ML20236H032
| ML20236H032 | |
| Person / Time | |
|---|---|
| Site: | Byron  |
| Issue date: | 06/29/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20236H027 | List: |
| References | |
| 50-454-98-11, 50-455-98-11, NUDOCS 9807070055 | |
| Download: ML20236H032 (30) | |
See also: IR 05000454/1998011
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U. S. NUCLEAR REGULATORY COMMISSION
REGION 111
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Docket Nos:
50-454;50-455
License Nos:
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Report No:
50-454/455-98011(DRP)
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Licensee:
Commonwealth Edison Company _
Facility:
Byron Generating Station, Units 1 and 2
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Location:
4450 N. German Church Road
Byron,IL 61010
Dates:
April 7 - May 30,1998
Inspectors:
E. Cobey, Senior Resident inspector
N. Hilton, Resident inspector
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B. Kemker, Resident inspector
T. Tongue, Project Engineer
C. Thompson, Illinois Department of Nuclear Safety
Approved by:
Michael J. Jordan, Chief
Reactor Projects Branch 3
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9007070055 900629
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ADOCK 05000454
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EXECUTIVE SUMMARY
Byron Generating Station Units 1 and 2
NRC inspection Report 50-454/98011(DRP); 50-455/g8011(DRP)
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This inspechon included aspects of licensee operations, maintenance, engineering, and plant
support. The report covers a 8-week period of inspection activities by the resident str4 and
' region based inspectors.
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Operations
The inspectors observed thorough evaluation of shutdown risk for planned activities
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during the Unit 2 refueling outage, effective heightened level of awareness briefings for
infrequently performed evolutions, strong reactivity management, and effective oversight
of infrequently performed evolutions by operations management and Quality and Safety
Assessment personnel. (Section 01.1)
The inspectors concluded that the licensee identified and initiated corrective action for a
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self-identified adverse trend in out-of-service (OOS) errors. The licensee's interim
. corrective actions initially appeared effective, focusing on human performance during
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placement and removal of OOS cards and computer program errors. However, during
the Unit 2 refueling outage, several OOS errors occurred, each involving the failure of
multiple barriers. These errors indicated that the licensee's actions were not completely
effective. The most noteb!c OOS errors included mechanics performing work prior to the
associated OOS being hung and inadequate OOS boundaries due to poor communication
between departments. A violation was cited. (Section 01.2).
The inspectors concluded that the shutdown of the Unit 2 reactor was conducted in a
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safe and controlled manner. . Specifically, management oversight of the shutdown was
evident; reactivity management of the evolution was effective; and the heightened level of
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awareness briefing was generally thorough. The inspectors also concluded that control
room operators adhered to the Nuclear Operations Division Operations Department
Standards during the shutdown, with the exception that operators often omitted the
response acknowledgment from directed communications. (Section 01.3)
During the refueling cavity floodup for the Unit 2 refueling outage, a valid high radiation
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engineered safety feature actuation signal occurred due to abnormally high radioactivity
levels in the reactor coolant system water. The inspectors concluded that the causes of
the event included inadequate cleanup of the reactor coolant system following a planned
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crud burst. Poor communication between operators and chemistry department personnel
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and a lack of administrative controls resulted in the licensee flooding the refueling cavity
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before the crud burst cleanup was complete. (Section 01.5)
The inspectors concluded that the spent fuel pool level was inadvertently lowered due to
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the licensee failing to follow Byron Operating Procedure RH-9, "Punip Down of the
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Refueling Cavity to the RWST [ Refueling Water Storage Tank)." The inspectors
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concluded that contributors to this event were poor communications, poor coordination of
plant evolutions, and poor administrative control of the sluice gate by the operations
department. A violation was cited.- (Section 01.7)
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The inspectors concluded that overall operator performance during the Unit 2 startup was
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good. The inspectors observed senior management and Quality and Safety Assessment
oversight of the startup. Operating shift management provided an effective high impact
activity briefing and closely supervised reactivity manipulations. However, the shutdown
bank control rods did not withdraw on demand due to the control room operators failing to
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bypass the high flux rod stop for an inoperable power range channel contrary to
procedural requirements. This failure constitutes a violation of minor significance and is
not subject to formal enforcement action, in addition, the inspectors noted one example of
a lack of a questioning attitude regarding unexpected loss of rod speed indication.
(Section 01.8)
Quality and Safety Assessment personnel and the inspectors independently concluded
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that the operating shift management and system engineer failed to recognize that an
operator error of securing the wrong battery charger invalidated the result of Byron
Operating Surveillance 7.5.e.1-2, " Essential Service Water Makeup Pump OB Monthly
Operability Surveillance," Revision 19. The inspectors concluded that the actions taken
for this issue by Quality and Safety Assessment personnel, including urging the licensee
to perform the surveillance test again, were indicative of a strong quality assurance
organization. A non-cited violation was issued. (Section 07.1)
The inspectors concluded that the licensee failed to perform a local leak rate test on the
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Unit 1 containment emergency hatch in accordance with Technical Specification (TS)
Surveillance Requirement 4.6.1.3.b due to ineffective inter-departmental communication
and failing to follow station procedures. In addition, the inspectors concluded that the
licensee's root cause investigation into the event was thorough and the corrective actions
delineated in the licensee event report appeared appropriate. A non-cited violation was
issued. (Section 08.1)
Maintenance / Surveillance
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- The inspectors concluded that the facility was in a condition outside of the ventilation
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design basis due to multiple examples of failing to follow station procedures.
Consequently, if a loss-of-coolant accident occurred while the non-accessible vent!!stion
system was outside the design basis, the offsite dose would have been increased by
approximately 15 millirem and the control room habitability dose would have been
increased by approximately 4.4 millirem. Two violations were cited. (Section M3.1)
Enoineerina
The inspectors concluded that the spent fuel pool (SFP) skimmer retum line and the SFP
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cooling suction piping were not designed to prevent inadvertent draining below 423 feet
2 inches, in accordance with TS 5.6.2. The inspectors did not agree with the licensee's
conclusion that the low level alarm and operator action constituted a design feature as
required in TS 5.6.2. This issue was considered an Unresolved item pending further
NRC review of a similar design issue at Braidwood. (Section E1.1)
The licensee failed to update the Final Safety Analysis Report to include the effects of
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Safety Evaluation T1-93-015.2, documented in October 1993, which concluded that
operation of the mini-purge system in lieu of the containment purge system did not
involve an unreviewed safety question. A violation was cited. (Section E8.1)
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Plant Support -
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The inspectors concluded that radiological postings and barriers were in place in
accordance with procedural requirements. The inspectors also noted that the
contaminated area barrier associated with the spent fuel pool skimmer pump did not meet
the standards and expectations delineated in the Radiation Worker Handbook,
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Revision 1, in that an electrical cord crossed a contaminated area barrier and was not
fastened at the barrier to preclude the spread of contamination. This failure is of minor
si nificance and was not subject to formal enforcement actions. (Section R1.1)
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Report Details
Summary of Plant Status
-The licensee operated Unit 1 at or near full power for the duration of the inspection period.
The licensee entered the inspection period in coastdown operations on Unit 2 in preparation for
entering Refueling Outage B2R07, which began on April 11,1998. Following completion of the
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refueling outage the licensee synchronized the unit to the grid on May 18,1998, and the unit was
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operated at or near full power until the end of the inspection period.
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I. Operations
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. Conduct of Operations
01.1' General Comments (71707)
During this inspection period, the inspectors conducted numerous observations of
operations depm ' ment activities. The inspectors observed the licensee provide a
thorou?h evaluation of shutdown risk for planned activities during the Unit 2 refueling
outage, several effective heightened level of awareness briefings for infrequently
performed evolutions, a strong reactivity management, and an effective oversight of
infrequently performed evolutions by operations management and Quality and Safety
Assessment personnel. Operations management oversight was particularly eviderst when
management stopped the withdrawal of the Unit 2 shutdown bank rods after discovering
that control rod speed indication was not available. The inspectors also noted that the
operators generally adhered to the Nuclear Operations Division Operations Department
Standards.
01.2 Out-of-Service (OOS) Prooram implementation Problems
a.
. Inspection Scope (71707)
The inspectors reviewed the actions taken by the licensee since the licensee identified an
adverse trend in the OOS program in October 1997.: The inspectors also reviewed the
circumstances surrounding three events involving OOS program implementation errors.
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. The inspectors interviewed operations and maintenance personnel and reviewed Root
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~ Cause Report 454-230-97-SCAQ00077, " Adverse Trend in OOS due to Personnel Errors
involving Planning, Scheduling and Work Scope, Hanging OOS Cards, Poor Human
. Performance and Computer Programming Errors," and Byron Administrative
Procedure (BAP) 330-1, " Station Equipment Out-of-Service Procedure," Revision 28.
b.
- Observations and Findinos
The licensee initially identified an adverse trend with the implementation of the OOS
program in October 1997. , The licensee trended OOS program related errors that
affected configuration control of the plant; specifically, any OOS configuration discovered
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that would have jeopardized personnel safety had work proceeded, or had the potential to
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damage isolated or adjacent equipment, or that did not match the OOS confi0uration on
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the OOS checklist. The inspectors noted that the licensee's definition of an OOS error
indicated that multiple barriers in the OOS program had failed prior to the identification of
the error. The licensee increased the operators' awareness of the errors during shift
change briefings and in the form of increased field monitoring. However, by
. mid-November 1997, the licensee determined that increased attention was not improving
performance and a root cause determination was initiated on November 13,1997.
