View source for RBG-23905, Responds to NRC Re Violations Noted in Insp Rept 50-458/86-14.Corrective Actions:Procedure Changed to Verify Proper Fuel Oil Strainer Valve Alignment for Diesel Generators During Each Shift

{{Adams
| number = ML20206S732
| issue date = 06/20/1986
| title = Responds to NRC Re Violations Noted in Insp Rept 50-458/86-14.Corrective Actions:Procedure Changed to Verify Proper Fuel Oil Strainer Valve Alignment for Diesel Generators During Each Shift
| author name = Cahill W
| author affiliation = GULF STATES UTILITIES CO.
| addressee name = Martin R
| addressee affiliation = NRC OFFICE OF INSPECTION &amp; ENFORCEMENT (IE REGION IV)
| docket = 05000458
| license number = 
| contact person = 
| document report number = EA-86-074, EA-86-74, RBG-23905, NUDOCS 8607070418
| title reference date = 05-22-1986
| package number = ML20206S701
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC
| page count = 11
}}

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GULF STATES                       UTILITIES                  COMPANY RIVER BEND STA            * ^m" W 220    SL f RAN,QJSVILLE. LOUIStANA 70775
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h                June 20, 1986 RBG- 23905 File Nos. G9.5, G15.4.1 Mr. Robert D. Martin, Regional Administrator U.S. Nuclear Regulatory Commission Region IV 611 Ryan Plaza Drive, Suite 1000 Arlington, TX 76011

==Dear Mr. Martin:==

River Bend Station - Unit 1 Refer to:       Region IV Docket No. 50- 458/ Report 86-14/EA 86-74 This  letter responds to the Notice of Violation, "NRC Inspection Report No. 50-458/86-14", transmitted to Gulf States Utilities Company   (GSU)      in your {{letter dated|date=May 22, 1986|text=letter dated May 22, 1986}}.                                  That letter refers to an inspection performed by Mr. D. D. Chamberlain during the period March 17-20,                      1986 of activities authorized by NRC Operating License NPF-47 for River Bend Station.
GSU's response to Notice of Violation 86-14A,                                            " Inoperable Division II Diesel Generator",                         86-14B,              " Failure    to Provide Written Procedures for Maintenance on the Diesel Generator", and 86-14C,   " Failure to Follow Procedures",                                    are provided in the enclosed attachments.                 This completes GSU's response to the Notice of Viclation.
Sincerely, j f/
                                                                                  . J. Cahill, Jr.
Senior Vice President River Bend Nuclear Group WJC/        /je 1
Attachments cc:  D. D. Chamberlain U.S. Nuclear Regulatory Commission Region IV Senior Resident Inspector 8607070418 860703 58 PDR      ADOCK 0500                    d                                                                                   l G
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UNITED STATES OF AMERICA NUCLEAR EEGULATORY CGGESSION l
                            =
STATE OF LOUISIAEA                      $
PARISH OF WEST FELICIANA                5                              .        i In the Matter of                        5          Docket Nos. 50-458 I
GULF STATES UTILITIES CGIFANT           $
(River Bend Station, Unit 1)                                                                c i
AFFIDAVIT l
W. J. Cahill,   Jr.,  being duly sworn, states that he is a Senior Vice President of Gulf States Utilities Company; that he is authorized on the part of said Company to sign and file with the Nuclear Regulatory Connais sion the documents attached hereto        and that all such documents   I are true and correct to the best of his knowledge, information and belief.
W      Cahill, Jr.
Subscribed and sworn to before me, a Notary Public in and for the State and Parish above named, this SO day of h/ H _C y ,19hr.
V          .
                                                  #ffAt .                     F oan W. Middlebrook(
F Notary Public in and for-West Feliciana Parish,                 I Louisiana My Connaission is for Life.
l l

