ML20248B096

Responds to Violations Noted in Insp Rept 50-346/89-16. Corrective Actions:Sys Procedure Sp 1104.69 Revised to Require Opening of Air Cooled Condenser Isolation Valves Prior to Starting Control Room Emergency Ventilation Sys

ML20248B096
Person / Time
Site:	Davis Besse
Issue date:	09/25/1989
From:	Shelton D TOLEDO EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
1-892, NUDOCS 8910030094
Download: ML20248B096 (16)

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. .. i TOLEDO EDISON- t A Centenor Energy Comp iny -

I DONAU) C. SHELTON ,

va mmoent-seer >

I'""'" #3 Docket Number 50-346-License Number NPF-3 Serial Number 1-892 1

l September 25,'1989 l United States Nuclear Regulatory Commission Document Control Desk Vashington, D. C. 20555 Subj ect : Response to Inspection Report 89016 Gentlemen:

Toledo Edison (TE) has received Inspection Report 89016 (Log Number 1-2139).

On September 13, 1989, the due date for the respons c to the Notice of Violation was extended to September 25, 1989, per discussion with the Senior Resident Inspector. Toledo Edison provides the following response.

Violation 89016-05: " Technical Specification (TS) Limiting Condition for Operation (LCO) 3.7.6.1 requires that two independent control room emergency ventilation systems (CREVS) be operable in Modes 1, 2, 3 and 4.

Contrary to the above, from 5:42 a.m. until 2:55 p..n. on i June 12, 1989, while the unit was in Mode i, both trains of CREVS vere inoperable and the provisions of Technical Specification 3.0.3 vere not followed."

Response: Acceptance or Denial of the Alleged Violation Toledo Edison acknowledges the alleged violation.

Reason for the Violation  !

On June 26, 1989, during the performance of the CREVS Monthly I Test, the cooling system compressor failed to start. The CREid i Train 1-1 was declared inoperable and the seven-day action statement of Technical Specification 3.7.6.1 was entered. The CREVS Number 1 compressor failed to start due to an existing refrigerant high pressure trip signal being present. The investigation of the compressor start failure also concluded i that the compressor had probably tripped on June 12, 1989, when l THE TOLEDO EDISON COMPANY EDISON PLAZA 300 MArtSON AVENUE TOLEDO, OHIO 43652

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' Docket Number 50-346 License Numbet NPF-3 ESerial Number 1-892 Page 2 the system was last operated. Control Room Emergency Ventilation System Train 1 was operated for approximately 11 minutes on June 12, following an inadvertent chlorine detector actuation which tripped the Number 2 Normal Control Room Ventilation System.

Additionally, it was determined that the high refrigerant pressure condition resulted from a premature automatic switchover of the CREVS from the water cooled mode to the air cooled mode. Operation of the system in the air cooled mode, which is not the normal mode of operation, requires the opening of manual isolation valves which are normally closed. The starting pressure for the CREVS Number 1 compressor, had exceeded the automatic switchover setpoint of 160 1 5 psig and initiated the premature switchover to the air cooled mode. The switchover to the air cooled mode was discovered by an operator 1 and system engineer on June 12 and the CREVS Number 1 was returned to the water cooled mode. The status of the pressure switch for the high refrigerant pressure trip can only be determined by visual inspection at local panel C6706 and was not noticed at that time. It was also determined during the investigation that CREVS Number 2 was inoperable for maintenance from June 8, 1989, until 2:55 p.m. on June 12, 1989. Therefore, since CREVS Number 1 had been inoperable from 5:42 a.m. on June 12, 1989 to June 28, 1989, neither CREVS train was available for approximately 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> and 13 minutes (5:42 am to 2:55 pm on July 12). This situation requires entry into Technical Specification 3.0.3. However, since prior to completion of the investigation, Operations personnel were unaware that both trains of CREVS vere inoperable, the action requirements of Technical Specification 3.0.3 were not followed.

Corrective Action Taken and Results Achieved System Procedure SP 1104.69 (DB-0P-06505), " Control Room Emergency Ventilation Procedure" was revised to require opening of the air cooled condenser isolation valves prior to starting the CREVS. This vill facilitate operation of the system in the air caoled mode if an automatic switchover occurs during a normal system startup. The revised procedure became effective on September 1, 1989 after all operations shift personnel received training on the procedure changes and the events which prompted the changes. The Technical Specification violation discussed previously was reported to the NRC on July 26, 1989 in LER 89-10.