Additionally, operations management decided to retrain operators on BAP 330-1 during
- January 1998.
During the review, of the OOS errors the inspectors identified two weaknesses, in
addition to the human performance issues previously identified by the licensee. First
weakness was that the operators frequently received poor descriptions of the work scope
when an OOS request was electronically submitted to the operations department. The
work scope was frequently vague and did not identify where a task was to be performed.
Operators were required to research each task to identify the scope. Second weakness
that the inspectors noted was that the determination of the current drawing revisions
represented another challenge to the operators. A feature of the electronic work control
system (EWCS) provided a pending change list to each drawing. However, the
inspectors noted that operators performing OOS preparation were frequently either not
familiar with the use of the EWCS change list or unaware of the existence of the EWCS
change list. Therefore, the inspectors concluded that the station's use of the EWCS
change list was not effective in communicating pending drawing revisions to certain
drawing users.
- On April 14,1998, Root Cause Report 454-230-97-SCAQ00077 was issued by the
, licensee. The inspectors noted that the root cause found that no conclusive common
. cause(s) could be identified; however, conditions that were inducing errors were noted.
The root cause report recommendations were primarily human performance
enhancements and improvements to the OOS computer program. The inspectors review
of the OOS error data in mid-April 1998, indicated that the OOS error rate had been
reduced to zero errors in March and one minor error in April.
During a 4-week period from mid-April until mid-May, approximately six additional OOS
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errors occurred that met the licensee's definition of an OOS error. At the end of the
inspection period the licensee had not completed a review to determine exactly how many
OOS errors had occurred. The inspecters identified that the licensee was not trending
OOS errors that were attributable in part to maintenance. Consequently, the licensee did
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not have a complete understanding of the magnitude of the OOS error rate.
The inspectors reviewed three exemples, each of which the licensee had not included in
- the OOS error trend, to determine contributing causes.
Inadeauste OOS Boundarv for the 2B Chemical and Volume Control (CV) Pump
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On May 2,1998, a modification was being installed to add additional venting capability to
the 2B CV pump. Construction personnel drilled a % inch hole into the 28 CV pump
suction piping which resulted in a coritinuous stream of water out of the hole. The
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licensee's subsequent investigation determined that the OOS boundary was inadequate.
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The inspectors reviewed OOS 970012670, "B2R07 Blanket OOS Activities (2B CV PP),"
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and DCP 9600182, " Install Vent Valves / Lines to CV Pump Suction Pipe and Balance
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Drum Pipe." The pump suction isolation valve was used as an OOS boundary; however,
the vent design required installation of the vent upstream of the suction isolation valve.
The inspectors noted that DCP 9600182 adequately indicated the modification scope;
however, the exact location of the vent installation was not clear without careful review.
The OOS stated, " Install vent valves / lines per DCP 9600182."
Technical Specification 6.8.1.a states that written procedures shall be established,
implemented and maintained for procedures recommended in Appendix A, of Regulatory
Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33,
Revision 2, February 1978, specifies equipment control, e.g., locking and tagging, as an
example of an administrative procedure. The inspectors noted that BAP 330-1,
Paragraph C.4.c.2 stated, in part, that the OOS must be sufficient to isolate the
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equipment being worked on. Paragraph C.2.3.a stated, in part, that second check
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verification will verify the adequacy of the isolation boundaries before hanging any OOS.
The inspectors concluded that OOS 970012670 was inadequate for the installation of
DCP 9600182 and therefore an example of a violation of TS 6.8.1.a.
(50-455/98011-01a(DRP)). The inspectors considered that although self-revealing, the
inadequate boundary provided in OOS 970012670 was a repetitive issue that could
reasonably have been prevented by the licensee's corrective action for a previous
licensee finding.
Failure to Hana an OOS on Electrohydraulic Control System Prior to Breachina t%
. System
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On April 13,1998, during the performance of Work Request (WR) 970105305-01, "B2R07
- Remove, inspect, Repair or Replace Valve [ Main Turbine Throttle Valve)," a contract
mechanic breached the electrohydraulic control (EH) system while it was in service. The
mechanic was sprayed with EH fluid; however, no injury occurred. Upon notification, the
operating shift immediately secured the EH system and tagged the system OOS.
The licensee's subsequent investigation revealed that operations had authorized
WR 970105305-01 on April 12,1998. Prior to disconnecting and removing the valve
actuators, the valves needed to be gagged open. Following the installation of the
gagging devices, the licensee should have secure the EH system ad place the system
OOS. However, on April 13,1998, following completion of gagging the valves open, the
mechanics continued with the maintenance activity without notifying operators or verifying
that the EH system was secured. Consequently, the system was breached while in
service.
The inspectors noted that WR 970105305-01 specified, in part, that prior to initiating work
the mechanical maintenance supervisor shall verify that the system is OOS and drained
and vented. The work request then yified that the removal and reinstallation of the
throttle valve be in accordance with Byron Malntenance Procedure (BMP) 3114-8, " Main
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Turbine Throttle Valve Removal / Installation," Revision 2, which provided direction to
disconnect the EH lines to the valve. However, the inspectors noted that the OOS for this
maintenance activity, OOS 970007159, was not hung prior to the start of maintenance.
The inspectors reviewed the licensee's root cause and noted examples where work was
performed prior to an OOS being authorized. The inspectors considered that although
self-revealing, the performance of work prior to the OOS authorization was a repetitive
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issue that could reasonably have been prevented by the licensee's corrective action for a
previous licensee finding. No violation was issued because the work was performed on
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non-safety related equipment.
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Failure to Hano an OOS on the 2B Reactor Coolant Pumo Prior to Performina Balancina
Activities
On May 17,1998, the licensee was balancing a new reactor coolant pump (RCP) motor.
Vibration testing determined that adjustments to the balancing weights were necessary.
The 2B RCP was shutdown by operators and an OOS initiated to allow mechanical
maintenance to adjust the weights. Prior to completion of the OOS, operators were
notified that the work had been completed. At the end of the inspection period, the
inspectors had requested, but not received, a copy of the appropriate work request and
OOS to complete a review of the issue. The inspectors considered the event another
exampic of a violation of TS 6.8.1.a, in that work was performed prior to all OOS tags
being in place. However, pending review of the associated work request and OOS, the
inspectors considered this an Unresolved item (50-455/98011-02(DRP)).
c.
Conclusions
The inspectors concluded that the licensee identified and initiated corrective action for a
self-identified adverse trend in out-of-service (OOS) errors. The licensee's interim
corrective actions initially appeared effective, focusing on human performance during
placement and removal of OOS cards and computer program errors. However, during
the Unit 2 refueling outage, several OOS errors occurred, each involving the failure of
multiple barriers. These errors indicated that the licensee's actions were not completely
effective. The most notable OOS errors included mechanics performing work prior to the
associated OOS being hung and inadequate OOS boundaries due to poor communication
between departments. A violation was cited.
01.3 Unit 2 Shutdown for Refuelina Outaae B2R07
a.
Inspection Scope (71707)
The inspectors observed the heightened level of awareness (HLA) briefing and the Unit 2
shutdown. The inspectors interviewed operators and reviewed the following procedures:
2BGP 100-4, " Power Descension," Revision 9
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2BGP 100-5, " Plant Shutdown and Cooldown," Revision 19
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2BOS 3.4.2.d-3, " Turbine Mechanical Overspeed Trip Surveillance," Revision 4
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b.
Observations and Findinas
On April 10,1998, the licensee commenced a Unit 2 shutdown for Refueling Outage
B2R07. The inspectors observed the HLA briefing for the shutdown and noted that the
briefing was thorough, in that, the briefing included a discussion of the expected plant
response, the chain of command and the roles and responsibilities of the participants in
the evolution However, the HLA briefing did not include a detailed discussion of the
transition into Byron Operating Surveillance (BOS) 2BOS 3.4.2.d-3, " Turbine Mechanical
Overspeed Trip Surveillance," Revision 4. Consequently, when the operators attempted
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to perform 2BOS 3.4.2.d-3, they were unable to latch the turbine as expected. Since the
operators had not completed Byron General Operating Procedure (BGP) 100-4,
Step F.31, the main generator lockout relays had not been reset and the turbine could not
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be latched. Following the resetting of the relays, the operators successfully latched the
turbine; however, the main turbine overspeed testing was not completed due to high
vibrations on several bearings.
In addition, the inspectors observed that Quality and Safety Assessment (Q&SA) and
senior management oversight was evident throughout the shutdown. The inspectors
noted that control room operators adhered to the Nuclear Operations Division Operations
Department Standards for reactivity management, professionalism, control room conduct,
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procedural adherence, and annunciator response. However, the inspectors noted that
the operators often did not meet the standards for three-way closed loop directed
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communications, in that the operators often omitted the third leg of the communications
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(response acknowledgment).
c.
Conclusions
The inspectors concluded that the shutdown of the Unit 2 reactor was conducted in a
safe and controlled manner. Specifically, management oversight of the shutdown was
evident; reactivity management of the evolution was effective; and the heightened level of
awareness briefing was thorough, with the one exception of not briefing the transition into
the main turbine overspeed testing. The inspectors also concluded that control room
operators adhered to the Nuclear Operations Divis;on Operations Department Standards
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during the shutdown, with the exception that operators often omitted the third leg
(response acknowledgment) of three-way closed loop directed communications.
