IR 05000369/1988024

Forwards 881027 Enforcement Conference Summary Re Insp Repts 50-369/88-24,50-370/88-24,50-369/88-29 & 50-370/88-29.Issues Re Operability of Hydrogen Skimmer Sys & Inoperability of Safety Sys Due to Inadequate post-mod Testing Discussed

ML20196A441
Person / Time
Site:	McGuire, Mcguire
Issue date:	11/25/1988
From:	Ernst M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:	Tucker H DUKE POWER CO.
References
NUDOCS 8812060008
Download: ML20196A441 (62)

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NOV 2 51988 $,'mau Gf .,

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Docket Nos. 50-369, 50-370 License Nos. NPF-9 NPF 17 .

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h hC Duke Power Company l f ATTN: Mr. H. B. Tucker, Vice President

Nuclear Production Department i 422 South Church Street  ;

Charlotte, NC 28242 j

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Gentlemen:  ;

r SUBJECT: ENFORCEMENT CONFERENCE SUMMARY

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(NRC INSPECTION REFORT NOS. 50-369/88-24, 50-370/88-24 AND  ;

50-369/88-29,50-370/38-P.9)

This letter refers to the Enforcement Conference held at our request on  !

t October 27, 198 This meeting concerned activities authorized for your [

l McGuire facilit The issues discussed at this conference related to l 1 operability of the Hyrdrogen Skimmer (VX) system and inoperability c? safety ;

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systems due to inadequate post modification testing. A brief sumary, a list j of attendees, and a copy of your handout are enclosed. We are continuing our l 1 review of these issues to determine the approp"fate enforcement actio \

5 In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, i T1tle 10, Code of Federal Regulations, a copy of this letter and its enclosures *

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will be placed in the NRC Public Document Roo Should you have any questions concerning this matter, please contact us.

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Sincerely, (Original signed by M. Ernst)

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Malcolm L. Ernst Acting Regional Administrator

Enclosures:

Enforcement Conference Sumary l

List of Attendees j Handout t t

<gcw/ enc 15:  !

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W . 1. McConnell, Station Manager l f

Jenior Resident inspector - Catawba i

State of North Carolina

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NOV 2 5 199g Duke Power Company 2 b> r: w/ enc 15:

NRu Resident Inspector Das Technical A:sistant

1. Hrnd, NRR Docun>ent Con *.rol Desk l

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4 ENCLOSURE 1 ENFORCEMENT CONFERENCE SU N RY On October 27, 1988, representatives from Duke Power Company (OPC) met with the NRC in the Region !! office in Atlanta, Georgia to discuss operability of the Hydrogen Skimmer (VX) system and the inoperability of sefety systems due to inadequate post modification testin Following opening remarks by J. P. Stohr NRC, Ri! Acting Deputy Regional

Administrator, DPC gave two presentations (see Enclosure 3) which addressed NRC concerns on the subjects listed above. On the VX system, in addition to covering a system overview, a sequence of events, and causes and contributing factors, DPC addressed specific NRC concerns regarding preoperational testing of the VX system, a decision to enter Mode 4 on Unit 2 with VX flows below that given in the FSAR, and OPCs operability determination process. DPCs

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presentation on the post modification testing program covered an overview / sequence of events, a safety analysis of each of the valves found to have problems, and corrective actions to enhance DPCs post maintenance / post modification testing progra The NRC is presently considering enforctment action on these issues. This meeting served to enhance Region II's understanding of the issues and DPCs corrective action ;

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ENCLOSURE 2 LIST OF ATTENDEES U.S. Nuclear Regulatory Coninission J. P. Stohr, Acting Deputy Regional Administrator C. W. Hehl, Deputy Director, Division of Reactor Projects (DRP)

A. F. Gibson, Director, Division of Reactor Safety (DRS)

E. W. Merschoff, Deputy Director, DRS G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff (EICS)

V. L. Brownlee, Branch Cr'ef DRP D. Hood, McGuire Projec ..anager, Office of Nuclear Reactor Regulation (NRR)

F. Jape, Section Chief, uRS W. T. Orders. Senior Resident Inspector, Catawba, DRP B. R. Bonser, Project Engineer, DRP F. K. VanCO)rn, Senior Resident Inspector, McGuire, DRP D. J. Nelsen, Resident Inspector, McGuire DRP ,

R. P. Croteau, Resident inspector, McGuire, DRP B. Uryc, Enforcement Coordinator, EICS Duke Power Company H. B. Tucker Vice President, Nuclear Production T. L. McConnell, Station Manager, McGuire N. Rutherford, Manager, Licensing B. H. Hamilton, Superintendent of Technical Services. McGuire W. M. Sample, Superintendent of Maintenance, McGuire R. O. Sharpe, Compliance Engineer B. L. Peele, Principal Engineer, Design Engineering

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ENCLOSURE 3 NOV 2 5 m i

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DUKE POWER COMPANY /NRC ENFORCEMENT CONFERENCE OCTOBER 27, 1988 VX OPERABILITY INTRODUCTORY REMARKS T. L. McCONNELL 11. OVERVIEW T. L. McCONNELL lli. SEQUENCE OF EVENTS B. H. HAMILTON IV. ROOT CAUSE AND CONTRIBUTING FACTORS B. H. HAMi LTON

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V. CONCERNS TO BE ADDRESSED B . H . HAM I LTON PREOPERATIONAL TESTING OF VX SYSTEM B. H. HAMILTON DECISION TO ENTER MODE 4 B. H. HAMILTON DPCo OPERABILITY DETERMINATION PROGRAM B. H. HAMILTON SAFETY ANALYSIS B. L. PEELE IV. SUMMARY T. L. McCONNELL FUNCTIONAL VERIFICATION PROBLEMS 1. OVERVIEW L. McCONNELL 11. SEQUENCE OF EVENTS T. L. McCONNELL lit. ROOT CAUSE/ CORRECTIVE ACTIONS SAMPLE IV. SAFETY SIGNIFICANCE M. SAMPLE V. SUMMARY STATEMENT T. L. McCONNELL CLOSING REMARKS T. L. McCONNELL s

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VX OPERABILITY

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OVERVIEW ,

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SEE ATTACHED SIMPLIFIED SCHEMATIC OF THE VX SYSTEM (HYDROGEN SKIMMER PORTION ONLY).

UNIT 1 DURING A UNIT 1 CONTAINMENT CLOSEOUT INSPECTION IN NOVEMBER OF 1987, NRC PERSONNEL NOTICED THAT A HYDROGEN SNIMMER (VX)

SYSTEM DAMPER APPEARED TO BE CLOSED. OPERATIONS PERSONNEL INSPECTED AND VERIFIED THAT EACH VX SYSTEM DAMPER WAS IN ITS CORRECT PRE-OPERATIONAL POSITION WITH THE EXCEPTION OF ONE DAMPER QUESTIONED BY THE NRC INSPECTOR. THE CORRECT POSITION 'dAS VERIFIED BY PAINT SHADOWS ON THE DAMPER ACTUATORS CREATED PRIOR TO UNIT 1 CRITICALIT THE QUESTIONED DAMPER WAS ONLY SLIGHTLY MISPOSITIONED IN THE CLOSED DIRECTIO SINCE THERE WAS NO PROCEDURE TO ASSURE PROPER DAMPER POSITIONS ON THE VX SYSTEM, NRC PERSONNEL WERE CONCERNED ABOUT THE UNIT 2 DAMPER POSITION STATION PERSONNEL AGREED TO DO VX FLOW BALANCE TESTS FOR BOTH UNITS DURING THElR NEXT REFUELING OUTAGE UNIT 2 AT THE END OF THE JULY 1988 REFUELING OUTAGE, PERFORMANCE PERSONNEL TOOK "AS FOUND" FLOW MEASUREMENTS USING A HAND HELD VELOMETER ON BOTH TRAINS OF THE UNIT 2 VX SYSTE SOME VX SYSTEM DAMPER COMPARTMENT FLOWS DID NOT MEET FSAR REQUIREMENTS AND TWO DAMPERS, BOTH SERVING THE REACTOR HEAD AREA, WERE FOUND CLOSED, ALL DAMPERS WERE ADJUSTED IN AN ATTEMPT TO ACHIEVE FLOW RATES LISTED IN THE FSAR. THIS WAS UNSUCCESSFUL BECAUSE SETTING THE