Actions Taken to Prevent Recurrence A setpoint change request was initiated to raise the setpoint for pressure switcher PS5900 and PS5901 (pressure switches for automatic switchover to air cooled mode for CREVS Number 1 and CREVS Number 2 respectively) from 160 psig to 175 psig. This change should prevent premature svitchover due to the initial pressure surge on system startup, while remaining below the high

' Docket Wumber 50-346 License Number NPF-3 Serial Number 1-892 Page 3 pressure cutout of 220 psig. The procedure changes referenced above vill permit satisfactory operation of the system in the air cooled mode if a switchover occurs before the setpoint change is implemented.

Date When Full Compliance Vill Be Achieved Full compliance vill be achieved upon implementation of the setpoint changes described previously. These changes are expected to be completed by October 20, 1989.

Violation 89016-11: " Technical Specification 4.7.9.1.1.c requires the fire suppression water system be demonstrated operable by verifying that each valve in the flow path is in its correct pocition at least every 31 days.

Contrary to the above the licensee verified the fire suppression water system valve positions on May 3, 1989, and did not verify their position again until July 8, 1989, which is in excess of 31 days."

Violatior 89016-12: " Technical Specification 3.7.9.1 requires that the NRC be notified by telephone within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of an inoperable fire j suppression system.

Contrary to the above the licensee determined on July 8, 1989, that a fire suppression operability surveillance which is i required to be performed at least every 31 days had not been )

performed since May 3, 1989. The licensee reported this event to the NRC on July 11, 1989, which was in excess of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />."

Response: Acceptance or Denial of the Alleged Violations Toledo Edison acknowledges the alleged violations. Due to the ;

interrelated nature of.these violations the responses have been combined. I Reason for the V 'ations j On July 8, 1989, at t"25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br />, the shift Supervisor noted that Surveillance Test ST 5016.09, " Fire Protection Valve Monthly Inspection" appeared to be beyond its Technical Specification late date of June 22, 1989. 'The Shift Supervisor directed that the surveillance be performed promptly as a precautionary measure while investigating to determine the status of the surveillance test, which should have been performed in June.

l This test which was completed at 1252 on July 8, 1989, verified that the fire suppression system was operablk by confirming that an adequate flovpath existed. On July 11, 1989, it was confirmed that the June surveillance had been missed. It was also determined that the applicable surveillance requirements of Technical Specification (TS) 4.7.9.1.1.c had not been completed

' Docket Number 50-346

, License Number NPF-3

". Serial' Number 1-892- ,

Page 4 ]

since May 3, 1989. This information was reported to the NRC by l telephone at 1609 hours0.0186 days <br />0.447 hours <br />0.00266 weeks <br />6.122245e-4 months <br /> on July- 11, 1989 to satisfy Action 4 Statement b.2.a of TS 3.7.9.1 and followed up by a telecopy of I the information at 1600 hours0.0185 days <br />0.444 hours <br />0.00265 weeks <br />6.088e-4 months <br /> on July. 12, 1989 to satisfy Action ]'

Statement b.2.b. Af ter further review of the reporting requirements for this occurrence it was determined that the call made'on July 11 should have been made prior to 08Z5 hours on June 9, 1989. This information was reported to the NRC in a follovup call made'at 1729 hours0.02 days <br />0.48 hours <br />0.00286 weeks <br />6.578845e-4 months <br /> on July 11, 1989. The missed survo:llance was also reported to the NRC via LER 89-08 on July 24, 1989, as required by 10CFR50.73 (a)(2)(1)(B).

A review of the events which led to the missed surveillance concluded that the cause was mainly attributable.to an incomplete follovup of the administrative details associated

.vith the disposition of test deficiencies when the. surveillance was performed in May. Surveillance? Test ST 5016.09, Fire.

Protection Valve Monthly Inspection, required all valves in the fire suppression flovpath to be in specified positions. When the May test was performed it was discovered that-some of the valves had been previously closed to isolate leaks. The test was then suspended due to the inability to perform the test as .

written. It was subsequently determined that sufficient valves vere in their correct position to meet the requirements of TS 4.7.9.1.1.C, by establishing an operable flovpath.

The suspension of this test with the system being declared operable created confusion among the affected departments. This resulted in the test being statused as suspended, rather than complete on the computerized surveillance tracking system and the June test consequently was not scheduled. Although, sufficient information was available'to determine that a scheduling anomaly existed, none of the responsible organizations acted to ensure that problems associated with the May test vere resolved.

Corrective Action Taken and Results A'chieved On July 8, 1989, Surveillance Test ST.5016.09 was performed and a flow path was verified as operable. ' Additionally, procedure DB-FP-03003, "31 Day Valve Alignment Verification",was made available for use. This procedure provides added flexibility in )

determining an operable flovpath to satisfy the surveillance- l requirements of TS 4.7.9.1.1.c. Circumstances surrounding this event were reported in LER 89-08.