ATTACHMENT 1 Response To Notice Of Violation 50-458/8614 REFERENCE Notice of Violation     -
Robert D. Martin letter to W. J. Cahill, Jr.
dated May 22, 1986.
A. INOPERABLE DIVISION II DIESEL GENERATOR REASON FOR VIOLATION At  1526 on 3/17/86, a valid failure of the River Bend Station Division II Diesel Generator (DG) to pass its surveillance test was experienced.
The DG unit was unable to maintain its full rated speed (450 RPM) after a successful start attempt. At approximately one minute after the start,      fuel oil pressure had not reached its normal operating range of 30-40 psig and the engine speed began to decrease. It was later found that the duplex fuel inlet strainer valve was improperly aligned and restricted fuel oil flow to the engine. The correct valve handle was installed on the fuel oil inlet duplex strainer assembly, but the handle was not properly installed on the valve stem.         This caused misalignment of the strainer valve itself. This misalignment created a restriction of flow to the fuel oil pumps and subsequently, the engine injector system. Further investigation revealed that during corrective action of a similar fuel pressure problem on the Division I DG on 2/14/86, the original handle from the Division II DG strainer was removed and placed on the Division I DG to facilitate alignment of its strainer. A new handle was then fabricated through the use of an unidentified Shop Work Order         (SWO)  and reinstalled on the Division II DG vithout proper written work authorization.        It is postulated that    the  new handle was  installed 90  degrees out  from the position the original handle was removed from, then afterwards rotated approximately 90 degrees during the performance of a Preventive Maintenance Task, thus misaligning the strainer valve.
The root cause of the failure to have three separate and independent Diesel      Generators   " Operable",    in   " Operational Condition    1",   is attributed to improper implementation of Administrative Procedure ADM-0028, " Maintenance Work Request".
CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED On  3/17/86 Prompt Maintenance Work Request (MWR) Nos. 18028 and 18029 were initiated to troubleshoot the failure.             It    was discovered    that    the duplex fuel inlet strainer valve was improperly aligned and restricted fuel oil flow to the engine.
The valve handle was improperly installed in such a way as to prevent the proper operation of the valve.

ATTACHMENT 1 (cont'd.)                 Page 2 of 3 The handle was reinstalled in its proper configuration and at 0405 on 3/18/86 the Division II DG was proven operable by the successful performance of STP-309-0202, " Diesel Generator Division II Operability Test".
CORRECTIVE STEPS WHICH WILL BE TAKEN AND THE RESULTS ACHIEVED In   addition to the immediate corrective action taken to restore operability of the Division II DG, several corrective actions have been    taken    in an effort to prevent a recurrence of the deficiencies identifi;d as a result of the two DG        events. These corrective actions are delineated below.
Operations Section Procedure (OSP ) -0 012 , " Daily Log   Report",   has been   changed via Temporary Change Notices (TCNs) 86-0512 and 86-0530 to verify proper fuel oil strainer valve alignment for DGs A, B and C during each shift.
l An inspection was performed (PMG-M-86-65 dated 4/2/86)         on other plant equipment for similar duplex strainer configurations in an effort to prevent similar alignment problems. As a result,           some equipment was identified as having a potential for misalignment.
These were the Control Building chiller oil filters, the DG A and B  lube oil filters,       and the turbine hydrogen seal oil filter.
With the exception of the DG lube oil filters, this equipment has been match marked       (valve and handle) to visually confirm proper alignment of handle to valve. Because of the design of the DG lube oil filters,      a sign was permanently affixed as an operator aid to ensure proper alignment.          The Reactor Core Isolation Cooling    (RCIC) lube oil filter has a similar duplex configuration but, because of its design, it has been determined that there is no potential for misalignment.
Administrative Procedure (ADM)-0020, " Plant Key Control", has been revised to make key control for doors a responsibility of the Security Department instead of Operations.         The doors affected include the doors to the DG rooms.       To obtain  these keys one must fill out a request        form and obtain     the   Shift Supervisor's signature allowing issuance of the key from Security.
A new Operations Section Procedure (OSP)-0013, "CTMT/ECCS/ Diesel Generator Valves Verification", has been written to provide a             i weekly review and independent verification of DG subsystems, major        l Emergency Core Cooling System flow paths, and primary containment         l I
isolation for proper valve alignment.
QA    has    developed    a  surveillance schedule for containment integrity, ECCS, and auxiliary power systems for the performance of system walkdowns to verify valve and breaker alignments in accordance with the applicable Station Operating Procedures.         This effort is scheduled for completion by December 31, 1986.         Periodic surveillances for these systems will continue.thereafter.

