ML20245L287
| ML20245L287 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 04/30/1989 |
| From: | Morris K OMAHA PUBLIC POWER DISTRICT |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LIC-89-349, NUDOCS 8905050366 | |
| Download: ML20245L287 (30) | |
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s Omaha Public Power District 1623 Harney Omaha, Nebraska 68102 2247 402/536-4000 April 30, 1789 LIC-89-349 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Mail Station Pl-137 Washington, DC 20555
References:
1.
L'ocket No. 50-285 2.
Latter from NRC (L. J. Callan) to OPPD (K. J. Morris) dated Mi.cch 17, 1989 3.
Letter from NRC (G. M. Holahan) to OPPD (K. J. Morris) dated February 9, 1989 4.
Letter from 0 PPD (K. J. Morris) to NRC (R. D. Martin) dated Apri' 5, 1989 (LIC-89-335)
Gentlemen:
SUBJECT:
Response to Notice of Violation and Unresolved Items Resulting from Operational Safety Team Inspection (OSTI)
Omaha Public Power District (OPPD) received the Notice of Violation dated March 17, 1989 which was included in Reference 2.
The violations and unresolved items were derived from the Operational Safety Team Inspection (OSTI) Report, which we received in Reference 3.
Per conversations between Mr. T. F. Westerman (NRC) and Mr. J. J. Fisicaro (0 PPD) an extension to April 30, 1989 was granted for the submittal of this response.
As described in Reference 4, OPPD has integrated the OSTI results into the Safety Enhancement Program (SEP).
The SEP Reference Numbers have been included in this response, as applicable.
Pursuant to the provisions of 10 CFR Part 2.201, please find in Attachment 1, OPPD's response to the violations.
The additional information which was specifically requested for the unresolved items can be found in Attachment 2.
Information on the remaining four open items can be found in Attachment 3.
The format of Attachment 1 is such that immediately following the programmatic responses to Violations B, C, D and F, information is provided to address each specific example.
[k 8905050366 890430 PDR ADOCK 05000285 i
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,U. S. Nuclear P.tquiatory Commission LIC-89-349 Page 2 T-If you have any questions concerning this' matter, please ao not hesitate to contact us.
Sincerely, orris Division Manager Nuclear Operations KJM/jak- :
Response to Notice of Violation : OSTI Unresolved Item Information
, : OSTI Open. Item Information c:
LeBoeuf,. Lamb, Leiby & MacRae
.T. E. Murley, NRC Director, Nuclear Reactor Regulation R. D.. Martin, NRC Regional Administrator
'P. D. Milano, NRC Project Manager P. H. Harrell, NRC Senior Resident Inspector
)
RESPONSE TO NOTICE OF VIOLATION During an NRC inspection conducted from October 31 through November 10, 1989, violations of NRC requirements were identified. The violations involved procedural control of shift turnover logs, failure to follow procedures, inadequate control of temporary procedure changes, inadequate instructions for the performance of safety-related activities, failure to comply with ASME Code requirements, and inadequate corrective action program.
In accordance with the
" General Statement of Policy and Procedure for NRC Enforcement Actions." 10 CFR Part 2, Appendix C (1988), the violations are listed below.
Page 1
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A.
No Procedural Control for Shift Turnover Loas Technical Specification 5.8.1 states, in part, that written procedures shall be established that meet or exceed the minimum requirements of Appendix A of Regulatory Guide 1.33.
Paragraph.1 of Appendix A to Regulatory Guide 1.33 requires that administrative procedures shall be established for shift and relief turnover.
Contrary to the above, the licensee failed to establish an adequate procedure for shift turnover in that Standing Order 0-29 did not specify that Forms FC-95 and FC-95A, used by operations personnel to record plant status, had to be completed for shift turnover. (285/88201-01).
This is a Severity Level IV violation.
(Supplement I)
OPPD Resoonse 1.
Admission or Denial of the A11eaed Violation OPPD admits the violation as stated.
2.
The Reasons for the Violation, if Admitted Standing Order 0-29, " Conduct of Operations," Revision 7, did not uniquely specify check list completion as part of the shift turnover process.
However, operation personnel routinely completed the shift turnover forms based on non-proceduralized guidance and the general instructions for shift turnover listed in Standing Order 0-29.
3.
The Corrective Steos That Have Been Taken and the Results Achieved Standing Order 0-29, " Conduct of Operation," Revision 10 was issued April i
14, 1989.
This revision provides specific guidance in regard to the shift l
turnover process including specific instructions for completion of shift turnover check lists, Forms FC-95 and FC-95A. Operations personnel are currently completing these forms per the instructions of Standing Order 0-29.
l 4.
Corrective Steos Which Will Be Taken to Avoid Further Violation No other corrective steps are necessary.
5.
Date When Full Comoliance Will Be Achieved OPPD is currently in full compliance.
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B. ' Failure to Follow Procedures Criterion V of Appendix B to 10 CFR Part 50 and the licensee's NRC-approved 4
quality assurance program states, in part, that activities affecting quality shall be prescribed by documented procedures, of a type appropriate to the circumstances, and shall be accomplished in accordance with these procedures.
Contrary to the above, six (6) examples were cited.
This is a Severity Level IV violation.