01.4 Unit 2 Reactor Coolant System Drain (71707)
The inspectors interviewed operators, reviewed the applicable operating procedures, and
observed the HLA briefing and selected portions of the Unit 2 reactor coolant system
(RCS) drain on Aoril 14 and 15,1998. The inspectors noted that during the evolution the
control room operators adhered to the Nuclear Operations Division Operations
Department Standards. The inspectors observed effective supervisory oversight of the
evolution and good coordination between operators and support personnel. The
inspectors also noted that a temporary change to the RCS drain procedure, which
allowed venting and draining of all four reactor coolant loops simultaneously, was briefed
and performed well. The licensee experienced some difficulty draining reactor coo! ant
loops "A" and "D" due to a failed valve in the waste gas system, which prevented venting
of the reactor coolant drain tank to the waste gas system. The licensee repaired the
valve and successfully completed the RCS draining. The inspectors concluded that the
draining of the RCS was performed in a safe and professional manner.
01.5 Unit 2 Enoineered Safety Feature Actuations Due to inadeauste Cleanuo after Planned
Crud Burst
a.
Inspection Scope (71707)
The inspectors reviewed the engineered safety feature (ESF) actuations that occurred
after the Unit 2 planned crud burst and subsequent reactnr vessel head removal. The
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inspectore discussed the event with licensee personnel and reviewed Licensee Event
Reports (LERs) 50-455/98-003 and 50-455/98-004.
b.
. Observations and Findinas
On April 16,1998, Unit 2 operators received an ESF actuation, a valid high radiation
signal, from the containment fuel handling incident radiation monitors during the refueling
cavity floodup in preparation for refueling. The licensee had performed a chemical crud
burst as part of the radiation dose reduction program. The cleanup of the crud burst had
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been in progress for 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> when the floodup began. The initial alarm was received
approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> after beginning tMe floodup of the refueling cavity. The operators
manually terminated the containment atmospheric release that was in progress. At
8:09 p.m., approximately 6 minutes later, the containment high radiation actuation of the
ESF system occurred. Radiation dose levels at the radiation detectors reached a
maximum of 60 milliroentgen per hr (mr/hr) and 500 mr/hr at the refueling cavity surface.
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The high radiation levels were due to inadequate cleanup of the RCS and poor
' administrative control of the crud burst cleanup.. The inspectors noted that the
inadequate cleanup of the RCS was due to poor communication and coordination of
letdown flow between operators and chemistry personnel. The inspectors also noted that
the licensee did not have any administrative controls to ensure that RCS activity was
sufficiently reduced prior to lifting the reactor vessel head and flooding the refueling
cavity.
The licensee also noted a failure of the operating experience (OPEX) program. A similar
event had occurred at another Commonwealth Edison station in 1996. Byron Station had
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been notified of the event; however, the notification occurred immediately after the event
prior to the establishment of a root cause and development of corrective actions. After
the event was understood and corrective actions identified, additional review of the issue
for applicability and action was not completed. Although the OPEX program was different
in 1996, the licensee concluded that similar weaknesses in the program existed following
the April 1998 event.
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On April 19,1998, a valid ESF signal (high radiation) was received by the Fuel Handling
Building Area radiation monitors. In preparation for refueling activities, operators had
' filled the fuel transfer canal with water from the refueling cavity. The water contained
elevated levels of radioactivity as discussed above. When the sluice gate separating the
fuel transfer canal from the spent fuel pool was opened, water level equalized. Water
flowing from the fuel transfer canal into the spent fuel pool caused the radiation levels to
increase to the area radiation monitors' alarm setpoint of 5 mr/hr. Radiation levels did not
exceed 5 mr/hr. The licensee concluded that the elevated radiation levels were expected
due to the elevated radioactivity levels in the refueling cavity water and no additional
. corrective actions were planned. The inspectors questioned why the refueling cavity
cleanup was not extended to lower the activity levels further prior to continuing on with
scheduled activities. The licensee responded that a since a significant amount of
refueling cavity cleanup had been completed, the decision was made to continue with the
refueling activities.
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Conclusions
During the refueling cavity floodup for the Unit 2 refueling outage, a valid high radiation
engineered safety feature actuation signal occurred due to abnormally high activity levels
in the reactor coolant system water. The inspectors concluded that the causes of the
event included inadequate cleanup of the reactor coolant system following a planned crud
burst. Poor communication between operators and chemistry department personnel and
a lack of administrative controls resulted in the licensee flooding the refueling cavity
before the crud burst cleanup was complete.
01.6' Unit 2 Refuelina Activities (71707)
The inspectors interviewed fuel handlers, observed refueling activities in containment and
- in the fuel handling building, and reviewed the following procedures: BAP 370-3,
" Administrative Control During Refueling," Revision 19; Byron Fuel Handling
Procedure (BFP) FH-4, " Fuel Movement in Spent Fuel Pool," Revision 7; and BFP FH-5,
" Fuel Movement in Containment," Revision 7.' The inspectors noted that each core
alteration was strictly controlled and that appropriate accountability methods were
employed. The inspectors concluded that the observed core alterations were performed
well and in accordance with the requirements of TS and fuel handling procedures.
01.7 . Inadvertent Reduction in the Spent Fuel Pool Level
a.
Insoection Scope (71707) .
The inspectors reviewed the circumstances surrounding the inadvertent reduction in the
spent fuel pool (SFP) level during the pump down of the Unit 2 refueling cavity. The
inspectors interviewed the root cause investigator, operations and fuel handling
department personnel. The inspectors also reviewed the following procedures:
BOP RH-9, " Pump Down of the Refueling Cavity to the RWST [ Refueling
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Water Storage Tank)," Revision 11
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BFP FH-29, * Operation of the Spent Fuel Pool Sluice Gates," Revision 3
BAP 370-3, " Administrative Control During Refueling," Revision 19
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b.
Observations and Findinos
On May 4,1998, in preparation for Unit 2 emergency core cooling system full flow testing,
the refueling cavity was to have been lowered approximately one foot to provide a volume
for testing. The transfer tube isolation valve between the refueling cavity and the fuel
transfer canal,2FH001, was open to allow the fuel handlers to transfer a reactor vessel
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levelinstrumentation system (RVLIS) probe out of the refueling cavity. Although the
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refueling cavity pump down was not normally performed with 2FH001 open, it was
allowed by BOP RH-9, at the Shift Manager's discretion. The operating shift determined
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that it was acceptable to lower the level of the fuel transfer canal along with the refueling
cavity by allowing 2FH001 to remain open.
<
11
l
- _ _
_
_- --
.
_ _ - - - _ _ - _ _ _
- _ _ _ _ _ .
_
..
.
The pre-evolution briefing for the pump down of the refueling cavity with 2FH001 open
l
was conducted by operations department personnel. ; During the briefing, BOP RH-9 was
discussed, including Section C.12, which required the sluice gate to be closed prior to
lowering water level. However, since no fuel _ handling personnel attended the briefing,
the fuel handling personnel were unaware that the refueling cavity pump down would
occur concurrent with the transfer of the RVLIS probe. In addition, the operators were
unaware that the fuel handling personnel intended to have the sluice gate open for the
RVLIS probe transfer.
'
,
Prior to commencing the evolution, the Unit Supervisor phoned the fuel handling building
to verify that the sluice gate was closed. However, the Unit Supervisor received an
incorrect report from an unknown individual that the sluice gate was closed.
Consequently, approximately 5 minutes after commencing the pump down, the Spent
Fuel Pit Low Level Alarm annunciated. Prior to stopping the drain down, the level of the
SFP was reduced by 8 inches. Tne SFP level reached 423 feet 11 inches, which was
,
above the minimum level required by TS.
!
1
10 CFR Part 50, Appendix B, Criteria V, " Instructions, Procedures, and Drawings,"
requires that activities affecting quality be prescribed by documented instructions, .
procedures, or drawings of a type appropriate to the circumstances and be accomplished
i
in accordance with these instructions, procedures, or drawings. The failure to ensure that
I
the sluice gate between the SFP and the fuel transfer canal was closed prior to lowering
the water level in the Unit 2 refueling cavity, in accordance with BOP RH-9, Section C.12,
is considered a violation of 10 CFR Part 50, Appendix B, Criteria V
(50-455/98011-03(DRP)). At the end of the inspection period, the licensee's investigation
was in progress and corrective actions had not been determined.
l
The operators subsequently restored the level in the SFP and the refueling cavity; and
upon completion of the RVLIS probe transfer, the refueling cavity was drained down with
2FH001 closed. In addition, the operators initiated problem identification form (PlF) .
B1998-0278 and commenced an investigation into the event. The inspectors concluded
that the licensee's initial response to the event was timely and appropriate.
In addition, the inspectors identified that operations controlled the configuration of the fuel
j
transfer valve; however, operations did not maintain control of the configuration of the
i
sluice gate. Fuel handling personnel operated the sluice gate as necessary without
{
receiving authorization from the control room. The inspectors also noted that the
operators did not recognize that the transfer of the RVLIS probe and the refueling cavity
pump down evolutions conflicted.
c.
