-and f:r r confirmation of a breaker trip. Interviews also ted'ca:ed that at least s:me operators questioned the validity of annunciators u,t1 they c:uld be c: tr ed :y independent indication. This need to verify caased the o;erators r, to take immediate action to trip the reactor based on a.ani:at:r indicati:n L'.u.4 on February 25, 1993 as discussed in operator res:crie issue 3.3. ...A-# NRC cuesth Qng 44 WysA bl hes,ta;q:rdactacN:y the licedgin res:ensd%)hould procuh u at a=%nt:sti(:.: s t, :; t i nn s i gn LQ g l a s s t*.an i milliseconc tr sing the rea, ar. Initial T sw of. s without sqt.ge, is fun t et g as dgwup of rtuate the hivy'tq'tr'arg. tedt: that es.,n , reautr trip s ;- a 10 to.. yliseconds to tecuit e

eakt s.

!= av e.ent, it is i::arent snas training in the a sas f the RPS and assect-4:e: :':n. itis are t'aa s is arranted.

• • 'G c e s t e Ac",ica - $Por_t Term

~ The NA: will re:utre the licenses to conduct the additional training recutred t ' t i.e !.1 a'.: ad:itteral Pa'9teg :n the RP1'ard ast::tated tedicadens a: s' eras (s: :i't:411y are Per these are de".and er ccnfirmatory and the use

',r's irf:r at,tP ), a=.: : reste.< the February 2 and 25 events with a11

aliPs.

l.': Pite AcCc6 t.:n Tvi

• The Nf. will re:utre the Itcensas to assure that AP5 training and associated s.2,de:ts in the ese stor qualtf tcation and requaltf tcation program address the a sas of (1) Icgic function af the API and (2) operation of the RPS and asso-

> c'a ed iadications. This training shall be incorporated in the ongoing regular 1 s'n'ag pr:; a l. 'f; 1:1';* f Pt "e9

• s:

.i evaluate t's acewacy and cotpletten of ratedtal training prior to . = ' ', ' ikt '.*it ! asitaat. ,.f! 1;t' n=',t*; *st, t 'l l '. n ' d.' t.:'i t's l' l's a s's ret.i t te P ci ;r: gram.

e t ,d> ["W

• sat.:

Res:: 14 g l ta ."e s i.s ::t at:rs en shif, f:r t[e Fe: Lar/ 22 a-c 25, '.li! eveSts ar.: . t- '0 a c ra' st'a.:e :trs:P.nel cis:',:se:. e f:i*o,i g: s. n tun esists, the c;erators took.20 u !", seconds to deter.tne the

e-ail ;'a t status arc initiate 4 ar.al es:u tric.

For the first e,er., this estluatten tegan itn s.e electrical bus transfer failure. c "M s evaluati:n was ne:essary becaust of,re resulting lar;e nymder'of alarms ar.d lost e:uipment controls and status indicaters. This evaluati:n ti e was nearly icentical to the sine it took for the plant conditiqns to cegrace causing the RPS to provide A reactor trip signal. For the.seconc event, the evaluation.r.f the plant status began when the reactor trip annunciator actuated and the evaluation determined that a reactor trip was, in fact, necessary cased en plant paraseters and RPS indicaters. This time could have teen snortened had the operators recogni:ed that A valid trip's was called. for.by the RP5. % wl.r M for.a. secvide the conte. ieom(i.e.,N4rstcutkelall95, 5' b i). minatec %diul4 (nd sa f e ty 9 '4 instrudng)isadequtot te se,

• ty tees.Y Aid 55 nt.

I&C anw tintenan.h qrsenne indicatec.nat, the f n out pane and the Rp5 7t?1(c are ni3r4y relia Ae. h Ouring)the first event, after an operator was directed to manually trip (scram the reac',or, the switch handle was not operated correctly. When the 540 called for a manual trip, the control handle was inadvertently

wn ec of f 'tre 2:ar.: and nad to to reinsertec to : aform the manual trip.

