ML20246D896
| ML20246D896 | |
| Person / Time | |
|---|---|
| Site: | Trojan File:Portland General Electric icon.png |
| Issue date: | 04/19/1989 |
| From: | Rebecca Barr, Mendonca M, Obrien J, Suh G, Wagner W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20246D887 | List: |
| References | |
| 50-344-89-05, 50-344-89-5, NUDOCS 8905110081 | |
| Download: ML20246D896 (26) | |
See also: IR 05000344/1989005
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NUCLEAR REGULATORY COMMISSION
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. Report No.
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License No.
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- Licensee':
Portland General. Electric Company
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121.S.W. Salmon Street
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Portland, OR 97204.
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Facility Name: Trojan
. Inspection at: Rainier, Oregon
Inspection conducted:
February 12 - March 25, 1989
Inspectors:
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R. C. Barr
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. Senior. Resident Inspector--
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~G. Y. Suh
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Resident Inspector
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J. P. O'Brien-
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Reactor Project Inspector-
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Approved By:
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M. M. Mendonca, Chief
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Reactor Projects Section 1
Summary;
Inspection on February 12 - March 25, 1989 (Report 50-344/89-05)
Areas Inspected;
Routine' inspection of operational safety verification.
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maintenance, surveillance, event follow-up, design engineering, and open item
follow-up.
Inspection procedures 30702,~30703, 37200, 37702, 38703, 61726,
62703, 71707, 90712, 92700,'92701 and 93702 were used as guidance during the
conduct of the inspection.
g905110081 890419
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Results:
This inspection identified six violations of NRC requirements.
Paragraph 3 discusses log keeping practices including the failure to log an
entry into containment while at power.
Paragraph 6 discusses inadequate work instructions of a maintenance request
for calibrating reactor plant control instruments.
Paragraph 6 also discusses
the requirements set forth in Regulatory Guide 1.33 for calibration procedures
for each instrument covered by Technical Specifications.
Paragraph 6 also discusses the need for supervisors to conduct detailed
pre-work briefing, particularly when work scope or work plans change.
Paragraph 7 discusses an instance where the reporting requirements of 10 CFR 50.73 for a 30 day Licensee Event Report was exceeded.
Paragraph 10 discusses the failure to follow procedural requirements in the
. control of top tier drawings.
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' Paragraph 11 discusses the failure to follow QA procedures for processing a
Non-Conformance Report (NCR) that allowed non-conforming weld filler material
to be used, and inadequate documentation of its use.
The subjects of these violations, quality of Maintenance work instructions,
procedural compliance and detailed supervisory and management involvement with
routine activities and off-normal events has our heightened concern.
There
appears to be a reluctance by both line and quality reviewers to challenge low
quality work instructions.
Additionally Managements' actions and follow-up
for improving the quality of work instructions, as exemplified by the steam
generator water level transient event, has been only partially effective.
As
a result of recent events, the licensee has taken action to lower the
threshold for when and how soon critiques will be held following off-normal
events.
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DETAILS
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1.
Persons Contacted
+*D.
W. Cockfield, Vice President, Nuclear
+*C. P. Yundt, Plant General Manager
+*T. D. Walt, General Manager, Technical Functions
+ L. W.-Erickson, Manager,. Nuclear Quality Assurance
- R. P. Schmitt, Manager, Operations and Maintenance
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+*D. W. Swan, Manager, Technical Services
- A. N. Roller, Manager, Nuclear Plant Engineering
M. J. Singh, Manager, Plant Modifications
J. D. Reid, Manager, Plant Services
- J. W. Lentsch, Manager, Personnel Protection
- J. M. Anderson, Manager, Material Services
M. D. Gatlin, Warehouse Supervisor
- A. R. Ankrum, Manager, Nuclear Security
+*M. R. Snook, Manager, Quality Support Services
R. E. Susee, Manager, Planning and Scheduling
D. F. . Levin, Supervisor, Plant Modifications
E. A. Curtis, Procurement Supervisor
- A. M. Puzey, Office Supervisor
P. A. Morton, Branch. Manager, Plant Systems Engineering
R. L. Russell, Operations Supervisor
R. H. Budzeck, Assistant Operations Supervisor
D. L. Bennett, Maintenance Supervisor
R. A. Reinart, Instrument and Control Supervisor
T. O. Meek, Radiation Protection Supervisor
R. W. Ritschard, Security Supervisor
+ C. H. Brown, Operations Branch Manager, Quality Assurance
- D. L. Nordstrom, Nuclear. Engineer, Nuclear Safety and Regulation
+ D. Wheeler, Quality Inspection Branch Manager
+ R. Prewitt, Quality Systems Supervisor
+ G. A. Zimmerman, Manager NSRD
+ 0. A. Desmarais, Mechanical Engineer, NPE
+ S. A. Bauer, Manager, Nuclear Regulation Branch
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+ J. Carter, Metallur0 st, NPE
+ M. Hoffman, Manager, Mechanical Branch, WPE
+ A. Ciapanno, Welding Engineer / Specialist
The inspectors also interviewed and talked with other licensee employees
during the course of the inspection.
These included shift supervisors,
reactor and auxiliary operators, maintenance personnel, plant
technicians, engineers, and quality assurance personnel.
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+ Denotes those attending the exit interview on March 9, 1989.
- Denotes those attending the exit interview on March 23, 1989.
2.
Elant Status
The plant operated at 100% power from February 12 through February 24,
1989.
From 8:05 a.m. February 25,1989 to 5:16 a.m. February 26, 1989,
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power was reduced to 55% to repair a circulating water to main condenser
leak.
On March 4,1989, with the reactor at 100% power, a water level
transient occurred in all steam generators as a result of attempting an
instrument calibration tnat could only be performed while shutdown.
Due
to a higher than normal containment atmosphere activity, on March 9,
1989, with the reactor at 100% power, a containment entry was made to
isolate an apparent leaking valve in the pressurizer vapor space sampling
line.
On March 25, 1989, the end of the inspection period, the reactor
was at 100% power with the licensee preparing for the 1989 Refueling
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Outage that is scheduled to begin on April 6, 1989.
3.
Operational Safety Verification (71707)
During this inspection period, the inspectors observed and examined
activities to verify the operational safety of the licensee's facility.
The observations and examinations of those activities were conducted on a
daily, weekly or biweekly basis.
Daily, the inspectors observed control room activities to verify the
licensee's adherence to limiting conditions for operation as prescribed
in the facility Technical Specifications.
Logs, instrumentation,
recorder traces, and other operational records were examined to obtain
information on plant conditions, trends, and compliance with regulations.
On occasions when a shift turnover was in progress, the turnover of
information on plant status was observed to determine that pertinent
information was relayed to the oncoming shift personnel.
The inspectors identified that the containment entry of March 9,1989,
was not recorded in the control operator log.
The containment entry was
logged in the Shift Supervisors log; however, neither the time nor
duration of the entry was recorded.
Further inspection identified that
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the administrative procedure that establishes the requirements for
containment entries, A0-3-11, " Containment Access, Integrity, Evaluation,
and Inspections", Revision 21, dated January 12, 1989, was followed.
The
inspectors noted A0-3-11 did not require logging the entry of
containment; however, Administrative Procedure, A0-3-6, " Conduct of
Operations", Revision 17, dated March 3, 1988, section II.C.7. states for
control operator logs that " Log entries shall include but not be limited
to:
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Maintenance Activities that affect operations..." and " i.
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Performances of special inspections or checks (overspeed trips, oil
filters, etc.)."
The entry into containment while at power to perform
maintenance and inspections clearly falls into these categories because
reactor operations are restricted so as not to change reactivity and
power, and the entry was to conduct a special inspectica and, if
necessary, corrective maintenance. The inspectors concluded that the
containment entry should have been logged in accordance with A0-3-6.