(Supplement I)
OPPD Response 1.
Admission or denial of the alleaed violation OPPD admits the violation.
2.
The reasons for the violation if admitted The six examples ~ cited were incidents in which personnel failed to follow procedures. As discussed in the response to the specific examples B.3, B.4, B.5 and B.6, a contributing factor was that the procedures involved provided inadequate guidance.
3.
Corrective stens that have been taken and the results achieved The Procedural Compliance effort (SEP Ref. No. 44) which is part of the Safety Enhancement Program has been used to ensure the proper use of, and compliance with procedures.
Plant personnel have been informed by memos and in meetings that the proper use of, and compliance with, procedures is required.
In addition, procedural compliance is included as an evaluation criterion on performance appraisals.
Incident Reports are being written to document and track procedural violations. To ensure proper compliance with procedures, supervisory review and one-on-one meetings have been conducted with most of the operators which emphasize personal accountability.
In addition, supervisors are now spending more time in the plant providing personal guidance and direction.
Standing Order 0-29, " Conduct of Operations," has been modified by Revision 10, issued April 14, 1989 to provide station personnel with additional administrative guidance on procedure use.
It defines when station personnel are required to have a procedure in hand and provides guidance regarding the review of the procedures prior to use.
4.
Corrective steos which will be taken to avoid further violations The Pr%edural LUT1pliance effort (SEP Ref. No. 44) will continue to place emphasis on the proper use of, and compliance with, procedures.
The Procedures Upgrade Project (SEP Ref. No. 48) will be used to improve the accuracy and completeness of appropriate procedures. Also, since human factors are considered during this upgrade effort, it will be easier for personnel to follow the procedures.
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5.
Date'When Full' Comoliance Will Be ~ Achieved OPPD is.c'urrently in. full compliance based on the corrective actions as described ~ in the responses to the six examples in regard to failure to follow procedures. The additional corrective actions involving procedure
-improvements, for example B.5 and 8.6, will be completed by June-_30,1989.
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t B.1 Paragraph 3.1.4.6 of Standing Order 0-24, " Log Entries" states, in part, that log entries should be made when documenting compliance with the requirements of a Technical Specification limiting condition for operation.
Contrary to the above, the licensee did not provide the appropriate log entries in that compliance with the limiting condition for operation for Technical Specification 2.19(4) for the motor-driven fire pump was not met and the appropriate log entry was not made.
(285/88201-02)
OPPD Response to B.1 The missed log entry for the inoperable motor-driven fire pump was due to
{
personnel error resulting from inattention to detail.
Operations personnel were reminded of the importance of detailed logging of activities related to inoperable equipment as required in Standing Order 0-24, " Log Entries".
In addition, the Control Room Turnover Sheets were reviewed to dctermine if inoperable equipment logging could be improved.
Form FC-95 was expanded to include a detailed section for Limiting Condition for Operation (LC0) entries.
Standing Order 0-29, " Conduct of Operations," Revision 10, now includes specific instructions regarding Form FC-95.
In addition, Technical Specification LC0's are tracked and updated daily by the shift technical advisors on the newly developed " Plan of the Day".
This enables station management, engineering, and maintenance personnel to be knowledgeable of all out-of-service technical specification related equipment.
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s l-B.2 Paragraph 2.3 of Standing Order 0-13, " Operations Memorandums,"
l' states, in part, that as soon as practical following the issuance of an operations memorandum, a review shall be conducted to ensure that all information is installed into all applicable operating procedures L
or instructions.
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Contrary to the above, operations memoranda were issued and the information not included into all applicable operating procedures or instructions in that operations memoranda affecting procedures had been issued for up to 10 years and the applicable procedure had not been changed.
(285/88201-03) l l
OPPD Response to B.2 As indicated in your letter, NRC (L. J. Callan) to OPPD (K. J. Morris) dated March 17, 1989, no response to Violation B.2 is required since the acceptable corrective action has been completed and is documented in NRC l
Inspection Report 50-285/89-03.
The one remaining Operations Memorandum, OPS Memo 88-06, " Inoperable Raw Water Pump," will be cancelled when Technical Specification Amendment 120, becomes effective on May 14, 1989.
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B.3 Paragraph 7.2.2 of Standing Order 0-25, " Temporary Modifications,"
states, in part, that the plant review committee must review and approve the temporary modification within 14 days after the date of its installation.
Contrary to the above, the plant review committee did not review temporary modifications within 14 days after installation in that i -
Temporary Modifications 88-E-46, 88-E-49, and 88-E-47 had been i
installed greater than 14 days without being reviewed by the plant review committee.
(285/88201-05)
OPPD Resoonse to B.3 At the time of the violation Standing Order 0-25, " Temporary Modification Control," Revision 25, allowed temporary modifications to be first installed and then reviewed by the Plant Review Committee (PRC) within 14 days of installation.
This created the situation in which temporary modifications 88-E-46, 88-E-47, and 88-E-49 were installed, but, due to the large volume of PRC review items, the temporary modification control process failed to provide the appropriate follow-up tracking which resulted in the PRC review and approval not being performed within the 14 day time i
limit.
Standing Order 0-25, " Temporary Modification Control," Revision 28 was issued February 21, 1989. This revision of 0-25 requires that temporary modifications be reviewed by PRC prior to installation.