to:a.se of *,se near caircident susc-atic trip sig 41,131: nay have c'en-t dt..it u t's c:ertur's f ailure to recognize t=a*, the automatic trip i, s u r a t. :ai's: f:r a trip are 64: f ailee to trip too reactor prior u t,ne manual trip. G,, !n spite of the positive indication of the reactor protection system failure during the second event, the operators neither understood nor ,e t, rusted *,P s indicat, tons. EeCause of this the catrators unnecessarily reevaluat,ed piant status. The operators manually tripped sne reactor in ris;:1se to trair evaluation of the plant s Atus and APS tedicators and ut due to re:sgnitic,i of the f 411t te of the reacter protection systen. 'N a..- ::'. r Ming v'ki caaw Isted en tne atsve,' the NRC concluded that for the event on february 22, the cperators' response was promet and fully satisfactory. For the event on February 25, d4 9M the deficiency in the reactor trip procedure and deficiona cies in training that resulted in (1) operators f ailing to recognize an RPS reactor trip demand and (2) the operators fat)(ng to understand the control rac9 indicat, toss, the operators' response tin was reasonable. Litea f Hlg t,14n Par 3 74r1 1, The NRC will require that in addition to the training required in issue 2, ese stors must be caut, toned on the use of the manual trip "J" handle

castrol,

%k

r l l

nstet : to ;4;e 11 4,.',. :

w. 1.

.:s fp d fit: to ':9e ';F.C oy lict9ste 11C ar.d. aintenar.ce personnel thst ve 'i s: ed ;t al and RPS logic's/ stems are highly reliable. Based on

nis infor ation, and the NRC's understanding of the logic of these systa 3 Ats.% ;#1, the NRC concluded that the information provided in tr.o c:ntrol room (i.e., first out panel alarms, illuminated RPS displays, and safety' grade instruments) was adequate to enable operata s to in:.ediately id'entify an Anl5 event. Subsequent to this find;ng and based on NAC questioning of the licensee on March 3 and 4, the licensee conducted tests whicA indicated that short duration signals (less than'10 milliseconds) could prJbce a reactor trip annunication on the first out 1

panel and a ccmputer print out indicating a reactor trip without actually tripping the reactor. Af ter reviewing test results, the licensee C.'. t a b s a goeted that the testing indicated %+t, the system JS functioning as s =i desi; red, requirbg trip s'gnals of more than 10 to 12.1111 seconds t l durstion to actuste the reactor trip circuit breakers. ~ Therefore the design of the first out panel can result in operators l l aueittoning the reitabliity of sne information provieed on inii panel. l O f a

t.dcenste !:t':n - t. n: Term 4-a 1. The N C will retuire the licensee to evaluate alternative means to perma e tly secure t.'e "J" hantie as part of the Catailed Control Roem ,j:.E.d Design 'eview. .L_ (j. M m w m issues) N /t c. v.-:.3 o.O - L.o ~~di TtD2Af i ). 7[ e. /./.'.:. w / L L-t M A l a #~1*tt

• %2-Lt ce.s.:S l? 6 's, fi N d y

/ /A) Ifents / +* 1. L.sNy 7s.+,n,+s7*/ o na, g, pi p),c,,, 1ch e un tgf Aa, Lec c W $ 'C Ur's d e 4 w s L a.d. d - 't ces fx o G t e ' y sua /~ 6,'3% m akt**

v.. m

' '"~l'. .e c 4 post-Tr'D Reviev The Itcensee did not determine that there had been a failure to trip on February 22 antti the computer printout of the sequence of events was reevalu- ' ated on February 26 as a result of NRC inquiries. Although the licensee con-ducted a reytow of each trip, there was no formal. procedure for conducting a systematic review. By letter dated March 1,1983, the Itcensee made a commit-ment to deve'op a post-trip and post-safety injection review procedure. The procedure will specify the review and documentation necessary to determine the cause of the event and whether equipment functioned as designed. Other liey elements of a post-trip review procedure are 1) necessary management authoritatics for restart, 2) debriefing of affected operators, 3) verification 'that reporting requirements were completed, and 4) followup review by safety committees. f 58*.49 E e l *. t * *. $ 1 t *.. l S t - C r t 12

16 Insert 2 to page Irr The !iRC will re gire -he licensece o reevaluate the design of the first out ;anel syste, witn regard to :he adequacy of information presented to ocerators, as a part of the detailed control rocm design revica. e W 8 W gag 4 e38 g' e' a; 9 4 0 0 6 e 4 4 8 e w s om 0 4 4 0 e f e

~ s _*:s see 1: ':- - I':-: e-- 4 = ~.; e;u'.re and : e li:ersee has ::r-i: ed :: deve :p anc issue';;s:- ri; a: ::s -safe: -infe: '.:r. review ;r::s:ure an

ain C:3-atiers Cepart ent

e-s:ra,ei :n : e re:virements prior :: L'n t : 1 restar,

1 : ' : r. - i : r - Ter- '..C.iil rev'tw the lice see's post-; rip ard :cs -safety injection revie4

-

:tcure to sr.sure the key elements n::ed ateve are acaquately addressed.

E. Master i:ut: ent List The itcensee maintains A 0 5f st that identifies activities, structures, com-

nents, and systems to which the Operatienal Cuality Assurance (QA) Program a

alies.

