IR 05000346/1988028

Insp Rept 50-346/88-28 on 880912-16 & 1011.Violations Noted. Major Areas Inspected:Licensee Action on Previous Insp Findings & Limited Scope Fire Protection Program Review, Including Field Exam of Plant Administrative Controls

ML20204J305
Person / Time
Site:	Davis Besse
Issue date:	10/19/1988
From:	Gardner R, Kubicki D, Ulie J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20204J297	List: IR 05000346/1988028 ML20204J295 ML20204J299
References
50-346-88-28, NUDOCS 8810250085
Download: ML20204J305 (15)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-346/88028(DRS)

Docket No. 50-346 License No. NPF-3 Licensee: Toledo Edison Company Edison Plaza, 300 Madison Avenue Toledo, OH 43562 Facility Name: Davis-Besse 1

! Inspection At: Oak Harbor, Ohio i Inspection Conducted: September 12-16 and October 11, 1988 Inspectors: W\\ v1. uCiv Wennis J. Kubpcki l Io-l?-ST l Date s

.Q..v1. c.tk

.loseph M. Ulie / o -19 -3 9 Date

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Approved By: Ronald N. Gardner, Chief to -f i- 8 f

Plant Systems Section Date

l Inspectior Summary l Inspection on September 12-16 and October 11, 1988 (Report No. 50-346/88028(DRS))

Areas Inspected: Routine, unannounced inspection of licensee action i

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on previous inspection findings, a l'mited scope fire protection program I review including a field examination of the plant administrative controls i implementation and of the fire protection organization through Licensee Event Reports review and an inplant evaluation of pending exemptions (30703, 64704,90712,92700,92701,and92702).

Results: Of the areas inspected, one violation was identified in the area of degradad fire watch patrols. One additional example of a violation of a -

degraded fire watch patrol was identified; however, in accordance with 10 CFR Part 2, Appendix C, Section V.G, a Notice of Violation was not issued. A weakt.ess in the licensee's fire watch program was evidenced by the examples of fire watch degradation, however, as discussed in Paragraph 3, significant ,

licensee effort to prevent future degradation in this area was observed during '

this inspectio l f

8810250005 8810193 DR ADOCK O l

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DETAILS i

1. Persons Contacted

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Toledo Edison Company / Contractor Personnel

• T.Almendinfer,FireBrigadeTrainingInstructor {

I *R. Brandt, ire Protection, Operations

! *R. Flood. Assistant Plant Manager, Operations l *G. Gibbs, Director, Performance Engineering  !

1 *D. Harris, Quality Assurance Director (Acting)  ;

1 *G. Gibbs, Director, Performance Engineering l * i l

Harris,Compliance

• G. Honsa, Quality Assurance Director Superintendent, (Acting)icensing Nuclear L Department

• M. Labor, Licensing Engineer l

• M. Murtha, Fire Protection Engineer t

• K. Prasad, Staff Engineer, Nuclear Engineering Department I

• D. Shelton, Vice-President

• R. Simpkins, Operations Training Manager

• G. Skeel, Security Operations Manager

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• F. Sondgeroth Licensing Engineer  ;

• R. Strauss,FIreProtectionCoordinator r

• J. Syrowski, Nuclear Training Director (Acting) i

• L. Young, Assistant to Fire Protection Compliance Manager l

• A. Zarkesh, Independent Safety Engineering Manager >

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Innovative Technological Systems, In l

• K. Scown, Operations Support, Fire Protection U.S. Nuclear Hegulatory Commission l

• D. Kosloff, Resident Inspector i i The inspector also contacted other licensee personnel during the !

l inspection visi [,

• Denotes persons attending the exit interview on September 16, 198 f 2. Action Taken on Previous Inspection Findings I

, (Closed) Violation (346/83-16-02): A fire in the auxiliary shutdown f panel, located in the Auxiliary Shutdown Panel and Transfer Switch Room, could cause the loss of control and indication for Auxiliary l