Action Taten To Prevent Recurrence j 1

A meeting was conducted by upper management' personnel on- l July 17, 1989 with the appropriate parties to emphasize the l interdepartmental responsibilities for ensuring Technical  ;

Specifications requirements are met. The causes and lessons learned from the specific occurrence cere discussed. It was noted that although specific groups were assigned. ,

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' Docket Number 50-346 License Number NPF-3 i ESerial Number 1-892 Page 5 3 l

responsibilities for suspended tests by the existing procedures j there vere additional opportunities for others to have prevented the missed surveillance.

Date When Full Compliance Vill Be Achieved Full compliance with the stated corrective ac tions was achieved on July 24, 1989 with submittal of LER 89-008 vhich detailed an I

analysis of the occurrence and corrective actions taken.

Violation 89016-08: " Technical Specification 4.11.1.1.1 requires radioactive liquid vastes shall be sampled and analyzed prior to the release of each batch.

Contrary to the above, on July 14, 1989, the licensee released approximately 1700 gallons of liquid radioactive vaste from Clean Vaste Monitor Tank 1-1 prior to sampling the contents of the tank."

Acceptance or Denial of the Alleged Violation Toledo Edison acknowledges the alleged violation.

Reason for the Violation On July 14, 1989, at 1735 hours0.0201 days <br />0.482 hours <br />0.00287 weeks <br />6.601675e-4 months <br /> an unplanned radioactive liquid release from Clean Vaste Monitor Tank (CVMT) 1-1 occurred while attempting to perform a release from CVMT 1-2. The release continued for approximately 10 minutes prior to its discovery and subsequent termination. Approximately 1700 gallons of liquid and 2.14E-3 Curies of entrained noble gases were discharged to the collection box during this release.

The cause of the unplanned release was an error in Procedure <

DB-0P-03011, Radioactive Liquid Batch Release. Section 5.12 of this procedure provides direction for performing a CVMT 1-2 release. Step 5.12.3 stated that if the CVMT Transfer Pump 1-2 ,

is being used to perform the release, then lineup CVMT 1-1 for i Makeup / Discharge, Normal Pump Lineup, in accordance with DB-0P-06105 (SP 1104.83), Clean Vaste Monitor Tank Operations.

The step should have called for the lineup of CVMT 1-2 for Makeup / Discharge. Because of the error, the operator used the wrong list of valve positions from SP 1104.83. This placed four valves in the open position that would have been closed had the correct list been used. This lineup allowed water from CVMT 1-1 to be released when the #2 transfer pump was started. ,

The appropriate sampling had previously been performed in preparation for a release from CVMT 1-2. However, due to the inadvertent release from CVMT 1-1, Technical Specification l Surveillance Requirement 4.11.1.1 to sample the tank prior to release was not satisfied. The estimated volume and activity

• Docket Wumber 50-346 License Number NPF-3

' Serial Number 1-892 Page 6 planned to be released from CVMT.1-2 was 22,000 gallons of liquid and 2.12E-2 Curies of entrained noble gases. Vater in the CVMT is filtered and demineralized. Both radiation monitors RE1770A and RE1770B that sample the common discharge line for the CVMTs were operable with very lov' alarm setpoints. Since the monitors did not detect any. unusual activity, offsite doses remained within allowable limits.

Corrective Action Taken and'Results Achieved Temporary Approval TA 89-4775 was issued on July 15, 1989, to correct the identified error ~in DB-0P-03011. Procedure sections necessary to perform a release from CVMT were re-validated.

A release from Clean Waste Monitor Tank 1-2 was successfully completed on July 16, 1989.

The additional procedure discrepancy described in Violation 89016-08, which involved a reference ~to Procedure DB-CH-03017, was corrected by TA 89-5758 on September 8, 1989.

The missed surveillance requirement was reported to;the NRC in LER 89-012, which also detailed.these corrective actions and an analysis of the occurrence.

Actions Taken to Prevent Recurrence The procedure. validation process has been upgraded since the ,

date of the revision for which the subject violation was '

identified. Improvements incorporated into the current validation process should preclude further occurrences of similar procedure discrepancies.

Date When Full Compliance Will Be Achieved-Full compliance was achieved with the approval of TA 89-4775 on July 15, 1989.