Conclusions
l
The inspectors concluded that spent fuel pool level was inadvertently lowered due to the
i
licensee failing to follow Byron Operating Procedure RH-9, " Pump Down of the Refueling
l
Cavity to the RWST [ Refueling Water Storage Tank)." The inspectors concluded that
j
,
contributors to this event were poor communications, poor coordination of plant
i
evolutions, and poor administrative control of the sluice gate by the operations
l
department. A violation was cited.
12
_ _ _ _ _ _
. _ _ _
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_-___ _____
_ _ _ _ - - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ - _ -
.
.
l
'
01.8 Unit 2 Startuo Followina Refuelino Outaae B2R07
a.
Insoection Scope (71707)
The inspectors observed the high impact activity (HIA) briefing and selected portions of
the Unit 2 reactor startup and low power physics testing. The inspectors interviewed
operators and engineering personnel and reviewed the following procedures:
q
2BGP 100-2, " Plant Startup," Revision 13
2 BOA INST-1, " Nuclear instrumentation Malfunction," Revision 53A
'*
,
SPP 98-046," Pre-Critical Alignment and Setup of the Advanced Digital Reactivity
L
.
l
Computer," Revision 0
SPP 98-047, " Low Power Physics Test Program with Dynamic Rod Worth
.
Measurement," Revision 0
b,
. Observations and findinas
On May 17,1998, the licensee commenced a Unit 2 plant startup following Refueling
Outage B2R07. The inspectors observed the HIA briefing for the startup and noted that
i
the briefing was thorough. The briefing included a discussion of industry events that
occurred during startup evolutions, the dilution to criticality including the estimated critical
boron concentration, startup termination criteria, the chain of command, and the roles and
responsibilities of the participants in the evolution.
During the performance of 2BGP 100-2, Section F.14, two problems arose. First, the
shutdown bank "A" control rods did not withdraw on demand. The subsequent
investigation conducted by the licensee revealed that the outward rod motion was
inhibited by a high flux rod stop. The rod stop was due to the installation of a reactivity
computer into power range Channel N41 in accordance with SPP 98-046, which tripped
all of the bistables associated with that channel. Power range instrumentation was not
required to be operable until the unit was in Mode 2. Following implementation of
2 BOA INST-1 for an inoperable power range channel, which bypassed the rod stop, the
operators successfully withdrew the control rods.
The second problem arose when operations management became aware that rod speed
indication was not available as expected and was caused when jumpers were installed to
,
f allow rod speed to be increased to 72 steps per minute in accordance with SPP 98-046,
Appendix A, Section 4.1, When the jumpers were installed, the operators and nuclear
i
engineer recognized the unexpected loss of indication; however, no action was taken.
1
The inspectors noted that the unexpected loss of indication was due to a lack of review
and understanding of vendor recommendations associated with the installation of
jumpers for the advanced digital reactivity computer. The inspectors also noted that a
questioning attitude by the operators and nuclear engineers could have resulted in the
- resolution of the unexpected loss of rod speed indication prior to the failure of the control
i
rods to withdraw on demand.
Operators control of the reactor during the startup was very good. The inspectors
observed effective reactivity management and close, continuous supervision during the
reactor startup. The inspectors noted that the operators kept distractions to a minimum,
including the group of nuclear engineers that were present to conduct rod testing. The
13
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l
_ - -_
- _ - ___- - _ - _ - ______-__ - _ _ - - _ - -
- _ _ _
.
!
l
inspectors also noted good use of the inverse count rate ratio plot during the approach to
criticality. The observed portions of the dynamic rod worth testing were completed as
predicted without challenging the operators.
c.
Conclusions -
l
The inspectors concluded that overall operator performance during the Unit 2 startup was
!
good. The inspectors observed senior management and Quality and Safety Assessment
oversight of the startup. Operating shift management provided an effective high impact
activity briefing, and closely supervised reactivity manipulations. However, of minimal
significance, the inspectors noted that the shutdown bank control rods did not withdraw
on demand due to the control room operators failing to bypass the high flux rod stop for
an inoperable power range channel. In addition, the inspectors noted one example of a
lack of a questioning attitude regarding uneitpected loss of rod speed indication.-
07
Quality Assurance in Operations
071
Essential Service Water Surveillance Invalidated by an Operator Error
a.
InsDeClion SCoDe (71707)
1
The inspectors reviewed the circumstances surrounding an operator error during the
I
performance of Byron Operating Surveillance (BOS) 7.5.e.1-2, " Essential Service Water
j
Makeup Pump OB Monthly Operability Surveillance," Revision 19. The inspectors
1
interviewed operations, engineering, and Q&SA department personnel and reviewed the
'
procedure and applicable documentation.
b.'
Observations and Findinas
On April 15,1998, during the restoration from OBOS 7.5.e.1-2, " Essential Service Water
Makeup Pump CB Monthly Operability Surveillance," Revision 19, a non-licensed operator
identified that the wrong battery charger had been secured in Section F.7 of the
procedure. The OEs pump battery charger "B" had been secured instead of the "C" battery
charger. Consequently, the surveillance, which demonstrates the operability of the
OB essential service water (SX) make-up pump to satisfy TS Surveillance
Requirements 4.7.5.e(1) through (3), tested the OB SX make-up pump with the battery
charger lined up to the selected battery instead of testing the pump on the battery alone.
In response to this error, the Unit Supervisor initiated PlF B1998-01742 and reviewed the
completed surveillance. The Unit Supervisor concluded, in conjunction with system
engineering, that the test was valid and did not need to be re-performed.
. During routine review of PlFs, Q&SA personnel identified that the operator error during
the performance of OBOS 7.5.e.1-2 invalidated the result of the test. In response to the
concems raised by Q&SA personnel, the operators successfully re-performed
OBOS 7.5.e.1-2, on April 17,1998. As a result of this event, Q&SA issued a Corrective
Action Record,06-98-035, to the operations department on April 20,1998. The
corrective actions planned by the operations department included revising the OA and
,
OB SX make-up pump monthly operability surveillance to improve the human factoring
r
. and to include additional acceptance criteria, reinforce proper usage of human
14
.
.
'
performance tools, and the delineation of operations management's expectations for
surveillance procedural non-compliances.
Technical Specification 6.8.1.a states that written procedures shall be established,
implemented and maintained for procedures recommended in Appendix A, of Regulatory
Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33,
Revision 2, February 1978, specifies service water system tests as an example of a
i
surveillance test procedure. The failure to secure the OB pump battery charger "C" as
required by OBOS 7.5.e.1-2, Revision 19, Section F.7, was a violation of TS 6.8.1.a. This
non-repetitive, licensee-identified and corrected violation is being treated as a non-cited
,
l
violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy
. (50-454/98011-04(DRP); 50-455/98011-04(DRP)).
c.
Conclusions
Quality and Safety Assessment personnel and the inspectors independently concluded
i
that the operating shift management and system engineer failed to recognize that an
operator error of securing the wrong battery charger invalidated the result of Byron
3
Operating Surveillance 7.5.e.1-2, " Essential Service Water Makeup Pump OB Monthly
J
Operability Surveillance," Revision 19. The inspectors concluded that the actions taken
for this issue by Quality and Safety Assessment personnel, including urging the licensee
. to perform the surveillance test again, were indicative of a strong quality assurance
organization. A non-cited violation was issued.
08
Miscellaneous Operations issues (71707, 92700, 92901)
l
08.1
(Closed) LER 50-454/98009: " Missed TS Test due to Failure to Follow Procedure." On
' March 18,1998, the licensee identified that the Unit 1 containment emergency hatch
outer door had not been leak rate tested in accordance with TS Surveillance
Requirement 4.6.1.3.b.
On March 6,1998, a radiation protection (RP) supervisor obtained ' approval from the Shift
i
Manager and sent a RP technician into the containment emergency hatch to post a
'
neutron radiation sign on the inner door. The RP supervisor completed BAP 1450-T2,
" Containment Entry Checklist," which specified that system engineering be notified of the
entry and that Byron Engineering Surveillance (BVS) 6.1.3.a-2, " Unit 1 Primary
Containment Type B Local Leakage Rate Tests of the Emergency Personnel Airlock Door
Gasket interspaces," be performed within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. The RP supervisor and the Shift
.
Manager each assumed that the other would notify system engineering of the entry,
!
Consequently, system engineering was not notified of the entry into the containment
emergency hatch on March 6,1998, and the required leak rate test was not performed
until the missed surveillance was subsequently identified on March 18,1998.
In addition, during the performance of operator daily logs, non-licensed operators were
required to visually inspect the tamper seal on the security cage for the containment
l
emergency hatch. if the seal was broken or removed, the tamper seal on the
containment emergency hatch outer door was required to be inspected to ensure that the
outer hatch door had not been opened. If the seal on the outer hatch door had been
broken or removed, BVS 6.1.3.a-2 was required to be performed within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.
However, since a temporary structure was in place during the refueling outage,
l:
15
1
I
,,
- _ _ __
.-
_ - - -
.
non-licensed operators had developed a practice of checking the security log to verify that
nobody had entered the emergency hatch. Consequently, between March 6 and March 18,1998,
non-licensed operators missed numerous opportunities to identify that the containment
emerger cy hatch had been entered and a leak rate test was required.