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Feedwater Pumps 1 and 2 at both the auxilitry shutdown panel and ;

the control roo '

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The licensee responded to this issue in a letter to the NRC dated November 7, 1986 (Serial No. 1-678) by committing to revise i Procedure AB 1203.02, "Serious Station Fire Procedure." This procedure is to be implemented in the event of a fire in this

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are The licensee affirmed that the preceduro, coupled with modifications related to the installatior of the motor driven feedpump which is physically and electrically independent of these fire areas, adequately resolves this concern. NRR has accepted the licensee's safe shutdown methodology. In addition Revision 3 to the above referenced procedure was rev4wed to confirm that the licensee-committed changes were implemented. On this bases, this issue is considered close i b. {L_i, tied) Violation (346/83-16-03): The Auxiliary Shutdown Panel and l Trat.:fer Switch Room was not provided with a fixed fire suppression system in accordance with the requirements of Section III.G 3 of Appendix R to 10 CFR 5 By letter dated January 12, 1987 (Serial No. 1327), the licenste requested approval of an exemption from the requirement for a fixeo fire suppression system. NRR has evaluated the licensee's justification and has concluded that the lack of this system ic not safety significant. On this bases, this issue is considered close l2 c. (0 pen) Unresolved Item (346/83-16-14): Automatic sprinklers were not installed in accordance with Chapter 4 of National Fire Protection Assoc 1ation (NFPA) Standard No.13 in areas containing equipment

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required for safe shutdow l l

By letter dated May 27, 1988 (Sarial No. 1361), the licensee

committed to conduct an engineering evaluation, by an independent ;

fire protection consultant, to assess the adequacy of the sprinkler i systems in question. By letter dated May 23, 1988 (Serial No. 1497),

the licensee presented the results of the evaluation. The evaluation had not been completed in that approximately 28% of the sprinkler l

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systems installed to satisfy the guidelines of Appendix A to BTP APCSB 9.5-1 had not been evaluate Of the systems which were

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reviewed by the consultant, the licensee identified a number of code ,

deviations which the ifcensee concluded, were not safety significan The licensee provided justification and requested approval of these f

] conditions. These conditions are presently being evaluated by NRR :

and will be addressed in a future safety evaluation (SE). '

For the remaining conditions, the licensee indicated their intent

to modify the sprinkler systems so as to conform to the applicable criteria of NFPA 13. The licensee, however, reserved the right to reassess this commitr.ent and te attempt to justify additional

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deviations from tre code, (

t Pending completion of the proposed modifications to the subject !

sprinkler systems and the evaluation of deviations to NFPA Standard '

No. 13 by NRR, this issue remains open,

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d. (Closed) Violation (346/83-16-15): Failure to control modifications to fire doors.

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By letter dated November 7,1986 (Serial No.1-678), the licensee responded to this finding by committing to replace a number of fire doors which had beea modified by the installation of security hardware. In addition, the licensee committed to develop a new

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maintenance procedure to more fully define the inspection criteri Subsequently, the licensee contracted with Factory Mutual Research (FMR), an independent fire testing authority, to evaluate the fire doors that had been modifie In a report dated December 19, 1986, FMR concluded that the security related modifications to the subject doors ". . are not expected to affect the fire resistance rating of these assemblies . . . ." Based on the results of this evaluation, the licensee concluded that the replacement of these doors were no longer necessar NRC has in the past accepted the l results of independent assessments of fire doors by a recognized authority to validate the fire rating.

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The licensee presented three surveillance test procedures for

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DB-FP-03026 "24-Hour Fire Door Visual Inspection" i'

t OB-FP-03027 "7-Day Fire Door Visual Inspection" l DB-FP-03028 "Fire Door 18 Month Inspection"

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These procedures were reviewed and found to be consistent with the applicable provisions of the Plant Technical Specifications as well !

as NRC fire protection guideline !