This was identified to the licensee as an apparent Severity Level V
violation (50-344/89-05-01). The inspectors also noted that frequently
the control room log continues to be maintained on scratch paper for
approximately an entire shift and then be transcribed to the legal record
near the end of the shift.
This is contrary to the industry accepted
standard that log entries should be made promptly.
This practice had
previously been discussed with licensee management.
Operations
Management acknowledged the inspector's findings and committed to provide
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additional guidance to the operating crews by clarifying A0-3-11 to
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include the requirement to log all at power containment entries.
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Additionally, the licensee conducted an evaluation of log keeping
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practices against the industry standard and is evaluating the need for
further corrective action.
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Each week the inspectors toured the accessible areas of the facility to
observe the following items:
(a) General' plant and equipment conditions.
(b) Maintenance requests and repairs.
(c) Fire hazards and fire fighting equipment.
(d) Ignition sourcesJand flammable material control.
(e) Conduct of activities in accordance with the licensee's
administrative controls and approved procedures.
(f) Interiors of electrical and control panels.
(g) Implementation of +.he licensee's physical security plun.
(h) Radiation protection controls.
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(i) Plant housekeeping and cleanliness.
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(j) Radioactive waste systems.
(k)= Proper storage of compressed gas bottles.
Weekly, the inspectors examined the licensee's equipment clearance
control with respect to removal of equipment from service to determine
that the licensee complied with technical specification limiting
conditions for operation.
Active clearances were spot-checked to ensure,
that their issuance was consistent with plant status and maintenance
evolutions.
Logs of jumpers, bypasses, caution and test tags were
examined by the irispectors.
Each week the inspectors conversed with operators in the control room,
and with other plant personnel.
The discussions centered on pertinent
topics relating to general plant conditions, procedures, security,
training and other topics related to in progress work activities.
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The inspectors examined the licensee's nonconformance reports (NCRs) to
confirm that deficiencies were identified and tracked by the system and
that these nonconformances were being tracked and followed to the
completion of corrective action.
Further details are provided in
paragraph 11.
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Routine inspections of the licensee's physical security program were
performed in the areas of access control, organization and staffing, and
detection and assessment systems.
The inspectors observed the access
control measures used at the entrance to the protected area, verified the
integrity of portions of the protected area barrier and vital area
barriers, and observed in several instances the implementation of
compensatory measures upon breach of vital area barriers.
The inspectors
noted that the licensee installed new monitors for detecting explosive
materials.
Portions of the isolation zone were verified to be free of
obstructions.
Functioning of central and secondary alarm stations
(including the use of CCTV monitors) was observed.
On a sampling basis,
the inspectors verified that the required minimum number of armed guards
and individuals authorized to direct security activities were on site.
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The inspectors conducted routine inspections of selected activities of
the. licensee's radiological protection program.
A sampling of. radiation
work permits'(RWP) was reviewed for completeness and adequacy of
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information.
During the course of inspection activities and periodic
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tours of plant areas, the inspectors verified proper use of personnel
monitoring equipment,' observed individuals leaving the radiation
controlled area and signing out on appropriate RWP's, and observed the
posting of radiation areas and contaminated areas.
Posted radiation
levels at locations within the fuel and auxiliary buildings were verified
using both NRC and licensee portable survey meters.
The involvement of
health physics supervisors and engineers and their awareness of
significant plant activities was assessed through conversations and
review of RWP sign-in records.
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The inspectors verified the' operability of selected engineered safety
features.' This was done by direct visual verification of the correct
position of valves, availability of power, cocling water supply, system
integrity and general condition of equipment, as applicable.
Portions of
the Emergency Diesel Generating System were verified operable during this
inspection period.
One apparent violation and no deviations were identified.
4.
Maintenance (62703, 92701)
The inspectors observed the performance of annual preventive maintenance
for the "C" service water booster pump motor.
The work was controlled by
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maintenance request MR 89-0587 and included physical inspection of the
electric motor, lubrication of the motor shaft bearings, and measurement
of the motor insulation resistance.
The work was performed by two
electrical maintenance personnel and was further controlled by
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radiological work permit RWP 89-21.
The inspectors reviewed the
associated clearance, verified that applicable tagouts had been made and
verified that measuring and test equipment calibrations were current.
In the lubrication of the motor shaft bearings, the maintenance personnel
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connected a grease gun to the grease fittings and delivered approximately
two pumps of the grease gun to each bearing.
The drain plug was not
removed during grease addition.
In conversations with maintenance
technicians and supervisory personnel, the inspectors understood that the
observed method may be the standard practice.
Review of the
manufacturer's technical manual showed that the manufacturer recommended
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a different annual lubrication practice which included cleaning of the
drain plug area, addition of grease until new grease is forced out the
drain, and motor operation for 30 minutes prior to replacing the drain
plug.
The lubrication survey provided by the grease manufacturer also
recommended a similar lubrication practice for electric motor bearings.
The inspectors' review of the equipment history file for the period of
1983 through 1989 of the service water booster pump motors did not reveal
bearing failures, but did indicate come history of bearing lubrication
problems.
At the exit licensee management committed to evaluate the
lubrication program.
The inspectors will follow-up on this issue during
routine inspection activity.
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No violations or deviations were identified.
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Surveillance (61726)
The inspectors observed the performance of portions of the inservice
testing of the "A" containment spray pump.
The test was conducted by
operations personnel and was controlled by Periodic Operating Test
POT-4-1, titled " Pump and Valve Inservice Testing / Eductor Performance,"
Revision 19, dated November 7, 1988.
POT-4-1 included testing of the
containment spray pumps, full stroke exercising of the eductor check
valve, and part stroke exercising of the refueling water storage tank
check valve in accordance with the licensee's topical report PGE-1048,
titled " Inservice Testing Program for Pumps and Valves Second Ten-Year
Interval." The scope of the present inspection was limited to inservice
testing of the "A" containment spray pump.
~The inspectors noted that test personnel had copies of the test procedure
and data sheets in hand during conduct of the test, and verified that an
independent verification was performed for the final position of valves
in the locked valve program.
Calibration of test equipmer.t and
instrumentation was verified to be current by review of completed
calibration sheets.
A review of completed POT-4-1 data sheets for 1988
and 1989 indicated that required test frequencies were being met, and
showed no significant changes in pump performance.
The inspectors also
reviewed the test procedure for conformance with the requirements of
technical specifications 4.0.5 and 3/4.6.2.1 and with the requirements of
Section XI of the ASME Boiler and Pressure Vessel (B&PV) Code.
In the review of the test procedure to the requirements of Section XI of
the B&PV Code, the inspectors identified the following items.
First,
paragraph IWP-3220 of Section XI required that all test data be analyzed
within 96 hours0.00111 days <br />0.0267 hours <br />1.587302e-4 weeks <br />3.6528e-5 months <br /> after completion of a test.
POT-4-1 required that the
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operations shift supervisor check test data against the value/ range
denoted on the data sheets within 96 hours0.00111 days <br />0.0267 hours <br />1.587302e-4 weeks <br />3.6528e-5 months <br /> but does not specify a time
limit for review of the test data by the test engineer.
POT-4-1
apparently provided the required action range for test quantities, but
did not provide the acceptable range limits or alert ranges for use by
the shift supervisor in his review.
The concern was whether the shift
supervisor review met the intent of the IWP-3220 requirement.
Second,
POT-4-1 does not provide any allowable ranges for bearing temperatures on
the applicable data sheet which was required to be checked by the shift
supervisor within 96 hours0.00111 days <br />0.0267 hours <br />1.587302e-4 weeks <br />3.6528e-5 months <br />.