Violation 1 89016-06: " Technical Specification 6.8.1.a requires that written j procedures shall be established, implemented and maint'ained. j covering the activities recommended in' Appendix A of Regulatory ,

Guide 1.33, November 1972. Regulatory Guide 1.33 specifies that '

procedures are required for the operation of the' Service Vater system. Contrary.to.the above the licensee failed to implement procedures for the Service Vater System which are recommended by. '

Appendix "A" of Regulatory Guide 1.33 as shown by the~following examples: l

a. On July 9, 1989, at'1:40 a.m. the licensee ~did not declare Emergency Diesel' Generator 1-1 inoperable as required by j Section 2.9 of Procedure SP 1104.11, " Service Water System Operating Procedure."

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' Docket Number 50-346 License Number NPF-3  ;

Serial Wumber 1-892 ]

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b. On July 9, 1989, the licensee did not electrically align the Service Water Pur.p 1-3 strainer and blowdown valve to Bus E12C when alig ning Service Vater Pump 1-3 to Service Vater Loop Number 1 as required by Procedure SP 1104.11."

Response: Acceptance or Denial of the Alleged Violation Toledo Edison acknowledges the alleged violation.

I Reason for Violation

a. Service Water (SV) Loop Number 1 was declared inoperable ]

after preliminary review of test data indicated that SW Pump j Number 1 had failed to meet the acceptance criteria of its i

,uarterly flow test. The plant entered the action statei.cnt I for Technical Specification 3.7.4.1, SV Pump Number 3 was eligned to Loop 1, and the Loop was declared operable after approximately 2% hours. Although the Technical j Specification Action Statement was met, plant personnel did not implement Section 2.9 of the Service Vater System Operating Procedure (SP 1104.11, Revision 15), which required that when the SV System is inoperable because of failure, repair work in progress or routine maintenance on i the system the associated ECCS Train and Emergency Diesel Generator be declared inoperable. Technical Specification 3.8.1.1 requires that the remaining A.C. sources be demonstrated operable by performing TS Surveillance ,

Requirement 4.8.1.1.1.a within one hour and at least once I per 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafter by performing TS Surveillance {

Requirement 4.8.1.1.2.a.4 vithin 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. Neither the j associated ECCS train nor EDG vere declared inoperable because responsible operations personnel did not observe Section 2.9 of the Precautions and Limitations section.

b. On July 11, 1989, at 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br />, while ,erforming weekly breaker line-up verifications per DB-SC-03041, Operations personnel discovered that MCC EF12C vas improperly aligned to Bus F12C rather than Bus E12C as required. As a' result, i there was no electrical separation between SV Pump Number 3 l and SV Pump Number 2 in that the strainer end blowdown j

, valves were povered from the same source. Investigation determined that the breaker had been misaligned on July 9.

1989, when SV Pump Number 3 was aligned to Loop 1 after SW Pump Number 1 had been declared inoperable at 0140 hours0.00162 days <br />0.0389 hours <br />2.314815e-4 weeks <br />5.327e-5 months <br />.

Therefore, SV Loop Number 1 had been inoperable since 0140 hours0.00162 days <br />0.0389 hours <br />2.314815e-4 weeks <br />5.327e-5 months <br /> on July 9, 1989. However, as configured, it was capable of performing its intended function. Review of Section 5.4 of SP 1104.11, which was used for the SV Pump Number 3 lineup, revealed that no guidance was included for povering its strainer and blowdown valve. This review also revealed that Section 5.2 had no guidance for this.

However, other sections which vere not in use at the time included a caution statement to ensure that the stra3ner and blowdown valve was povered from the proper electrical bus.

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' Docket Number 50-346 License Number NPF-3 Serial Number 1-892 i Page 8 Toledo Edison's root cause evaluation concluded that SP 1104.11, Revision 15 was inadequate since not all applicable sections of the procedure addressed the alignment of EF12C.

This procedure had been revalidated in late 1988; however 1 the deficiency was not identified since the focus of the j

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validation effort was to verify that the information in the procedure was. technically correct. The fact that caution statements were not included in Sections 5.2 and 5.4 was overlooked.

'This deficiency was identified later and a Procedure Change Request (PCR) 89-3376 was generated on May 6, 1989,  ;

requesting that a caution be added to Section 5.2 to ensure that when SV Pump Number 3 is realigned to the opposite train, EF12C is realigned. The PCR was deferred to the next revision based on the progress of the SV System Procedure rewrite and the belief that this was a routine operation with adequate guidance in the existing procedure.

Operations personnel failed to recognize the importance of the change. Appropriate action vould have been to initiate a change at that time.