Based on the results of the FMR evaluation and the content and scope ;

of the surveillance procedures, this item is considered close e. (Closed) Unresolved Item (346/83-16-19): The minimum number of operable fire detection instruraents specified in Technical Specification 3.3.3.8 is inconsistent with the licensee's i commitments to ini. tall fire detectors in accordance with

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NFPA Standard No. 720,

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The Plant Technical Specifications have b u n structured to conform to the Standard Technical Specifications pertaining to tire detection !

systems. These specifications reflect the philusophy that the total

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number of fire detection instruments installed in an area need not be operational at any one time to assure an acceptable level of t safet NRR has reviewed these specifications and has concluded that they satisfy NRC fire protection guideline With regard to the licensee's commitments to conform to the  ;

applicable provisions of the NFPA Codes, the licensee has, by l letters dated May 27, 1987 (Serial No. 1361), and May 23, 1988  !

(Serial No. 1497), expressed their intent ta conduct an independent j engineering evaluation of the fire detection systems against the l critaria of NFPA Standards No. 720 and No. 72E. Where deviations i frem these rodes are identified, the Itcensee will either implement '

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modifications to upgrade the systems to be in conformanca with the I codes or will justify tuch deviations to IIRR in writing. On this basis, this issue is considered close ,

f. (0 pen) Open Item (346/83-16-20): The 1980 Fire Protection Audit, by -

Professional Loss Control, Inc., identified the potential of "cold soldering" of sprinkler heads due to the' configuration of sprinkler piping at elevation 657 in the Heater Bay Area (cold soldering occurs I when water from one sprinkler cools the heat sensitive element in i l snother sprinkle * which may prevent or at least delay operation of i the sprin(ler being wetted).  :

By letter dated May the lics..see proposed ;

23,by to correct this problem 1988 converting (Serialthe No.exis3 1497),1ng "pre-action" type l sprinkler system to a "wet pipe" design which conforms to the a)plicable sections of NFPA Standard No. 13 and by de-activating tie )arallel "water curtain" syste The modific1tions, as o scribed [

by tie licensee, will eltuinate the cold solde-ing concern. Pending completion of the sprinkler system conversion, this issut remains ,

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g. (Closed) Open Item (346/83-16-21): Unquel!fied control room fire i Doors (No. 509 and No. 512).  !

In conjunction with the licensee's efforts to reassess the Davis-Besse '

Fire Protection Program against the requirements of Appendix R to i'

10 CFR 50, certain fire area boundaries were re-delineated. With regard to the control room, the licensee re-defined the boundary to *

avoid having to take credit for the security modified doors re krenced t above. Instead, the boundary is now defined by the elevator / stairway vestibule doors outside of the control room. This reconfiguration  !

has been accepted by NRR as satisfying the criteria of Appendix i On this basis, this item is considered close .

h. (Closed) Violation (346/83-16-228): Surveillance Test (ST)

Procedure 5T 5016.09 (Fire Protection Systems Valve OperabiH ty)  :

dit not specify verifying fire protection system valve operability  !

as specified by NFPA 2 :

L During this inspection the licensee provided ST Procedure No. ST 5016.09.)5. entitled"FireSystemValveMonthlyInsp(ction"  !

dated August 19, 198 Step 8.3 of this pieceduri specifies that each valve be verified lock wired in the position indicated i (on Enclosure 1), therefore, this item is considered close ;

i. (Closed) Unresolved Item (346/83-18-23): A concern was raised over !

the conflict between the fire wrap deficiencies written record and t tne as-found missing fire wrap j By N".C letter dated August 31, 1988, it has now been decided due i to the age of the matter, not to conduct any further investigation, i Therefore, this item is considered close !