This created the possibility that bearing
temperature test data may not have been analyzed in a timely manner.
Third, review of completed vibration amplitude meter calibration sheets
indicated that the instrument accuracy requirements specified in Table
IWP-4110-1 of Section XI may not have been met.
The inspectors discussed
these items and other questions with test engineering personnel and
requested further information.
This is considered an unresolveu item
(50-344/89-05-02).
No violations or deviations were identified.
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Event Follow-up (62703, 92701, 93702)
Steam Generator Water Level Transient
At approximately 10:59 a.m. on March 4, 1989, while conducting
calibration of reactor plant control instrumentation, referred to by
licensee, instrument technicians as Hagan (the instrumentation
manufacturer) Cals, a steam generator (SG) level transient from a normal
operating level of 44% (narrow range-NR) to a transient level of 58% (NR)
occurred.
At the time of the event the cause of the SG water level
transient was.not obvious to the instrument technicians performitig the
calibrations or the operating crew, even though that crew had released
the instrument calibration-work to be performed. As soon as the transient
was terminated, the shift' supervisor discontinued all possible work
activity that coulu have caused the transient until the event could be
understood sufficiently to restart acintenance activities without
incident.
Subsequent operating crew and-instrument technician evaluation determined
that an instrument technician had momentarily removed a fuse while
establishing conditions necessary to check the calibration of the
lead-lag module (LY-505-E) for first stage turbine impulse pressure
signal conditioning;-and that LY-505-E should not have been attempted to
be calibrated at power since that module was required for controlling SG
water level with the reactor at power.
When the Shift Supervisor
concluded he understood the cause of the event, he contacted the Duty
Plant General Manager and informed.him of the plant transient.
The Duty
Plant General Manager concluded the event did riot require immediate
critique since to him it appeared the Shift Supervisor was taking
conservative actions.
On March 6, 1989, the Plant General Manager
decided an event report and a critique were required to expeditiously
gather the event facts.
The inspectors conducted a detailed assessrint of this event from March
6-10, 1989.
The following paragraphs describe the inspectors' findings.
On February 8, 1983, Maintenanc.e Reque;t (MR) 89-1538, a Preventive
Mair;tenance work request tc perform annual calibrations of approximately
450 reactor control instrument inodules, was processed by the acting Work '
Group Craft Supervisor.
The inspectors noted that the MR did not have a
list of the instruments to be calibrated or a clear indication of the
scope of the work to be performed.
The MR desc*ibed the work to be
conducted as " Calibrate Hagan Modules in protection racks, control racks
and associated control board inaicators." The MR work instructions were:
1.
Obtain permission from C0 and shift supervisor
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Remove from service using appropriate PICT
3.
Check calib of modules
4.
Return modules to service
These work instructions were insufficient to prevent the performance of
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the calibration of LY-505-E while in an operating condition that would
not support its calibration.
LY-505-E calibration is part of " Shutdown
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folder 22."
Shutdown folder 22 62 alt with the calibration of 18 modules
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including a turbine impulse pressure instrumentation circuit.
The
inspectors reviewed applicable interconnecting wiring diagrams and held
discussions with engineering and maintenance personnel.
Based on this
review, the following modules appeared to be in the safety related
portion of the instrumentation circuit:
signal summator PY-505 B (used
in computation for high steam flow), signal isolator PY-505A (used in
isolation from steam dump control), signal,comparator PB-505C (used for
rod block signal), and signal comparator PB-505 AB (used as input to low
power permissive signals).
The inspectors found that the licensee
program for calibrating instruments relies on the knowledge of the
instrument technician, and his use of electrical diagrams, vendor manuals
and calibration data cards.
Only several formal pre-written procedures
for each individual calibration have been developed to direct the
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craftsman while performing instrument calibrations.
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The MR and its work instructions were developed by the acting Work Group
Craft Supervisor.
In discussions with the individual, the inspectors
ascertained that the method used to develop the work instructions were
similar to the method used for the calibrations conducted in previous
years.
Besides not including a list of the instruments to be calibrated,
the MR also did not include a list of the procedures to be used by the
technicians performing the calibrations or special precautions to be
observed while performing the calibrations.
The calibration activity was
segmented into approximately thirty folders, referred to as shutdown
folders by the technicians, each containing from one to sixty-four
instruments for calibration.
Four of the shutdown folders, folders 8, 9,
12 and 22, contained instruments that could be calibrated while operating
or shutdown, and instruments that could only be calibrated.while
shutdown.
The other folders contained instruments that could be
calibrated either at power or shutdown.
Inspector' discussions with the Instrument and Controls Technician Work
Group Supervisor (WGS) revealed that the technicians had been provided
with an uncontrolled, marked-up, computerized copy of the instruments to
be calibrated within the scope of the MR and that the list had not been
attached to the MR when it was routed for review and approval.
The WGS
- further noted that the work was divided into groupings referred to as
" shutdown folders" and that the technicians used these in the performance
of the calibrations.
He continued by noting that the cover sheet to each
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shutdown folder listed all'the instruments in the folder and the general
maintenance procedures the technician should refer to when calibrating
those instruments.
He also noted that the tect:icians were required to
- be knowledgeable of the procedures used to caliorate the instruments on
which he was working.
However, the inspectors verified through interview
with the instrument technician that was conducting the calibrations that
he had not reviewed the general calibration procedures immediately prior
to conducting the calibrations nor did he have these procedures or the
vendor manual at the job site with him.
The inspectors also noted the
technicians had not been periodically required to recertify their
knowledge of tnese procedures and that one of the technicians performing
the calibrations had not co7 ducted these calibrations during the last
four years.
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The licensee does have Maintenance Procedures that provide general
guidance to.the technician on conducting calibrations.
In interviews
with the Maintenance Manager and the I & C Work Group Supervisor, the
inspectors concluded the licensee justification of this methodology is:
Maintenance Procedure (MP) 2-5, Revision 5, " Electrical Analog
Instrumentation", implements the standard for inspection and maintenance
of this equipment.
Additionally, this procedure references other
-maintenance procedures and vendor technical manuals with which the
technician should refer when conducting instrument maintenance and
calibrations.
However, the inspectors found that the vendor technical
manuals do not provide plant specific direction for the calibration of
all instruments.
Additionally for this specific set of instrument
calibrations, general procedure, MP-2-1, "Hagan Process Control and
Protection Equipment", Revision 6, identifies the steps necessary to
safely isolate, perform maintenance, test and return to service plant
instrumentation and control equipment.
It should be noted that during
the SG water level transient of March 4,1989, the technicians performing
the calibrations did not have nor had they reviewed this procedure
immediately prior to conducting the calibrations.
Knowledge of these
procedures has been considered by the licensee to be within the skill
level of the craftsman.
In the review of MR 89-1538 the inspectors also noted, in acco/ dance with
licensee Administrative Order (AO) 3-9, Revision 30, " Maintenance
Requests", other licensee reviews were required prior to releasing the
work to be performed.
For this MR the other reviews were conducted by
the Initiating Supervisor, a Quality Control Reviewer, the Cognizant
Supervisor (who in this case was also the initiator of the MR), and a
Shift Supervisor.
In reference to the Quality review, a portion of the
QA review requires, per Quality Support Ser/ ices 8 ranch Procedure,
" Quality Review - Work Packages / Documents," Revision 0, that the Quality
Reviewer assure " Applicable procedures are referenced".
While the review
was conducted, the reviewer failed to identify that no procedures had
been referenced.
Additionally, discussions with the reviewer indicated
to the inspectors that the review was superficial in that the reviewer
thought that the scope of the work was to have calibrated between three
and five instruments.
Since the MR did not have a list of the
instruments to be calibrated, it was understandable the QA Reviewer did
not realize the scope of the MR; however, the instructions did indicate
multiple calibrations were to be performed and should have generated
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additional questions on the part of the Quality Reviewer.