Technical Specification Surveillance Requirement 4.6.1.3.b specBes that each
containment airlock shall be demonstrated operable by conducting airlock leakage tests in
l
accordance with Regulatory Guide 1.163, September 1995, and 10 CFR Part 50,
Appendix J, Option B. Regulatory Guide 1.163, " Performance-Based Containment
Leak-Test Program," dated September 1995, specifies, in part, that Nuclear Energy
Institute 94-01, " Industry Guideline for implomanting Performance-Based Option of
10 CFR Part 50, Appendix J," Revision 0, provides methods acceptable to the NRC staff
i
for complying with the provisions of Option B in Appendix J to 10 CFR Part 50. Nuclear
Energy Institute 94-01, Section 10.2.2.1, specifies that when containment integrity is
required, airlock door seals should be tested within 7 days after each containment
access. The inspectors concluded that the failure to perform a leak rate test of the
,
containment emergency airlock following access on March 6,1998, was a violation of
TS 4.6.1.3.b. This non-repetitive, licensee-identified and corrected violation is being
treated as a non-cited violation, consistent with Section Vll.B.1 of the NRC Enforcement
Policy (50-454/98011-05(DRP)).
The inspectors concluded that the licensee missed TS Surveillance
Requirement 4.6.1.3.b due to ineffective interdepartmental communication
and failing to follow station procedures. In addition, the inspectors concluded that the
licensee's root cause investigation into the event was thorough and the corrective actions
delineated in the LER appeared appropriate.
08.2 (Closed) LER 50-454/96001-00 and 01: " Unrecognized Change in System Flow Results
in Operation Outside Technical Specification." This event was originally discussed in
,
detail in NRC Inspection Repor150-454/96003(DRP); 50-455/96003(DRP) and resulted
'
in a violation. The violation was subsequently closed in NRC Inspection
Report 50-454/98005(DRP); 50-455/98005(DRP). The licensee's evaluation of the event '
resulted in the initial LER. The supplemental LER provided additional information which
did not change the nature of the event nor would it affect the previously issued NOV.
This LER and the supplement are closed.
)
i
08.3 (Closed) Violation (50-454/455-96003-01(DRP)): Failure to Follow Procedures, Five
Examples.
a.
A reactor operator failed to determine the cause of an alarm " Primary Water Flow
Deviation" by ensuring a proper valve lineup before taking action of starting to add
boric acid to the reactor coolant system. For corrective action, the licensee
generated a daily order to reemphasize self-checking, and modified procedures by
adding steps to heighten the awareness of infrequent evolutions and flow paths,
and developed a plan of action for routine actuation of the primary water and boric
acid alarms. The following procedures were modified: BOP FC-14, " Boron
i
Addition to the Spent Fuel Pool or the Transfer Canal," and BOP SI-13, * Filling the
'RWST." The associated alarm procedures, Byron Annunciator Response
Procedure (BAR) BAR 1 and 2-9-A6, "BA [ Boric Acid] Flow Deviations," and
i
16
1
,
. . _ __ _ _ _ - _ _ ____ -.
.
.
!
t
<
BAR 1 and 2-9-B6, "PW [ Primary Water] Flow Deviation," were also modified by
adding actions if the alarm was not authentic.
b.
Failure to maintain a water-tight door shut when the room was not occupied. This
was caused by contractor workers. The licensee enhanced training for contractor
supervisors by adding a list of procedural requirements and a list of water-tight
doors from Procedure BAP 1100-3, " Fire Protection Systems, Fire Rated
Assemblies, Ventilation Seals, Flood Seals, and Water-tight Door impairments."
c.
Failure to shut a valve in SFP purification system that resulted in an inadvertent
transfer of about 1000 gallons of water from the reactor water storage tank to the
SFP. The licensee counseled the equipment attendants involved and modified
'
Procedure BOP FC-7,"Startup of the Purification System to Purify the Refueling
Water Storage Tank," to include the use of check lists for valve lineups.
d.
Operator error resulted in the inadvertent trip of a control rod drive motor
generator set. The licensee counseled the equipment operator involved on the
importance of self-checking.
e.
Operator error resulted in the inadvertent tripping of a running emergency diesel
generator. The licensee counseled the reactor operator involved on the
importance of accuracy and self-checking. The operator was also temporarily
removed from duty pending the licensee investigation.
The inspectors reviewed the licensees corrective actions and the modified procedures,
and found the actions acceptable. This violation is closed.
08.4 (Closed) LER 50-455/98-003: "Interdepartment issues and OPEX Cause High RCS
Activity and ESF Actuation." This event was initially discussed in NRC Inspection
Report 50-454/98010(DRS); 50-455/98010(DRS) and inspection Follow-up item (IFI)
Number 50-455/98010-03 issued for follow-up of the licensee's corrective actions
documented in the LER. Additional discussion of the causes of the event are discussed
in Section 01.7 of this report. Therefore, LER 50-455/98-03 is closed and followup
actions will be tracked by IFl 50-455/98010-03.
08.5 (Closed) LER 50-455/98-004: "FHB [ Fuel Handling Building) Rad Monitor ESF Actuation
due to High Dose Water in Fuel Transfer Canal." The LER described elevated radiation
levels in the FHB and noted that the levels were caused by the event described in
LER 50-455/98-003 (discussed in Section 01.7 of this report). The licensee did not
identify any corrective actions in LER 50-455/98-004 in addition to the actions described
in LER 50-455/98-003. This LER is closed.
08.6 (Closed) LER 50-454/96007: " Loss of Offsite Power Due to a Failure of an Insulator on
Phase B of the Unit 1 Station Auxiliary Transformer From Water intrusion." This event
l
was documented in NRC Inspection Report 50-454/96005; 50-455/96005. In addition to
the Unit 1 loss of offsite power (LOOP), Unit 2 was manually tripped due to a loss of
service water. At the time of the Unit 1 LOOP (May 23,1995), the running service water
pumps were powered from Unit 1. The inspectors reviewed the licensee's corrective
actions. The actions included repair of the damaged Unit 1 station auxiliary transformer
(SAT) bus ducts and inspections of the unaffected Unit 1 and all of the Unit 2 SAT bus
17
l
,
-
_
- _ _ _ _ - _ _ - _ - _ .
._
_
- __
_
ducts. Insufficiently caulked areas were repaired. The inspectors verified that the
licensee had added steps to the SAT inspection program to verify weather proofing. This
LER is closed.
Although not documented in the LER, the licensee's investigation following the Unit 1
' LOOP identified numerous unit inter-dependence concems resulting from a loss of power
to the opposite unit. The most significant, that which would cause a trip of the opposite
unit in a short time, included the OB service water (WS) pump. The OB WS pump was
powered from Unit 1. The Unit 1 LOOP in 1995 caused a trip of Unit 2 because both OA
i
and OB WS pumps were powered from Unit 1. Without service water, the Unit 2 main
generator auxiliaries and service air compressors lost cooling water. Engineering
personnel designed a modification that would allow power to the OB WS pump to be
supplied from either Unit 1 or Unit 2; therefore, one WS pump could be supplied from
each unit at all times. The modification was approved by the licensee in 1998 and
j
'
scheduled to be installed in 1999. The licensee also planned actions to correct several
other vulnerabilities identified during the inter-dependance review. The inspectors
considered the inter-dependance review and following actions good.
II. Maintenance
.
M1
Conduct of Maintenance
M1.1 Maintenance Observations
a.
Inspection Scope (62707)-
The inspectors observed the performance of all or portions of the following work requests
(WR). When applicable, the inspectors also reviewed TS and the Updated Final Safety
Analysis Report (UFSAR).
WR 98003158-01
Troubleshoot and Recalibrates Flow Instrument FI-0972,
.
,
i
RWST outlet flow gage
!
Troubleshoot and Repair the area radiation monitor for the
.
,
piping penetration area
.
c.
Conclusions
l
L
The inspectors concluded that observed maintenance activities were conducted well.
Specifically, oversight of maintenance activities was evident; maintenance activities were
completed in accordance with station procedures; and maintenance personnel were
1
,
'
knowledgeable of the associated activities.
18
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-____
_ _ - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
.
.
1
M1.2 Surveillance Test Observations
l
a.
Inspection Scope (61726)
The inspectors interviewed operations and engineering personnel, reviewed the
completed test documentation, and observed the performance of selected portions of the
following surveillance test procedures.
1BOS 6.3.3-8.2
Train B Process Sampling Containment isolation Valve
.
Stroke Test.
1BOS 3.2.1-816
Unit One ESFAS [ Engineered Safety Feature Actuation
.
Signal] Instrumentation Slave Relay Surveillance (Train B
Automatic Safety injection-K611).
SPP 98-047
Low Power Physics Test Program with Dynamic Rod Worth
.
Measurement
c.
Conclusions
The inspectors concluded that each of the observed surveillance tests were performed
well. Specifically, the surveillance tests satisfied the requirements of TS; and each of the
testea components met their respective acceptance criteria and remained operable.
t
M3
Maintenance Procedures and Documentation
M3.1 Facility Outside Ventilation Desion Basis due to Failina to Follow Procedures
a.
Inspection Scope (62707 and 37551)
The inspectors reviewed the circumstances surrounding the impairment of multiple
ventilation barriers in the non-accessible ventilation system. The inspectors interviewed
operations, maintenance, and engineering department personnel and reviewed the
following procedures.