The only exceptions allowed to this prior review requirement is in the case of an emergency modification as determined by the Shift Supervisor.
In this situation PRC review will be obtained within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of the emergency modification.
To date there have been no emergency modifications.
Since Standing Order 0-25, Revision 28, has been issued, 13 temporary modification packages have been reviewed by the PRC prior to installation.
OPPD realized that temporary modification control at Fort Calhoun Station needed additional review and improvement, therefore SEP Ref. No. 71,
" Temporary Modification Control Improvements," was added to the Safety Enhancement Program.
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B.4 Paragraph 1.2 of Standing Order 0-17 states, in part, that the approved operating instructions will be used to start-up, operate, and shutdown all plant systems and equipment.
Contrary to the above, licensee personnel failed to use procedures for operation of plant systems in that the component cooling water and resin transfer systems were operated without the use of procedures.
(285/88201-09)
OPPD Response to B.4 The component cooling water system was operated correctly in that the procedure steps of Operating Instruction 01-CC-4, " Component Cooling Systems Outage for Maintenance," Revision 8 were followed, however, the operator did not have specific guidance that he should have the procedure "in hand."
The incident involving the failure to follow procedures during spent resin transfer resulted from an inadequate procedure in that certain steps were provided in the prerequisite section rather than as clearly defined steps in the procedure.
The problem was compounded when the individual involved continued on his own rather than stopping work and obtaining an approved On the Spot Change (OTSC) before proceeding.
Standing Order 0-29, " Conduct of Operations," has been modified by Revision 10, issued April 14, 1989 to provide station personnel with additional administrative guidance on procedure use.
It defines when station personnel are required to have a procedure in hand and provides guidance regarding the review of the procedures prior to use.
It also allows a shift supervisor to take action outside the scope of a procedure when required to protect plant personnel and equipment or to meet Technical Specification requirements.
Specific instructions are provided which.
define the subsequent actions and documentation requirements.
Operating Instruction OI-CH-6, "CVCS Resin Transfer," has been revised to correct identified procedural deficiencies. Revision 12 was issued on April 27, 1989.
The Procedure Upgrade Project (SEP Ref. No. 48) will be used to improve the accuracy and completeness of revised Operating Instructions.
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B.5 Paragraph 5.9.9 of Standing Order G-17, ' Maintenance Order," states, in part, that the craftsman is responsible for recording the purchase order number for parts and materials used that are CQE (safety-related), limited CQE, fire protection, or radioactive waste packaging materials.
Contrary to the above, the craftsman failed to provide the appropriate data on the maintenance order in that the purchase order number was not recorded on Maintenance Order 884163 for parts used to repair the breaker for Charging Pump CH-lC.
(285/88201-10)
OPPD Response to B.5 The part which was used (the breaker racking position indicator) was not a CQE part. Standing Order G-17, " Maintenance Orders," Revision 55, and the associated Maintenance Order (M0) Form FC-63 were unclear as to what information was to be included on the M0 for non-CQE subcomponents which are acceptable for use in CQE components.
Standing Order G-17 provided no guidance for the documentation on M0 Form FC-63 of the use of non-CQE subcomponents in CQE components.
Therefore, the individual completing the M0 section regarding the Purchase Order No. did not have adequate guidance.
M0 884163 was reviewed by the System Engineer and it was confirmed that the non-CQE part could be acceptably used in the repair of the breaker for Charging Pump CH-1C without degrading its safety related function.
A revision to the Station Standing Orders will be issued by June 30, 1989, which will provide clearly defined instructions regarding documentation of non-CQE parts used in CQE components.
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B.6 Procedure ST-ISI-RW-3, " Raw Water Pump Inservice Inspection," states, in part, that the craftsman shall measure and record the pump peak-to-peak vibration amplitudes on the stuffing box just below the bearing packing nut, perpendicular to the pump shaft. The exact location should be marked by a yellow "X".
If no mark is present, check vibration amplitude completely around the circumference and use I
the maximum amplitude found. Mark the location for the greatest amplitude for future reference.
l Contrary to the above, licensee personnel failed to follow procedure in that no. mark was present on the stuffing box and the craftsman failed to check the vibration amplitude completely around the circumference of the stuffing box.
(285/88201-22)
OPPD Response to B.6 i
The individual performing the vibration test knew the location regarding the placement of the probe based on prior experience.
Because the procedure was with the operator in the control room who was directing the test, the technician performing the vibration monitoring did not have the procedure "in hand" and could not follow the procedure exactly as written regarding the requirement to take multiple readings if the " yellow X" was not visible.
Subsequent review of Surveillance Test ST-ISI-RW-3, " Raw Water Pump Inservice Inspection, " Revision 17, revealed that it was improperly written in regard to performing the vibration test if the " yellow X" was 6
missing or obscured.
Three additional readings were taken on the stuffing box immediately following the observed incident, however, in some areas readings could not be obtained due to space limitations in setting up the probe.
The " yellow X's" used to identify the proper locations for the vibration test probe placement were remarked and are now clearly visible.
Surveillance Test ST-ISI-RW-3 has been performed successfully 5 times since the violation occurred and no problems regarding the proper placement of the test probe have been experienced.