A Master Equipment List (MEL) is used by the licensee as the reference dec; ent fer determining the safety classification of individual e;uipment. Th'e MEL is' intended to be a ccmprehensive list of all station. e;ui;r.ent and identifies ea.ch item as nonsafety related or safety related. '~.en preparing mat-ntenar4+;; york orders, the MEL is cons ited to determine if CA

.e s;e f :ne w:rk is netessary.

Licensee and NRC review identified three

-::le s ass:ciated with the MEL.

These problems are, *) the accuracy and c::;;eteness of the document, 2) issuance as a nen: ente:lled cocument, and 3) lack of understarding of its proper use. The MEL was derived frca engineering source docu ents and a construction

r:;ra-d::u er.: called f reject Cire:tive 7 (70-7) and -as proviced to statica

ers:enel :y the Engineering De; art en: as' a reference d:: cent in July 1931.

-1:r t: iss;ar.:n cf the MEL, the P0-7 was used as the reference document. The P.EL, n:.e. e r, -a s n:: issued as a ::n:rellec :::. ment, therefere verification

_,tf ~its accuracy and ccmpleteness en issuance was not assured, and it was not ~' etdated in the plant as necessary. The reactor-trip cir:uit breakers and the R?S were not included in the MEL. In addition, sc:e personnel were not familiar with how to use the MEL for determining the classification of a articular piece of equi;:ent. Maintenance persennel a: knowledged that reference was ace :: 7C-7 on occasien during the January - February 1983 pericd. Lice.ste Acti:n - Sher: Term The NRC will require that the licensee: 1. Verify the MEL is complete and accurate with:respe:t to emergency core cooling (ECCS),; including actuation systems, RPS, auxiliary feedwater, ar.d centain ent isolation systems. 2. Instruct a;;repriate personnel in the purpose and use of the MEL. Licensae Acticn - Lono Term ' 7.C wili're:uire tnat t'ha licen'see serify the cc pleteness and a::uracy cf the j a '?EL and reissue it as a centrolled d:cumente t

N s s:: ':. :- - 5 :r ~e--

g..

-i'* :erf:rn sa : ; eview Of. - e MEL :n :ne above systems.

• 1:-':n - L: : Tern

  .i ::nfirs ::. ;1e:':n of the licensee's I:ng er a::ic'.

n V:-k Ceder pe::ed -es ~ 7 e review identified that the perscenel preparing main enance work orders were r.:: ::: plying with ins ructions c:ntained in the station administrative precedures. Spec.ifically, _for the work perfer:ed en the reactor-trip circuit breaker in January 1933, the engineering department 'was not consulted to verify safaty classificatten, and an erroneous nonsafety determination was made. Such censul:ation is required if equipment is not listed in the MEL. There was, -herefore, no independent review within the maintenance organization, and the .I Quali y Assurance Department was not involved in the work. Historically, there was ne requirement fer QA personnel to be involved in the review of work orders as_ they were processed 12.,4)sure that appropriate steps were taken to assign a s s' fica-icn. 4 Lf:ensee Actien - Short Term The li:ensee has =ade a cc:mitment to have the CA. Department review all non-safety--elated work orders prior to starting work, and to implement a program a.-d rai-ing.o ensure -Ja w:rk ceders are pr:;erly classified. Lf:ensee Actien - Lon: Tern T. e licensee will review work orders written since issuance of the MEL for

1. ~p'r::er classificatica ar.d will evaluate safety censequences of those found i= pre;erly classified.

• 0 A

  #:n - ih:-t Term

!..:.;.i11 revies licensee's w:rk crder classijica:ica program. 7. Timeliness of Even: Nctification 0: -hree occasions between January 30 and February 25, 1933, the licensee n::ified NRC of significant events belatedly. In each case, the notification vas a:;roxicately 30 minutes late. Two of these reports were for the February .22 and 25 events. Furthermore, in the February 22 event, the first noti,fi-catica did not contain kncwn significant information regarding actuation of. er.;ineered safety features and opening of the power operated relief valves. This 1:diti:nal inf:rnati:n was ;revided apprcximately a0 minutes later. The n::ifi atien prc:edure used by the licensee warrants further evaluation as to 'e ;riority assigned f:r NRC no-ification. I I l --..,-,...-.-...-.,.....-..........n.n. ~.. . ~, -, .n.,v~-.-