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i DAMDERS FOR ONE TRAIN TO MEET FSAR FLOWS WOULD CAUSE FLOW RATES FOR THE OTHER TRAIN TO Fall THE FSAR FLOW REQUIREMENTS. FINAL FLOWS WERE MEASURED WITH A VELOMETER AND LATER TRAIN A FLOWS WERE CONFIRMED WITH THE MORE ACCURATE FLOW HOOD. DESIGN ENGINEERING (D.E.) PERSONNEL THEN BEGAN AN EVALUATION ON THE NEW VX SYSTEM FLOW RATE PLANT PERSONNEL TERMINATED THE FLOW BALANCE TEST USING THE MORE ACCURATE FLOW HOOD BEFORE COMPLETING TESTING ON TRAIN B OF THE VX SYSTEMS AND UNIT 2 ENTERED MODE 4 BASED ON A VERBAL OPERABILITY DETERMINATION FROM D.E. RATIONALE FOR THIS DECISION WILL BE DISCUSSED LATE LATER THAT DAY, D.E. ISSUED A WRITTEN OPERABILITY DETERMINATION FOR VX BASED IN PART ON THE AVAILABILITY OF THE OPERABLE HYDROGEN MITIGATION SYSTEM TO SUPPORT THE OPERABILITY OF THE VX SYSTE IN THClR REVIEW THE NEXT WEEK, THE NRC JUDGED THE OPERABILITY DETERMINATION BASED ON THAT ASSUMPTION TO BE INADEQUAT WE AGREE WITH THi NRC DETERMINATIO PERFORMANCE PERSONNEL COMPLETED THE ACCESSIBLE COMP /RTMENT FLOW MEASUREMENTS ON TRAIN B OF THE VX SYSTEM USING THE MORE ACCURATE FLOW HOOD DEVIC A NEk UNIT 2 OPERABILITY DETERMINATION WAS ISSUED BY IT CONCLUDED THAT THE PRESENT FLOW BALANCE CONDITION OF THE VX SYSTEM WAS SUFFICIENT AND WAS CONSIDERED OPERABL THE NRC HAS SUBSEQUENTLY REVIEWED THIS OPERABILITY STATEMENT AND HAS AGREED WITH i UNIT 1 FOLLOW-UP IMMEDIATELY AFTER SHUT 10WN FOR THE CURRENT UNIT 1 OUTAGE, ALL DAMPERS WERE VERIFIED OPEN AND THElR POSITIONS WERE MARKE THE UNIT 1 VX FLOW BALANCE TEST WAS CONDUCTED USING THE FLOW HOOD METHO ALL FLOWS MET THE NEW ACCEPTANCE CRITERIA DEVELOPED EXCEPT FOR TRAIN A OF THE PRESSURIZER CAVITY AND BOTH TRAINS OF THE REACTOR HEAD AREA. THE IMPACT OF THESE LOW FLOWS WILL BE DISCUSSED LATE ,- - - - - - - _ _ _ _ _ _ _ _ _ - - - - - - - _ _ _ _ - - - - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - _ _ _ _ _ _ _ _ .

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. VX OPERABILITY

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SEQUENCE OF EVENTS

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11/08/87 ---- NRC PERSONNEL NOTICED THAT SOME UNIT 1 VX SYSTEM DAMPERS APPEARED TO BE CLOSE ,

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NRC PERSONNEL QUESTIONED OPS PERSONNEL ABOUT l THE POSITIONS OF THE UNIT 1 VX SYSTEM DAMPER ',

11/09/87 ---- OPS PERSONNEL VERIFIED THAT EACH UNIT 1 VX ,

SYSTEM DAMPER WAS IN ITS PRE-OPERATIONAL r POSITION AS EVIDENCED BY PAINT SHADOWS ON THE i DAMPER ACTUATOR ONE DAMPER WAS MISPOSITIONED IN THE CLOSED DIRECTIO IT WAS RETURNED TO I ITS PROPER POSITION,

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NRC PERSONNEL WERE CONCERNED ABOUT THE POSI-TlONS OF THE UNIT 2 VX SYSTEM DAMPERS, AND CONSEQUENTLY, STATION PERSONNEL AGREED TO DO A  ;

VX FLOW BALANCE TEST FOR EACH UNIT DURING THEIR NEXT REFUELING OUTAGE /19/88 ---- PERFORMANCE PERSONNEL TOOK "AS FOUND" FLOW j

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MEASUREMENTS USING A VELOMETER ON BOTH TRAINS OF UNIT 2 OF THE VX SYSTEM. SOME VX SYSTEM (

DAMPER COMPARTMENT FLOWS DID NOT MFfT THE f MCGUIRE FINAL SAFETY ANALYSIS REPr.RT (FSAR) [

REQUIREMENTS AND TWO DAMPERS SERVING THE REACTOR HEAD AREA WERE FOUND CLOSE DESIGN ENGINEERING WAS NOTIFIED OF THESE FINDING /20/88 ---- DESIGN ENGINEERING REQUESTED MORE ACCURATE f MEASUREMENTS BE TAKEN USING A FLOV HOO f

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l f 5, . 7/21/88 ~0100 PERFORMANCE PERSONNEL BEGAN THE RF. TEST OF THE VX 2A SYSTEM USING A FLOW HOO !

0900 THE TRAIN A VX RETESTS WERE COMPLETED AND  ;

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TRAIN 2B RETESTS WERE BEGU .

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DESIGN ENGINEERING PERSONNEL REEVALUATED THE VX SYSTEM FLOW RATES THAT WERE LISTED IN THE FSA THEY EXPRESSED CONFIDENCE THAT THEY COULD f

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PROVIDE A TECHNICAL JUSTIFICATION FOR THE OPERABILITY OF THE VX SYSTE !

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~1430 PLANT PERSONNEL TERMINATED THE 2B VX FLOW  !

BALANCE TEST BEFORE IT WAS COMPLETED. THIS WAS {

A MANAGEMENT DECISION WAS BASED UPON INPUT ,

TilAT FINAL B TRAIN NUMBERS WERE NO LONGER  ;

ESSENTIAL AND ALL THE INFORMATION REQUIRED FOR THE OPERABILITY DETERMINATION HAD BEEN GATHERE ~1500 STATION MANAGEMENT COMMUNICATED THE DECISION f TO TERMINATE THE 2BVX FLOW BALANCE TEST TO THE j NRC RESIDENT INSPECTOR AS A COURTES THE j OPERABILITY DETERMINATION WAS STATED AS THE ,

REASON, HOWEVER, SPECIFICS WERE NOT DISCUSSED AT THIS TIM j

~1700 STATION MANAGEMENT REVIEWED DRAFT OF DESIGN'S i

j VX OPERABILITY DETERMINATION AND EVALUATION.

i AFTER INITIAL DISCUSSION VERBAL AGREEMENT WAS [

l REACHED WITH DESIG i 1822 UNIT 2 ENTERED MODE 4 PER MANAGEMENT DECISIO l

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, 7/22/88 ---- DESIGN ENGINEERING PERSONNEL ISSUED THE SIGNED i OPERABILITY DETERMINATION BASED IN PART ON THE -

OPERABILITY OF THE HYDROGEN MITIGATION SYSTE !

s 8/1/88 ---- AFTER FURTHER REVIEW, THE NRC PERSONNEL JUDGED THE UNIT 2 OPERABILITY DETERMINATION TO BE

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INADEQUATE BECAUSE DESIGN ENGINEERING PERSONNEL TOOK CREDIT FOR THE HYDROGEN MITIGATION SYSTEM [

TO SUPPORT THE VX SYSTEM OPERABILITY

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DETERMINATIO /2-15/88 ---- DESIGN ENGINEERING PERSONNEL BEGAN REEVALUATING THE VX SYSTEM FLOW RATES IN A [

MANNER CONSISTENT WITH REGULATORY GUIDE 1.7, l REVISION 2, AND 10CFR50.44, WHICH REDUCED THE REQUIRED FLOW RATES FOR THE VX SYSTE /16/88 ---- PERFORMANCE PERSONNEL COMPLETED ON-LINE FLOW  !

MEASUREMENTS ON ACCESSIBLE PORTIONS OF TRAIN B OF THE VX SYSTEM USING THE FLOW HOOD. THIS WAS i

DOME TO EVALUATE BOTH TRAINS AGAINST THE NEW ACCEPTANCE CRITERIA UNDER DEVELOPMEN /19/88 ---- DESIGN ENGINEERING PERSONNEL ISSUED A NEW UNIT 2 OPERABILITY DETERMINATION AND CONCLUDED THAT f THE PRESENT FLOW BALANCE CONDITION OF THE VX ,

SYSTEM WAS SUFFICIENT AND WAS CONSIDERED  ;

OPERABL THIS CONCLUSION ALSO APPLIES TO THE  !

OPERABILITY OF THE SYSTEM ON 7/21/88 WHF.N MODE  !

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9/16/88 ---- A MCGuinE NRC RESIDENT INSPECTOR NOTIFIED STATION MANAGEMENT THAT NRC HAD FULLY REVIEWED {

AND ACCEPTED THE OPERABILITY STATEMENT AND EVALUATIO I

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IO/12/88 ---- PERFORMANCE PERSONNEL ENTERED THE UNIT 1 REACTOR BUILDING IMMEDIATELY AFTER S/D AND -

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PRESSURIZER AREAS WERE OPEN AND MARKED THEIR POSITION. THIS WAS DONE TO ENSURE "AS FOUND" ;

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10/18/88 ---- PERFORMANCE PERSONNEL CONDUCTED THE UNIT 1 VX FLOW BALANCE TEST USING THE FLOOD HOOD METHO ALL FLOWS MET THE NEW ACCEPTANCE CRITERIA DEVELOPED IN THE 8/19/88 OPERABILITY DETERMINATION WITH THE EXCEPTION OF "A" TRAIN PRESSURIZER CAVITY AND BOTH TRAINS IN THE REACTOR HEAD AREA.