Corrective Actions Taken and Results Achieved

a. The procedural requirement to. declare the associated ECCS i system and EDG inoperable was removed since it is not-consistent with Toledo Edison's current interpretation of-Technical Specification requirements. This was accon.plished by Temporary Approval 89-4843 dated July 19, 1989.

b. EF12C was aligned to E12C at 0225 hours0.0026 days <br />0.0625 hours <br />3.720238e-4 weeks <br />8.56125e-5 months <br /> on July 11, 1989 thus restoring SW Pump Number 3 to operability. Temporary Approval 89-5160 to SP 1104.11 was issued on August 6, 1989.

This added caution statements to Sections 5.2 and 5.4 to ensure proper electrical lineup.

Action Taken to Prevent Recurrence All operating crews were briefed on the above concerns and the appropriate corrective action for similar situations. This coupled with the specific corrective actions should preclude recurrence.

Date When Full Compliance Vas Achieved

a. Full compliance was achieved on July 19, 1989, when TA 89-4843 was issued.

b. Full compliance was achieved on August 6, 1989, when TA 89-5160 was issued.

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" Docket Number 50-346

, License Number NPF-3 Serial Number 1-892 Page 9 Violation 89016-01: "10CFR50, Appendix A, " General Design Criteria for Nuclear Power Plants," Criterion 4, " Environmental and dynamic effects design bases" requires that components important to safety be protected from the effects of discharging fluids which may result from equipment failuces.

l The Service Water Pumps are components important to safety.

Flooding of the Service Vater Pumps is an effect of discharging l fluids from which they must be protected. Rupture of the Circulating Vater System piping is an equipment failure which discharges fluids.

Contrary to the above, from April 22, 1977, until February 10, l 1989, the Service Water (SV) Pumps were not protected from flooding which could have resulted from rupture of the Circulating Vater System due to a hole in the vall between the condenser pit and the SV tunnel."

Response: Acknowledgment or Denial of the Alleged Violation Toledo Edison acknowledges the alleged violation.

Reason for the Violacion The original submittal of the Final Safety Analysis Report (PSAR) did not discuss the effects of a circulating Vater System rupture. During the review of the FSAR for initial licensing the NRC asked Toledo Edison to:

" Provide elevation drawings showing the water level in the turbine building at various times after a complete rupture of the main condenser circulating vater rubber ,

expansion joint. For each time increment discuss which, if any, essential system and components could be rendered inoperable. Include in your discussion the consideration given to passageways, pipe chases, )

cableways, and all other possible flow paths joining the flooded space to otner spaces containing essential l systems and components. Discuss the effect of the i flood waters on all submerged essential electrical systems and components."

The response submitted in Revision 3 to the FSAR, dated November 1973, stated:

l Assuming a complete rupture of the main condenser circulating water expansion joint (108 inch ^.D. pipe) on the inlet side of-the condenser, two circulating pumps on one train will run out. In addition, water from the cooling tower and piping vill _ flow back j through the rupture. The condenser pit (El. 567) vill  !

flood, inundating the main feed pump turbine hydraulic 1 and lube oil pump motors at El. 573. This vill result l

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' Docket Number 50-346 'd

. License Number NPF-3  !

- ' Serial Number 1-892 Page 10 in a trip of the main feed pump turbines. At about ,

El. 575 the condensate pump motors vill be flooded, ~1 causing the trip of these pumps. There is no other major equipment of. consequence belov El. 585. No essential components are located in the turbine i building. There are no paths for water to escape i belov El. 585. 'See figures 3-42, 3-43, and 3-44."

However, on February 6, 1989 the NRC Resident Inspector notified Toledo Edison of a blockout in the Condensate Demineralized

. Holdup Tank Room which could permit water from a circulating.

I water expansion joint rupture, to flow into the Service Water l Pipe Tunnel. 'This construction blockout has been in existence since construction.

Subsequent evaluation determined that the Service Vater. pumps vould be affected by a' circulating water expansion joint rupture. Assuming the main condenser circulating vater expansion joint on the inlet side of the condenser ruptures flooding of the condenser pit and the Condensate Demineralized Holdup Tank Room would occur. When the water. level' reaches the height of the blockout, the Service Water Pipe Tunnel vould also flood. The water vould then backup through the Service Water Pump Room drains and flood the Service Water pumps. l Corrective Action Taken and Results Achieved .

l As a precaution, a Standing Order,89-026 was issued on February {

10, 1989, instructing operators to plug the floor drains ~in SV I Pump room in the event of a SV. tunnel flooding event. Abnormal procedures AB1203.17, Loss of Service Vater Pumps / Systems.and AB1203.24, Circulating Water Pump Trip / Circulating Water System Ruptures, vere revised on Harch 23, 1989, to add guidance fur the operators in response to SV tunnel flooding.