~_ b _' e -i e s A : ' : - 5 'r : r e -- ~ s .::.,- re:.' e :..e li:e see

ris nas<:e re::r:ing rectiremen s wi n all 3<e and :n-:til a a;s.e-

arsen.ei act wi

'

sevalua e cetift:a-icn tr':ri-iss. B ':: 4:-':n i.:.0 will c:r#irm -hat licensee's sh:rt-term a :icn is c mple:sd. 5. U:datin: " ender Secolied Information ~ As a result of tt.e Febru.ary_25,1983 event and NRC IE Bulletin 83-01, the licensee indicated not being aware of the existence of two Westinghouse technical service bullilins that provided preventive maintenance recommenda-tic'ns for the reactor-trip circuit breakers. The two documents in question were published by Westinghouse in 1974. The licensee has requested documenta-tion for all Westinghcuse equipment and will incorporate this information into - statien documents. While we are not aware of any problems with other vendor ' d:cumentation, an.NRC staf;f. cencern is whether a similar situation exists with i res:ect te d:cumentation 91r other vendor-supplied safety-related soutpment ard hew the licensee will main'tain vendor-supplied information current in the f; ure. - L'censee A:tien - Short Term Tr.e if:ensee has ade a ::r-ittent to a progran :: update existing c::u er:atica en. safety ~ equipment and to ensure that vendcr documentation is e-der a centrolled system. Licensee Actien - Lone Term The licenses will ecmplete the above program in a timely manner. l N.C Actien - Leno Term N.0 will perf:rm inspecti:ns te verify the implementation of licensee's pr: cram. 9. Involve:en of OA persennel With Other Station Oeoartments The Quality Assurance Department did not review maintenance work orders asso-ciated with repair of the reactor-trip circuit breakers in January 1983 because the work was not designated safety related. Further examination determined that the QA Department does not review for proper determination of classifica-ti n the work rders designated nonsafety related by other depart:ents. Dis-cussions with the licensee indicate that the QA Department has been somewhat is-la ed fr:m the activities of other depart:ents. As a result of prior-decisions, the licensee had initiated steps in January l ,r??3 ::.releca e the OA Capartrent frem the cer; orate offices in Newark, N.J. j

e the site and is taking ste;s to increase QA Department involvement in other statien activities.

Cc pietion of this program of increased QA ihvolvement tj - ~~

t .'-- ::ser stati: a:it. f 'e s caed.s.: be ::-5's:sc prict o res art, because

-- i ':r :f sr.: :- er 1:-i:35 i-s t;s s--

iss.is a-d 5 is s.fficient ~

::-rec CA defic's c'es in the th:r: t e r..

L':e see Action - Shcr-Ter-T.s l'censee has ade a c:--i man: to irst':. e a ; cgram to acre fully 'nte;ra e CA activi-ies in o the everall 1:-ivities. ~ Licensee Action - Lone Term i The licensee will complete the above QA integration program. NRC Action - Leno Term., Mcmitor licensee's icplementation of the above QA integration program. 10. post-Maintenance Ocerability Testing Past practice at Salem fosjpost maintenance operability testing has varied. 5.ch testing may be specined by the preparer,0f the maintenance work order or left to the discretien of maintenance personn'ei. or safety related equipment ge.erally, post-mainter.ance surveillance testing is done bef:re returning the ecuipment to service. Additional functional p st-caintenance and repair i testing of ecuipment, such as surveillance tes-ing, may need to be performed to de cns rate operability as an integral part of the larger ccaponent or system in which it qust functica. Licensee Acti n - L:no Term Ihe licensee will review and revise precedures and practices as necessary to _: ensure that functional testing of the everall components or system is performed E te de=enstrate operability prior to returning -he equipment to service follow-inc maintenance and recair. Measures will be revised, as necessary, to assure tha c;erations departmen persennel review .he testing prior.to returning such o e u'pment to service. NRC-Actica - Lono Term NRC will review licensee's revised procedures and their implementation to assure that appropriate postcaintenance operability testing is being acecmplished before equipment is returned to service. IV. Conclusions The issues discussed in this report were developed from examination of the information revealed during numercus interviews, dccument reviews, and meetingi conducted by NRC staff and centract:r persennel wi-h licensee representatives. Eased upon the staff's c:nclusion that the cause of the failures is attributed to the failure of the UV trip attachment to au:cmatically trip the reactor and defician'cies in 1 s ma'n enance and care, res ar: Of-Unit 1 should be permitted l su:f ect to the folicwing: l-3 -. - - - ~ .,y..-_,_.____,.,_m,.-,.,,m. m.m.,,,_.,__,.._-,,.,,,,.,.._--..._m~