As a result of
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the reviewer not understanding the scope of the MR, the reviewer did not
schedule inspection hold points or observations of these calibrations by
the Quality Assurance organization.
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The QA department reviewed the work instructions with responsible
individuals and assured appropriate understanding.
Additionally, based
on this review a change to the QA procedure has been initiated to provide
clarification.
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As noted previously, prior to work authorization the MR was also reviewed
by an Operations representative, who is also a licensed senior reactor
operator and also a shift supervisor.
This reviewer recognized the full
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scope of the work; however, he did not challenge the quality of the work
instructions nor the absence of a list of instruments to be calibrated.
He also did not refer to Maintenance Procedure (MP) 2-1, "Hagen Process
Control and Protection Equipment", to evaluate the need for additional
precautions which in section III states: "There are a few instruments in
the control racks that maintenance cannot be performed on unless the
plant is shutdown." Therefore, no additions were made to the work
instructions to alert the shift supervisors that some calibrations within
the Hagan Process Control Racks could only be performed while shutdown.
The Operations Department determined that operators were given confidence
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by discussions with I&C which indicated work was to be conductd in
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accordance with approved procedures. Operators relied on I&C knowledge.
The licensee determined that operations personnel acted appropriately and
that the bulk of the corrective action was required in the maintenance
control and instruction area.
Based on the above, the licensee does not have appropriate, specific
procedures for each calibration of instruments called out in the
Technical Specifications as required by Regulatory Guide 1.33.
This is
an apparent violation (50-344/89-05-03).
Subsequent to the reviews the MR was authorized and released to be worked
by Operations. Each week the Planning and Scheduling organization
conducts a planning meeting with all planners present to schedule the
maintenance activities to be conducted for the next week and over the
weekend.
For the weekend of March 4, 1989, the calibration of the
instruments associated with ' shutdown folders' 16 and 23 were to be
performed. However, on Saturday March 4, 1989, when the technicians went
to the control room and requested permission from the Shift Supervisor to
conduct the scheduled calibrations, the Shift Supervisor would not
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release the MR since the plant conditions, due to previously planned and
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scheduled maintenance not being completed, were not compatible with the
calibrations to be conducted. The technicians then returned to the
instrument shop and discussed with the Work Group Supervisor the
alternative of conducting the calibrations associated with another
' shutdown folder' (folder 22). The WGS directed the technicians to
perform calibrations associated with Protection Set 1 (PICT-3-1, i.e.
' shutdown folder' 22). Licensee procedure A0-3-9, Revision 30,
' Maintenance Requests,' section 4.5.1 states in part, " The Work Group
Craft Supervisor shall:...b. Review the work instructions with the
craftsman / technician prior to the start of work and establish safety
requirements for the job." This review was conducted for the scheduled
work; however, whcn the planned work was deferred a review in accordance
with A0-3-9 was not conducted for the fill-in work.
This is an apparent
violation (50-344/89-05-05).
The technicians returned to the control room and requested permission
from the shift supervisor to conduct calibrations on the Hagan control
racks associated with Protection Set I.
The shift supervisor's review
of the work he released did not ascertain that the shutdown folder had
instruments within it that could only be calibrated when shutdown.
Although the licensee concluded that operation's response was appropriate,
the licensee needs to assure that operations personnel assume a sense of
ownership and a leadership role in assuring work activities are appropriate.
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At the time of the event the technicians were calibrating instruments contained
within ' shutdown folder' 22. The technicians, because the work instructions
were of inadequate detail, the required pre-work briefing was not conducted
per procedures and the shutdown folder's instrument list did not identify
plant conditions required to calibrate each instrument, attempted to calibrate
LY-505-E, an instrument that should only be calibrated while shutdown. When
the technician deenergized the lead-lag module for calibration by momentarily
removing a fuse, the transient occurred. The technician, because he felt
uncomfortable with what he was doing, immediately reenergized the
lead-lag module, thereby minimizing che transient.
The inspectors also
noted that the circuit diagram the technician was using when establishing
the conditions to check the calibration of LY-505-E was an uncontrolled,
out-of-date, partial print maintained within the Hagan control rack door.
In summary, without more detailed work instructions and an att:ched list
of instruments to be calibrated the MR reviewers, the technicians, and
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the operating staff could not determine the scope of the work being
conducted. Without adequate work instructions, an adequate pre-work
briefing and proper segregation of work to be performed for the
appropriate plant conditions, the technicians could not perform work
acceptably. This event represents a breakdown of work control practices
within the Maintenance Program. This event is very similar to a previous
citation (50-344/88-40-03), where a reactor trip resulted from an
instrument technician performing an instrument calibration without
The inspectors reviewed their findings and conclusions of this event with
plant management.
Plant management acknowledged the findings and
committed to implement the following corrective actions:
- Generate a separate MR to address all Hagan modules and
instruments calibrated under an individual PICT. A separate MR will
be written each time an instrument to be calibrated requires the use
.of a different PICT to take them out of service and return them to
service.
- Generate a list of each specific instrument to be calibrated via
an MR and attached it to the applicable MR and state that only these
instruments are to be calibrated under that MR.
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- Notes will be added to the applicable I&C-4 data sheets to state
that calibration of this module is not to be performed while
operating.
I&C-4 data sheets will also be updated to include notes
to designate if they must be deenergized to perform the calibration.
- Conduct a Lessons Learned training session with the I&C shop led
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by the involved technicians.
- Move to Sundays the schedule date for Hagan cals to allow return
to the original intent which was to perform these activities when no
other maintenance is in progress.
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- An MR with appropriate instructions and prior reviews, including
the requisite pre-job briefings, will be prepared, reviewed,
approved, and scheduled for each train of the Hagan rack.
- In the long term, a review of all Hagan rack modules will be
conducted and all modules requiring the plant to be shutdown will be
separated into different folders and scheduling groups.
- MRs used to initiate preventative maintenance will insure that
adequate direction is'provided to bound all plant conditions and
will list specific equipment to be worked under that individual MR.
Two apparent violations and no deviations were identified.
7.
Follow-up of Licensee Event Reports (92700, 90712)-
a.
The following LER is closed based on in-office review, inspector
verification of the implementation of selected corrective actions
and licensee commitment to perform future corrective actions:
LER 88-26, Revision 0 and Revision 1, (Closed), " Reactor Trip on Low
Reactor Coolant Loop Flow Signal Due to a Technician's Procedural
Error".
This LER and its revision discussed a reactor trip that
resulted from technician error, inadequate work instructions and
ineffective supervisory involvement and oversight.
A detailed
discussion of the event was included in inspection report
50-344/88-40.
All NRC open items associated with this event have
been previously closed.
b.
The following LERs are closed based on inspector. follow-up that
included discussions with licensee representatives, detailed event
evaluation, verification of appropriateness and implementation of
corrective actions and licensee commitment to perform future
corrective action:
LER 88-05, Revision 1, (Closed), " Surveillance Interval for Valves
Exceeded Due to Personnel Procedural Error." This LER discussed two
separate instances where surveillance associated with in-service
testing were missed.
The first event, identified by NRC inspectors
and reported in Inspection Report 50-344/88-13, discussed exceeding
the surveillance interval for testing Chilled Water return valves
CV-10015 and CV-10016.
Additionally during licensee assessment of
the event, five other cases were identified where valves had not
been tested within'the required surveillance interval.
The licensee
attributed personnel error to be the cause of the missed
surveillance for these cases, since an engineer incorrectly logged
dates of testing performance and an inadequate procedure, PET 9-4,
provided insufficient detail for performing equipment testing at-
increased frequency.