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ROOT CA'USE

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WO PROBLEMS EVENTUALLY LED TO THIS SITUATION:

(1) THE PREOPERATIONAL TEST PERFORMED ON THE VX SYSTEM WAS INSUFFICIENT TO PROVE OPERABILITY. THE STATION PERSONNEL'S DEGREE OF UNDERSTANDING OF THE SYSTEM AND OUR DEPENDENCE UPON PREVIOUSLY AGREED UPON TESTING COMMITNENTS LED US TO OMIT FLOW BALANCE TESTING OF THIS SYST M FROM THE PREOPERATIONAL TEST FROGRA (2) APPROPRIATE MEASURES WERE NOT TAKEN TO ENSURE THE FLOW BALANCE OF THIS SYST m WAS MAINTAINED EITHER THROUGH PF.RIODIC TESTING OR CONTROL OF DAMPER POSITION CONTRIBUTING FACTOR BY DESIGN, THE VX SYSTEM !!AS A SINGLE HEADER THAT DRAVS AIR FROM EACH OF THE CONTAINMENT COMPARTMENTS BY USE OF REDUNDANT FANS LOCATED ON EITHER END OF THE HEADER. EITHER FAN IS CAPABLE OF DRAWING THE TOTAL DESIGN BASIS FLOWS FROM THE AREAS SERVICE HOWEVER. THE EQUIPMENT CONFIGURATION OF THE SYSTEM IS SUCH THAT BALANCE OF THE INDIVIDUAL COMPARTMENT FSAR FLOW RATES IS UNOBTAINABLE WHEN OPERATING THE FANS INDEPENDENTLY. THE SYSTEM IS BEING MODIFIED TO CORRECT THIS DEFICIENC SUBSEQUENT TESTING WILL VALIDATE THE NEW DESIG PREOPERATIOJAL TESTING OF THE VX SYSTDI UNIT #1 THE ORIGINAL PREOPERATIONAL TEST PREPARED AND PERFORMED FOR UNIT #1 WAS BASED ON THE CHAPTER 14 FSAR ABSTRAC THE

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ABSTRACT INCLUDED NO PROVISIONS FOR FLOW BALANCING THE SYSTEM AND NO BALANCE WAS PERFORMED. STATION PERSONNEL ASSUMED THAT THE HVAC VENDOR HAD BALANCED THE SYSTEM. THIS WAS THE NORMAL PRACTICE FOR HVAC SYSTEMS. THIS SYSTEM WAS DIFFERENT. THE HVAC VENDOR WAS NOT ASSOCIATED WITH THE SUCTION RING HEADE LATER IN UNIT #1'S PREOPERATIONAL TEST:lNG, THE PROPER POSITIONING OF CERTAIN DAMPERS OF THE VX SYSTEM WAS QUESTIONE IN ORDER TO RESOLVE THESE QUESTIONS PLANT PERSONNEL CONDUCTED A FLOW BALANC THE FLOW BALANCE WAS INADEQUATE AS A RESULT OF BOTH TRAINS BEING OPERATED SIMULTANEOUSLY. THIS FLOW BALANCE WAS DOCUMENTED IN A 3/23/81 MEMORANDUM TO FILE AND WAS NOT PART OF THE PREOPERATIONAL TEST PROGRA IT WAS DONE TO ANSWER SYSTEM OPERABILITI QUESTION IT WAS STILL ASSUMED THE HVAC VENDOR HAD PROPERLY BALANCED THE SYSTE . UNIT 2 AFTER REVIEWING THE UNIT 2 PREOPERATIONAL TESTING FOR THE VX SYSTEM, IT IS DIFFICULT TO DETERMINE EXACTLY WHAT WAS DONE IN REGARDS TO FLOW BALANCING THE SYSTEM. AGAIN HEAVY DEPENDENCE WAS PLACED UPON THE HVAC VENDOR PROPERLY BALANCING THE SYSTEM. WITHOUT FURTHER 'INFORMATION WE CAN ONLY CONCLUDE THE "A" TRAIN WAS BALANCED. HOWEVER, THE RESULTS ARE NOT CONSISTENT WITH CURRENT PERFORMANCE OF THE SYSTEM. THOSE INVOLVED WITH THE UNIT 2 TESTING ARE NO LONGER WITH DUKE POWER COMPANY AND FOR THIS REASON FURTHER INVESTIGATION IS RESTRICTE .

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. 3. INADEQUACY OF THE VX PREOPERATIONAL TEST AT THE TIME OF OUR PREOPERATIONAL TEST PROGRAM, OUR PRIMARY EMPHASIS WAS ON ECCS SYSTEMS. THE TEST PROGRAM FOR BALANCE OF PLANT, SAFETY RELATED SYSTEMS WAS NOT AS CAREFULLY

SCRUTINIZED. THIS WAS TRUE OF THE HVAC SYSTEMS WHERE TWO FACTORS COMBINED TO INHIBIT PROPER TESTING. THE FIRST FACTOR

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WAS THE CLARITY AND AVAILABILITY OF DESIGN BASIS INFORMATION

ON THESE PARTICULAR SYSTEMS. THE OTHER FACTOR WAS THE DEPENDENCE ON THE HVAC VENDOR FOR SYSTEM START U '

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i ANOTHER FACTOR LEADING TO THE INADEQUATE PREOPERATIONAL TEST ON THE VX SYSTEM WAS THE FAILURE TO INCLUDE FLOW BALANCE REQUIREMENTS IN CHAPTER 14 0F THE FSAR. DURING THIS TIME

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) PERIOD CHAPTER 14 0F THE FSAR AND THE TECHNICAL

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COMMITMENTS. AT THE TIME OUR PREOPERATIONAL TEST PROGRAM WAS CONDUCTED WE DID NOT PROGRAMATICALLY LOOK BEYOND THESE DOCUMENTS FOR OTHER TESTING REQUIREMENTS.

l l 4. CORRECTIVE ACTIONS SPECIFICALLY FOR THE VX SYSTEM:

• WE WILL MODIFY THE SYSTEM TO ENRANCE OUR ABILITY TO 1 BAIANCE THE SKIMMER FLOWS.

i e WE WILL CONDUCT A TEST TO OPTIMIZE THE FLOW BALANCE I

OF THE VX SYSTEM.

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HYDROCEN SKDGER

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AND CONTAINNENT AIR RETVEN SYSTEM (VI)

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REVISED ARRANCEMENT ,,,

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. GENERIC ACTIONS:

UPON REVIEW WE HAVE CONCLUDED THE PREOPERATIONAL TEST PROGRAM AT MCGUIRE MAY HAVE BEEN INADEQUATE FOR A SPECIFIC CLASS OF SYSTEMS: THOSE BEING SAFETY RELATED, BALANCE OF PLANT SYSTEM IN ORDER TO ADDRESS THIS CONCERN, WE ARE REVIEWING THE PREOPERATIONAL TESTING FOR EACH OF T1'ESE SYSTD(S TO ENSURE IT WAS ADEQUAT IN CONJUNCTION WITH THIS WE ARE EVALUATING THE SURVEILIANCE TESTING CONDUCTED TO ENSURE IT IS SUFFICIENT TO ENSURE CONTINUED OPERABILIT THIS REVIEW HAS BEGUN. THE AUXILIARY FEEDWATER SYSTEM IS BEING USED AS A "PILOT" SYSTEM. AFTER THIS REVIEW IS COMPLETE, A SCHEDULE WILL BE ESTABLISHED FOR ALL SYSTEMS INVOLVE IT IS ANTICIPATED THE REVIEW WILL BE DONE BY MAY OF 198 DECISION TO ENTER MODE #4 SITUATION ON JULY 21, 1988 THE VX FLOW BALANCE WAS PERFORMED AT THE END OF THE UNIT #2 REFUELING OUTAGE WHILE IN MODE # IT WAS ONE OF MANY TESTS PERFORMED, MOSTLY AS A RESULT OF MAINTENANCE AND MODIFICATIONS, DURING THE LAST WEEKS OF THE OUTAGE. MOST OF THESE TESTS, INCLUDING THE VX FLOW BALANCE, WERE REQUIRED TO BE COMPLETED PRIOR TO MODE # TESTING PERSONNEL HAD BEEN MAINFAINING A VERY INTENSE SCHEDULE FOR APPROXIMATELY 2 WEEK _ _ _ _ _ _ _ _ _ _ _ _

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2 .' PERSONS INVOLVED WITH THE DECISION

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THE DECISION WAS MADE AT THE APPROPRIATE LEVEL OF MANAGEMEN THE SUPERINTENDENT OF OPERATIONS, MAINTENANCE. TECHNICAL SERVICES, AND INTEGRATED SCHEDULING ALL WERE INVOLVED IN THE DECISION. ALSO INVOLVED WERE THE DESIGN ENGINEERING SITE OFFICE MANAGER AND OTHER MANAGEMENT PERSONS FROM THE CORPORATE DESIGN ENGINEERING GROU THE SENIOR RESIDENT INSPECTOR FOR THE NRC WAS MADE AWARE OF THE DECISION AS A COURTES HIS CONCURRENCE WAS NOT SOUGHT OR OBTAINED. AT THE TIME THE DECISION WAS COMMUNICATED TO THE SENIOR RESIDENT, DETAILS OF THE OPERABILITY DETERMINATION WERE NOT YET AVAILABL _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _

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. FACTORS CONSIDERED IN THE DECISION FOLLOWING THE COMMUNICATION OF TEST RESULTS TO THE CORPORATE DESIGN ENGINEERING GROUP. THOSE INVOLVED AND RESPONSIBLE FOR THE DESIGN OF THE VX SYSTEM WERE VERY CONFIDENT THAT THE VX SYSTEM WOULD STILL PERFORM ITS DESIGN FUNCTION IN ITS DEGRADED CONDITION. THESE DESIGN EXPERTS CLEARLY BELIEVED THEY COULD PRESENT A TECHNICALLY CORRECT JUSTIFICATION FOR THE OPERABILITY OF THE VX SYSTEM. AND EXPRESSED THIS CONFIDENCE THROUGHOUT THE EVALUATION PERIO THE FLOW BALANCE TESTING HAD GONE THROUGH SEVERAL UNSUCCESSFUL ITERATIONS. THE ORIGINAL INTENT OF THE TEST HAD BEEN TO BALANCE THE SYSTEM TO FSAR FLOW VALUES. WE HAD DISCOVERED THIS WOULD NOT BE POSSIBLE. THE NEW PURPOSE HAD BECOME TO GATHER ENOUGH DATA TO SUPPORT THE CORPORATE DESIGN ENGINEERING GROUP'S EFFORT TO JUSTIFY THE OPERABILITY OF THE VX SYSTM. ONCE THE DESIGN EXPERTS STATED THEY HAD SUFFICIENT DATA TO SATISTY THIS NEED. FURTHER TESTING WAS UNNECESSARY. THE LETERMINATION THAT SUFFICIENT DATA HAD BEEN GATHERED OCCURRED DURING THE FLOW HOOD MEASURD(ENTS ON UNIT 2

"B" TRAIN. THUS A COMPLETE SET OF "B" TRAIN FLOW HOOD MEASURD(ENTS WAS NOT TAKEN PRIOR TO ENTERING MODE # STATION MANAGD(ENT'S DECISION TO PROCEED TO MODE #4 WAS PRIMARILY BASED OP.4 INPUT FROM EXPERTS FAMILIAR WITH THE VX SYSTEM. THESE EXPERTS CLEARLY BELIEVED THE SYSTEM WOULD PERFORM ITS DESIGN FUNCTION. WITH THIS CONFIDENCE STATION

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MANAGEMENT SAW NO REASON TO DELAY THE SCHEDULED START-UP OF UNIT 2 FOLLOWING THE REFUELING OUTAG . CORRECTIVE ACTIONS ALTHOUGH THE OPERABILITY DETERMINATION OF 8/19/88 LATER CONCLUDED THAT THE VX SYSTEM WAS CAPABLE OF PERFORMING ITS DESIGN FUNCTION, THE DECISION TO PROCEED TO HODE I/4 ON 7/19/88 WAS BASED ON INCORRECT INFORMATIO THE DECISION ITSELF WAS NOT AT FAULT, BUT THE PROCESS BY WHICH IT WAS ARRIVED AT HAD WEAKNESSE THE OPERABILITY DETFAMINATION PROGRAM WILL BE STRENGTHENED TO HELP PRECLUDE ERRORS SUCH AS THIS IN THE FUTUR C. OPERABILITY DETERMINATION PROCESS THE VX OPERABILITY DETERMINATION BROUGHT SEVERAL CONCERNS TO LIGHT INVOLVING DUKE POWER COMPANY'S JUSTIFICATION FOR CONTINUED OPERATION /0FFRABILITY DETFAMINATION PROGRA THESE ARE SUMMARIZED HERE:

+ ALTHOUGH OPERABILITY DETERMINATIONS ARE DOCUMENTED IN ACCORDANCE WITH ESTABLISHED PROCEDURES AND ARE TYPICALLY TECHNICALLY STRONG. THEY DO NOT PROGRAMATICALLY INCLUDE 10CFR50.59 EVALUATION No PROCEDURES EXIST FOR THE REVIEW AND APPROVAL OF OPERABILITY DETFRMINATIONS BY NUCLEAR PRODUCTION DEPARIMENT PERSONNE (THE DESIGN ENGINEERING

__ _ _ _ _ _ _

. ,

'

.

. DEPARTMENT PERFORMS INTERNAL REVIEWS.) AS A RESULT, OPERABILITY DETERMINATIONS RECEIVE VARYING DEGREES OF f REVIEW AND APPROVA l

'

4 NO PROCEDURES EXIST TO CONTROL OPERABILITY

'

DETERMINATIONS AND TRACK THDi ONCE THEY HAVE BEEN ACCEPTE j e THE PROCESSES OF PERFORMING A JUSTIFICATION FOR .

l CONTINUED OPERATION (JCL), AN OPERABILITY DETERMINATION, j L

AND ANSWERING A PROBLD1 IDENTIFICATION REPORT (PIR) HAVE ,

!'

BECOME INTERCHANGEABLE. THIS HAS APPARENTLY LED TO A

GREAT DEAL OF CONFUSION IN OUR COMMUNICATIONS WITH THE

!

NR RECENT DISCUSSIONS WITH REGION II PERSONNEL HAVE MORE CLEARLY ESTABLISHED THE DISTINCTIONS BEIVEEN THESE PROCESSE i

,

IN ORDER TO RESPOND TO THESE PROBLEMS, THE FOLLOWING CORRECTIVE l ACTIONS ARE BEING PLANNED. THESE CORRECTIVE ACTIONS WILL APPLY To ,

ALL 3 DUKE POWER COMPANY NUCLEAR FACILITIE i (a.) OUR NUCLEAR PRODUCTION DEPARTNENT DIRECTIVE WILL BE REVISED TO INCLUDE THESE UPGRADES: ,

e THE JCO, OPERABILITY DETERMINATION, AND PIR RESPONSE PROCESSES WILL BE CLEARLY DEFINED. EXPECTED LEVELS OF [

l NRC INVOLVEMENT WILL BE ESTABLISHE l l

4 REQUIRDtENTS TO CONSIDER THE QUESTIONS ADDRESSED IN l 10CFR50.59 WILL BE ESTABLISHE I

• REVIEW RESPONSIBILITIES BY NUCLEAR PRODUCTION PERSONNEL I

WILL BE ESTABLISHED, APPROVAL LEVELS WILL BE SE f I

i (

I t

!

__

e e

- (b.) PROCEDURES WILL BE ESTABLISHED AT THE STATION TO CONTROL AND TRACK OPERABILITY DETERMINATION THESE UPGRADES ARE NOW IN PREPARATION AND ARE EXPECTED TO BE COMPLETE IN THE FIRST QUARTER OF 198' ,

i e

- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

e

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.

UNIT 1 HYDROGEN SKIMMER TAN COMPARTMENT FLOW MEASUREMENT AS TOUND DATA 10/18/88 Required compartments riew HSF-1A HSF-18 SG-1A 121 214 916 50-1B 121 671 360 SG-1C 121 521 254 SG-1D 121 300 771 PZR 121 () 283 ACC-1A 4 46 37 ACC-1B 4 36 20 ACC-1C 24 68 86 ACC-1D 24 43 70 Inc. R Rx. H (h) (h) Tan R Tan R l l The above flows were measured per TT/1/A/9100/217 and are given in SCT Each of the thirteen compartments above is served by two intake damper The "as-found" condition for each of the twenty-six dampers was open or throttled. Eight dampers (serving the S/Gs)

were 100% cpen, with remaining damper positions varied, throttled closed by as much as 95%.

Total flow for each HSF was measured by traversing the suction duc Results were HSF-1A = 3307 SCTM; HST-1B = 3212 Scr [d /T 7 P. W. Roberson NP Engineer, Performance j file:dvx.dw4.vxflow.ul.101988

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l

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- Table 14.1.3-1 (Page 30)

CONTAINMENT AIR RETURN AND HYDROGEN SKIMMER SYSTEM FUNCTIONAL TEST Abstra Purpose To descnstrate the capability of the system to operate and to provide design air flow Prerequisites The .cs condenser inlet doors are blocked closed to prevent operatio Test Method Each containment air return fan and hydrogen skimmer fan is operated. Tests are performed to demonstrate the proper head and flow characteristics of eacn fan. Automatic operation of the Containment air return fans is verified for a simulated high-high containment pressure signal (S ). System interlocks are P

also verifie A

REGION THAT DOES NOT DIRECTLY BENEFIT FROM CIRCULATirN PRODUCED BY THE C)NTAINMENT AIR RETURN FAN THE CALCULATED MINIMUM SKIMMER SYSTEM FLOW RATE TO LIMIT COMPARTMENT HYDROGEN CONCENTRATION TO BELOW FOUR VOLUME ,

PERCENT IS 121 CUBIC FEET PER MINUTE (CFM). MEASURED FLOW RATE W!TH FAN 1B OPERATING WAS 281 CFM, AND MEASURED FLOW WITH FAN 1A OPERATING WAS 85 CF :

BASED ON THE FLOW MEASUREMENT RECORDED FOR FAN 1A, THE PRESSURIZER I

COMPARTMENT HYDROGEN CONCENTRATION COULD HAVE RLACHED 4.8 VOLUME PERCEN ALTHOUGH 4.8 VOLUME PERCENT EXCEEDS THE CONSERVATION l

DESIGN BASIS LIMIT OF 4.0 VOLUME PERCENT, IT IS VERY UNLIKELY THAT l HYDROGEN AT 4.8 VOLUME PERCENT WOULD IGNITE AND BURN EVEN IN DRY AIR AND IN THE PRESENCE OF AN IGNITION SOURCE. HOWEVER, IF BURNING ,

WERE TO OCCUR, ESSENTIAL EQUIPMENT LOCATED IN THE PRESSURIZER i

COMPARTMENT HAS BEEN ANALYZED AND DETERMINED ABLE TO SURVIVE EVEN l

THE BURNING OF HYDROGEN FROM THE 75'$ METAL WATER REACTION OF A ,

I DEGRADED CORE ACCIDEN THE ANTICIPATED MAXIMUM CONCENTRATION OF 4.8 VOLUME PERCENT IS CLEARLY WELL BELOW DETONABLE LEVELS, AND IS NOT CONSIDERED A DETRIMENT TO MAINTAINING CONTAINMENT INTEGRITY AND TO CONDUCTING A STABLE POST-ACCIDENT RECOVERY.