Subsequently, an additional concern was identified and evaluated. It was determined that the Service Water Valve Room-would flood and render valves, SV-1399 and SV-1395,. incapable of closing in this event. The failure of these-valves to close vould. prevent isolation of the non-essential-heat loads from the l Service Water System and potential Service Water pump runout. )

An interim safety evaluation (SE 89-0177). performed-on August 1, j 1989 concluded that given current and expected SV supply requirements through August 31, 1989 that isolation'could.be j assured prior'to flooding until the blockout could be filled.  !

As a result of this concern, the blockout has been filled to i create the required flood barrier.

l Date When Full Compliance Vill Be Achieved .

The blockout has been filled to create.the necessary flood' i barrier. Actual physical work associated with this task was ,

completed on August 31, 1969. The Operations procedures were I changed on March 23, 1989, to instruct the operators on the j l

' Docket Number 50-346

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License Eumber NPF-3

-Serial Number 1-892 Page 11 actions to take in the event of Service Vater Tunnel flooding.

Standing Order 89-026 was issued on February 10, 1989.

Full compliance has been achieved.

Violation 89016-15: "10CFR50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed by procedures appropriate to the circumstances.

Contrary to the above, the licensee knowingly issued a fire protection procedure which contained errors which is not appropriate to the circumstances."

Response: Acceptance or Denial of the Alleged Violation Toledo Edison disagrees with the violation as written. However, Toledo Edison acknowledges that circumstances surrounding the usage of DB-FP-04002 constitute examples of failure to follow procedures.

Reason for the Violation l

Procedure DB-FP-04002, Monthly Fire Hose House Inspection is used to verify that each fire hose house contains the minimum required equipment for fire fighting purposes and that the general condition of the hose houses is satisfactorily maintained. Hose houses were formerly inspected using periodic j test procedure PT 5116.07. DB-FP-04002 replaced PT 5116.07 and revised the hose house verification requirements to satisfy a later version of NFPA 24. During the initial performance of DB-FP-04002 on April 5, 1989, twenty (20) test deficiencies were identified. The test deficiencies identified differences between the hose house inventory required by the procedure and )

actual inventory verified during the inspection.

Part of the acceptance criteria for DB-FP-04002 stated that the fire hose houses contain the minimum required equipment listed on procedure attachments. This acceptance criterion was signed off on April 5, 1989 even though the test deficiencies affected the acceptance criteria. Contrary to Note 6.3.3 of Procedure DB-DP-00013, Surveillance and Periodic Test Program, the supervisor for the test signed the Test Coversheet as completed with unresolved test deficiencies. The test deficiencies were not resolved prior to the next scheduled performance of the test on May 5, 1989, and the test was subsequently suspended.

The procedure utilized during the April hose house inspection was written with the intent of satisfying NFPA code requirements. The performance of the inspection identified areas which required additional evaluation to reconcile differences between the existing hose house equipment inventory and what was actually required to satisfy the intent of the NFPA code requirements. There was no intent to perform testing with

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' Docket Number 50-346

_' License Number NPF-3

-Serial Number 1-892 Page 12 a procedure which could be characterized as deficient or erroneous.

The improper dispositioning of identified test deficiencies 4 allowed the scheduling of a subsequent test prior to i satisfactory resolution of the deficiencies. This was partially attributable to a misinterpretation of guidance in Procedure DB-DP-00013 concerning the resolution of test deficiencies j affecting acceptance criteria. This is evidenced by additional j' occurrences documented in Potential Condition-Adverse to Quality Report (PCA0R) 89-0255 in which test deficiencies involving acceptance criteria were inadequately dispositioned.

Corrective Action Taken and Results Achieved The test deficiencies from the April 5, 1989 performance of DB-FP-04002 vere dispositioned on May 19, 1989. The resolution of these deficiencies required changes to the hose house inventory specified in Procedure DB-FP-04002 and the installation of additional hose house equipment where applicable. The revised test was successfully completed on August 8, 1989.

Actions Taken to Prevent Recurrence The scheduling of the May 5 test performance prior to resolving the April 5 test deficiencies was attributed to an incorrect interpretation of the requirements of Procedure DB-DP-00013, Surveillance and Periodic Test Program, concerning the resolution of test deficiencies. DB-DP-00013 has been revised to clarify the test deficiency requirements.

Date When Full Compliance Vill Be Achieved Full compliance vill be achieved when the new revision of DB-DP-00013 becomes effective. This is expected to be accomplished by October 15, 1989.