Standing Order 0-29, " Conduct of Operations," has been modified by Revision 10 issued April 14, 1989 to provide station personnel with additional administrative guidance on procedure use.
It defines when station personnel are required to have a procedure in hand and provides guidance regarding the review of the procedures prior to use.
ST-ISI-RW-3 was reviewed to establish the basis for the requirement to take multiple readings around the circumference of the stuffing box if the single " yellow X' was not visible.
It was determined that taking readings at the same single point was the preferred method to obtain reliable pump vibration trend data. The multiple reading requirement appeared to be a i
carry over from the initial pump vibration test which was used to determine l
which single point provided the highest vibration reading.
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Surveillance Test ST-ISI'RW-3 " Raw Water Pump Inservice Inspection," is being revised to include specific instructions to place the probe in the single correct location that will provide reliable vibration trending
'd at a.
These instructions will provide for the correct placement of the probe without reliance on a mark which could be obscured between tests.
This revision is expected to be issued by June 30, 1989.
The Procedures Upgrade Project (SEP Ref. No. 48) will be used to improve the accuracy and completeness of revised Surveillance Tests. The Surveillance Test Performance Improvement effort (SEP Ref. No. 72) is also applicable.
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C.
Inadeauate Control of Temporary Procedure Chances Technical Specification 5.8 states, in part, that temporary changes to procedures may be made provided that the intent of the original procedure 1
is not altered and-the change is documented, reviewed by the plant review I
committee and approved by the Manager, Fort Calhoun Station within 14 days of implementation.
I Contrary to the above, two examples were cited.
i This is a Severity Level IV violation.
(Supplement I)
)
OPPD Response i
1.
Admission or Denial of the Alleaed Violation i
0 PPD admits the violation for example C.1 in that it was a case of failure to follow procedures combined with an inadequate instructions problem rather than inadequate control of temporary procedure changes.
Refer to the response to C.2 for the justification that the temporary procedure change control process was appropriate and adequate in regard to example i
C.2.
2.
The Reasons for the Violation, if Admitted As discussed in the response to example C.1, there were inadequate instructions regarding the use of "not applicable" for acceptance criteria sections of the Surveillance Test ST-DC-1, " Station Batteries."
3.
The Corrective Steos That Have Been Taken and the Results Achieved The actions regarding compliance with procedures have been addressed in the response to Violation B, " Failure to Follow Procedures." The actions regarding inadequate instruction has been addressed in the response to example C.I.
g 4.
Corrective Steos Which Will Be Taken to Avoid Further Violation Guidance regarding the acceptable methods to document results while performing a Surveillance Test is being addressed in the Surveillance Test Performance Improvement effort (SEP Ref. No. 72).
Surveillance Test procedures will be reviewed for accuracy and completeness as part of the Procedures Upgrade Project (SEP Ref. No. 48).
The compliance with procedures will continue to be stressed as part of the Procedural Compliance effort (SEP Ref. No. 44).
5.
Date When Full Comoliance Will Be Achieved OPPD is currently in full compliance based on the corrective actions in regard to failure to follow procedures.
Surveillance Test ST-DC-1,
" Station Batteries," Revision 38, corrected the inadequate instruction problem of example C.I.
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C.1 Contrary to the above, the intent of a procedure was changed without prior approval of the plant review committee in that the acceptance criteria provided in Surveillance Test ST-DC-1, " Station Batteries,"
was deleted during performance of the surveillance test.
(285/88201-15)
OPPD Response to C.1 When Surveillance Test ST-DC-1 " Station Batteries," Revision 33, was performed on February 2, 1988 there was inadequate guidance concerning the use of "not applicable" statements in the completion of the procedure.
The individual performing the Surveillance Test did not have proper guidance, therefore he assumed he was not altering the procedure when he indicated "NA",
" test values not available." Therefore, he did not initiate a procedure change.
The Surveillance Test ST-DC-1 was subsequently reviewed and revised with the appropriate PRC approval.
The revision re-worded the initial conditions and procedural steps so that clearly defined responses are now required.
Surveillance Test ST-DC-1, " Station Batteries," Revision 38, which revised the inappropriate steps, was issued on September 2, 1988.
Guidance regarding the acceptable methods to document results while performing a Surveillance Test is being addressed in the Surveillance Test Performance improvement effort (SEP Ref. No. 72).
Revisions to Surveillance Tests will be reviewed for accuracy and completeness as part of the Procedures Upgrade Project (SEP Ref. No. 48).
Compliance with procedures will continue to be stressed as part of the Procedural Compliance effort (SEP Ref. No. 44).
In addition, OSTI Report Unresolved Item (285/88201-15) contained another example related to the improper use of an On The Spot Change (OTSC) for conducting Surveillance Test ST-FIL-2, " Charcoal /HEPA Filter Bank In-Place Testing."
The technician performed the test on October 20, 1988-using a procedure marked " DRAFT 10-10-88" with a copy of Procedure Change No. 25450 attached which indicated it was an OTSC initiated on October 18, 1988.
Upon investigation of this incident it was discovered that the original Procedure Change No. 25450 had undergone PRC review on October 19, 1988 and was approved by the Plant Manager on October 20, 1988.