BMP 3300-25, " Refueling Water Storage Tank (RWST) Pipe Tunnel Hatch Cover
.
(BILCO)," Revision 0
BAP 1100-3, " Fire Protection Systems, Fire Rated Assemblies, Ventilation Seals,
.
Flood Seals, and Water Tight Doors impairments," Revision 11
b.
Observation? and Findinas
During routine inspections in the auxiliary building on April 7 through 11,1998, the
inspectors identified several examples of ventilation barriers being impaired without
Barrier / Fire Protection Systems impairment Permits, BAP 1100-3T1, in accordance with
BAP 1100-3. In each case these barriers were impaired as a result of equipment being
staged in preparation for the Unit 2 refueling outage. For example:
On April 7,1998, the inspectors identified that a 4-inch penetration sleeve (a
.
ventilation barrier) above Door ODSD269 going into Area 5, the Unit 1 Spray
Additive Tank Room and Pipe Penetration area, was impaired by power cables
without a permit.
19
.
.
- - - - - - _ _ _ _ - _ _ _ _ _ _ _ _ _ - _ - _ _ _ _ _ _ . _ _ _ -
_ - _ _ _ _
_
__
_
l
\\.
1:
.
.
On April 7,1998, the inspectors identified that a 4-inch penetration sleeve (a
-
.
l
ventilation barrier) above Door ODSD278 going into Area 7, the Unit 2 Spray
lL
Additive Tank Room and Pipe Penetration area, was impaired by power cables
l
without a permit.
On April 11,1998, the inspectors identified that the 28 safety injection (SI) pump
j
.
room door (a ventilation barrier) was impaired by cables and hoses without a
permit.
On April 11,1998, the inspectors identified that the 2B chemical and volume
!
.
1
control (CV) pump room door (a ventilation barrier) was impaired by cables
l
without a permit.
10 CFR Part 50, Appendix B, Criteria V, " Instructions, Procedures, and Drawings,"
l
requires that activities affecting quality be prescribed by documented instructions,
procedures, or drawings of a type appropriate to the circumstances and be accomplished
in accordance with these instructions, procedures, or drawings. Byron Administrative
Procedure 1100-3, Section C.1, specifies, in part, that a Barrier / Fire Protection Systems
impairment Permit, BAP 1100-3T1, is required for all ventilation seals which are impaired.
,
The failure to process a Barrier / Fire Protection Systems impairment Permit,
BAP 1100-3T1, for each impaired ventilation barrier is considered a violation of
10 CFR Part 50, Appendix B, Criteria V (50-455/98011-06(DRP)).
In addition, on April 11,1998, the inspectors identified that the RWST pipe tunnel hatch
cover, which is a ventilation barrier between the auxiliary building and the outside
atmosphere, had two 6-inch and four 4-inch penetrations simultaneously impaired by
cabling. Byron Maintenance Procedure 3300-25, Section F.4, specifies, in part, that only
one penetration sleeve be open at a time to maintain the auxiliary building pressure
negative. The opening of two 6-inch and four 4-inch penetrations simultaneously is
considered a violation of 10 CFR Part 50, Appendix B, Criteria V
(50-455/98011-07(DRP)).
l
' As a result of the inspectors questions, the licensee evaluated the effect of the above
' ventilation impairments combined with those impairments for which a permit existed. The
licensee's evaluation concluded that during an accident scenario approximately 200 cubic
feet per minute of air flow would have leaked from the highly radioactive Si and CV pump
rooms to the general auxiliary building and ultimately the outside atmosphere. This air
flow would have resulted in lodine bypassing the charcoal absorbers in the non-
accessible ventilation plenums; hence, the offsite dose would have been increased by -
approximately 15 millirem and the control room habitability dose would have been
increased by approximately 4.4 millirem.
v
.
.
i
l
The UFSAR specified that the system controlled radioactivity by staging air from clean
!
1
- areas to areas of greater potential contamination. In addition, the UFSAR specified that
effluents from the non-accessible cubicles were routed through charcoal absorbers
following a safety injection signal. However, the licensee concluded that the
200 cubic feet per minute bypass flow was not routed through charcoal adsorbers; and
due to the impaired ventilation barriers, it flowed from areas of greatest contamination to
least contamination. Consequently, the facility was outside the ventilation system design
basis.
20
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_
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- ---------- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - -
- - - - - -
.
c.
Conclusions
The inspectors concluded that the facility was in a condition outside of the ventilation
design basis due to multiple examples of failing to follow station procedures.
Consequently, if a loss-of-coolant accident occurred while the non-accessible ventilation
l
system was outside the design basis, the offsite dose would have been increased by
approximately 15 millirem and the control room habitability dose would have been
increased by approximately 4.4 millirem. Two violations were cited.
M4
Maintenance Staff Knowledge and Performance
M4.1 Containment Sorav Additive Flow Rate Settina Exceeded TS Limits
a.
Inspection Scope (61726)
On March 21,19%, the licensee identified that 1/2BVS 6.2.2.d-1, " Containment Spray
Additive Flow Rate Verification," failed to incorporate a density adjustment for water
flowing through a flow cell calibrated for sodium hydroxide solution. The inspectors
originally documented this event as Unresolved Item 50-454/96003-05; 50-455/96003-05.
b.
Observations and Findinas
On March 21,1996, licensee personnel identified that BVS 6.2.2.d-1, " Containment Spray
Additive Flow Rate Verification," failed to incorporate a density adjustment for water
flowing through a flow cell calibrated for a sodium hydroxide solution. This resulted in
mispositioning the Unit 1 and Unit 2 containment spray (CS) additive tank throttle valves.
The mispositioning resulted in a spray additive flow rate (as measured by primary water
flow) exceeding the TS 4.6.2.2.d limit of 68 +6/-0 gallons per minute (as measured by
primary water flow) from about 1982 for Unit 1 and 1986 for Unit 2. The engineering
evaluation and safety consequence of this problem are discussed in Paragraph E8.3 of
this report. The licensee modified BVS 6.2.2.d-1 to include a density compensation
based on pH for the use of primary water instead of sodium hydroxide and re-performed
the test. The failure to properly position spray additive throttle valves for a spray additive
flow rate of 68 +6/-0 gallons per minute is a violation of TS 4.6.2.2.d. The licensee
determined that the root cause for not compensating for density in the containment spray
additive flow rate was due to an inadequate procedure. The licensee corrected the
procedures. This non-repetitive, licensee-identified and corrected violation is being
treated as a non-cited violation, consistent with Section Vll.B.1 of the NRC Enforcement
Policy (50-454/98011-08(DRP); 50-455/98011-08(DRP)). Refer to Section E8.3 for the
follow-up and closure of Unresolved item 50-454/96003-05(DRP);
50-455/96003-05(DRP).
c.
Conclusions
The inspectors concluded that the licensee failed to properly perform density corrections
for the spray additive flow rate as part of 1/2BVS 6.2.2.d-1, " Containment Spray Additive
Flow Rate Verification" over an extended period of time. This resulted in the
mispositioning of the Unit 1 and Unit 2 containment spray additive tank throttle valves
resulting in a spray additive flow rate (primary water flow) exceeding the TS limit of
21
-_
-___
_ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ - - - _ _
- _ - _
.
.
1
74 gallons per minute (primary water flow) from 1982 for Unit 1 and 1986 for Unit 2. A
non-cited violation was issued.
-M8
Miscellaneous Maintenance issues (92700,92902)
MB.1 (Closed) LER 50-455/96001-00: " Inadvertent Letdown isolation During Slave Relay
. Surveillance Due to Electrical Jumper Falling Off." This self-revealing event was promptly
identified by the operators, the appropriate LOCAR was entered, timely, appropriate
corrective action was taken, the electrical jumper was replaced, and the . surveillance was
l
completed without further incident. The long term corrective action was to place banana
jacks on the appropriate electrical terminals. There was no violation of regulatory
requirements, and licensee actions were timely and appropriate. This LER is closed.
M8.2 (Closed) LER 50-455/98005: " inadvertent Administrative Controls Lead to Operation
Outside the Ventilation Design Basis." This issue is discussed in Section M3.1 of this
report. This LER is closed.
M8.3 (Closed) LER 50-454/9500R: " inadequate Tracking of Brass Plugs for the Fuel Transfer
s
Tube Flange Prevents Proper Local Leak Rate Test." On November 9,1995, the
licensee identified that two small plugs used as foreign material prevention devices were
.+
installed in the fuel transfer tube flange local leak rate testing pressurization ports. The
plugs had been installed October 19,1994, during the previous refueling outage and were
identified during the next mid-cycle outage. The plugs prevented the successful
completion of the localleak rate test required by TS 3.6.1.2. " Containment Leakage," at
the end of the Fall 1994 refueling outage.
A system engineer inspected and determined that the flange seating surfaces and
O-rings were in good condition. A subsequent local leak rate test was completed
satisfactorily. Additionally, a review of work history by system engineers indicated that
the flange normally passed the local leak rate test.