... 3.,....... 3, .........,..,, 3 ,;,..,,,,a.,,. n,......m n .c...,...... .....,.,.a........._............. ,.;a.g z. 2 ..., n. 1. .. a. .--..a. .z,. ..,a..s.., on ,..,-.=..,, .s .ss..<,..s 4 se.,. ...s a.,..., aa... v,.s,..s r'c and A7.-l5 piccecure. l l f l ......_a ........,3 4 vci",a....or=..--.=.~.=..<.'.=..i..'.ar...'..-..dc ...-....= v e a n i.... =. - r.. d'ats safe y i. plica-icn; further cre, these ic g-term issues will be recen-s'ce ed in it;h: cf the results of the generic evaluations being conducted by an NR'. Task ?crce. In -he ir.teri: -he staff intends to. Establish cc::itments fer c:rrective acticns and implementation schedule, and intends to assure timely i ;;e er.tatica of these at the Salem facility. The s aff also believes that the long-term corrective actions related to the ma. z;trent issues at the Salem facility can be further evaluated as to ccm-plater.ess and applicability by an independent and more in-depth assessment. Ac: crit ;1y, the Office of Inspection and Enforcement is plannine to perform a perfcrmance Appraisal-:eam { PAT) inspection of the licensee within the next few scr.:hs. .d@YO Ia J p m e G e g .s. _ J

a .w. g Ap

• i. F.di X A

,e e .....g p? ....--.g ".........a a-

• 03....

. i ?.. 3 ; r.T P.. i 3 4 1 J a l l..u. J.-

. dr. s - )-

at 5*.E.'."Cl.E.Q GENE:aTI"3 STATICN / ..........,..................- c.::....., _...,,,. _ .. -. t.u.: Su-a v a.-d Ini-t al - Findin:s nitial inspecti:n of the UV trip attachment i$dicates a pos'siblity of multiple cen:rit;-ir.g causes of failure. Dossible contributors are (1) dust and'dfrt; (2) lack of lubri.ca-icn;.(3.1 wear; (4) more frequent operation than intended by design; (5) cerrosion from improper lubrication in January 1933; and (6) nick-in; cf la ch surfaces cIused by vibration from repeated Operation of the breaker. The centributors appear to be cumulative, with no one main cause. The initial investigation indicates that the failure was age related and that a new device wouid perfcam properly. Many surfaces of the latch mechanism are worn and the additional friction tended to prevent proper operation. Proper lubrication thr:v;.hout,,tjpalife of the device might have prevented the wear that can be seen en the sat.ile. The tes s and exasinatiens prcposed by the staff and its contractor will attemp-to determine the cause of failure and if possible reproduce it. The fc11: wing sus:ari:es the initial findings and list,s the proposed tests. Of scussi:n a-d Ci curs ances A site visit was ::nducted on March 3,1953 by NRC and Franklin Research Center

ers

n el

ir.spe:- the type 05-50 circuit breaker undarveltage trip attache-en: t an effer-to de:ernine the most probable cause of failure.

The reactor . rifrip circuit breaker rocms for Units 1 and 2, each of which contain four 08-50 circuit breakers, were visually inspected and the following cbservations were cade: 1. A:1 four CE-50 Unt: 1 circuit breakers and UV trip attachments were re :ved fr:: the ci-cuit breaker cabinet,s. The enclosures were generally c'ean and free of dust. The ambient temperature was be ween 85 and 95'F, wi-h war: exhaus air frem inverter cabinets being directed at the 02-50 circuit breaker cabinets. The spacing between cabinets is approximately 3 f.et. I 2. All four 0E-50 Unit 2 circuit breakers were also inspected. The UV trip a-tach =ents were re:oved, however. The circuit breaker cabinets contained a layer of icese dust approximately 1/16 inch thick. The ambient temper-a ure was in the 7C'F range. UV trip attachments are counted on the tcp cf the circuit-breaker platform, to the right of the shunt trip attachmenti -hich is several inches from the bettem of the circuit breaker cabinet. Interviews were c:nducted with an electrical maintenance supervisor who discussid the cir: vesta :es of the removal of the circuit breakers that were in.cF.ad wi-h t..a incicent :n Unit 1, and an electrical sucerviscr who had also

t -:-;id :- fra :f r:.f-breaksrs ir :.y-~ icn in August g22, Theinfer:gtpT~~ s:t -as - a- - ! :'-:.'

rsa;s s a : f e '

."l r ; 't ; 3 -:- 3 7. ; 3 gg :3,7 e

s 1:sd # e: sn 1;. anc r.ad 0;sra,s: d. ring su vsillance testing wi-hin a few

a s :ri:r

the incidsn.