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j. (Closed) Open Item (346/85-28-01): Documentation was not available to verify the fire rating of low density siliconc foam fire barrier penetration seal By letter dated February 12, 1987 (Serial No. 1352), mee submitted typical fire barrier penetration secl details, st summary shoe s for each detail, and the applicable qualifyi, '

a test reports for each detai NRR has e'taluated this infore 1 and has concluded that the fire test reports confirm that f penetration s tre seals, which are installed per the seal details, are equivalent in fire ratina to the fire barriers in which they are installed. As such, they satisfy the criteria of Appendix R to 10 CFR 50, Appendix a to BTP APCSB 9.5-1 and Generic Letter 85-1 On this basis, this issue is considered close k. (Closed) Open Item (346/85-28-02): Three maintenance procedures each indicate that the minimum depth of silicane foam sealant to be installed is 11 inches for low density foam or 12 inches for high density foam in any penetration through a wall or floor, except where the wall or floor thickness is less, then the ug th is to be equal to the thickness of the wall or floo These procedures did not differentiate between fire barrier and non-fire barrier walls and floors. This condition resulted in the potential for fire barrier- having less sealant material than the thickness required to achieve a three hour fire ratin The licensee affirmed during the inspection that the subject maintenance procedures have been superseded by the following procedures: <

MP 1405.33.05 "Installation of Silicone Foam / Caulk Penetration Sealing Systems" MP 1701.06.00 "Installation of Pre-Mixed High-Density Silicone Elastomer Per,etration Seals" PB-MM-01005.R00 "Core Bores and Cut Outs Through Barriers" The new procedures each contain a paragraph that directs that the seal be installed in accordance with the applicable seal detail These d; tails establish the minimum seal depth as well as other pertinent information, such as the placement of damming material to assure that the seal is installed consistent with its fire ratin Plant tours were subsequently conducted to confirm on ar, audit basis that seals were installed consistent with the above-referenced procedures. A number of individual seals were observed in walls and floor / ceiling assemblies with dimensions less than the required thick:sss of the seal. In these instances the licensee had insta~ised a "collar" or "sleeve" at the penetration which assured I that sufficient seal material was installed to achieve the required )

fire rating. In one locatior, the depth of the seal was less than l

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the required amount. However, the licensee had conducted a fire hazards analysis, consistent with the guidance issued in Generic Letter 86-10, to substantiate that the existing seal configuration was sufficient to prevent fire propagation from one area to anothe Based on the revised maintenance procedures referenced ab'ove and'

observations of a sample of in plant seals, this issue is considered close . (Closed)UnresolvedItem(346/87026-01(ORP)): This item regarded three reports of missed fire watch patrol Based on the review of Licensee Event Reports (LERs) regardin missed fire watch patrols addressed b Paracraph 3 of tne report, this item is considered close m. (0 pen) Open Item (346/87-27-02): A number of deficiencies were observed in plant fire drill During this inspection. the inspectors witnessed two unannounced fire drills conducted utilizing the on-duty operations shift personne Attachment No. 2 of the NRC document entitled, "Nuclear

. Plant Fire Protection Functional Responsibilities, Administrative l

Controls, and Quality Assurance," dated June 14, 1977, indicates that fire brigade drills should be performed in the plant so that the fire brigada can practice as a team. This document further entailed other drill parameters. The licensee commitment to the NRC document is described in the SE dated July 26, 197 The first fire drill postulsted un oil type fire in the air ccmpressor area while the second fire drill postulated an ordinary cimbustible fire in Auxiliary Pump Room 1-1. The inspector reviewed the fire dr'll scenarios and pre-fire plans which N1uded a

. walkthrough of the "fire" areas prior to the drill In preparing to witness the fire drills, the inspector also reviewed appropriate portions of licensee procedures which relate to fire discovery and subsequent fire extinguishmen These procedures includad the following: Abnormal Procedure No. AB 1203.37, Fire Procedure, Revision 3, approved November 27, 1985; i Abnormal Procedure No. AB 1203.02, Serious Station Fire,

Revision 3, approved December 9, 1986; Administrative Procedure DB-FP-00005, Fire Brigade, Revision 00, dated July 29, 1988;