Surveillance Test ST-FIL-2, Revision 16 was issued for use on October 20, 1988.
The technician used the draft version of Revision 16 rather than the properly reviewed, approved and issued Revision 16. The requirement to use the latest approved procedure is included in the Procedural Compliance effort (SEP Ref. No. 44) which will continue to emphasize the proper use of, and compliance with, procedures. The difference between the draft and issued versions was in the prerequisite section. Revision 16 draft stated
" Personnel qualification and calibration records are available for QA review" whereas the issued version stated " Personnel qualification and calibration records have been reviewed and accepted for use by QA."
The intent of the procedure was not significantly changed between the draft version which was used and the formally issued version.
This was an incident where the individual failed to obtain the latest approved procedure prior to performing the test.
The requirement to use the latest approved procedure is included in the Procedural Compliance effort (SEP Ref. No. 44) which will continue to emphasize the proper use of, and compliance with, procedures.
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C.2 Contrary to the above, the plant review committee did not review and 4
the Manager, Fort Calhoun Station, did not approve temporary procedure changes within 14 days in that temporary changes were made to Surveil-lance Test ST-CONT-2, " Local Leak Rate Testing-Type B," and the tempor-ary changes were not approved within the 14-day time limit.
(285/88201-19)
OPPD Resoonse to C.2 As described in the following response to the specifics of the OSTI Report Unresolved Item 285/88201-19 the temporary procedure change control process was appropriate and adequate.
I Because Surveillance Test ST-CONT-2, " Local Leak Rate Testing - Type B,"
was conducted over several weeks, the test activities involved the use of procedure Revision 26 in effect at the start of the test.
Revision 26 had been subsequer.tly updated with On The Spot Changes (OTSC's).
The technician had followed the authorized practice of continuing to use l
Revision 26 and attaching the approved OSTC's to his work package during the on-going testing.
As indicated in the OSTI report, the NRC inspector, during the review of this activity, was using Revision 29. The technician was using Revision 26 in conjunction with three approved 0TSC's which provided the equivalent of Revision 29. The three OTSC's No. 24726, No. 24764, and No. 25069; were implemented on 9-28-88, 9-29-88, and 10-11-88; and were reviewed by PRC l
and approved by the Plant Manager on 10-1-88, 10-7-88 and 10-25-88, respectively. The OTSC's therefore had proper PRC review and Plant Manager approval within the 14 day time limit.
The issue raised in the Unresolved Item 285/88201-19 was what happens if the PRC disagrees or has concerns about an OTSC that has already been implemented in the plant.
If the PRC has a concern regarding an OTSC an Incident Report (IR) is issued to track, evaluate the effect on plant safety and document the resolution of the concern.
Since January 1, 1989, 388 OTSC's have been initiated.
Two Incident Reports have been initiated to address PRC concerns regarding three of these OTSC's.
IR-89-0009 were issued on OTSC 27362 and IR-89-0400 were issued on OTSC's 27858 and 27860.
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y D.
Inadeouate Instructions for Performance of Safety-Related Activities Criterion V of Appendix B to 10 CFR Part 50 and the licensee's NRC-approved quality assurance program states, in part, that activities affecting quality shall be prescribed by documented instructions of a type i
appropriate to the circumstances.
Contrary to the above, two examples were cited.
This is a Severity Level IV violation.
(Supplement I)
OPPD Response 1.
Admission or Denial of the Alleaed Violation 1
OPPD admits the violation as stated.
2.
The Reasons for the Violation. if Admitted The specific reasons for the two examples are discussed in the response to D.1 and D.2.
The generic problem with inadequate procedures has been acknowledged and is being addressed in the Safety Enhancement Program as part of the Procedures Upgrade project (SEP Ref. No. 48) and other procedures upgrade efforts in progress.
3.
The Corrective Steos That Have Been Taken and the Results Achieved Safety related procedures are currently being reviewed and revised per the l
Procedures Upgrade Project (SEP Ref. No. 48).
The spectfic corrective action taken for the cited examples can be found in the response to D.1 and i
D.2.
4.
Corrective Steos Which Will Be Taken to Avoid Further Violation The Safety Enhancement Program will continue to be applicable to the cited examples as well as other safety related procedures.
5.
Date When Full Comoliance Will Be Achieved OPPD will be in full compliance at the completion of the safety related portion of the Procedures Upgrade Project (SEP Ref. No. 48) in conjunction
)
with the Preventative Maintenance Program which is currently scheduled for i
completion by December 31, 1989.
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i D.1 Contrar.* to the above, Procedure PM-EE-4.0, '7700 Line Motor Control Center.," that provided instructions for post-maintenance testing of 480-volt breakers did not provide instructions for post-maintenance testing of all 480-volt breakers.
For example, no instructions were included in the procedure for post-maintenance testing of the breaker for the pressurizer relief isolation valve (HCV-150).
(285/88201-13)
OPPD Response to D.1 Procedure PM-EE-4.0, "7700 Line Motor Control Centers," due to an oversight in the preparation of the procedure, did not list the breaker for the pressurizer relief isolation valve (HCV-150).
The breaker for HCV-150 was cycled as part of the plant start-up from the 1988 outage which confirmed its post maintenance operability.