A s: es; was made to Sa'.an nana;emsnt :: pr: vide ene ef the UV trip a a:h-e. s arb a shun trip a: a:; man; fcr esti ; a: Franklin Research Can er ( :~). This reques was ::mplisd with, and an investiga-i:n of these devices i s r:w under way at FRC. Rese :s of Initial Examinatien Initial investigations indicated roughness in the cperation of the trip latch. There is scme dragging of the echanism, and portions of the latch mechanism have obvious signs of wear. Pcssible centributing factors to the failure to operate are a lack of lubrication, wear, jarring of the UV attachment as a result of circuit breaker operation and more frequent cperation of the UV trip attachment than was intended during design. It is postulated that under most industrial applications, the UV' attachment would be used very infrequently and pr:bably wculd be.cperats$lonly during test sequences at perhaps yearly or 1:nese interval s. Therefsfe, in industrial applications, it wculd cperate only a fed tices, perha;s 20 or 30 cycles during its lifetica,.and wculd not be a n:real tripping mechanism for the breaker. However, in its use at Salem and other nuclear pcwer plants, it is the prime tripping device for the circuit breaker, and is therefore called up n to operate on the order of 50 times per ~ea. This would mean that at its current age, in 1983, there would have been-

ssibiy 400

5CO tri; :pera-icns of this device.

Curing the initial investigation, it was noted that the shunt trip attachmen: '.as basn :psrated once every sevsn days since August 1982, rather than at 1:ncar intervals. This means that the circuit breaker is tripped and closed 2'-invery seven days. This causes jarring of the entire mechanism of the circuit breaker and its attached relays and coils due to the normal operation of the breaker. This may or may not be significant, but it should be noted that the U7 attachment stayed energized during these trips, and its latch mechanism was f arred semewhat by cperation of the circuit breaker. This possibly added to the friction built up in the latch rechanism from normal cperation by causing the latch.:schanis: to just slightly nick the surface -hat it rices on and

herity tend to prevent cperation.

Further investigation will try to determine whe:her this is inceed a. prcblem. It appears from initial inspection of the device that wear and roughness of cating surfaces in the trip latch are present. Proper lubrication might have prevented the current situation or could have reduced the roughness to the point whe.re proper operation could CCCu". . ur:r.er investigation will attempt to determine whether the CRC-2-25 lubricat-i..g and cleaning spray added to the operating problem by either causing c:rrosica :r removing all residual lubrication from initial construction and-possible caking of dust and dirt. It appears that from the tice of initial ccnstructicn of the UV trip attachments up until January of 1983, no lubrica-5t: ;re'cedures had been performed, and then, in Janwary of 1933, lubricatic:

2

::e:. es -ere. :e a.e. :y -he

.si.:. era :e :erse-el ag c a klestinghcuse .e:- ':'a. A: 's :' e,. e :C-2-25 1;brica.

et e

..as s:rejec :n ei) f:. c.' rt: a :a:r e. s a s s::iated, with ..e U,it I circuit breaker. This .:-icar-i s be'9; :r::u-ed by ~?.C f:r :ss,ing purp;ses. s: ef Investi:atier.s Tc 3e performec by NRC Centract - (:RC) 1. The firs

ss will be to perform various deenergizations and energiza-

-icns of the UV trip attachment anc r.cnitor the device under various conditions. 2. The second test will be to disassemble the latch mechanism to cbserve the surfaces of the varion parts of the latch and to photograph these sur-faces through a mir.yescope to determine the various levels of wear on these surfaces. .3. The third test is to deter =ine the effects of CRC-2-25 spray on the various types of o tals used in this devices. An a-tempt will be made to use metals other than those in the actual attachment. If possible, the chemical cons.istencdf this spray will be determir.ed from the manufacturer. To pr:ve that the sample UV trip attachment is identical to all such Salem devices, a visual inspection of all existing Salem Unit 1 and 2 UV trip attach-ments will be perferred. This can take place at Salem, wi-h no disassembly needed. The ins;e:ti:n can be made with the devices mounted on the circuit b eakers or i::se. These inspectiens should be done as sc:n as possible, and T.;esday,.V. arch 3,1.953 i s rece: mended. If fur-her tests a a re:uired they evill be based en the results of these . initial tests. All tests will be nondestructive such that the device can be

1. ' sed for further testing and returned to the utility.

u Additienal Test To 2e Conducted l by the Licensee, as Revised by NRC Staff This test will require -he use of a spare circuit breaker. The UV trip and s%nt trip at.a:h ents will be counted en the breaker, and the breaker will be

perated repeatedly to de ermine the effect cn the shunt and UV trip attach-me.t s.

I. is sur,ised -hat while the attachments are energized and the breaker i crips and closes a number of times, additional friction of the trip latch may c:ur frca the vibra-icn. This test is described in de ail in the following

• section.