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, Emergency Plan Drill Procedure No. HS-EP-0200, Emergency Plan Drill and Exercise Program, Revision 1, approved February 20, 1987; , Unannounced Fire Brigade Drill Scenarios for the Air' Compress'or ,

Area and Auxiliary Pump Rooms; and

. Fire Protection Strategy Procedures FPSP-II, FPSP-E and FPSP-F each dated July 26, 198 The first unannounced tire drill was initiated on September 15, 1988, at approximately 0445 hour0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> The inspector was stationed

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initiall to the "yfire" at the fireobserving area brigade station the brigade and followed until thethe firefire drillbrigade was terminate The inspector observed six fire brigade members assemble and don  !

protective clothing including self-contained breathing apparatus (SCBA) at a fire brigade station (fire equipment room). The inspector evaluated the fire brigade personnel actions in determining

. and observing the following: (1) fire brigade members' conformance with established plant firefighting procedures; (2) an assessment  ;

of the fire brigade leader's direction of the firefighting efforts; (3) actual donning and use of the SCBA; (4) actual donning of '

protective clothing; (5) simulated use of a 1 and 1/2 inch fire hose station; (6) use of portable radio communication equipment; (7) brigade timeliness in response and numbers of personnel responding with proper firefighting equipment, and (8) brigade leader interaction with the Radiation Control Technician (RCT) ,

and other support personne :

The inspector participated in the post-drill critique and provided  !

the following comments regarding his observations: l (1) Positive Observations

. * Brigade leader direction was evidtot including brigade discussions held prior to and at the fire scen * The number of fire brigade members res)onding exceeded NRC minimum requirements and the fire 3rigade response to the fire scene was conducted in a timely manner.

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• Fire brigade personnel safety taken during the drill'

relative to proper wearing of the protective clothing and SCBA, and the bringing of adequate fire equipment to the fire scene was all satisfactor (2) Deficiencies

• The length of the fire hose from the hose station chosen was inadequate to effectively reach the inside of the room

announced as the alarmed "fire" are I

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• The fire hose utilized at the fire scene was' incorrectly installed on the hose reel resulting in the hose coming off the reel improperl * Due to minor confusion and difficulty, a delay occurred in setting up the foam system for operation, although the 1 and 1/2 inch fire hose line was already in place and in simulated us * A fire brigade member left the brigade equipment station without the SCBA face shield / breathing mask requiring that brigade member to return back to the equipment statio Also, this SCBA unit's high pressure fitting was found loose causing a reduction in the useful breathing air time afforded by the SCB The second unannounced fire drill was initiated on September 15, '

1988, at approximately 1930 hours0.0223 days <br />0.536 hours <br />0.00319 weeks <br />7.34365e-4 months <br />. The inspector was stationed initially in the control room, then at the fire brigade station and subsequently followed the fire brigade to the fire scene observing the brigade until the fire drill was terminate Both inspectors participated in the second drill post-drill

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critique. Based on the inspectors observations of this drill, it appeared that improved brigade leader direction and size-up of the fire scene was still neede In addition, an inspector reviewed the fire protection strategy

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plans for the cable spreading room and the annu:us, where entry by fire brigade members would be difficult, and subsequently discussed firefighting procedures in these and other areas with fire brigade members. The inspector concluded that the existing fire protection strategy plans mty not realistically reflect the brigade's ability to enter certaia areas and put out the fire, The licensee responaed that the fire protection strategy plans are currently being redrafted. This issue will be further evaluated during a future inspectio . Licensee Event Reports Review I

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Through direct observations, discussions with licensee personnel, and review of records, the following event reports were reviewed to determine that reportable event requirements were satisfied, immediate corrective action was accomplished, and corrective action to prevent recurrence had been or would be accomplished in accordance with Technical Specifications:

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(Closed) 346/87005-LL: As a result of information provided to Toledo Edison's independent Ombudsman, allegations were made that various forms t of misconduct by contract fire watch personnel had occurred during a t

five month period (November 1986 through March 1987). Certain of these allegations were validated which resulted in the licensee documenting