!

_ - - - - - - _ _ - - - - - - - - - - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---- - ---

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<

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e

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ANALYSIS OF SAFETY SIGNIFICANCE METHOD i

USE REVISED ASSUMPTIONS FOR H 2 SOURCE

'

-

TERMS

,

-

RECOMPUTE REQUIRED FLOW RATES PER ,

COMPARTMENT

-

COMPARE TO AS-FOUND VX SYSTEM CAPABILITY

!

-

FURTHER ASSESS ANY LOW-FLOW l COMPARTMENTS

,

!

!

,

Y

, - . - - - , _ - _ . _ _ - - - - _ _ - _ _ . - _ _ . . _ - _ . - - - _ . - _ , . - - - - _ - - . , _ . _ , _ -- - _ _

.- _ . _ , - _ - , _ - . - - - - - - - - - - _ _ - _ . . _ _ . - . _ _ _ _

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COMPARTMENT MODEL t

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X sefm m m V V I

t AN Ak

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- - _ _ __ - -_ _ . _ _ - _ -

- - - - _ - _ - - _ - _ . - _ _ _ _- -- _

- . _ _ _ , - _ _ _

l

.

.

.

t ORIGINAL,W ANALYSIS

,

I

$

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X sofm

'

1.8% 3.5%

,

i i k JL

i H, ZlRC REACT H, - RADIOL ,

(6.0%) H , - Al  !

(CONSTANT) ,

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4 l'

I

- ...

-

.

.

.

.

.

REVISED DUKE ANALYSIS l X' s of m

'

0.6% 3.9%

i l JL H 2 - ZlRC REACT H 2- RADIOL (1.5%) H 2- Al + Zn H 2- PRIM COOL (TEMP DEP)

l l

_ ___ _ _ . ___ __ _. _--

.-- _ _ ._ . _ . _. ._

-

.

.

.

s

.

EXAMPLE FLOW COMPARISON COMPARTMENT: SG-1 A ORIGINAL WESTINGHOUSE 138 SCFM

.

REVISED DUKE 121 SCFM AS FOUND (VX-A) 214 SCFM  ;

,

AS FOUND (VX-B) 916 SCFM

_ _ - . , _ _ _ - . - , _ _ _ _ _ _ _ . . . _ _ _

. _ _ _ . - _ _ _ _ _ _ . . . _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ . _ . . . _ _ _ _ _ _ __ _ . _ _ _ . _ _ _ _

~

,

,

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'

. COMPARTMENTS WITH LOW FLOW

'

(AS-FOUND)

COMPARTMENT ASSESSMENT UNIT 1 REACTOR HEAD THERMAL CONVECTION PRESSURIZER COULD HAVE REACHED 4.8% WELL BELOW DETONABLE UNIT 2 -

REACTOR HEAD THERMAL CONVECTION EAST FAN ROOM AIR RETURN FAN VENTILATION WEST FAN ROOM AIR RETURN FAN

..

VENTILATION ACCUM. ROOM 20 AIR RETURN FAN VENTILATION ACCUM. ROOM 2D AIR RETURN FAN VENTILATION

- _ - _ _ _ . . . . - . - _ - -

.

e e

4 ANALYSIS OF SAFETY SIGNIFICANCE CONCLUSIONS

. ONE COMPARTMENT ON ONE UNIT COULD EXCEEDED DESIGN LIMI .

- NO SIGNIFICANT SAFETY IMPAC . NEGLIGIBLE EFFECT ON POSTULATED DEGRADED CORE ACCIDEN ,

e  ;

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FUNCTIONAL VERIFICATION PROGRAM DEFICIENCIES ,

!

DEFINITIONS POST-MAINTENANCE TESTING - THE POST-MA.NTENANCE iESTING PROGRAM AT McGUIRE CONSISTS OF A FUNCTIONAL VERIFICATION PROGRAM AND A RETEST PROGRA FUNCTIONAL VERIFICATION - A CHECK TO ENSURE THAT THE REQUESTED MAINTENANCE WAS PERFORMED AND THAT THE SUBJECT EQUIPMENT PERFORMS ALL OF ITS INTENDED FUNCTIONS AND IS FUNCTIONING PROPERLY PRIOR TO DECLARING THE EQUIPMENT OPERABL RETEST - THE FORMAL PERFORMANCE OF ALL OR PORTIONS OF PREOPERATIONAL OR PERIODIC TESTING TO VERIFY THE COMPONENT OR SYSTEM MEETS APPLICABLE ACCEPTANCE CRITERIA AND/OR TECHNICAL SPECIFICATION REQUIREMENT SOME MAINTENANCE MAY ONLY REQUIRE A FUNCTIONAL VERIFICATION WHILE OTHER MAINTENANCE MAY REQUIRE BOTH FUNCTIONAL VERIFICATION AND RETES POST-MODIFICATION TESTING - THE POST-MODIFICATION TESTING IS TESTING CONDUCTED TO CONFIRM THAT MODIFICATIONS PERFORM AS EXPECTED AND THAT OTHER SYSTEMS OR COMPONENTS ARE NOT ADVERSELY AFFECTE POST MODIFICATION TESTING MAY CONSIST OF ANY COMBINATION OF FUNCTIONAL VERIFICATION, RETEST, OR SPECIAL TEST k e

o

.

. OVERVIEW / SEQUENCE OF EVENTS THIS PRESENTATION INVOLVES SEVERAL EVENTS, SOME VERY COMPLEX, DATING BACK TO FEBRUARY, 1987. A DRIEF DESCRIPTION OF THE EVENTS THAT LEAD INTO THE DISCOVERY OF THE NATURE OF THE PROBLEMS WILL BE PROVIDED AND THEN A HISTORICAL REVIEW AND BRIEF DESCRIPTION OF ALL THE EVENTS MENTIONED IN THE NRC INSPECTION REPORT WILL BE PRESENTE RECENT EVENTS THAT UNCOVERED THE NATURE OF THE FUNCTIONAL VERIFICATION PROGRAM DEFICIENCIES INV-1428 CATAWBA NUCLEAR STATION RECENTLY FOUND SOME LINKS OPEN IN SAFETY

, RELATED ELECTRICAL CIRCUITS AND PASSED ON THE CONCERNS TO

McGUIRE, THROUGH DUKE'S OPERATING EXPERIENCE PROGRA McGUIRE l

FELT WE MAY BE VULNERABLE TO THE SAME PROBLEM SO WE INSPECTED OUR SYSTEMS AND FOUND AN OPEN LINK ON A SAFETY RELATED VALVE IN THE CHEMICAL AND VOLUME CONTROL SYSTEM (VALVE INV-1428). THIS LINK

, WAS PART OF THE ELECTRICAL CIRCUITRY WHICH PROVIDED AUTOMATIC CLOSURE OF THE VALVE. THE LINK HAD BEEN LEFT OPEN FOLLOWING THE IMPLEMENTATION OF A MODIFICATION DURING THE UNIT 1 1987 REFUELING OUTAG PERSONNEL ERROR WAS THE POSSIBLE ROOT CAUS FUNCTIONAL VERIFICATION OF THE MODIFICATION HAD FAILED TO ENSURE THE LINK WAS CLOSE ", t O

.

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INS-18(1)

AS A RESULT OF THE INV-142 INCIDENT, PROJECTS PERSONNEL AND ISE MET AND DECIDED TO REVIEW OTHER SiMILAR MODIFICATIONS ON UNIT 1 AND UNIT TESTS WERE DEVELOPED AND CONDUCTED TO VERIFY THAT THE MODIFIED COMPONENTS WERE STILL FULLY OPERABLE. THIS TESTING REVEALED THAT 2 OTHER VALVES, INS-18 AND INS-1, IN THE CONTAINMENT SPRAY SYSTEM, WERE INOPERABLE DUE TO INCORRECT WlRIN AS IN THE INV-142B INCIDENT, THESE PERSONNEL ERRORS WERE NOT DETECTED BY THE FUNCTIONAL VERIFICATION OF THE MODIFICATIO Dbd IN JUNE OF 1988 DURING THE IMPLEMENTATION OF A MODIFICATION, IT WAS DISCOVERED THAT ANOTHER WIRING ERROR HAD OCCURRED MAKING A VALVE ON THE DECAY HEAT REMOVAL SYSTEM INOPERABLE (VALVE 2NU-48). THE WIRING HAD BEEN IN THIS CONFIGURATION SINCE THE PREVIOUS MODIFICATION ON THE VALVE THE YEAR BEFOR AGAIN, THIS PERSONNEL ERROR WAS NOT DETECTED BY THE FUNCTIONAL VERIFICATION CONDUCTED AS PART OF THE POST MODIFICATION TESTING PROGRA s 0

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!