It was determined that corrections to procedure PM-EE-4.0 and the review and revision of other maintenance procedures to correct deficiencies regarding post maintenance testing would be included as part of the Procedures Upgrade and Preventative Maintenance Projects.
Post-maintenance testing of safety related equipment in 480 volt Motor Control Centers, is being addressed in the Safety Enhancement Program, Post-maintenance Testing Requirements Criteria effort (SEP Ref. No. 35).
The review and revision to the procedures using the post-maintenance l
testing requirements criteria developed from SEP Ref. No. 35 will be performed as part of the Procedures Upgrade Project (SEP Ref. No. 48) and the Preventative Maintenance Project (SEP Ref. No. 41).
The Post-maintenance Testing Requirements Criteria effort (SEP Ref. No. 35) is scheduled for completion June 1,1989.
The safety related portion of the Procedures Upgrade Project (SEP Ref. No. 48) is currently scheduled for completion September 30, 1989. The revised Preventative Maintenance Program is currently scheduled for implementation by December 31, 1989.
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l D.2 Contrary to the above, Procedure ST-ISI-RW-1, " Raw Water Valves Inservice Testing," did not provide instructions for testing of Bettis valve operators; however, the procedure was issued for testing the valve stroke time for a valve with a Bettis operator.
(285/88201-21)
OPPD Response to D.2 Prior to the 1988 Refueling Outage, OPPD initiated a program to provide an interim upgrade of outage-related procedures since the Procedures Upgrade Project was just beginning.
Surveillance Test ST-ISI-RW-1, " Raw Water Valves Inservice Testing," was upgraded as a part of this interim program.
The purpose of the interim program was to provide an immediate improvement in procedures to facilitate procedural compliance during the outage. This upgrade included format changes and, to some extent, procedure content upgrades. The review process lacked sufficient detail to verify correct i
instructions for testing of the Raw Water pump discharge valve Bettis l
operators.
ST-ISI-RW-1, Rev. 11, provided only a general statement to open the valve and did not specifically include the method to accomplish this activity.
The procedure as changed in Revision 12 as part of the interim upgrade attempted to provide more specific steps, however, the instructions were incomplete.
The upgraded procedure in Revision 12 should have included all steps necessary to complete the test, however, due to an inadequate review of this procedure this objective was not met. As a result, steps previously performed in Revision 11 by technician knowledge of starting the associated pumps to open the valves were not included in the procedure.
The limited review process of the interim procedures upgrade program focused on differences between Revision 11 and the upgraded Revision 12 and did not detect the inaccurate step included in Revision 12.
Revision 13 to ST-ISI-RW-1 was issued and approved by the PRC on November 8, 1988. This revision contained the correct steps to perform the tast.
This and other procedures changed during the interim procedure upgrade effort are currently undergoing reviews for accuracy and completeness and are subject to the verification and validation effort of the Procedures Upgrade Project (SEP Ref. No. 48). The Surveillance Test Performance Improvement effort (SEP Ref. No. 72) is also applicable.
Page 17
'E.
Failure to Comolv With ASME Code Reauireme.nti Section 50.55a(g)(4) of 10 CFR Part 50 requires that the appropriate provisions of Section XI of the ASME Code be applied during conduct of-inservice tests of the operability of pumps and valves. Article IWV-3413 of Section XI states that full-stroke time'is that time interval from initiation of the actuating signal to the end of the actuating cycle.
Contrary to the above, the licensee performed inadequate inservice testing of Valve HCV-1749 in that the full-stroke time was determined from the time of actuation of the local solenoid until the end of the actuating cycle in lieu of the determination of the full-stroke time from initiation of the actuating signal (i.e., when the control switch for the valve is operated).
(285/88201-16)
This is a Severity Level IV violation.
(Supplement I)
OPPD Response 1.
Admission or Denial of the Alleaed Violation OPPD admits the violation as stated.
2.
The Reasons for the Violation. if Admitted At the time of the violation the FCS Inservice Inspection program used the l
locally measured stroke time from beginning to end of valve stroke motion, because it was assumed that the time from actuating signal to the start of valve motion was negligible. The initial test values were measured locally i
so the subsequent trending values were also measured locally and intended to indicate degrading valve conditions.
3.
The Corrective Steos That Have Been Taken and the Results Achieved The ISI Program is currently developing acceptance criteria for valve stroke times based on the initiation of the actuating signal to the end of the actuating cycle.
4.
Corrective Steos Which Will Be Taken to Avoid Further Violation After the liniiting values are determined and the required ISI program changes are approved, the ISI Surveillance Tests will be upgraded as part of the Procedures Upgrade Project (SEP Ref. No. 48) to include timing the l
valves from the remote station to include full stroke time from initiation I
of the actuating signal (i.e., when the control switch for the valve is operated). Additionally, remote position indication will be periodically verified such that the two year ASME code requirement will be met.
The Surveillance Test Performance Improvement effort (SEP Ref. No. 72) will also be applicable.
5.
Date When Full Comoliance Will Be Achieved These actions are scheduled to be completed by November 15, 1989.
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F.
Inadeauate Corrective Action Proaram Criterion XVI of Appendix B to 10 CFR Part 50 and the licensee's NRC-approved quality assurance program states, in part, that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected.