As corrective actions, the licensee confirmed
that testing had been done in the six cases and revised PET 9-4 to
clarify testing at an increased frequency.
Subsequent to the submittal of Revision 0 of this LER, the licensee
identified another instance of a missed surveillance in the area of
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in-service testing.
POT-2-3-DD, ' Safety Injection System, ECCS
Valve Quarterly In-Service Test' was missed as a result of errors on
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the part of two operations staff members.
First, the operations
clerk provided the wrong surveillance, POT-2-3-DB, ' Safety Injection
System, ECCS Valve Monthly In-Service Test' instead of POT-2-3-DD,
' Safety Injection System, ECCS Valve Quarterly In-Service Test' to
the control operator for performance.
Second, the shift supervisor,
who had the responsibility for ensuring the correct surveillance,
were performed and recorded, failed to recognize that the incorrect
surveillance was performed.
The inspectors noted the shift
supervisor reviewed POT-2-3-DB and incorrectly annotated that
POT-2-3-DD had been performed.
As corrective actions, the licensee counseled the personnel involved
and performed P0T-2-3-DD.
The licensee Project Review Board (PRB) on May 4, 1988, determined
this most recent identified missed surveillance was reportable.
Because the event was similar in subject to LER 88-05, Revision 0,
the PRB incorrectly ' decided to revise LER 88-05 vice submit a new'
Licensee Event Report.
The practice of adding additional events to
an already submitted LER is appropriate only when a continuing
review of a previous event identifies additional instances of the
same event with the same root cause.
In those cases, to comply with
10 CFR 50.73, the licensee is required to submit the revised LER
within thirty (30) days.
Therefore, the licensee should have
submitted a new LER vice LER 88-05 Revision 1, and in any event the
revised LER should have been submitted within thirty days from
discovery.
This was identified to the licensee as an apparent
Severity Level V violation (50-344/89-05-06).
At the exit the
licensee stated that the PRB is now assigning each event its own
separate event report number and as such amending previously
reported events has been discontinued.
LER 88-45, Revision 0, (Closed), " Reactor Coolant System Check Valve
Leak Rate Not Measured Due to Construction Error".
This LER
discussed the invalid performance of leek rate testing for the "C"
reactor coolant loop first-off pressure isolation check valve
(894]C) due to not drilling an orifice in a fitting of a section of
the safety injection test line associated with check valve 8948C.
Therefore with the test line blocked, the leak rate tests performed
from 1977-1982 and from 1984-1988 were invalid.
In July 1983, a
valid leak rate test was conducted yielding a leak rate of 2.9 gpm.
In November of 1988, another valid leak rate was performed yielding
a leak rate of 4.1 gpm.
From this data the licensee concluded from
1977-1988 that the leak rate had not exceeded the technical
specification limit of 5.0 gpm.
On three occasions the licensee had the opportunity to identify that
a blockage existed in the test line.
In 1983 the licensee suspected
the test line was blocked and conducted an alternate test.
No
attempt was made at that time to identify the cause of the blockage.
In 1984 an attempt, blowing air tnrough the test line, was made to
clear the blockage.
Plant personnel concluded the blockage was
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cleared, but no test was performed to verify the blockage had been
cleared.
In July 1988, the method of performing the leak rate
testing was changed and the test results indicated a blockage;
however, neither the operator nor the engineer that reviewed the
test recognized the test indicated a blockage existed.
As a corrective action when the licensee recognized the orifice had
not been drilled, the licensee performed valid leak rate testing.
Additionally, the_ licensee considered drilling an orifice in the
test line fitting.
The licensee concluded for radiological and
mechanical consideration not to drill the orifice, but to continue
testing by an alternate method.
LER 88-25, Revision 0, (Closed), " Construction Activity
Inadvertently Disturbs Archeological Site"
This event occurred as
a result of the licensee not conducting a timely safety evaluation,
as required by 10 CFR 50.59.
In November 1987, NRC conducted a
management meeting with the licensee to clarify when safety
evaluations should be conducted.
During this meeting examples were
presented that were similar to the activity that resulted in this
event.
However, the licensee believed that an effective safety
evaluation program had been implemented and, therefore, did not
review the safety evaluation program for weaknesses. As a result of
this event, the licensee conducted a review of the safety evaluation
associated with facility modifications not directly related to the:
reactor plant cnd implemented improvements stated in the LER.
One apparent violation-and no deviations were identified.
8.
Follow-up on Notices of Violations and Deviations (91700, 92701)
The following open items are closed based on a review of licensee
response to Notices of Violation and/or Deviation, the licensee's
in-depth root cause analysis, and inspector follow-up and verification of
licensee committed actions.
Open Item 87-18-02, (Closed), Violation of Procedural Compliance While
Sluicing Between Safety Injection (SI) Cold Leg Accumulators. This
violation described a procedural noncompliance during the transfer of
water between SI cold leg accumulators.
Since the event the licensee has
emphasized coroliance with procedures by conducting both formal and
informal meeting. with all levels of management and supervision.
Additionally, the licensee has initiated the Quality Operations Rover
program.
Weekly, a member of the Quality Assurance Organization
evaluates various aspects of nuclear plant operation, including
procedural compliance, to assess the plant staffs' compliance with
procedures.
The Rovers' evaluations indicate improved compliance with
procedures.
The inspectors' evaluations have also indicated improved
compliance with procedures by plant operators.
The inspectors will
continue to evaluate procedural compliance by all plant personnel during
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routine inspection.
Open Item 87-18-05, (Closed), Violation of procedural Compliance to Post
Quality Control (QC) Hold Tags for Defective Equipment. This violation
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describes a procedural noncompliance in that QC Hold Tags were not posted
on equipment damaged as the result of transferring water between SI
accumulators prior to understanding and correcting the cause of the
damage.
Since this event, the inspectors verified the licensee had
strengthened Nuclear Division Procedure 600-1 " Control of Nonconforming
Materials, Parts, and Components".
The inspectors verified the licensee
has extensively used QC Hold Tags to control significant equipment and
component non onformances.
A recent example was the hanging of QC Hold
Tags on safety * elated nonconforming circuit breakers to alert operators
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of the potentiai for certain plant circuit breakers not to be able to be
remotely shut after a seismic event.
Open Item 67-31-01, (Closed), Deviation for Instrument Air System
Deviations from UFSAR.
The licensee determined that when the Su11 air
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Compressor (C116) was installed, the subsequent FSAR revision did not
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clarify that the "oilless compressor cylinder" referred only to the
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reciprocating compressors (C 102 A, B and C).
As part of an action plan
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in response to NRC Generic Letter 88-14, the licensee has completed a
detailed review of the as-built Instrument Air system as compared to
descriptions in UFSAR, design bases document and PPID's.
This review was
completed 3/3/89, and appropriate UFSAR revisions are in progress.
Open Item 88-30-01, (Closed), Violation for Failure to Include Service
Water Pump Bearing Water Flow Indicators in the Preventive Maintenance
Program.
The licensee concluded personnel error was the cause of the violation.
Because the gages could not be physically calibrated, they were not
included in the calibration program; however, by oversight the vendor
requirement to periodically inspect and clean the instrument to maintain
instrument accuracy was omitted.
As corrective action, the licensee
committed to include the subject flow instruments in the Preventive
Maintenance Program by May 1, 1989.
The instrument had been included in
the PM program by the end of the reporting period.
Additionally, one of
the three instruments had been cleaned and inspected.
These instruments
will be cleaned prior to the end of the 1989 Refueling Outage.
The
licensee also committed to evaluate the need for sending the instruments
to the vendor for calibration by' July 1, 1989.
A search for other
instruments of this type was made and none were identified.
Open Item 88-30-02, (Closed), Violation for Inadequate Administrative
Controls to Control Overtime of Maintenance Personnel.