.

. HISTORICAL OVERVIEW AS A RESULT OF THESE THREE EVENTS, NRC AND DUKE CONDUCTED A REVIEW TO EVALUATE OUR HISTORY WITH FUNCTIONAL VERIFICATIO LISTED BELOW, IN CHRONOLOGICAL ORDER, ARE THE EVENTS THAT WERE JUDGED TO BE ASSOCIATED WITH FUNCTIONAL VERIFICATION, BY DUKE AND/OR THE NR FEBRUARY, 1987 -

VALVE INM-26 - A WlRING FAULT IN A NEW ACTUATOR WAS NOT IDENTIFIED BY FUNCTIONAL VERIFICATION WHEN INSTALLED. THIS IS AN EXAMPLE IDENTIFIED IN THE RECENT NRC INSPECTION REPOR APRIL, 1987 -

INPO IDENTIFIED A FINDING IN THE AREA OF FUNCTIONAL VERIFICATION. ALTHOUGH THEY DID NOT FIND SIGNIFICANT EVIDENCE OF FAILURE TO ADEQUATELY PERFORM FUNCTIONAL VERIFICATION, THEY FELT OUR PROGRAM WAS TOO DEPENDENT ON THE INDIVIDUAL JUDGMENT OF THE TECHNICIAN AND SUPERVISION. THEY FELT WE SHOULD STRUCTURE THE PROGRAM AND MAKE IT MORE PRESCRIPTIV DUKE AGREED TO ENHANCE THE PROGRAM BUT AT THAT TIME DID NOT BELIEVE WE HAD INOPERABLE EQUIPMENT IN THE FIEL AUGUST, 1987 - VALVE IND-67 - THE WORK CONTROL SYSTEM HAD INCORRECTLY IDENTIFIED THIS VALVE AS NON-SAFETY RELATED AND ALSO DID NOT SPECIFY A FUNCTIONAL VERiflCATION TO BE DONE FOLLOWING ROUTINE CAllBRATION OF THE INSTRUMENT THAT CONTROLS THE VALVE. A PERSONNEL ERROR OCCURRED IN THE CAllBRATION LEAVING THE VALVE INOPERABL THIS IS AN EXAMPLE IDENTIFIED IN THE RECENT NRC INSPECTION REPOR 's o

.

.

NOVEMBER, 1987 -

VALVE 1RN-2358 - REPAlR WORK WAS DONE ON THIS VALVE AND SUBSEQUENTLY FUNCTIONALLY VERIFIED AND RETESTED PROPERL ADDITIONAL REPAlR WORK WAS NEEDED SO MAINTENANCE PERSONNEL USED THE SAME WORK REQUEST TO COMPLETE THE REPAIR AND AGAIN FUNCTIONALLY VERIFIED THE VALVE PROPERLY BUT IT WAS NOT RETESTED (STROKE TIMED). THE VALVE WAS OPERABLE WHEN LATER RETESTE Tili3 VAS A PERSONNEL ERROR IN THE WORK CONTROL PROCESS IN IMPLEMENTING POST MAINTENANCE RETEST. THIS IS AN EXAMPLE IDENTIFIED IN THE NRC INSPECTION REPOR FEBRUARY, 1988 -

VALVE 1RN-21 - A MAINTENANCE WORK PLANNER FAILED TO SPECIFY THE REQUIREMENT TO RETEST THIS VALVE FOLLOWING A PACKING ADJUSTMEN THIS WAS A PERSONNEL ERROR IN THE WORK

. K~ROL PROCESS IN IMPLEMENTING POST 40 NTENANCE RETEST. THIS IS AN EXAMPLE

.9 TIFIED IN THE RECENT NRC INSPECTION nEF ( JUNE, 1988 -

VALVE 2ND-4 - PREVIOUSLY DESCRIBE AUGUST, 1988 -

VALVE INV-142B - PREVIOUSLY DESCRIBE SEPTEMBER, 1988 - VALVES INS-18 S INS-1 - PREVIOUSLY DESCRIBE ALTHOUGH ALL THESE EVENTS WERE RELATED IN VARYING DEGREES TO THE FUNCTIONAL VERIFICATION / RETEST PROGRAM, THE LAST 3 EVENTS WERE THE MOST SIGNIFICANT SINCE THEY HAVE IDENTIFIED A DEFICIENCY IN THE BASIC STRUCTURE OF THE FUNCTIONAL VERIFICATION PROCES THE REMAINDER OF THE PRESENTATION WILL FOCUS ON THcSG 3 SPECIFIC EVENTS, THEIR ROOT CAUSES, OUR CORRECTIVE ACTIONS AND THE SAFETY IMPAC '

o .

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FUNCTIONAL VERIFICATION PROGRAM

.

SEQUENCE OF EVENTS

,

DATE TIME EVENT 4/87 ----

AN INPO AUDIT IDENTIFIED DEFICIENCY (MA.3-1)

IN THE FUNCTIONAL VERIFICATION PROGRAM. THE DEFICIENCY STATED THAT THE GUIDELINES FOR FUNCTIONAL VERIFICATION TESTS 00 NOT SPECIFY ALL APPROPRIATE TESTS THAT SHOULD BE CONSIDERED FOLLOWING MAINTENANC /87-5/88 ---- A NEW MECHANICAL MAINTENANCE PROCEDURE MMP 1.6 WAS BEING DEVELOPED TO PROVIDE MORE SPECIFIC GUIDELINES ON FUNCTIONAL VERIFICATION TESTIN '

6/87 ----

A MODIFICATION WAS PERFORMED TO MOVE THE TORQUE SWITCH BYPASS TO AN ADD-ON PACK, AND TO REPLACE ALL JUMPERS WITH QUALIFIED WIRE. WIRE NO. 16 WAS NOT PART OF THE JUMPER WIRE CHANGE, BUT WAS DISCONNECTED AND SUBSEQUENTLY RECONNECTED TO THE WRONG TERMINAL AFTER THE JUMPER WIRES WERE REPLACED WITH QUALIFIED WIRE. WIRE NO. 16 WAS INDEPENDENTLY VERIFIED AS BEING ON THE PROPER TERMINA IT WAS LATER DISCOVERED NOT TO BE THE CAS ~ - _ . .- - . . . - . -- - -._- _ _ - . _ . _ _- - . - - -

. - - _ .

.,

'~

,

,

?F ,-

'-. 9/87-10/87 ---- IAE PERSONNEL PERFORMED THE TORQUE SWITCH BYPASS MODIFICATION ON VALVE ACTUATORS

__ 1NI-184B(185A). THE MODIFICATION INCLUDED MOVING THE PERMISSIVE INTERLOCK WIRING FOR VALVES-1NS-1B(18A) TO A PREVIOUSLY UNUSED SET

,, OF LIMIT SWITCHES TO MAKE ROOM FOR THE BYPASS

/- WIRIN /15/88 ---- CMD PERSONNEL WERE PERFORMING A MODIFICATION ON 2NI-184 AND FOUND WlRE NO. 16 TO BE INCORRECTLY CONNECTED TO TERMINAL 4 t

.

---

CMD PERSONNEL COMPLETED THE MODIFICATION AND PLACED WIRE NO. 16 ON TERMINAL 31 AS PART OF

!

THE MORE RECENT MODIFICATIO /27/88 ----

QA PERSON DISCOVERED THE MISPLACED WIRE ,

DURING AN AUDIT OF THE MODIFICATIO QA PERSON RESEARCHED THE ELECTRICAL CIRCUlTRY FOR THE WIRE AND DETERMINED IT WAS PART OF THE AUTOMATIC CLOSURE CIRCUlTRY FOR VALVE 2ND- /29/88 ----

lAE PERSONNEL WERE PERFORMING AN INSPECTION

,

OF ATC4A AND DISCOVERED LINK l-1 OPEN.

l

---

IAE PERSONNEL RESEARCHED THE ELECTRICAL CIRCUlTRY FOR LINK l-1 AND FOUND THAT THE LINK

'

WAS PART OF THE AUTOMATIC CLOSURE CIRCUITRY FOR VALVE INV-142 /29/88 ---- lAE PERSONNEL NOTIFIED OPS CONTROL ROOM PERSONNEL OF THE OPEN'D LINK IN THE AUTOMATIC CLOSURE CIRCUlTRY FOR VALVE INV-142 .

.y

> 1

.

.

.

. 8/29/88 ----

IAE PERSONNEL CLOSED LINK l-1 AND FUNCTIONALLY VERIFIED THAT THE AUTOMATIC CLOSURE CIRCUlT WAS NOT OPEN FOR V'ALVE INV-142 ~8/30/88- ---- PROJECT SERVICES PERSONNEL REVIEWED ALL 9/1/88 PREVIOUS TORQUE SWITCH BYPASS MODIFICATIONS FOR DOCUMENTATION OF AN ADEQUATE FUNCTIONAL VERIFICATIO /2/88 ----

PROJECT SERVICES PERSONNEL INITIATED A WORK REQUEST TO REVERIFY THE INTERLOCKS BETWEEN VALVES 1NI-184B (185A) AND INS-1B(18A).