.II. REVISED SURVEILLANCE OF REACTOR-TRIP CIRCUIT BREAKER OPERATION AND VERIFICATION TESTING ~._ The licensee proposed the follcwing increased surveillance of reactor-trip circuit breaker 0;eraticn: Main,and bypass breakers will be shunt-tripped weekly. 1. Y 2. Main trea5.ers will :} UV-tripped monthly.

t s'~1::s: Ib:y :f ni s ravi s s: surgatllance cf reac :--Erip ci-:uit breaker

s ir :-

Es :sst s.tius s: :y '.:.: :sff. Eass: : an 5 aiys's ::-d.: sd by 5:t, i.t:n ::nsi:sred rea:::r-trip sys e unavaiia:i',i y, reac er-: rip

t -:.'

rst;.s r f ai'.ure ra a s, and :ss t intervals, the f:li: wing c nclust:ns w s -a c r t.em.

.irst, :hs pre;0 sed test of each reactor-trip circuit breaker UV tr : a :a:r sn :.:e every 30 days is accec 1:le. Sec:nd, the pro;essd test of 3 - s sn.-- rip a :1:r en- :nce avery seven cays is c:nsidered to ba excessive a.d ty '.;ac: n :. s re'iability of the reac cr trip sys sm by increasing the

e--4 al for a single failure.

During tes-tr.g, a single failure in the'legic

r '

n of the rsac cr : rip system cculd prevent an au:cmatic SCRAM.

Thus, it is s::rmar.ded that the shunt trip attachmen-be tested en the same schedule as the UV trip attachment; that is, on:e every 30 days. It is also recommended that the UV trip of the bypass breakers be tested prior to restart and every refueling thereafter. Ciscussion The acceptabilTty of tht proposed test intervals for the reactor-trip circuit breakers was based on NRC staff review of reactor-trip circuit breaker failure rate data ebtained from.ktdynsee Even-Reports (LERs). The generic RpS unavailability of 3 x 10-5f(used ~in both NUREG-0?o0, " Anticipated Transients Wi-heut Scram for Light Water Reacters," and by the ATWS Task Force and 5 aeri g Grcup in the develcpment of the proposed ATWS Rule) was used in evaluating the licensee's proposed test intervals. In addition, the following c:nsidsrations were incorporated into the NRC staf.f recctmendation: s shu : trip a ajhment previcas a divarse means :f ripping the sact:r-trip circuit breaker, which is electrically independent of the UV ric attachment. The UV trip attachment is supplied by a 48-V de source a..t is senergi:sd : tri:. The snun trip attach:3nt is su; plied by a 125-V de source ar.d is energized to trip. 2. The shunt trip attachment is an energize-to-actuate device and is not " fail safe" in that a loss of power will not cause a trip. However, the shunt trip is p:wered from a reliable Class 1E battery-backed source. 3. It.ce the shunt trip attachmen; is an energite-to-actuate device, it is net subfsc: to -he constant heating effects that the centinueusly energizac UV rip a tachment ex;eriences. The heating effects may

ntribute to the higher failure rate of the UV trip attachment.

• 4.

The mechanical construction of the shunt trip attachment is less ccmplex than that of the UV trip attachment. The shunt trip attachment does not rely on the successful cperation of the complex latching mechanism that has.been deternined to be the source of the majority of the failures of -he UV trip attachment. 5. The maf:rity of the electrical circuit breakers used in the high-volt' age electrical distribution system have dc pcwered energize-to-actuate shunt trip attachments. These circuit breakers.are used for manual, as weil as av:: mat':, trip functions for load shedding and pcwer switching. Relia-bility Of snergi:e o-actuate shunt trips in similar applications thr ugh-cut the nuc'vear pcwar industry has been shcwn to be significantly higher - te f:r devices tha; are c:ns antly energi:ed.

i I C.er 7'N Of - 6 4 : - sa:::r-:.ip circuit breaker.fgilures aere caused by '.V

-4: a;;s:- e ; #at'. es.

7. '<:s cf -he ::r: erns re' attn; {: the events a-Salem en.ebruary 22 and 25, 1953 are reia ed :: the c;eration of the UV trip attachment. During

ne ever.:s a: Saler,Fe shunt trip attachment functiened properly.