This violation
describes an instance where overtime hours for maintenance personnel were
not sufficiently controlled to prevent exceeding work hour limitations.
The licensee concluded that oersonnel error was the cause of the
violation, in that the Maintenance Department supervisors did not
adequately monitor the overtime of personnel.
Also, Plant Management
failed to implement lessons learned from a similar event during the 1989
refueling outage.
The inspector verified that the corrective actions the
ifcensee ccmmitted to in the LER, review what controls exist and to set
up a system to assist Maintenance supervisors in maintaining control of
work hours, had been implemented.
Maintenance workers will report
overtime daily to a clerk, who will check to determine if a risk of
exceeding work-hour limits exists.
When an individual approaches-the
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limits, the supervisor will be alerted.
Also, the Plant General Manager
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issued a memoranuum directing all branch managers to review their
controls on work-hour limitations, and to establish measures appropriate
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for their work functions to ensure limits are not; exceeded.
The
inspectors also reviewed a recent QA audit, that covered the last forced
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outage, that concluded adequate controls exist concerning control of work
hours.
The NRC inspectors found that no formal written guidance existed for the
established measures" for the' Maintenance Department on the control of
work hours, that is,'no Maintenance Department procedure, no policy
statement nor change to the job descriptions of the clerk or craft
supervisors has been made.
Also, the new " Conduct of Maintenance Manual"
does not address the requirements for the individual worker to report
their time daily, nor the Supervisors' responsibilities to monitor
overtime.
Without these formal documented measures the potential to.
again exceed work hour limitations appears likely.
Additionally, the
absence of formal guidance on controlling work hour limitation appears to
conflict with recent Management policy on clear definition of
responsibility =and accountability.
The inspectors will continue to
closely assess licensee control of work hours during routine inspection.
Open Item ~ 88-30-05, (Closed), Violation for Failure to Initiate and
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' Document Required Investigation for Recorder LR-5521 Out-of-Calibration.
The licensee concluded the cause.of this violation was personnel error on
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the part of the I & C Supervisor, in that he failed to use an instrument'
list for a quality related test.
As a result of this error, an
out-of-calibration' form was not generated, and therefore, did not prompt
the required investigation.
A review of recent surveillance test data was performed, and the review
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indicated that since the last out-of-calibration occured in Febraury
1988, Periodic Operating Test (POT)-7-1 had since been performed with
satisfactory results and with the LR-5521 in-calibration.
The Systems Engineering Group performed the required out of-calibration
evaluation..for this occurrence, and recommended the use of the 1986
instrument list be discontinued.
This instrument list was compiled by
Plant Engineering in.1986, and is not formally controlled or maintained
current.
Use of the list has been terminated, and the I & C Supervisor
will prepare an out-of-calibration form for all quality related
instruments that are out-of-calibration.
The Systems engineering group
will-perform the evaluations as appropriate.
Open Item 88-30-07, (Closed), Violation for Lack of Adequate Management
Oversight to Ensure Maintenance Problems and Discrepancies Are Resolved
q
Before Proceeding.
The licensee determined that the root causes of the
event were inadequate management oversight and the lack of a trending
program for maintenance history.
Contributing to this issue was an
inadequate system for monitoring and tracking open MRs.
An engineering
evaluation by the licensee was conducted to address the~ low flow
condition, and appropriate revisions to the Operating Instructions were
implemented.
An improved system for tracking and monitoring the status
of open'MRs was developed and implemented on February 15, 1989.
A long
term program to improve maintenance f.istory, and to trend equipment
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problems and maintenance request problems was implemented in March 1989.
The effectiveness of these later two items will be addressed in future
NRC inspections.
Open Item 88-30-08, (Closed), Violation for Failure to Perform
Preventive Maintenance (PMs) on Equipment in Storage.
The license
determined that the root cause of the violation was personnel error by
warehouse employees.
Contributing to the procedural compliance
deficiency were two factors:
a.
Lower-tier procedures established in 1987 were cumbersome and
difficult to understand.
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b.
No formal support program was developed to ensure compliance
(ie. QA audit, nor preventive maintenance scheduling system).
The inspector verified that the following interim corrective steps had
been taken:
a.
All materials requiring desiccants had been inspected and where
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necessary, desiccants were replaced.
This was completed on
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October 6, 1988.
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b.
Shaft rotation maintenance had been performed on all equipment
and material requiring such preventive maintenance.
This
action was completed on October 6, 1988.
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c.
Electrical energization of materials requiring such preventive
maintenance was completed November 8, 1988.
d.
Meggering of electrical motors requiring such preventiva
maintenance was completed October 18, 1988.
e.
Examination of inventory items for shelf-life was completed by
December 31, 1988.
f.
A review of the Trojan Materials Management Department
improvement action plan was performed to identify any other
programs which were not receiving the correct priorities.
No
other problems were identified.
g.
Procedures for a comprehensive preventive maintenance program
were developed and fully implemented by January 16, 1989.
i.
These included lower-tier procedures which will provide clear
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direction for warehouse personnel.
Training was provided for
warehouse personnel prior to implementing the procedures.
The inspector also reviewed packages submitted to plant engineering for
all storage items identified to require PMs.
Engineering review is
expected to include a review of applicable technical manuals and vendor
recommendations for any additional required PMs (e.g. maintenance needed
to extend shelf-life).
The inspector also reviewed documents concerning
a computerized system to track required PM actions.
This program will
provide a formalized notification process to alert maintenance crews and
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warehouse management when action is required.
Follow-up of the revisions
to the PM program, as a result of the engineering review, and
effectiveness of the computerized tracking system will be addressed in
future NRC inspections.
Open Item 88-30-09, (Closed), Violation for Failure to Perform and
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Document Leak Test per ASME Criteria for Service Water Strainer Gasket
Replacement.
The licensee's root cause analysis concluded the cause of
the violation was personnel error due to the craftsman's failure to
document that he performed the inspection.
Licensee questioning of the
craftsman determined that the craftsman did inspect the system for
leakage.
Additionally, the licensee identified that the practice of
revising a work request to include additional work, which has been since
discontinued, prevented the reviewers from recognizing the inspection had
not been documented.
Also, the licensee identified that in the process
of generating the maintenance request (MR) the work group planner had not
recognized the repair as an ASME code repair, and therefore,.did not
require an inspection to be performed.
The licensee reviewed the MR and
the subject of code repairs with the planning staff to prevent
recurrence.
The NRC inspectors reviewed recent MRs to verify the
practice of appending work requests with additional repairs had been
discontinued.
Additionally, a recent maintenance request associated with
the service water system was assessed to verify the requirement to
inspect for leakage had been included.
Open Item 88-30-10, (Closed), Unresolved Item Concerning Inablity to
Retrieve Maintenance Request Packages.
This concern was raised due to
the inability of the work planning group to find seven of the eighty
Maintenance Request packages asked for by the team.
The licensee has
since identified the problems in locating these packages.
A review of
the work planning procedures and issues raised in response to violation
50-344/88-30-07 has resulted in the licensee developing an improved
system for tracking and monitoring the status of open MRs.
This system
was implemented on February 15, 1989.
The effectiveness of this program
will be observed during the 1989 refueling outage, and evaluated in
future NRC inspections.
Open Item 88-43-03, (Closed), Violation for Quality Control (QC)
Inspector's Failure to Report a Nonconforming Activity (NCAR).
This violation resulted from the QC inspector's misconception that
nonconformances were not required to be formally documented if a " circle
Q",
required observation, was not annotated on the work document; and
Quality Assurance supervision discouraging the inspectors from initiating
NCARs on inspector perceived " insignificant" procedure violations.