9/2/88 ----

IAE PERSONNEL DISCOVERED ELECTRICAL PERMISSIVE INTERLOCK CONTACT IAS3 BETWEEN VALVES INI-184B(185A) AND INS-1B(18A) OPEN WHEN IT SHOULD HAVE BEEN CLOSED AND CONTACTED OPS PERSONNEL CONCERNING THE DISCREPANC /3/88 PROJECT SERVICES PERSONNEL INITIATED A MODIFICATION TO JUMPER THE OPEN CONTACT 1AS3 AND IAE PERSONNEL INSTALLED A JUMPER AROUND PERMISSIVE INTERLOCK CONTACT lAS3 AND THIS RETURNED ELECTRICAL CONTROL OF VALVES INS-1B (18A) TO OPS CONTROL ROOM PERSONNEL.

l 9/9/88 ----

STATION PERSONNEL REVIEWED AN EARLIER INCIDENT IN WHICH A WIRING ERROR ON 2NI-184B DISABLED THE REQUIRED SWITCHOVER FUNCTIO /1/88 ----

FUNCTIONAL VERIFICATION PROCEDURE MMP 1.3 IS PHASED OUT AND REPLACED BY MMP 1.6.

,

.,,

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1NV-142 PROBLEM DISCOVERED - 8/29/88 OPEN ELECTRICAL LINK FOUND WHICH DEFEATED AUTOMATIC CLOSURE OF VALVE 1NV-14 ROOT CAUSE DURING MODIFICATION ON VALVE IN 1987 REFUELING OUTAGE TO C)lANGE OPERATOR MODEL AND ADD ELECTRICAL ANTI-HAMMER CIRCUIT, A WIRING CHANGE CONNECTED A PREVIOUSLY UNUSED ELECTRICAL LIN PERSONNEL ERROR RESULTED IN LINK REMAINING OPE ,

o

.

. j

. (

., , 1NV-142 '

,.,

SAFETY ANALYSIS A) THE SAFETY SYSTEM SIGNAL FOR THE AUTOMATIC CLOSURE OF VALVE 1NV-142B HAD BEEN DEFEATED, HOWEVER:

VALVE INV-142B COULD HAVE BEEN CLOSED LOCALLY AS WELL AS FROM THE CONTROL ROO *

VALVE INV-141A WAS OPERABLE DURING THIS TIME PERIOD AND CAPABLE OF ISOLATING THE VC B) IN THE EVENT OF A SMALL BREAK LOCA DURING THIS TIME PERIOD AND INV-141A WAS INCAPABLE OF BEING CLOSED:

THE VCT WOULD BE DEPLETED AND ITS HYDROGEN BLANKET COULD ENTER THE NV PUMP SUCTION LINE, RENDERING THE PUMPS INOPERABLE IN APPROXIMATELY 18 1/4 MINUTES AFTER SAFETY ACTUATIO *

VALVE INV-142 COULD HAVE BEEN CLOSED LOCALLY IN 15 MINUTE *

THE REACTOR COULD BE SHUTDOWN SAFETY WITH THE CONTROL ROD MAKEUP TO NC SYSTEM WOULL BE PROVIDED BY SI PUMPS WHEN PRESSURE REACHED 1500 PSI *

.

.

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. . NORMAL LETDOWN AND CHARCINC 9, .

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LETDOWN FROM NC SYSTDI V

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NV-141

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NV PIMP t NV-221 MAKEUP TO C 4 < RWST SYSTEM i

NV-222 v

NV PUMP l

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-

-

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,

k CORRECTIVE ACTION 1NV-142 1) IAE PERSONNEL CLOSED LINK L-1 AND FUNCTIONALLY VERIFIED AUTOMATIC OPERATION OF VALVE INV-14 ) ALL MODIFICATION PACKAGES ON VALVE OPERATORS FOR BOTH UNITS WERE REVIEWED FOR ADEQUATE FUNCITONAL VERIFICATIO TEMPORARY TEST PEOCEDURES WERE INITIATED WHERE APPROPPIAT ) MAINTENANCE MANAGEMENT PROCEDURE 1.6 ISSUED WHICH DEFINES THE MINIMUM FUNCTIONAL VERIFICATION REQUIREMENT REVISION IN PROGRESS AT TIME OF EVENT DISCOVER ) CHANGES TO PROCEDURES ON REMOVAL AND INSTALLATION OF VALVE OPERATORS WHICH INCLUDE FUNCTIONAL VERIFICATION REQUIREMENTS FOR ALL LIMIT SWITCHES, ASSOCIATED ,

INTERLOCKS AND AUTOMATIC FUNCTION !

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INS-1, 18 PROBLEM DISCOVERED 9/2/88

.

ELECTRICAL CONTACT FOUND OPEN WHICH BLOCKED OPEN PERMISSIVE t

NECESSARY TO OPEN INS-1,18 WHEN 1NI-184, 185 REACHED FULL OPEN POSITIO ROOT CAUSE POSSIBLE PERSONNEL ERROR IN TORQUE SWITCH BYPASS MODIFICATION ON 1NI-184, 185 DURING 1987 REFUELING OUTAG ,

.

.

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.

.

SAFETY ANALYSIS, THE FUNCTION OF NS-1,18 IS TO ISOLATE THE A(B) NS PUMP FROM REACTOR BUILDING SUMP LINE A(B). DURING THE INJECTION PHASE OF A LOCA NS-1,18 IS CLOSED AND THE NS PUMP IS TAKING A SUCTION FROM THE FWST VIA NS-20(3). ON A LOW-LOW FWST LEVEL NS PUMP A(B) IS STOPPED AND ITS SUCTION IS REALIGNED BY THE CONTROL ROOM OPERATOR FROM THE FWST TO THE CONTAINMENT SUMP BY CLOSING NS-20(3) AND OPENING NS-18(1)

SINCE NI-185(184) HAS ALREADY OPENED AUTOMATICALL NS PUMP A(B) IS THEN RESTARTE THEREFORE, IN ORDER FOR NS-18(1) TO OPEN, NI-185(184) MUST BE OPEN AND NS-20(3) CLOSE DURING THE ABOVE TIME PERIOD, NS-18(1) COULD NOT HAVE BEEN OPENED FROM THE CONTROL ROOM IF THE NS-20(3) AND NI-185(184) PERMISSIVES HAD BEEN MET DUE TO THE 1AS-3 CONTACT SETUP ERROR IN THE SWITCH PACK ON N1-185(184). NS-18(1) COULD HAVE BEEN MANUALLY OPENED LOCALLY IF N1-185(184) WERE TO OPE THE NORMAL ALIGNMENT OF NS IS WITH NS-20(3) OPEN AND NS-18(1) AND N1-185(184) CLOSE THE US SWAP OVER TO THE CONTAINMENT SUMP FROM THE FWST IS PERFORMED BY CONTROL ROOM OPERATORS USING EMERGENCY PROCEDURE EP/1/A/5000/ THUS, DURING THE ABOVE TIME PERIOD WHEN THE SUBJECT INTERLOCK WAS NOT FUNCTIONAL THE NS-18(1) VALVE REALIGNMENT COULD HAVE BEEN PERFORMED MANUALLY IF REQUIRE ,

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CORRECTIVE ACTION INS-1,18 1) OPS SHIFT PERSONNEL WERE INFCRMED THAT INS-1B AND 18A WOULD HAVE TO BE MANUALLY OPERATED LOCALLY DURING ACCIDENT CONDITIO ) IAE PERSONNEL IMPLEMENTED MEVN-1454 WHICH RETURNED CONTROL TO CONTROL ROOM SWITCH BY PLACING JUMPER AROUND OPEN CONTAC ) MODIFICATION INITIATED TO REMOVE JUMPER AND CORRECT OPEN CONTACT AT VALVE OPERATO TO BE COMPLETED DURING 1988 REFUELING OUTAG ) CHANGES TO PROCEDURES ON REMOVAL AND INSTALLATION OF VALVE OPERATORS WHICH INCLUDES FUNCTIONAL VERIFICATION REQUIREMENTS FOR ALL LIMIT SWITCHES, ASSOCIATED INTERLOCKS, AND AUTOMATIC FUNCTION ,

5) IAE PERSONNEL HAVE REVIEWED ALL WORK REQUESTS WHICH INVOLVE SAFETY RELATED MOTOR OPERATED VALVE ACTUATOR WORK SINCE THE LAST ESF TEST ON BOTH UNIT ) IAE PERSONNEL WILL HEAD A REVIEW GROUP TO STUDY THE STATION'S FUNCTIONAL VERIFICATION, RETEST AND POST-MODIFICATION TESTING PROGRAMS TO ENSURE PROPER OVERLAP EXIST ,

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2ND-4 PROBLEM DISCOVERED - 6/27/88 WIRE WAS CONNECTED TO WRONG TERMINAL ON 2NI-184 OPERATOR WHICH CAUSED THE INTERLOCK THAT AUTO CLOSES 2ND-4 TO BE INOPERABL ROOT CAUSE PERSONNEL ERROR WAS MADE DURING MODIFICATION ON TORQUE SWITCH BYPASS IN 1987 REFUELING OUTAG .