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Technical Specifications related investigation findings. Consequently, an in-office review by a regional fire protection inspector of the following documents was perfctmed: (1) LER No.87-005, dated March 26, 1987, (2) the licensee's "Industrial Security Investigation" Case No.87-018, dated April 1,1987, and (3) an "Evaluation of Degraded Fire Watches," Revision 1, dated April 24, 1987. During the performance of various inspections 'NRC and licensee) certain required fire barriers were determined to be degraded, therefore, these barriers were considered inoperable. As a result, in accordance with Technical Specification 3.7.10, either continuous or hourly fire watch personnel were required to be pested depending on certain plant specific fire protection feature Based on a review of the above documents and discussions with licensee and NRC personnel, it was determined tnct on four occasions persons performing continuous fire watch duties were found inattentive (sleeping or dozing)

and on three additional occasions fire watch personnel had either left their areas of responsibility prior to being relieved or were relieved incorrectly; or hourly fire watch patrols had missed patrolling their required area The specific list of the above mentioned occurrences are as follows: On four occasions, persons performing continuous fire watch duties were found inattentive (sleeping or dozing) as follows:

(1) On or about November 6, 1986, an individual assigned to a continuous fire watch post was observed to be inattentive while on duty in the Demineralizer Tank Are (2) On or auout November 21, 1986, an individual assigned to a continuous fire watch post was observed to be inattentive while on duty in the pipe tunnel are (3) & (4) On or about February 17, 1987, an individual assigned to a continuous fire watch post was observed to be inattentive twice while on duty in the stairwell near Door 104-A on the 555 elevation leve On three additional occasions, continuous fire watch personnel had either left their areas of responsibility prior to being relieved or were relieved incorrectly; or hourly fire watch patrols had missed patrolling their required areas as follows:

(1) On or about December 7, 1986, an individual assigned to a continuous fire watch post left the assigned post (stairway AB3A) without being properly relieved. However, this fire watch post was believed to have bean left withont fire watch coverage for only a short duration (exact duration was not determined).

(2) On or about March 2,1987, a temporary fire detector was J installed in Stairwell AB3A which allowed the assigned 1 continuous fire watch to be replaced with a roving fire watch patrol. As a result of inadequate communication, the fire watch patrol in Stairwell AB3 (not AB3A) was incorrectly relieved. Approximately two and a half hours

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passed before the licensee determined that Stairwell AB3 still required a continuous fire watc (3) On or about January 27, 1987, an individual assigned as a roving fire watch missed patrolling the non-RACA area during the 1600 hours0.0185 days <br />0.444 hours <br />0.00265 weeks <br />6.088e-4 months <br /> patro These examples of fire watch degradation identified by the licensee illustrate the failure of the licensee to adequately oversee the fire watch program, and are considered examples of a violation (346/88028-01(DRS)) of Technical Specification 3.7.10.a Limiting Condition for Operation Action statement. The licensee through their review of this matter identified that their contractor had been falsifying records of certain of these and other activitie The licensee terminated that contract.

In addition to the above Technical Specification related deficiencies,

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a roving fire watch patrol was established (November 20, 1984) for

non-TS reasons as part of the original Appendix R Compliance l Assessment Report compensatory measures which were planned to l be implemented until plant modifications could be mad However, l an individual assigned as a roving fire watch patrol failed to patrol the Diesel Oil Pumphouse area. Due to the lack of documentation, it was not determined on what day (s) the patrols were missed. It is believed this occu*i'ed during February 1987 (February 25,1987).