The licensee identified that BMP 3118-7, " Reactor Vessel Closure Head Installation," did
not adequately track the status of the plugs, either by inventory of the plugs or specifically
stating what was included in the signature for the completion of each step. The failure of
BMP 3118-7 to provide appropriate guidance to track the status of these plugs is a
violation of 10 CFR Part 50, Appendix B, Criteria V. The inspectors verified a procsdure
revision to BMP 3118-7 was completed that made the plug removal requirement clear
and required a second person removal verification and signature. The inspectors
considered the corrective actions adequate to ensure that the fuel transfer tube plugs
were removed. This non-repetitive, licensen identified and corrected vi.olation is being
treated as a non-cited violation, consistent with Section Vll.B.1 of the NRC Enforcement
Policy (50-454/98011-09(DRP)). This LER is closed.
M8.4 - (Closed) LER 50-454/95004: " Resistance for Intercell Connection o!1he 125 Volt
Batteries Has Not Been Measured Due to Procedural Deficiency." This issue was
discussed in NRC Inspection Report 50-454-95009(DRP); 50-455-95009(DRP) and a
non-cited violation was issued. This LER is closed.
22
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_ ___ _ _ __
- _ _ _ _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ - _ - _ _
.
.
111. Enainesrina
1
E1
Conduct of Engineering
E1.1
poent Fuel Pool Coolina Suction Lines and Skimmer Desian
' a.
inspection Scope (37551)
'
'The inspectors discussed the design of the SFP cooling system with licensee personnel
and reviewed PlF B1998-01574, Operability Assessment 98-028, and UFSAR
Sections 9.1.3 and 9.1.4.3.4.
b.
Observations and Findinas
On April 8,1998, the licensee documented a potential SFP design issue on
PlF B1998-01574, after several discussions with the inspectors and notification from
Braidwood Station of similar issues with the Braidwood SFP. The inspectors were
concemed that the SFP did not meet TS 5.6.2, which stated that the spent fuel storage
pool was designed and maintained to prevent inadvertent draining of the pool below
. Elevation 423 feet 2 inches; Specifically, the inspectors noted that the SFP skimmer
i
system discharge piping did not contain an anti-syphon device and entered the SFP
about one foot below the surface of the SFP and made a 90 degree downward tum for
. approximately 5 feet.
During the review of the operability assessment, the inspectors noted that the suction
piping for the cooling system did not contain siphon protection. The inspectors verified
that no anti-siphon devices existed by reviewing Plan Drawings M-365 and M-366 for
Units 1 and 2 respectively. The fuel pool cooling suction piping entered the pool at
approximately 421 feet 6 inches and tumed downward to 417 feet 9 inches.
The licensee concluded in the operability assessment that the design feature referenced
in TS 5.6.2 was a low level alarm that actuated at an elevation of 424 feet 2 inches and
various makeup sources that would be initiated by operators in response to the
annunciator alarm procedure prior to reaching an elevation of 423 feet 2 inches. The
licensee concluded that the configuration of the SFP did not represent a degraded or
non-conforming condition and that no compensatory or corrective actions were required.
The inspectors considered the lack of a design feature in the SFP skimmer retum line and
in the fuel pool cooling suction piping a violation of TS 5.6.2. However, the inspectors
were considering the issue an Unresolved item pending further NRC review for a similar
design issue at Braidwood (50-454/98011-10(DRP); 50-455/98011-10(DRP)).
c.
Conclusions
,
The inspectors concluded that the spent fuel pool (SFP) skimmer retum line and the SFP
l
cooling suction piping were not designed to prevent inadvertent draining below 423 feet,
!
2 inches in accordance with TS 5.6.2. The inspectors did not mree with the licensee's
l
I
conclusion that the low level alarm and operator action consf
- 1 a design feature as
required in TS 5.6.2. This issue was considered an Unresolveo item pending further
I-
NRC review.
23
'
L________________.____
_ _ . - _ - - _ _
- _ - - _
_
- . - - -
. - - -
-
_
__ - - _ - _ _ _ - _ _ - - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
.
E8
Miscellaneous Engineering issues (92903)
E8.1
(Closed) Unresolved item 50-454/98009-04(DRP): 50-455/98009-04(DRP): " Potential
Failure to Submit a UFSAR Revision for Containment Purge Operation." The inspectors
reviewed Safety Evaluation T1-93-0152, completed on October 16,1993, which
documented a change to the operation of the containment purge system. The safety
evaluation specified that the containment mini-purge system would be in operation, in lieu
of the containment purge system. The inspectors concluded that the change in the
operation of the containment purge system documented in the safety evaluation did not
constitute an unreviewed safety question. In addition, the inspectors noted that the safety
evaluation specified that a change to the Final Safety Analysis Report (FSAR) was
required. However, the licensee did not submit the required revision to the FSAR in their
submittals dated December 1994 or December 1996; and at the end of the inspection
period, the licensee had not subrnitted the required revision to the FSAR.
10 CFR Part 50.71(e) requires, in pad, that the licensee shall update periodically, as
provided in paragraph (4), the FSAR to assure that the information included in the FSAR
contains the latest material developed. The FSAR shall be revised to include the effects
of all safety evaluations performed by the licensee in support of conclusions that changes
did not involve an unreviewed safety question.10 CFR Part 50.71(e)(4) requires, in part,
that revisions must be filed annually or 6 months after each refueling outage provided that
the interval between successive updates does not exceed 24 months. The revisions
must reflect changes up to a maximum of 6 months prior to the date of filing. The failure
to update the FSAR to reflect the changes contained in Safety Evaluation T1-93-0152,
completed on October 16,1993, was considered a violation of 10 CFR Part 50.71(e)
(50-454/98011-11(DRP); 50-455/98011-11(DRP). This Unresolved item is closed.
E8.2
(Closed) LER 50-454/96002-00 " Containment Spray Additive Found Outside Technical
Specification Required Range Due to Incorrect Testing Methodology Specified in
Procedure." This issue is addressed in detailin Section M4.1 of this report. The licensee
conducted an analysis, developed new additive flow settings, reset the additive flow
control valves and modified Procedures 1/2BVS 6.2.2.d-1 " Containment Spray Addition
Flow Rate Verification." A non-cited violation was issued.
E8.3 (Closed) Unresolved item 50-454/96003-05(DRP): 50-455/96003-05(DRP): On
March 21,1996, the licensee identified that procedures 1/2BVS 6.2.2.d-1 " Containment
Spray Additive Flow Rate Verification," failed to incorporate a density adjustment for
water flowing through a flow cell calibrated for a sodium hydroxide solution. The
inspectors were concemed that the proper initial conditions were not observed for the
licensees analysis. During the design basis reconstitution of the containment spray
system and the spray additive system, the licensee identified that the UFSAR description
was incorrect and contained conflicting information. The licensee also determined proper
flow settings for spray additive flow and eductor motive flow. The licensee made
changes to the UFSAR to remove incorrect and/or conflicting information and changed
the TS surveillance test procedures to reflect the proper spray additive tank level, spray
additive flow rate, and eductor motive flow rate. The inspectors reviewed the revised
1/2BVS 6.2.2.d-1 and verified that the acceptance criteria was corrected to meet the TS
and UFSAR requirements.
24
__
_ _ _ .
. _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ .
_ _ _ _
. _ _ _ _ _ _ _ -- _ - -_____ - _-__ _ _ _ _______ _
- - _ _ - - _ _
!
.
The licensee determined that during the early segment of the injection phase of a CS
actuation, the pH of the spray additive solution injected into the containment atmosphere
could exceed the environmental qualification pH limits of certain equipment inside the
containment for about 31 minutes. The licensee performed an operability determination
- and an evaluation of equipment environmental qualification at increased pH and
concluded that there would be no negative effect. An analysis performed by the NRC
staff also arrived at a similar conclusion. This was documented in an NRR to Region lll
memo of September 12,1996, " Request for Assistance in Evaluation containment Spray
Addition System (CSAS) Conformance with Design Basis and TS (AITS 96-0311). A
non-cited violation was issued in this inspection report (see Section Mt.1) for exceeding
the TS limit for spray additive flow. - This item is closed.
E8.4
(Closed) Insoection Follow-up item 50-454/455-95013-08(DRP): This inspection follow-
up item was opened to track the licensee's action to revise TS Table 4.4-5, " Reactor
Vessel Material Surveillance Program - Withdrawal Schedule." An incorrect irradiated
l
reactor vessel material specimen was removed from Unit 1 due to a discrepancy in
Table 4.4-5. Westinghouse Commercial Atomic Power (WCAP) had modified its
recommended schedule for future capsule removals based on its specimen analysis of
the first test specimen, Although the TS table accurately reflected the original WCAP
schedule, it had not been updated in accordance with the revised WCAP schedule.
Either selection of specirnens was acceptable to WCAP and the inspectors concluded
that there were no safety or reactor operability concems. Accordingly, the licensee
}
intended to update the TS table in accordance with the WCAP specified schedule;
l
however, the licensee had not done so as of the date of NRC Inspection
Report 50-454/95013(DRP); 50-455/95013(DRP). Amendment 98 to the TS removed the
table in lieu of a reference to the Pressure and Temperature Limits Report (PTLR). The
inspectors concluded that the irradiated reactor vessel material specimen removal
schedule in the current PTLR (dated January 7,1998) for each unit was correct and
approved in accordance with the requirements of Appendix H to 10 CFR Part 50. This
item is closed.