To
prevent recurrence, the licensee took the following corrective actions:
initiated an NCAR, issued a memorandum outlining expectations on
documentation of procedural non-compliances for Nuclear Quality Assurance
Department (NQAD) personnel, and revised Quality Inspection Procedures to
clarify the requirements for reporting and documenting procedural
noncompliance.
The inspectors verified Administrative Order (AO) 13-1,
" Inspection Control" had been revised (February 1, 1989) and that
supplemental training had been provided to Quality Inspections personnel.
Additionally, NRC inspectors have inspected maintenance that had been
observed by the licensee Quality Control inspectors.
An additional
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instance of a QC inspector failing to document a procedural noncompliance
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was identified in NRC inspection report 50-344/89-01.
It appears
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additional licensee corrective action is required to ensure all
inspectors are knowledgeable of documentation requirements.
The
licensee's corrective action to the Notice of Violation associated with
inspection report 50-344/89-01 is being drafted and will be evaluated
upon receipt.
No violations or deviations were identified.
9.
Follow-up on 10 CFR Part 21 Reports (92700, 92701)
10 CFR Part 21 Report on ASEA Brown Boveri K-Line Circuit Breakers
(0 pen Item 89-08-P Closed):
A Part 21 report was submitted which dealt
with the need to install slow close lever rebound springs on various
K-line circuit breakers to ensure proper operation after a seismic event.
The inspectors reviewed the licensee's actions in response to the
information provided in the Part 21 report.
Licensee review of drawings
and technical manuals revealed that there were approximately ninety
applicable K-Line circuit breakers installed in the plant.
Of these,
seven breakers had been purchased after July 1974.
According to the Part
21 report, breakers manufactured after July of 1974 were equipped with
the rebound spring.
Licensee inspection of breakers manufactured before
and after July 1974 confirmed the need to install rebound springs on the
older breakers.
A nonconformance report, NCR 89-033, was initiated which concluded that
continued use was acceptable.
This was based upon the finding that the
only safety-related equipment affected by the potential failure of the
circuit breaker to close after a postulated seismic event and a loss of
off-site power were the containment air coolers.
Licensee calculations
concluded that the plant could be maintained in Mode 3, Hot Standby, for
about eight hours without adversely affecting the environmental
qualification of equipment inside containment assuming no containment air
coolers were functioning.
Rebound springs were being ordered at the time
of inspection with plans to install them on safety related breakers in
the 1989 refueling outage and on non-safety related breakers as
preventive maintenance became due on each per the maintenance schedule.
The inspectors performed a sampling inspection to verify the licensee
tabulation of applicable breakers, reviewed the nonconformance report,
and discussed the supporting analysis with licensee engineering and
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licensing personnel.
A review of operating procedures verified that
operators were instructed to start containment air coolers in response to
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a loss of offsite power event.
In addition, the inspectors observed a
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demonstration that was attended by operations personnel of the necessary
actions to reset the slow close lever.
Discussions with maintenance
management indicated that electrical maintenance personnel would normally
reset the slow close lever, if needed.
The inspectors concluded licensee
actions addressed the concerns raised in the Part 21 report.
No violations or deviations were identified.
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10.
Review of Design Change Program (37702, 92701)
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The inspectors conducted a review of the' licensee's design change
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program.
The program as described in the following procedures was
reviewed for consistency with regulatory requirements set forth in the
administrative control section of the technical specifications and with
guidelines outlined in industry standards:
Nuclear Division Procedure NDP 200-1, Revision 8, titled
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" Design Change Control"
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Nuclear Plant Engineering Procedure NPEP 200-14, Revision 7,
titled " Detailed Construction Package Preparation and Control"
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Nuclear Plant Engineering Procedure NPEP 200-11, Revision 1,
titled " Verification of Design"
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Nuclear Plant Engineering Procedure NPEP 200-15, Revision 7,
titled " Processing of As-Built Packages"
Nuclear Plant Engineering Procedure NPEP 200-6, Revision 3,
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titled " Preparation of Engineering Drawings"
The above procedures discussed the licensee's request for design change
(RDC) process which included preparation of a preliminary design,
performance of independent design verifications, review and approval of
the design change by engineering management and the Plant Review Board,
preparation of a detailed construction package (DCP), implementation of
the design change by the construction work group, and turnover to the
plant operations department.
The procedures also addressed the process
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by which the implemented design change is reflected on engineering
drawings and documents.
The inspectors reviewed two recently completed safety-related as-built
design packages and discussed the design changes with engineering and
plant modifications personnel.
The design packages were RDC 85-052/DCP
13, which dealt with modifications to the remote shutdown station room
and equipment base frame supports, and RDC 83-061/DCP 1, which controlled
the replacement of 18 packless globe valves in various emergency core
cooling systems and the reactor coolant system.
RDC 85-052/DCP 13
involved a revision of the detailed construction package.
In the review
of the RDC's and DCP's, the inspectors verified that required independent
design verifications were performed, that the need for system change
descriptions which initiated changes to procedures and personnel training
was addressed, and that appropriate reviews and approvals were obtained
for DCP revisions.
The inspectors also verified the review and approvals
obtained for field changes to the detailed construction packages.
No
significant discrepancies were identified in the review.
In the control of engineering drawings, the use of drawing change notices
(DCN) was one method to show as-built changes to an existing nuclear
plant design drawing.
Per NPEP 200-6, DCNs were required to be
incorporated in new or revised drawings within 90 days of issuance or
whenever the number of DCNs against a particular drawing exceeds five in
number.
The inspectors reviewed a sample of control room drawings and
noted that DCNs for piping and instrument diagrams appeared to meet the
above requirement.
Various electrical drawings, however, either had more
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than five associated DCNs or had recent DCNs which were not closed within
90 days of issuance.
Examples of findings are described below.
Three of the electrical drawings were designated by the licensee as top
documents which were defined in NPEP 200-15 as those design documents
which are of prime interest to plant operations personnel.
Drawing E-45
which dealt with 120 VAC safety relatec instrument bus panels had DCN 69
and 70 issued for revision 37 which were not closed within 90 days of
issuance.
Drawing E-46 which dealt with other 120 VAC instrument bus
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panels had DCN 113, 114, and 115 for revision 63 which were not closed
within 90 days of issuance.
Drawing E-22, the electrical fuse schedule,
had DCN 80, 81, 82, and 84 for Revision 8 which were not closed within 90
days of issuance.
Drawing change notices 80 and 84 dealt with safety
related components of the auxiliary fet dwater system and chemical and
volume control system, respectively.
L-45, E-46, and E-22 were
designated us top documents per NPEP 200-15.
In addition, E-22 had 15
associated DCNs for Revision 8 before llevision 9 was issued.
At the time of inspection, the following electrical drawings had more
than five associated DCNs:
E-29, Revinion 58, the pull and terminal box
schedule with 17 DCN's; E-191, Revision 37, electrical raceway schedule
with 37 DCNs; and E-192, Revision 36, the electrical circuit schedule
with 53 DCNs.
A number of these DCNs had also been issued in excess of
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90 days.
.These findings indicata the need for increased attention to assure
compliance with procedtral requirements for drawing revisions.
The
inspectors consider the above findings to be an apparent violation
(50-344/89-05-07).
One apparent violation and no deviations were identified.
11.
Commercial Grade Procurement (38703)
In response to a Region V request, the licensee, on February 21, 1989,
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submitted additional information regarding commercial grade material use
in the Main Feedwater system.
This included a list of pressure-bearing
materials, the approximate quantity installed, identification or heat
number, manufacturer, supplier, and the physical and chemical test
results to date.
This list also identified all weld filler material used
in the MFW piping replacement.
In addition, the submittal documented the
licensee's evaluation that the feedwater piping was acceptable for
continued use until the 1989 refueling outage.