According to the licent.ee, during this missed fire watch patrol, the pumphouse area fire detection system was operabl (Closed) 346/88005-LL; 346/88009-LL; 346/88010-LL and 346/88011-LL:

Due tc personnel error, on the following four additional occasions, continuous fire watches had not been established within one hour

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as required:

i (1) On January 21,1988, at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br />, the Shift Supervisor

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was notified that an inoperable fire barrier', identified as 426-N/427-S, did not have operable fire detection on either side and a continuous fire watch was not in plac This condition had existed for approximately 45 hour5.208333e-4 days <br />0.0125 hours <br />7.440476e-5 weeks <br />1.71225e-5 months <br /> (2) On April 4, 1988, at approximately 1800 hours0.0208 days <br />0.5 hours <br />0.00298 weeks <br />6.849e-4 months <br />, it was determined that an inoperabic fire barrier existed with i no fire detection system on either side and a continuous I fire watch was not in place. This condition had existed l since June 24, 198 (3) On April 6, 1988, at approximately 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br />, maintenance 1 l was in progress which isolated the sprinkler header above Main l l

Feedwater Pump 1-2 and caused an alarm on fire clarm/ annunciator Panel C410 This isolation of the sprinkler header effectively rendered the fire detection system for the Turbine Building j

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inoperable. A continuous fire watch was not in place. This '

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condition coupled with two inoperable fire barriers required l l a continuous fire watch at Fire Doors 4?3 and 327. This l condition had existed for approximately eight hour l

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(4) .0n April 8, 1988, following maintenance on Fire Door 422, the Shift Supervisor incorrectly declared Fire Door 422 operable and terminated the continuous fire watch for Fire Barrier.AB1-N/4225. This condition was . identified on April 28,

!.988, during'a subsequent review of the surveillance test used for post-maintenance testing. Fire protection personnel discovered that only selected portions of the surveillance >

test were performed. These portions of.the surveillance procedure. performed only tested the maintenance that was performed, but did not confirm the complete Technical Specification operability surveillance requirements that were past du This condition had existed for approximately 20 day ,

These examples of fire watch degradation identified by the licensee are considered additional examples of a violation f 346/88028-01(DRS))

of Technical Specification 3.7.10.a Limiting Condition for Operation -

Action statemen As mentioned in the above five LERs, the licensee's corrective actions taken as a result of the identified fire watch degradations are as follows:

(1) Terminated the contracted fire watch compariycin-place during

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theaboveoccurrences(346/87005-LL).

(2) An upgraded administrative program to maintain adequate i fire watch personnel has been completed. Administrative .

. Procedure AD 1810.00, "Statior rire Protection," has been :

upgraded and AD 1810.05 "Technwal Specification Fire Watch" has been developed which includes a licensee fire w3tch '

i managementprogram(346/87005-LL).

(3) The frequency and scope of fite watch surveillance has been ,

j increased and the Shift Supervisor has been given an active, supervisory role in its administration (346/87005-LL).

l (4) An improved system cf c<>ntinuous fire watch training for company supervisors and security personnel is now in place <

(346/87005-LL). f I5) An increased priority has been placed on repairing deficient j

- fire barriers (346/87005-LL).

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l (6) The Fire Protection Compliance group will provide Operations :

with a concise list of fire detection zones and their t corresponding fire barriers. Operations personnel will be provided training on the use of this list to improve their response to inoperable fire detection alams (346/88005-LL).

(7) Fire i'rotection Coordinators w',11 be given training in the fire l

protection programatic and regulatory requirements to support ,

the maintenance order review process (346/88009-LL).  :

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(8) Standing Order 88-047 has been revised to provide temporary guidance for implementation of compensatory measures for inoperable fire protection equipment (346/88010-LL).

. (9) Operations Management will discuss with the Shift Supervisors the proper methodology to declare systems operable following maintenance (346/88011-LL).

The. licensee provided for review updated procedures and other documents now in use having fire watch relevance including Administrative rrocedure 08-FP-00001 (formerly AD 1810.00),

Revision 00, dated April 29, 1988; Administrative Procedure DB-FP-00009 (fonnerly AD 1810.05), Revision 2, dated August 31, 1988;.and Standing Orders88-061 dated July 28, 1983 and 88-047 dated April 21, 198 During this inspection, inspector followup of selective licensee corrective actions including a review of documentation and interviews of personnel was conducted. These actions were

, evaluated and determined to be satisfactor As a result of this review, 611egation No. RIII-87-A-0115 is considered closed.