In the case of significant conditions adverse to quality,.the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
Contrary to the above, two examples were cited.
This is a Severity Level IV violation.
(Supplement I)
OPPD Response 1.
Admission or Denial of the Alleaed Violation OPPD admits the violation as stated.
2.
The Reasons for the Violation. if Admitted The corrective action program in the Fort Calhoun Station Quality Assurance Plan lacks specific guidance in regard to reviews concerning operational safety considerations and the associated identification and follow-up requirements.
3.
The Corrective Steps That Have Been Taken and the Results Achieved The definition for significant deficiencies has been revised to lower the threshold for reporting of conditions adverse to quality in this classification. The definition now includes elements which include operational safety considerations. More deficiencies are now being reported as significant.
4.
Corrective Steos Which Will Be Taken to Avoid Further Violation The Quality Assurance Plan section on corrective action will be revised to require an operational safety assessment of identified conditions adverse to quality that could potentially have operational safety significance.
The implementing procedures for the corrective action program will be revised accordingly.
In addition, the overall Safety Enhancement program will effectively address and correct the deficiencies that were discussed in the OSTI Report for Unresolved Item 285/88201-24.
5.
Date When Full Compliance Will Be Achieved j
The Quality Assurance Plan and implementing procedures will be revised by January 1990.
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F.1 Contrary to the above, a condition potentially adverse to quality was not resolved in that the stroke time for Valve HCV-1749 varied from 3.8 seconds for the remote indication to 12.2 seconds for the local 1
indication and the discrepancy was not identified to the appropriate j
licensee personnel. As a result, no corrective was initiated to promptly resolve the identified discrepancy.
(285/887.01-17)
OPPD Response to F.1 The HCV-1749 remotely measured stroke time of 3.8 seconds was less than the locally measures stroke time of 12.2 seconds because the remote indicator was not properly adjusted. The difference in the two recorded times was i
not identified as a problem since both times are recorded simultaneously at different stations and the only acceptance criterion is less than 30 seconds.
Both times were less than 30 seconds and therefore were both determined as acceptable.
Since only local valve timing was trended, the discrepancy for the remote station time was not identified.
Standing Order G-23, " Surveillance Test Program," has been revised and i
approved by the PRC.
The change includes a checklist for items to be considered when revicuing completed Surveillance Tests.
Included in the checklist is a review of test results by the responsible supervisor to insure that the System Engineer is promptly notified of any marginal or unacceptable results so that corrective action can be taken.
If unacceptable acceptance criteria is identified the Shift Supervisor will be promptly notified.
Standing Order G-23, " Surveillance Test Program,"
Revision 29 will be issued during the first week of May, 1989 when the " Hot Line" training has been completed.
The surveillance tests for ISI valve stroke times will be reviewed and upgraded, as applicable, as part of the Procedures Upgrade Project (SEP Ref. No. 48) to include timing the valves from the remote station. After remote position indication has been initially verified local timing will no longer be used for trending. A significant change in the valve stroke time caused by malfunctioning position indicators will show up as a definite abnormal trend and will be picked up in the trend review.
Remote position indication will be periodically verified based on the two year ASME code requirement.
The Surveillance Test Performance Improvement effort (SEP Ref. No. 72) is also applicable.
These actions are scheduled to be completed by November 15, 1989.
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g F.2 Lantrary to the above, the licensee has not est:.blished adequate measures to assure conditions adverse to quality are promptly identified in tSat the corrective action program does not contain all the elements necessary to address operational safety as listed below.
Corrective actions specified in response to audit findings.
Corrective action responses to material deficient conditions.
Licensee review of NRC Information Notices does not consider the generic aspects of potential problems identified in the notices.
Corrective action to be taken in response to preventive maintenance specified by the equipment vendor.
i The corrective action to be taken.. hen post-maintenance testing had not been performed on safety-related equipment.
Corrective action to ensure installed deficiencies would not affect equipment operability.
l The licensee's threshold for identification of deficiencies as significant is inadequately defined.
The examples listed above identify areas where operational safety is not considered in the corrective action program.
(285/88201-24)
OPPD Response to F.2 The corrective action program specified in the Quality Assurance Plan for Fort Calhnun Station does not require an operational safety assessment of conditions adverse to quality.
The definition for significant deficiencies has been revised to lower the threshold for reporting of conditions adverse to quality in this classification. The definition now includes elements which include operational safety considerations. More deficiencies are now being reported as significant.
The Quality Assurance Plan section on corrective action will be revised to require an operational safety assessment of identified conditions adverse to quality that could potenti?lly have operational safety significance.
The implementing procedures for the corrective action program will be revised accordingly.
Additionally, the accomplishment of the Safety Enhancement Program will effectively address and correct the deficiencies that were discussed in the OSTI Report for Unresolved Item 285/88201-24.
The Quality Assurance Plan and implementing procedures will be revised by January 1990.
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... s a Response to OSTI Unresolved Items UNRESOLVED ITEM 285/88201-04 Inaccurate entry of information into the temporary modification log.
.OPPD RESPONSE The inaccurate entry into the temporary modification log occurred due to personnel error resulting frcm weakness of the Temporary Modification Control process in effect.at the time of the OSTI review.