ATTACHMENT 1 (cont'd.)                                  Page 3 of 3 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED
: 1)    The handle for the Division II DG was replaced and the DG
;                              proven operable on 3/18/86.
: 2)    OSP-0012 has been revised via TCN's 86-0512 and 86-0530 for
;                              verifying the proper fuel oil strainer valve alignment on the DGs.
: 3)    Equipment         identified as being a potential for                              similar
.                              misalignment has been match marked or signs posted.
j                        4)    ADM-0020          has    been          revised        to assign              Security          the l                              responsibility for key control of doors.
: 5)    OSP-0013 has          been         initiated and approved to                   provide               an i
independent review for proper valve alignment.
i j                        6)    QA will         complete surveillances to verify valve and breaker                                          i
 ;                             alignments by December 31, 1986. Periodic surveillances will                                                !
4 continue thereafter.                                                                                       }
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ATTACHMENT 2 Response To Notice Of~ Violation 50-458/8614 REFERENCE
:g Notice of Violation       -
Robert D. Martin letter to W. J. Cahill, Jr.
dated May 22, 1986.
B. FAILURE TO PROVIDE WRITTEN PROCEDURES FOR MAINTENANCE ON THE DIESEL GENERATOR REASON FOR THE VIOLATION As   a result of the Division I Diesel Generator (DG) operability failure on 2/14/86, the fuel oil strainer valve handle was removed from the Division II DG and used as a pattern for the Maintenance Shop to fabricate a new handle. The fabrication of the new handle was performed under an unidentified Shop Work Order (SWO). The new handle was installed on the Division II DG fuel oil strainer without    issuing      a Maintenance Work Request           (MWR).       Retest requirements were not evaluated, and the work performed was not documented. These conditions occurred as a result of Maintenance personnel's failure to follow the procedural requirements of ADM-0028,   " Maintenance Work Request". The failure to follow the procedure resulted from personnel misinterpreting the procedural requirements. The failure to follow procedural requirements contributed to the Division II Operability Failure on 3/17/86.
CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED Immediately     after     the    Division II DG failed its monthly surveillance test on 3/17/86, Prompt MWR's 18028 and 18029 were initiated to trouble shoot fuel oil strainers 1EGF*STR3B and lEGF*STR3E and fuel oil strainers lEGF*STR4B and lEGF*STR4E, respectively. The results of MWR 18028 showed that the plug valve between the two strainer baskets was misaligned and that the valve handle was installed in such a position as to prevent proper operation of the strainer.           The handle       was     removed                        then reinstalled    in it's   proper  configuration. The Division       II DG                     was proven operable by      the   successful     completion   of   STP-309-0202,
        " Diesel  Generator Division II Operability Test", on 3/18/86. MWR 18029 related to fuel oil strainers 1EGF*STR4B and 1EGF*STR4E was closed with no work performed based upon the details of MWR 18028.
A meeting was held by the Assistant Plant Manager of Maintenance and Materials with the Mechanical Maintenance Supervisors and Foremen to discuss the violation and the events which lead to it.
It was emphasized that following procedures is mandatory and that anything less is unacceptable performance.