For additional inspector review details of the fire watch program

area conducted concurrently during this inspection in response to an allegation followup, refer to Inspection Report No.

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50-346/88034(DRS).

(Closed) 346/88-004-LL: On January 20, 19;8, at 1900 hours0.022 days <br />0.528 hours <br />0.00314 weeks <br />7.2295e-4 months <br />, the hourly fire patrol was not perfonmd as required by the action statements of Technical Specifications 3.3.3.8 and 3.7.10.

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However, the hourly fire patrol was missed because of an inadvertent ;

. gaseous release inside the Auxiliary Building. As a result of the

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release, the Radiological Control Area (RCA) was evacuated as a precautionary measure for ALARA concern The NRC has no further concerns regat ding this issu (Closed) LER 346/88-014-LL: On June 9, 1988, with the reactor

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defueled, a review of the Technical Specification Fire Watch Log identified that the hourly fire watch patrol time limits for five turbine building rooms had been exceede This was caused by the i fire watch patrol beino distracted by the testing of a new bar code ,

system for improving fire watch documentation and by the training i of an individual to caduct fire watch patrol l According to the LER, personnel performing roving fire watches have been counselled concerning this event with emphasis on the timeliness I of fire watches and how to deal with circumstances that delay the fire watch patrol Trom the fire watt:hes' appointed round l l j

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The violation was' considered to have met the criteria of 10 CFR 2, Appendix C, Section V.G.I. Therefore, no Notice of. Violation was issued and this matter is close . ' Administrative Controls The in:,pector-examined, in part, the implementation of. the administrative controls procedures while performing plant tours on September 13-15, 198 Those procedures utilized for this review included: (1) Administrativa Procedure No. AD 1835.00, Plant Cleanliness inspection Program, Revision 7, approved on June.30,1987; and (2) Administrative Procedure No. AD 181 Control of Combustibles and Ignition Sources, Revision 7, approved on September 7, 1985.

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During this review consideration was given by the inspectors for the plant being in a refueling outage conditie During plant tours conducted on September 13-15, 1988, implementation of the Plant Cleanliness Program was determined to be satisfactor . Quality Assurance

.The inspector examined the licensee's program for tddressing and correcting internally identified fire protection inspection fsnding This was t

accomplished through the review of Quality Verification Surveillance No. SR-88-086-P, dated July 12-22, 1988, and the response to Quality j Assurance Audit Finding Report No. AR-88-FIREP-01 dated September 8,

1988. The examination of these documents indicated that the level of fire protection review and recomended actions were of sufficient technical depth and were consistent with NRC criteria. Due to the recent

identification of the audit findings, additional review will be needed to detemine the adequacy of licensee responsiveness in implementing the planned audit report recomended actions. With regard to the Quality Verification surveillance, the inspector determined that the licensee verification review was sufficiently detailed. However, basad on the past fire watch patrol deficiencies, continued surveillance in the fire

watch program area appeared warrante I Fire Watch Allegation Revig

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The fire watch allegation review portion performed during this inspection relative to Allegation No. RIII-88-A-0057 is to be documented in an upcoming inspection report (planned for Report No. 346/88034) detailing the allegations entire review finding . Exit Interview e

The inspectors met with licensee representatives (denoted in Paragraph 1)

at the conclusion of the inspection on September 16, 1988, and summarized a the scope and findings of the inspection. The inspectors also discussed the likely informational content of the inspection report with regard to documents reviewed by the inspectors during the inspection. The licensee did not identify any of the documents as proprietary.

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In addition, on October 11, 1988, additional discussions regarding changes in the previously discussed inspection findings were hel between the licensee and the NP.C Region III inspection team membe ,

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