E8.5 (Closed) Violation 50-454/455-97008-03(DRP)): " Failure to Assure that Applicable
Regulatory Requirements and the Design Basis are Correctly Translated into
Specifications, Drawings, Procedures, and instructions." The temporary alteration
program was not adequate to ensure design control measures commensurate with those
i
applied to the original design were implemented prior to connecting a strip chart recorder,
.!
i
a temporary system alteration, on the Bus 211 battery charger for troubleshooting. The
i
l
- inspectors reviewed the licensee's corrective action which revised BAP 330-2,
I
l
" Temporary Alterations," and BAP 400-9, " Troubleshooting and Maintenance Alterations."
Corrective actions were found to be acceptable. The inspectors noted no recurrences of
a similar nature. This violation is closed.
i
!
l
25
l
L
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_ . _ _ _ _ _ _ _ _ _ _
1
.
.
IV. Plant Suonort
R1
Radiological Protection and Chemistry (RP&C) Controls
l
R1.1
Radiological Postinos and Barrig.rg
a.
Inspection Scope (71750)
The inspectors routinely observed the status and posting of radiologically controlled
areas. The inspectors interviewed operators and radiation protection personnel and
reviewed the following procedures:
BRP 5000-7, " Unescorted Access to and Conduct in Radiologically Posted Areas,"
.
Revision 7 -
BRP 5010-1, * Radiological Posting and Labeling Requirements," Revision 15
.
- Radiation Worker Handbook," Revision 1
.
b.
Observations and Findinos
During routine inspections in the Auxiliary and Fuel Handling Buildings on April 14,1998,
the inspectors identified one example of a radiological barrier that did not meet the
standards and expectations delineated in the Radiation Worker Handbook, Revision 1.
Specifically, an electrical cord crossed the contaminated area barrier associated with the
spent fuel pool skimmer pump and was not fastened at the barrier. Consequently, the
cord was free to move across the barrier and created the potential for contamination to
be spread from the contaminated area to the adjacent clean area. In response to the
inspectors concems, the licensee removed the electrical cord from the area and verified
that the spread of contamination had not occurred. This failure is of minor significance
and is not subject to fomial enforcement action.
c.
Conclusions
The inspectors concluded that radiological postings and barriers were in place in
accordance with procedural requirements. The inspectors also noted that the
contaminated area barrier associated with the spent fuel pool skimmer pump did not meet
the standards and expectations delineated in the Radiation Worker Handbook,
Revision 1, in that, an electrical cord crossed a contaminated area barrier and was not
fastened at the barrier to preclude the spread of contamination. The failure was of minor
significance and was not subject to formal enforcement action.
V. Management Meetinos
>
X1
Exit Meeting Summary
The inspectors presented the inspection results to members of licensee management at
the conclusion of the inspection on June 1,1998. The licensee acknowledged the
findings presented. The inspectors asked the licensee whether any materials examined
during the inspection should be considered proprietary. No proprietary information was
identified.
l
26
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_ - - - - _ _ . - - _ _ _ _ - - _ . - - _ _ _ _ _ - _ _ . - . _ _ _ _ _ _ _ _ _ . _ - _ _ _ _ - . . . - -
.
.
.
..
.
. . . , .
.
.
PARTIAL LIST OF PERSONS CONTACTED .
,
Licensee
l
K. Graesser, Site Vice-President
K. Kofron, Byron Station Manager
J. Bauer, Health Physics Supervisor
D. Brindle, Regulatory Assurance Supervisor
E. Campbell, Maintenance Superintendent
T. Gierich, Operations Manager
T. Schuster, Manager of Quality & Safety Assessment
M. Snow, Work Control Superintendent
B. Kouba, Engineering Manager
i
i
4
l
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27
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- _ _ _ - - - - _ _ _ - - _
..
1
.
.
INSPECTION PROCEDURES USED
IP 37551:
Engineering
IP 61726:
Surveillance Observations
l
lP 62707:
Maintenance Observations
l
IP 71707:
Plant Operations
IP 71750:
Plant Support
'IP 92700:
Onsite Foilowup of Written Reports of Nonroutine Events at Power
Reactor Facilities -
1P 92901:
. Followup Operations
IP 92902:
Followup Maintenance
IP 92903:
Followup Engineering
ITEMS OPENED, CLOSED, AND DISCUSSED
Qpened.
50-455/98011-01a
Failure to implement the OOS program and ensure that the
OOS boundary was adequate
50-455/98011-01b
Failure to implement the OOS program and ensure that the
.
OOS was hung prior to commencing work
50-455/98011-02
Review the failure to ensure that the OOS was hung prior
to commencing work on the 2B RCP
'50-455/98011-03.
Failure to follow BOP RH-9 which resulted in level being
. inadvertently lost from the SFP -
50-454/455-98011-04
NCV Failure to follow OBOS 7.5.e.1-2 which invalidated the
surveillance test
50-454/98011-05
NCV Missed TS Surveillance Requirement 4.6.1.3.b (LLRT) on
the containment emergency hatch
i
50-455/98011-06
Multiple examples of failure to follow ventilation barrier
impairme.nt process
50-455/98011-07
Failure to follow maintenance procedure regarding the
.
control of penetration sleeves on the RWST tunnel hatch .
=
,
'
50-454/455-98011-08
NCV Inadequate procedure resulted in missed TS Surveillance
i
Requirement 4.6 2.2.d on the containment spray additive
flowrate
50-454/98011-09
NCV Inadequate procedure resulted in inadequate LLRT on fuel
transfer tube flange
50-454/455-98011-10
Review the lack of a design feature in the SFP skimmer
i
retum line and in the futl pool cooling suction piping in
accordance with TS 5.6.i'
50-454/455-98011-11
Failure to update FSAR as required by 10 CFR 50.71(e)
Closed
50-454/455-98011-04
NCV Failure to follow OBOS 7.5.e.12 which invalidated the
surveillance test
50-454/98011-05
NCV Missed TS Surveillance Requirement 4.6.1.3.b (LLRT) on
the containment emergency hatch
!
28
,
t
.
.
. _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ _ _ .
.
.
50-454/455-98011-08
NCV Inadequate procedure resulted in missed
TS Surveillance Requirement 4.6.2.2.d on the
containment spray additive flowrate
50-454/98011 09
NCV inadequate procedure resulted in inadequate LLRT
!.
on fuel transfer tube flange
l
50-454/455-96003-01
Failure to follow procedures, five examples
l
50-454/455-97008-03
Failure to assure that applicable regulatory
l
requirements and the design basis are correctly
translated into procedures
50-454/455-96003-05
Containment spray additive outside TS required
range due inadequate procedure.
50-454/455-98009-04
Potential failure to submit a UFSAR revision for
containment purge operation
,
50-454/45595013-08
IFl
. Track licensee action to revise TS Table 4.4-5
50-454/95-04
LER < > Resistance for intercell connection of the 125 volt
< batteries has not been measured due to procedural
. deficiency
50-454/96-07
LER
Loss of offsite power due to a failure of an insulator
on Phase B of the Unit 1 station auxiliary
j
transformer from water intrusion
1
50-454/95-08
LER
Inadequate tracking of brass plugs for the fuel
'
transfer tube flange prevents proper local leak rate
test
. 50-454/96-00, Rev. 00 and 01
LER
Unrecognized change in system flow results in
operation outside TS
50-455/96-01
LER
inadvertent letdown isolation during slave relay
surveillance due to electrical jumper falling off
50-454/96-02
LER
Containment spray additive found outside TS
required range due to incorrect testing methodology
specified in procedure
50-455/98-03
LER
Interdepartment issues and OPEX cause high RCS
activity and ESF actuation
50-455/98-04
LER
FHB rad monitor ESF actuation due to high dose
waterin fuel transfer canal
'
50-455/98-05
LER
inadvertent administrative controls lead to operation
'
outside the ventilation design basis
1
,
50-454/98-09
LER
Missed TS test due to failure to follow procedure
1
i
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29
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.
.
LIST OF ACRONYMS USED
BAP
Byron Administrative Procedure
Byron Annunciator Response Procedure
l
BFP
Byron Fuel Handling Procedure
i
BGP
Byron General Operating Procedure
BMP-
Byron Maintenance Procedure
Byron Operating Procedure
BOS
Byron Operating Surveillance
BRP:
Byron Radiological Protection Procedure
{
BVS
Byron Engineering Surveillance
-
CV
Chemical and Volume Control System
EH
Electrohydraulic Control System
Engineered Safety Feature
EWCS
Electronic Work Control System
FHB
Fuel Handling Building
Final Safety Analysis Report
HLA
Heightened Level of Awareness
HlA
High impact Activity
LER
,
.
Licensee Event Report
l
LOOP'
Non-Cited Violation
-
Out-of-Service
Operating Experience Program
P&lD
Piping and Instrumentation Drawing
~ Public Document Room
PlF
Problem identification Form
Pressure and Temperature Limits Report
-Q&SA
~ Quality and Safety Assessment
Reactor Coolant Pump
Radiation Protection
- RVLIS
Reactor Vessel Level Instrumentation System
Rafueling Water Storage Tank
Station Auxiliary Transformer
Spent Fuel Pool
Safety injection
SPP
Special Plant Procedure
Essential Service Water
TS
-
Technical Specifications
Updated Final Safety Analysis Report
'
Unresolved item
WCAP.
Westinghouse Commercial Atomic Power
Work Request
i
WS
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30
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