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SAFETY ANALYSIS 2ND-4 THE RESIDUAL HEAT REMOVAL (ND) AUTOMATIC SWITCH OVER SEQUENCE FROM THE INJECTION MODE TO THE COLD LEG RECIRCULATION MODE CAUSES THE CONTAINMENT SUMP ISOLATION VALVE 2NI-184B TO OPE THIS AUTOMATICALLY INITIATES THE CLOSURE OF 2ND-4 THIS OPERATION ISOLATES THE WST ND PUMP SUCTION AND ALIGNS IT TO THE CONTAINMENT SUM THE MIS-WIRED INTERLOCK WOULD HAVE PREVENTED THE CLOSURE OF 2ND-4 ON VERIFICATION OF SWITCH OVER, THE OPERATOR WOULD NOTE THAT 2ND-4B WAS STILL OPEN AND CLOSE I THE OPERATOR STILL RETAINED FULL REMOTE CONTROL OF THE VALV ALSO, PER PROCEDURE, THE UPSTREAM FWST ISOLATION VALVE 2FW-27A, WOULD BE CLOSP.D BY TTfE OPERATOR AFTER SWITCH OVE THI.a ISOLATES FWS THE MIS-WIRED INTERLOCK HAD NO ADVERSE EFFECT ON THE SAFETY INJECTION RECIRUT ATION VALVE ALIGNMENTS AND OPERATOR ACTION TO CLOSE 2ND-4B IS AVAILABL THEREFORE, THE SAFETY INJECTION FUNCTION REMAINED OPERABL *

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CORRECTIVE ACTION 2ND-4 1) ALL NSM PACKAGES WERE REVIEWED FOR ADEQUATE FUNCTIONAL VERIFICATIO TEMPORARY TEST WERE WRITTEN TO PERFORM FUNCTIONAL VERIFICATION WHERE APPROPRIAT ) MAINTENANCE MANAGEMENT PROCEDURE 1. 6 ISSUED WHICH DEFINES THE MINIMUM FUNCTIONAL VERIFICATION RZQUIREMENTS FOR A PARTICUU R COMPONEN REVISION IN PROORESS AT TIME OF EVENT DISCOVER ) CHANGES TO PROCEDURES ON REMOVAL AND INSTALLATION OF VALVE OPERATORS WHICH INCLUDE FUNCTIONAL VERIFICATION REQUIREMENTS FOR ALL LIMIT SWITCHES, ASSOCIATED i

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INTERLOCKS, AND AUTOMATIC FUNCTIONS.

l l 4) REVIEW )F ALL WORK REQUEST ON SAFETY RELATED MOV'S ACTUATORS.

l 5) REVIEW GROUP TO STUDY FUNCTIONAL VERIFICATION, RETEST AND POST-MODIFICATION TESTING PROGRAM .

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GENERIC CORRECTIVE ACTIONS 1) FUNCTIONAL VERIFICATION RE JIREMENTS, MMP-1.6, FULLY IMPLEMENTED WITH ALL TRAINING COMPLETE ) CHANGES MADE TO THE FOLLOWING PROCEDURES TO GIVE MORE DETAILED GUIDANCE FOR WORK ON VALVE OPERATOR IP/0/A/3066/01A - REMOVAL & INSTALLATION OF LIMITORQUE ,

vPERATORS -

IP/0/A/3066/02A - REMOVAL & INSTALLAT*0N OF ROTORK OPERATORS 3) RELATED INSTANCES WILL BE REVIEWED WITH ALL IAE PERSONNEL REVIEW IN PROGRES ) HAVE REVIEWED ALL WORK ON UNIT 2 SAFETY RELATED MOV'S ACTUATORS SINCE LAST SAFEGUARDS FUNCTIONAL TEST AND ADEQUACY OF FUNCTIONAL VERIFICATION EXNIINE SIX UNIT 2 VALVES HAVE BEEN IDENTIFIED FOR FUFTHER EVALUATIO ESF TESTING WILL BE COMPLETED ON UNIT 1 DURING CURRENT REFUELING OUTAG ) SPECIAL REVIEW GROUP REVIEWING FUNCTIONAL VERIFICATION, RETEST, AND POST-MODIFICATION TESTING TO ENSURE ALL AREAS ARE COVERE r 6) ENGINEERED SAFETY FEATURES ACTUATION TEST WILL BE

CONDUCTED AT END OF FUTURE REFUELING OUTAGES TO ENSURE E

I SYSTEMS FUNCTION AS DESIGNED.

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FURTHER REVLEW OF POST OCCURRENCES BY NRC AND STATION PERSONNEL HAVE IDENTIFIED ADDITIONAL POTENTIAL INDICATORS OF INCOMPLETE FUNCTIONAL VERIFICATION FOLLOWING MAINTENANC EXAMPLE 1: "lN FEBRUARY 1987, POST MAINTENANCE TESTING ON INM26B WAS INADEQUATE IN THAT WHATEVER TESTING WAS PERFORMED Dl0 NOT  ;

REVEAL THAT TERMINALS HAD SHORTED, CAUSING THE VALVE TO CYCLE OPEN ON AN ESF SIGNAL INSTEAD OF CLOSE".

A FAILED ACTUATOR MOTOR WAS REPLACED AND THE VALVE WAS FUNCTIONALLY TESTED BY CYCLING IT ' LECTRICALLY c FROM THE CONTROL ROO THE VALVE'S INDICATIONS WAS VERIFIED TO WORK CORRECTLY AND ,

THE LEAK TEST AND VALVE STROKE TIMING TEST WERE COMPLETED

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SATISFACTORlLY. LATER, THE VALVE CYCLED CONTINUOUSLY DURING A

$ SLAVE RELAY TEST AND A WIRE TERMINAL WAS FOUND SHORTED AGAINST THE BARREL NU SINCE INM-26B HAD BEEN SUCCESSFULLY CYCLED FROM 1HE CONTROL BOARD, ITS FUNCTION WAS DEMONSTRATE EXAMPLE 2: "lN AUGUST, 1987, NO RETEST WAS PERFORMED ON THE FLOW INSTRUMENT CONTROLLING ND PUMP 1B RECIRCULATION VALVE, IND67B, ,

RESULTING IN A VIOLATION".

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WORK WAS PERFORMED ON THE FLOW INSTRUMENT CONTROLLING ND PUMP 1B RECIRCULATION VALVE IND678, USING A PROCEDURE THAT DID NOT i IDENTIFY THE COMPONENT AS BEING SAFETY RELATED AND DID NOT REQUIRE FUNCTIONAL VERIFICATION SUBSEQUENT TO MAINTENANCE. HOWEVER, THE  :

ROOT CAUSE OF THE INCIDENT WAS DUE TO A FAILURE TO FOLLOW l PROCEDURE WHICH LEFT THE INSTRUMENT ISOLATED AND PROPER FUNCTIONAL  !

VERIFICATION WAS NOT PERFORME f I

EXAMPLE 3: "ON NOVEMBER 19, 1987, WHILE REVIEWING AN lAE WORK  ;

REQUEST FOR FINAL SIGNOFF, AN lAE STAFF PERSON DISCOVERED THAT f ADDIT ONAL TESTING WAS NEEDED ON 1RN235B, 1B NS HEAT EXCHANGER f

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COOLING WATER INLET".

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- A SEAT LEAK ON VALVE 1RN-235B WAS REPAIRED UNDER A WORK REQUES A RETEST AND FUNCTIONAL VERIFICATION WERE SUCCESSFULLY COMPLETED ON THE VALVE. WHEN A LEAK DEVELOPED, THE NEXT DAY THE ORIGINAL WORK REQUEST WAS REOPENED TO PERFORM THE WOR NO RETEST WAS PERFORMED ON THIS VALV THE ROOT CAUSE FOR THIS INCIDENT WAS PERSONNEL ERRO A CONTRIBUTING CAUSE WAS DUE TO A PROCEDURAL DEFICIENCIES (MMP 1.0 AND 1.3) WHICH ALLOWED A WORK REQUEST TO BE REOPENED ONCE IT HAS BEEN SIGNED COMPLETE. SUBSEQUENT CHANGES TO THE WORK CONTROL SYSTEM HAS ELIMINATED THE USE OF A WORK REQUEST FOR ADDITIONAL WORK AFTER RETEST IS COMPLETE AFTER FURTHER REVIEW, THE FOLLOWING ONE EXAMPLE, CITED IN NRC INSPECTION REPORT 369/88-29, INDICATE A PROBLEM WITH THE WORK CONTROL SYSTE THIS PROBLEM HAS BEEN ADDRESSED SEPARATELY TO RCDUCE THE POSSIBILITY OF RECURRdNC EXAMPLE 4: "ON MARCH 28, 1988, IT WAS DETERMINED 1RN21 UNDERWENT i MAINTENANCE WITHOUT A SUBSEQU21T RETEST".

A PACKING ADJUSTMENT WAS PERFORMED ON 1RN21 UNDER A WORK REQUES THE WORK REQUEST INCORRECTLY IDENTIFIED THAT A RETEST WAS NOT l REQUIRED AND RN21 IS IDENTIFIED AS A COMPONENT REQUIRING RETEST l PER STATION DIRECTIVES. HOWEVER, THE ERROR THAT OCCURRED WAS THE RESULT OF PERSONNEL ERROR AND A FAILURE TO FOLLOW PROCEDURES AND l

WAS NOT DUE TO THE FAILURE OF THE FUNCTIONAL VERIFICATION PROGRA .

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