Standing Order 0-25 has undergone extensive review and upgrading to improve i
the overall Temporary Modification Control process.
Standing Order 0-25, Revision 28 issued February 21, 1989 improves the temporary modification process by having the cognizant System Fngineer being accountable for the necessary process steps.
The Procedural Compliance effort (SEP Ref. No. 44) will be used to ensure the proper use of, and compliance with, procedures.
In addition, the Temporary Modification Control Improvements effort (SEP Ref. No. 71) will also be applicable.
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UNRESOLVED ITEM 285/88201-06 Operability requirement of the steam generator blowdown radiation monitors affected by temporary modifications.
1 OPPD RESPONSE Standing Order 0-25, " Temporary Modification Control," in effect at the time of this incident was inadequate in that the proper review of temporary modifications prior to their installation was not required to be performed.
Standing Order 0-25 has undergone extensive review and upgrading to improve the overall Temporary Modification Control process.
Standing Order 0-25, Revision 28 issued February 21, 1989 now requires that the Plant Review Committee (PRC) review and approve temporary modifications prior to their installation.
Operability requirements for redundant systerc and components is a factor which is now considered before a temporary modification is approved for implementation. Also the cognizant System Engineer's comprehensive review of the Temporary Modification will address operability requirements for redundant components.
The Temporary Modification Control Improvements effort (SEP Ref. No. 71) will be applicable for any other enhancements that may be made to the Temporary Modification Control process.
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-<e UNRESOLVED ITEM 285/88201-07 Temporary Modification drawing control.
OPPD RESPONSE As stated in your lotter, NRC (L. J. Callan) to OPPD (K. J. Morris) dated March 17, 1989, a response to this unresolved item was not required since our response to the violation issued in NRC Inspection Report 50-285/89-03 will addressed this issue.
The response was forwarded in our letter, OPPD (K. J. Morris) to NRC dated March 31, 1989 (LIC-89-326).
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1 UNRESOLVED ITEM 285/88201-08 l
Plant Review Committee review of temporary modifications within 14 days, j
i OPPD RESPONSE 1
I Standing Order 0-25, " Temporary Modification Control," in effect at the time of this incident was weak in regard to the necessary steps required to assure proper and timely review of temporary modifications.
Standing Order 0-25 has undergone extensive review and upgrading to improve the overall Temporary Modification Control process.
Standing Order 0-25, Revision 28 issued February 21, 1989 now requires that the-Plant Review Committee (PRC) review and approve temporary modifications prior to their installation.
The Temporary Modification Control Improvements effort (SEP Ref. No. 71) will be applicable for any other enhancements that may be made to the Temporary Modification Control process.
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. UNRESOLVED ITEM 285/88201-18'
,The control room indication for valves HCV-11078 and HCV-1108B was not
. tested.
OPPD RESPONSE
. This unresolved item is addressed in the response to Violation E.
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a UNRESOLVED ITEM 285/88201-23 Quality Assurance reviewed Surveillance Test ST-DC-1 which had the acceptance criteria deleted and the quality assurance auditor did not identify the discrepancy.
OPPD RESPONSE The Quality Assurance Surveillance Program, in effect at the time of the activity referenced in this unresolved item, did not provide appropriate guidance to the auditor. Audit Report 2-88-1 indicated that no deviations or deficiencies were identified for Surveillance Test ST-DC-1, Revision 33, performed on February 2, 1988 because the procedural steps appeared to be adequate based on the limited guidance available to the auditor at that time.
The surveillance plans have been revised to provide more guidance to the auditors for observing activities.
The auditors have been instructed to be more specific in the reporting of activities they observe. The surveillance plan for surveillance test observation now includes a specific item to observe the progress of the test and to assure that the procedural steps are followed.
As part of the Safety Enhancement Program, Ref. No. 20 " Evaluate, improve depth and strengther quality audit and surveillance program," OPPD's Quality Assurance Surveillance Program has undergone extensive improvement including additional guidance to the auditor.
SEP Ref. No. 20 was completed on March 31, 1989.
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j OPEN ITEM 285/88201-11 Electrical safety and electrical safety training concern.
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OPPD Action I
The Training Department is reviewing and upgrading, as necessary, of the
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Electrical Safety Training program to address the concerns of this Open Item. The need to be aware of electrical safety requirements has been discussed during Maintenance Department meetings and with the craft foreman and supervisor.
OPEN ITEM 285/88201-12 Clearance Procedure regarding use of Danger Tags.
OPPD Action The Operations Department is reviewing and revising, as necessary, Standing Order 0-20, " Equipment Tagging Procedure," to address the concerns of this Open Item.
Standing Order 0-20 will be upgraded and training conducted prior to implementation.
OPEN ITEM 285/88201-14 Improve QC inspection guidance for CQE component repair and modifications.
OPPD Action The Quality Assurance and Quality Control Department is reviewing and upgrading, as necessary, the QC inspection guidance to address the concerns of this Open Item.
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OPEN ITEM 285/88201-20 Concerns related to the adequacy of the penetration test rig.
OPPD Actions Station Engineering and Maintenance will evaluate the penetration test rig and respond to the specific concerns identified in this Open Item.
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