E. The by; ass breakers are required to trip in respcase to a UV trip demand sig..al shcult this cc:ur when the main breakers are being t'ested. Since the est fre;.ency of the main breakers has been increased, the bypass breakers should be tested to verify the capability to perform their backup safety functi:n. 4 Verification Testino It is recommended that a bench test be performed on one 03-50 reactor-trip circuit breaker. The purpose of the test will be to cycle the 08-50 with the UV trip and shunt trip-attachmen,ts in place for a total of 2000 cycles to de: ermine if any adverse effects can be identified and, if there are no adverse effects, show that a progstly maintained breaker and its subcomponents can cperate for an extended nty5er of cycles. The breaker'will be tripped, with each cycle being al ernated with the UV and shunt trips. The ambient tempera- ~ ture should be 100".: to simulate the expected service environment, and the circuit breaker should be cycled no more often than once every 30 minutes to alicw for return to steady-state conditions. The results of each circuit breaker c;eration will be doeurented and a visual ' heck made. Additio'nal c ce ails for -his :y;e of_ test will be provided at a later time. i mF%- 6 0 f* G e-e k h he e e .e e-

9 A * '. i ". d i /. 5 .,. *.. i t. e.' :..- - ;.;.; : w*:. ..r..,.t '.: v i.* i. .a,1*. *. : : r..- .~ ::

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r r.. -....... ? ~.. .~,.a s. s a## revie-ed the licensee's main ent ;e Orc:edure, Sale: Generating i a ':- Mainte a :e 'e:1 -. e r. "anual Mai tesan:e Fr::edure M.2C-2, Revision 1. 's :::.nen-i :*.:es a prc edure for verifying proper c;erati:n of the UV -': at a:hre t anc testing of the UV trip attach ent ceil follcwing re: 3:e ent. NRC s aff also reviewec the licensee's pr:;osad rea: cr rip

r:.i-iretker ;eraticnal verification ;r: gram, which references ?re:epure yI;-E.

The foilewing cc :ents and recommendations were made concerning..these c::u ents- ~ The main enance prccedure d:es not specify whether the maintenance and testing described are applicable to both the main and bypass breakers. It should specify that it does. 2. The maintenance precedure should specify required actions to be taken in the event ar.y accepta$le tolerances, as identified in En. closure 7 of v20-2, are not cet. ~ 2. The frequency of all maintenance and testing specified in -he precedure, w'.th the exception of the verification testing identified folicwing UV trip attachment replacement, should be specified. 1 . e prc:edure sn:ui.d be ::dified 0 require cleanir.g cf the entire circuit breaker 're::, the re:0 val Of all four circu.'t breakers and cleaning of -he

acinets by vacutaing, and cleaning of the breakers during every refueling cutage.

5. Section 9.7.2.1 of Procedure M20-2 specifies that the UV trip attachment is to be cleaned with a standard: solvent. The precedure should specify the exact solvent to be used. NRC will request FRC and BNL to determine the adequacy of -he proposed selvent and any potential adverse effects fre.- its use. (This evaluation need not be ccmeleted prier to plant startup). 5. Section 9.7.2.2 specifies the cceposition cf the lubricant to be applied specific points of the UV trip attachment. This specification should state whether the mechanism is to be lubricated each time maintenance is perforced. NRC will recuest FRC and ENL to determine the adequacy of the lubricant and the points of application spec.ified, as well as the frequency of lubrication. 7. Any UV trip attachment that d:es not successfully cc=plete the 25 ~ c:nsecutive cycles of testing to be performed by Westinghouse shculd not te acceptec cr installed by the licensee. ?. Section 9.7.4.15 s;ecifies the testing to be perfer ed on the UV trip a t'achrent c:ii following its replacement. The main enance pro:edure -? --,.-_,r. e-

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,::ts s'.y :: :'a:e 5 ::n sa:.i'ye :;.:'es:;e ent UV, tri; a ta:heents f

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in5 a'Ia- ~ eci f t ed in :..e ain- .e ar.:e : ::e:ure. .!;C re::: ends 33 cic.::es fcr the raas:ns specified 3:ect 'f e:. A::en:ix A. ARC staff believe he increase in test cy iss, and the i a::a;;ar.:a criteria s acified if any failures c ur cur:ing this testing, Are sas:nable and should be in::r;; rated into cair.tenance precedura M3Q 2 9. Te:hnt:ai Department Prc edures.'ics. IIC-15.1.011 referen:ed by the licensee, should be reviewed and their aand LIC-18.1.010, deter:fr.ed o'y HRC s:sif. cceptability Feilewing revision of the maintenance pr6cedure and the associated propose t reae::r-tri; circuit breaker cperaticnal verification program to incorporate the abeve comments and recccmendaticas, the NRC staff will reevaluate the 1 d::ucents and provide another report that will include the results of the NRC i centractor's evaluatior.s and will d::ument the final NRC evaluation and c:nclusions ccncerning the adequacy of the maintenance procedure and preoperational ver.ificat.isa program. 1 .e 1 i t i i 1 4 .I a r f ] t f I. 1 i t i \\ j _I.!'+-

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