1      .
ATTACHMENT 2 (cont'd.)                              Page 2 of 3 CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS To eliminate any future similar problems, when determining the appropriate document for performing maintenance on Permanent Plant Equipment, ADM-0028 has been revised to delete the SWO Program.
The Station Operating Procedures require that work on permanent plant equipment be performed under a valid MWR or Preventive Maintenance LPM) document. Memorandum No. PMG-M-86-53 was issued on 3/19/86,      instructing Mechanical Maintenance personnel of the procedure change and emphasizing that there are to be                             no exceptions      to  the  MWR    program.           The  Mechanical       Maintenance personnel were directed that work on permanent plant equipment is to be performed under a valid MWR or PM document. They were also informed of the addition of match marks to the valve shaft and handle,     their responsibility for ensuring that the handle is properly installed and aligned after performance of maintenance, and the requirements for retest. Training was also performed (TPP 22,     "Special Training", and TR 0009,                   " General     Maintenance Training") by the Training Department to reiterate the above to all Mechanical Maintenance personnel.
To determine that this was an isolated occurrence, approximately 600 SWO's written since initial criticality were reviewed by Maintenance, Compliance and a Senior Reactor Operator to ensure that the work performed was within the scope of a SWO.                            No discrepancies were identified.
.i          On 3/18/86 Prompt MWR No. 7325 was initiated to verify the proper position of the DG fuel oil strainer valve handles and to match mark the valve and handles to indicate the proper direction of flow.      The proper valve positions were verified by readings i          obtained from local instrumentation and the handle and stem were match marked to indicate the direction of flow on 3/18/86.
Plant PM Tasks ME-00229, 00230, 00233 and 00234 used to clean the strainer screens were revised to incorporate the reference to the match marks on the PM Task Card and                          to    specify    retest requirements.      Retest requirements were not previously specified since it is not necessary to remove the handle in order to clean the screen. Retest requirements are to be specified on applicable PM Task Cards as stated in Maintenance                          Section    Procedure (MSP)-0003,    Revision    7, "     Preventative     Maintenance     Program", Step 5.4.2.16.
In     addition to the corrective action taken by Maintenance, Operations Section Procedure (OSP)-0012, " Daily Log Report", has been changed via Temporary Change Notices (TCNs) 86-0512 and 86-0530 to verify proper fuel oil strainer valve alignment for DGs A, B, and C during each shift.