The inspector's technical evaluation of the licensee's submittal involved
matching ASTM chemical and physical requirements to that specified on the
Certified Material Test Reports and the licensee's laboratory test
results.
The MFW piping replacement was procured to standard
specification ASTM A 106, Grade B or ASTM A 333 Grade 6.
The laboratory
test provided independent mechanical and chemical test data as supporting
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evidence that the critical characteristics of the installed piping
materials conform to code requirements.
The ASTM material
specifications, the CMTRs and the results of the licensee's independent
testing were found to be within tolerance.
The licensee's hardness
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testing of materials supports the acceptability of materials where
physical testing had not been conducted.
In general, the licensee's
review of the various manufacturers and suppliers found that they had QA
programs of varied degrees with several having ASME Quality Systems
Certificates (QSC).
Most had been audited by organizations other than
PGE.
The below discussed items summarize the material that was
relat-ively weakly addressed.
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. Flow Bend 14-inch elbows, heats 8278 and A403
No independent chemical, physical, or hardness testing had been
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performed by the licensee to verify the associated CMTRs due to
the unavailability of material samples.
No known manufacturer QA program.
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The inspector considered the material to be acceptable for the
following reasons:
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Three other heats of Flow Bend elbews were independently tested by
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the licensee and found to be satisfactory, indicating the validity
of Flow Bend CMTRs.
Bechtel audited Flow Bend in 1983, 1984, 1985, and 1989.
Flow
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Bend is considered by Bechtel to be a good commercial supplier.
Flow Bend is not known by the NRC to be an unacceptable
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supplier.
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In process construction inspections and tests of the subject
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material indicate that it is acceptable material.
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Additional testing will be performed during the 1989 outage.
Mills Iron 14 x 16 reducers (2), heat 80A
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No independent chemical, physical or hardness testing done had-
been performed by the licensee to verify the validity of the
associated CMTRs.
The inspector considered the material acceptable for the following
reasons:
The raw steel was procured by Mills Iron from U.S. Steel.
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Two other Mills Iron fittings of a different heat in the
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warehouse tested satisfactory.
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The QA program has been favotably audited by Bechtel to
NCA3800.
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Various small pieces' including:
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2 ft. of 4-inchipipe'from Nippon.
.(4) 1-inch half. couplings.from Fuji.
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reasons:
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All of the material has been in ' service since 1987.
All of the material was subject to weld inspections and
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hydrostatic testing.
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Nippon has a QSC.
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The small quantity and size involved minimize the potential of
problems.
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' Weld rod
Generally no independent chemical or physical testing had been
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done.
Information. supporting the quality of the materials includes:
[All.boughtfrommanufacturerswithanASMEQualitySystems
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Certificate (QSC).
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E-7018 bought in sealed containers, thereby minimizing the
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possibility of supplier problems.
The inspector's independent evaluation of the information provided by the
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licensee, regarding the MFW piping and fittings, is that sufficient
-evidence of quality in the subject material exists to conclude that this
material was acceptable for continued use until the 1989 refueling
outage. "The licensee has scheduled additional testing to restive any
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remaining material concerns prior to completion of the 1989 refueling
. outage.
The quality of the weld filler materials were evaluated
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separately.
In order to evaluate the acceptability of the weld material used in
welding the MFW replacement piping, the inspector reviewed the
radiographs associated with welds made on the feedwater pipe.
The welds
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were :randcaly selected from design drawing numbers EBB-3-1 (Revision 13)
and EBB-3-2 (Revision 11).
These drawings identify the weld numbers and
' locations within the applicable Steam Generator Loops (A, B, C and D).
.The radiographs reviewed were for the following welds: Weld No. P25923
from Loop A, Weld Nos. P25876 aGd P25972R4 from Loop B, Weld Nos.
P25991R1 and P25889 from Loop C, and Weld No. P25881R4 from Loop D.
Intermittent radiographs were included in'the inspector's review; these
are "information only" shots taken at various stages of the welding
process to identify any deficiencies that would cause weld rejection.
Rejected welds that required repair are identified by placing an R after.
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the weld number.
For example, P25972R4 indicates that 4 repairs were
made before the weld joint was determined to be acceptable in accordance
with ASME Section XI requirements.
For the radiographs of the weld
joints reviewed, the inspector observed that.the weld repairs were always
made to the weld root and, in each case, involved the use of 1/8" E705-2
' Heat No. 065502.
Discussions with licensee personnel revealed an
exp.assed concern, by the welding ar.d QC departments, on the use of this
particular weld rod.
High levels of porosity were identified with the
use of this weld rod which resulted in one MFW pipe weld root being cut
.out,.and the failure'of previously qualified welders to qualify based on-
radiographic rejection of the welders test coupons.
When questioned why
this problem wasn't addressed on a Nonconformance Report (NCR), the
inspector.was informed that on July 30, 1987 an NCR was initiated.
A
copy was~provided for the inspector's review.
This NCR described the
nonconforming condition as '/ Filler metal (Linde or L-Tec) E705-21/8" to
3/32" G.T.A,W. wire do not produce x-ray quality welds, for welder
qualification and in plant requirements of piping components that.have to
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meet such criteria." This NCR, however, was not validated and assigned
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an NCR number.
The Plant Modifications Manager, when informed, had the
1/8" E70S-2 weld rod placed on hold in the warehouse;.but no NCR was
generated to formally address the problem.
Although this nonconforming
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weld rod was not dispositioned through the NCR process, the inspector is
satisfied that the MFW pipe welds selected for review were satisfetory.
This conclusion is based on the inspector's review of the intermittent
- radiographs and the final radiographs taken of the repaired welds for
code acceptability.
The failure to process the NCR in accordance with.the established QA
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program procedures to assure that the nonconforming weld rod is promptly
identified, the root cause of the condition is determined and corrective
action taken to preclude repetition is an apparent violation of
10 CFR 50, Appendix B, Criterion V (50-344/89-05-08).
.At the inspector's request, the Materials Manager had the warehouse
searched to identify if any of this weld rod was located onsite.
All of
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the 1/8" E705-2 Heat No. 065502-was removed from the warehouse and sent
to local schools.
However, the 3/32" E705-2 Heat No. 065472 was in
stock;'this rod produced weld porosity although to a lesser extent than
the 1/8" rod.
The licensee stated they would try to determine if any of
the 1/8" rod is still available and, if so, obtain some for testing.
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the interim, the licensee committed to perform some tests on the existing
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supply of the 3/32" E70S-2 rod.
The inspector will review the results of
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this, effort during a future inspection when evalurting licensee actions
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taken'to address the nonprocessed NCR.
12.
Unresolved Item
.An unresolved item is a matter about which more information is required
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to ascertain whether it is an acceptable item, a deviation, or a
violation.
An unresolved item is discussed in paragraph 5.
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13.
Severity Level V Violations
As stated in Section V.A of 10 CFR Part 2, Appendix C, " General Statement
of Policy and Procedure for NRC Enforcement Actions," 53 Fed. Reg. 40019
(October 13, 1988), a Notice of Violation will not normally be issued for
isolated Severity Level V violations provided that the licensee has
initiated appropriate corrective actions before the inspection ends.
Two
apparent Severity Level V violations for which a Notice of Violation was
not issued are discussed in paragraphs 3 and 7 of this report.
14.
Exit Interview (30703)
The inspectors met with the licensee representatives denoted in paragraph
1 on March 9,1989.
The inspectors summarized the scope and findings
associated with the Commercial Grade Procurement follow-up inspection
conducted March 8-9, 1989.
The inspectors met with the licensee representatives denoted in paragraph
1 on March 23, 1989, and with licensee management throughout the
inspection period.
In these meetings the inspectors summarized the scope
and findings of the inspection activities.
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