Violation j 89016-02: "10CFR50.73(a), requires that the holder of an operating license l submit a Licensee Event Report for any event described in I Paragraph 30.73 vithin 30 days after the discovery of the event.

The occurrence of any condition or event that results in the nuclear power plant being in a condition outside the design basis of the plant is an event described in Paragraph 50.73.

The design basis of the plant includes adherence to 10CFR50, Appendix A, " General Design Criteria for Nuclear Power Plants,"

Criterion 4, " Environmental and dynamic effects design basis."

Flooding of the Service Vater Pumps with circulating water is a  ;

dynamic effect from which the Service Water Pumps were not protected. '

Contrary to the above, on February 7, 1988 (sic), the licensee I identified that the plant had been operated outside the design l

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• Docket Number 50-346

, License Number NPF-3

- Serial Number 1-892 Page 13 basis from April 22, 1977, until February 7, 1988 (sic), and did not submit an LER for the event until May 10, 1989; more than 30 days after discovery of the event."

Note: February 7, 1988 should be February 7, 1989.

Response Acknowledgment or Denial of the Alleged Violation Toledo Edison denies that the License Event Report (LER) submittal date exceeded the 30 day period provided by 10CFR50.73(a).

Reason for Denial of the Alleged Violation Contrary to the violation, as stated, Toledo Edison identified a condition (s) on February 7, 1989, that potentially resulted in the plant operating outside the design basis since April 22, 1977. However, whether the condition (s) actually resulted in the plant operating outside the design basis could not be determined without further evaluation. Further evaluation was performed for both conditions via the PCA0R process. Conditions considered potentially reportable are assigned a higher priority and allowed a shorter evaluation period than other conditions dispositioned through the PCA0R process.

The LER rule (10CFR50.73) states that reports shall be submitted within 30 days of a reportable event. NUREG 1022 acknowledges that some conditions may require evaluation before it can be determined whether they constitute a reportable event. NUREG 1022, Supplement 1 clarifies the applicability of the 30-day q clock for situations like this. In response to Question 14.5 of I NUREG 1022, Supplement 1 (page 22), it states that for a single f event or condition the discovery date (which starts the 30-day I clock) can have as many as four applicable dates. It further st tes that one of the applicable dates can be the "hvortability" Date, the date when someone decides or  !

" discovers" that the event is reportable. Therefore, for this specific situation, the 30-day clock started on April 11, 1989, when Toledo Edison completed its deportability determination and decided the event was reportable. The LER vas submitted on May 10, 1989, 29 days after the deportability determination. ,

Thus, the 30 day time limit was not exceeded. A brief summary '

of Toledo Edison's internal evaluation process for these two l concerns is provided below.

On February 6, 1989, the Resident Inspectors informed Toledo Edison of a hole in the vall between the condenser pit and the Service Vater (SV) tunnel, which was contrary to USAR Section  ;

3.6.2.7.2.13, and that there was no procedural guidance for 1 operators to isolate the SV Tunnel from the SV Pump Room in the event of flooding in the SV Tunnel, which was contrary to USAR Section 9.2.1.2. The Inspection Report states that the inspectors informed the licensee that the combination of the two conditions meant that the Service Water Pumps were not protected j

Docket Number 50-346 License Number NPF-3

% -Serial Number 1-892 Page 14 from flooding caused by a circulating water line break. Toledo Edison then initiated two Potential Condition Adverse to Quality Reports (PCA0Rs) on February 7, 1909, to evaluate and disposition the two concerns. j i

Potential Condition Adverse to Quality Report 89-0082 addressed the lack of procedural guidance for plugging of the SU pump room drains taken credit for in USAR Section 9.2.1.2. As a l precaution until an evaluation of the potential concern could be f performed, immediate action was initiated to stage plugs and )

installation equipment in the SV pump room, and to generate a Standing Order (which was issued on February 10, 1989) to instruct operators to plug the floor drains in the SV Pump Room j in the event of SV tunnel flooding. Thus, this action reduced i the potential for flooding due to this concern before the-significance was evaluated. Additionally, appropriate abnormal procedures were changed to add guidance for operators responding ,

to SV tunnel flooding. The personnel responsible for determining deportability were unable to make a deportability determination with the information available and requested j additional time to determine whether a credible scenario existed i to cause flooding of the SV pump room via SV pump room floor drain due to SV tunnel flooding. Subsequent evaluation (March 15, 1989) by Nuclear Engineering concluded that since piping in the SU tunnel was seismic category I that piping failures in the tunnel need not be postulated, therefore, operator action for sealing drains in the SV Pump area for a service water system pipe break was not required. (Note: This evaluation did not consider flooding of the SV tunnel by outside sources.) Based on this information, the responsible department concluded on March 21, 1989, that the condition was not reportable as an LER.