_ - . . - _ - _                   -                                               . - _ = - - _ .              . .-                   . _-.             .- - - .
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ATTACHMENT 2 (cont'd.)                                       Page 3 of 3 As an interim measure, a Compliance Analyst and four                                                              (4) Quality Assurance           (QA)                         Engineers were temporarily assigned to perform an
,                                                  independent review of Maintenance Department activiites to ensure i                                                  procedural adherence for the conduct of maintenance. This effort
;                                                  is estimated to be complete by June 30, 1986.
j                                                  DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED j                                                 1)   The Division II DG handle was properly installed and the DG i                                                       was proven operable on 3/18/8J.
: 2)   ADM-0028 has been revised to delete the SWO Program.
: 3)   The DGs fuel oil strainer valve and handle were match                                                                       marked to indicate the proper direction of flow.
: 4)   Retest                  requirements are now specified in the subject PM task cards, i
j                                                 5)   OSP-0012 has been revised to verify proper fuel oil strainer
}                                                       valve alignment for DG's A, B and C during each shift.
: 6)   Mechanics                                   assigned to Mechanical Maintenance have been directed to work under a valid MWR or PM document.                                                                Training has been performed.
!                                                  7)   The independent review by the Compliance Analyst and QA i
Engineers of Maintenance Department activities is estimated i                                                       to be complete by June 30, 1986.
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i ATTACHMENT 3 Response To Notice Of Violation 50-458/8614 l
1 1
REFERENCE Notice of Violation                     -
Robert D. Martin letter to W. J. Cahill, Jr.
.                       dated May 22, 1986.
:                       C.      FAILURE TO FOLLOW PROCEDURES l                               REASON FOR THE VIOLATION i
!                               Ccndition Report (CR) 86-0179 was issued on 2/14/86 identifying J                               the performance failure of the Division I Diesel Generator (DG) during an engine                  start          per            Surveillance               Test     Procecure (STP)-309-0201,             " Diesel Generator Division I Operability Test".
The investigation revealed that the fuel oil strainer valve was i                               misaligned causing a loss of fuel flow to the DG. In response to                                                           1 I                               the CR, Nuclear Plant Engineering provided corrective action on                                                            i
 ,                              2/15/86.             The corrective action required that the fuel oil                                                      l
 !                              strainer valve be re-aligned and that successful operation of the
 !                              diesel be demonstrated.                        The response, in it's determination of
;                               root cause,              failed to identify generic action                                       to        prevent l                              recurrence and or any remedial or general corrective action to be implemented by other departments. Therefore, a similar Division II DG operability failure occurred on 3/17/86. The root cause was determined to be a combination of a misunderstanding of the l                              responsible department on adequate corrective action and untimely review of the CR's disposition.
1
}                               CORRECTIVE STEPS WHICH HAVE BEEN TAKEN AND THE RESULTS ACHIEVED i
CR   No. 86-0179          was         closed       noting               that the issuance of CR No.                     ,
86-0311 on 3/17/86 would address the                                    generic corrective actions                         ;
i                               for the DG failure.                         CR No. '86-0311- has been dispositioned,
!                               reviewed and closed.                   The corrective actions stated herein and in
]                               Attachments 1 and 2 collectively identify the generic corrective j                               action taken for the subject violation.
Additional             investigation          identified that Preventive Maintenance (PM) Tasks ME00227 and ME00228 were performed on 2/5/86.                                                              The purpose of these tasks is to clean the fuel oil strainer screens which requires operating the duplex strainer plug valve.                                                             As a
;                               result of discovering that the fuel oil strainer valve handle was j
missing, plant personnel employed a wrench to operate the valve
;                               stem during the performance of the preventive maintenance tasks.
!                               Due to lack of availability of the correct manufacturer's handle, j                               the fuel oil strainer valve was misaligned and resulted in the a                               failure of the surveillance operability test on 2/14/86.
t The Division I DG was proven operable on 2/5/86 by the successful                                                           l 1
performance of STP-309-0201. The only documented work on the fuel                                                           !
4                               oil strainer, between the successful operability test on 2/5/86                                                              l
 ;                                                                                                                                                          i
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ATTACHMENT 3 (cont'd.)                     Page 2 of 3 i
j                    and the operability test failure on 2/14/86, was the performance of the PM tasks on 2/10/86.                    It has been concluded that the duration of time which the strainer had been misaligned was from 4
2/10/86 to 2/14/86.
A handle was installed on the Division I DG fuel oil strainer and I'                   the strainer valve was re-aligned on 2/14/86 via Prompt MWR 19664.
CORRECTIVE STEPS WHICH WILL BE TAKEN TO AVOID FURTHER VIOLATIONS In the future,      the Plant Manager will ensure that CR's, the i                    documents initiated to identify problems, are assigned to the appropriate    organizations for evaluation in accordance with Administrative Procedure (ADM)-0019, " Initiation and Processing of Condition Reports",
f                    Nuclear Plant Engineering (NuPE) personnel were instructed via J                    Memorandum NUPE-86-447, dated 3/24/86, as to the proper method for
            -        evaluation of CR's. The evaluation should identify the root cause of the event and fully describe any remedial or generic corrective action taken to minimize the probability of recurrence.
1 ADM-0019 has been revised to standardize the form used for identification of problems.                 The revised procedure         provides explicit instructions on identification of root cause of the problem and corrective action, both remedial and generic, to prevent recurrence.          The revision also provides for Quality Assurance (QA) involvement during the evaluation and closecut review stages to provide greater assurance that the root cause has i                    been identified and that the corrective action is adequate.
a                    Training for applicable management personnel was performed on revised procedure ADM-0019.
Compliance    completed its accelerated review and closure of backlogged CR's on 6/15/86. This review includes the backlog of i                    approximately 400 CR's plus CR's initiated since 3/17/86. A total 1                    of 613 CR's were closed. During the backlog review, CR's found to have inadequate corrective action were returned to the responsible discipline for further information as required by ADM-0019.                   Only 4                    33 CR's remain outstanding in the Compliance Department; all of which have been evaluated, but have restraints for final closure.
j                    The backlog will be managed to minimize the total number of i
dispositioned CR's received by compliance which have not been reviewed for acceptable corrective action.
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4 ATTACHMENT 3 (cont'd.)                     Page 3 of 3 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED i                                           1)  NuPE personnel have been instructed as to the                  proper        method i                                               of-evaluating CR's.
: 2)  ADM-0019 has been revised to standardize the form used for identification of problems and training has been performed.
;                                           3)  The closure of approximately 400 backlogged CR's is complete.
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