Concurrently, PCAOR 89-0083, which addressed _the open pipe chase, was evaluated for significance by the Systems Engineering Group. Their initial evaluation concluded that flooding of the SV Pump Room was not a concern. However, this evaluation had taken credit for installing a floor drain plug. On March 3, 1989, the PCAQRB directed Systems Engineering to perform a calculation for SV pump room flooding assuming no floor drain plug was installed to determine deportability. After review of System Engineering's calculation and associated response on April 7, 1989, which concluded that a circulating water line break would result in flooding of the SV Pumps and cause a loss l of service water, the condition was determined reportable on April 11, 1989.

Since the length of time between the event date and the

" deportability" date exceeded 30 days, Toledo Edison should have explained the reason for the length of time between the discovery of the potential condition and the determination that this condition resulted in the plant being in a condition outside the design bases. Although this explanation was not provided, the LER does identify the date that the nonconforming

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TDocket Number 50-346 License Number NPF-3 E Serial Number 1-892 Page 15 conditions vere first identified (i.e., February 7, 1989).

Toledo Edison acknowledges that there vere deficiencies in the information content of the LER and vill submit a revised LER.

which resolves the deficiencies identified by the NRC Resident Inspectors. The revised LER will also address the additional concern, identified subsequent to the LER submittal, related to flooding the Service Water valve room and its effect on' Service Water System operability.

Violation-89016-09: "10CFR 50, Appendix B, Criterion II requires that the quality assurance program shall provide control over activities affecting the. quality of systems and components consistent with- .

their importance to safety.

{

The licensee implements'this requirement through the Nuclear Quality. Assurance Manual (NOAM). Section 8.4.1.1 of the NOAM  ;

requires that housekeeping encompasses all activities related to -

the control of cleanliness of facilities and equipment' Procedure DB-HN-00015, )

including protection of equipment.

" Plant Cleanliness and Material Readiness Inspection Programs,"

delineates these requirements and Item 4 of Attachment 1,

" Cleanliness Inspection Guidelines," requires that tops of panels, electrical boxes and equipment are free from dust.or other items.

Contrary to the above, on June 27 and on July 14, 1989, the inspectors observed dirt and other items including pieces of metal on the tops of motor control centers which are in violation of housekeeping requirements."

Response: Acceptance or Denial of the Alleged Violation-Toledo Edison acknowledges the alleged violation with the clarification provided below.

Reason for the Violation

. Attachment 1, " Cleanliness Inspection Guidelines" is referred to .i in Procedure DB-MN-00015,." Plant Cleanliness and Material Readiness Inspection Programs" as guidelines rather than housekeeping requirements to be utilized in conjunction with the ,

experience and expertise.of personnel performing cleanliness' j inspections. However, the objective of Procedure DB-MN-00015 '!

l is to ensure that station facilities and equipment are . j maintained at an acceptable state.of material readiness and  !

cleanliness. Violation 89016-09 identified an example which illustrated that this objective was not being met. The example given involved the accumulation of dust and debris on top of j electrical cabinets which had been noted on several' occasions. I It was determined that the stated objectives of Procedure DB-MN-0015 vere not being adequately implemented. This deficiency is attributable to scope of the task and the size of i the currently assigned cleaning areas ~ .

~ Docket Number 50-346

, License Number NPF-3 Serial Number 1-892 Page 16 Corrective Action Taken and Results Achieved The tops of switchgear and Motor Control Centers (MCCs) were cleaned during the month of August 1989. Additionally, small gaps which previously existed on the tops _of MCC's have been sealed to prevent the introduction of foreign objects to these electrical cabinets.

Actions Taken to Prevent Recurrence Procedure DB-MN-00015 is being revised to subdivide the cleaning areas assigned at present. The general areas for conducting the cleanliness and material readiness inspections vill be made more specific so that more attention can be focused on identifying and resolving discrepancies in each area. Additional personnel from the Facility Modification department will be integrated into the inspection program to augment the present responsible organizations. These actions in conjunction with efforts to

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modify work practices which contribute to housekeeping deficiencies vill result in an improved state of material readiness.

Date When Full Compliance Will Be Achieved Full compliance vill be achieved by November 30, 1989, with the implementation of the previously referenced revision to DB-MN-00015.

Very trul yours, 1

1 i M l

f 1

RWG/dlm cc: P. M. Byron, DB-1 NRC Senior Resident Inspector A. B. Davis, Regional Administrator, NRC Region III T. V. Vambach, DB-1 NRC Senior Project Manager l

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