IR 05000461/1997014

Insp Rept 50-461/97-14 on 970524-0707.Violations Noted. Major Areas Inspected:Operations,Maint,Engineering & Plant Support

ML20212B467
Person / Time
Site:	Clinton
Issue date:	10/14/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20212B400	List: IR 05000461/1997014 ML20212B395 ML20212B453
References
50-461-97-14, NUDOCS 9710280092
Download: ML20212B467 (25)

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' U.S. NUCLEAR REGU'.ATORY COMMISSION

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Docket Nos: 50-461

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' License Nos: NPF 62 Report No: 50-461/97014 (DRP)

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Licensee: Illinois Power Company

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Facility:- Clinton Power Station; Location: Route 54 West Clinton, IL 61727 Dates: May 24 - July 7,1997 '

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Inspectors: T. W. Pruett, Senior Resident inspector K. K. Stoodter, Resident inspector  ;

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R. A. Langstaff, Resident inspector

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F. D. Brown, Act. Senior Resident inspector-T. Tella, Eagineering Inspector

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D. E, Zemel, Resident inspector, IDNS

. D. R. Desaulniers, NRR/HHFB R. M,' Pelton, NRR/HHFB

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B. Hughes, NRR/HOLB M. Katzalas, NRR/HHFB

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._ Approved by- Geoffrey C. Wright, Chief 1 Reactor Projects Branch 4

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97_10280092 971014

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PDR ADOCK 05000461 '

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EXECUTIVE SUMMARY Clinton Power Station NRC Inspection Report No. 50-461/97014(DRP)

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This inspection included aspects of licensee operations, engineering, maintenance, and plant support. The report covers a 6-week period of resident inspectio l Qperations

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The failure to correct a deficient condition on two leaking reactor water cleanup valves resulted in an undocumented operator workaround and a tank overflow (Section 01.2).

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A violation was identified for the inadvertent actuation of a reactor water clean up system containment isolation valve due to the failure to refer to electrical diagrams, as required by a caution statement in a load impact list, when trouble shooting a ground in a safety related motor control * enter (Section 01.3).

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Main control room deficiencies received a high degree of management attention and were tracked continually during the sixth refueling outage. Operations developed a means to -

identify, disposition, and track new deficiencies following refueling outage 6 (Section O2.2).

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Operator knowledge and familiarity with the leak detection calculation method as incorporated into the process computer was weak in that they were unfamiliar with the limitations associated with its use (Section 04.1).

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A special NRC inspection identified that licensee staff perceived weaknesses in plant management's worsight of activities, salety focus, and organizationalinterfaces. The inspectors identified documented performance issues which could have been attributable to such weaknesses. The causal factors contributing to these performance issues appear similar to those disclosed through a 1989 Operation Safety Team inspectio These and other issues will be further developed and refined through implementation of the ongoing Clinton independent Safety Assessment and NRC Special Evaluation Team (Section 08.1).

Maintenance

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One violation was identified for the failure to use official working copies vf procedures and documents during maintenanco on the Division il inverter (Section M'i.4).

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A notable decline in the maintenance area occurred due to several examples of poor maintenance work practices. The licensee recognized the decline in the quality cf maintenance and initiated a condition report on June 16 to increase supervisory oversight

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and identify the root cause of the decline. As of July 8, no actions had been taken to identify the root cause (Section M1.5).

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Engineering's response to their identification of deficiencies in the fatigue monitoring program were prompt and conservative (Section E1.1).

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Engineering's selection of coating adhesion test sites did not initial!y represent all observed problem areas. After discussions with the inspectors, engineering selected '

additional test sites which adequately represented observed problem areas (Section E2.1).

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A violation was identified for the failure to initiate a temporary modification permit for a modification which breached the main control room envelope boundary. No deficiencies were identified during the review of open temporary modifications (Section E2.4).

Plant Support

A radiological work practice weakness was identified for not labeling two bags containing relatively low levels of radioactive material (Section R1.1).

A violation was identified for the failure to ensure exterior areas within the protected area were illuminated to not less than 0.2 foot-candles (Section S1.1).

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Report Details Summarv of Plant Status The unit remained in a refueling outage'for the entire inspection period. Major work completed included outages on Division I,11, and lit equipment, tap changes to the reserve auxiliary transformer and the emergency reserve auxiliary transformer, and pull tests on containment coating l. Operations 01 Conduct of Operations -

O General Comments (71707)

Operations maintained proper control room staffing and access to the control roo Operators were attentive to their watch .h ring periods in which activities had the potential to be a distraction. Operators were generally aware of work beir g conducted in the plant that involved plant safety. Communications were acceptable with some crews using three-way closed loop communications. Other crews were observed to use one-way, open communications, but no instances of problems in the operation of the plant were observed to have been caused by this practic .2 Untimely Repair Results in Operator Workaround and Tank Overflow Inspection Scope (71707/62707)

The inspectors reviewed the circumstances surrounding the June 4,1997, overflow of the reactor water cleanup (RT) resin addition tank. Additionally, the inspectors performed a review of the licensee's program for identifying, dispositioning, and tracking operator workarounds, Observations and Findinas in April 1996, the licensee initiated maintenance work request (MWR) D71078 to document a deficiency concerning leakage past the seats of RT Precoat Tank Fill From CY/MC isolation Valve 1G36-F045 and RT Resin Tank Fill From CY/MC isolation Valve 1G36-F046. Since the leakage past the valves caused the RT resin addition tank to fill with water, operations personnel implemented non-proceduralized compensatory actions to drain the tank on a tegular basis to prevent overflo Following the June 4,1997 tank overflow event, the "C" area operator stated that he was unaware of the compensatory actions in place for the resin addition tank, therefore he had not taken action to drain the tank. While no increase in contamination occurred following the overflow, the potential existed to contaminate several elevations of containment due to the degraded condition of the valve The inspectors considered the actions taken to compensate for the leaking valves an operator workaround (e g., An operator workaround is a degraded or non-conforming

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condition that complicates the normal operation of plant equipment and in compensated for by operator action.) The inspectors noted that this condition was not listed as an operator workaround in the licensee's program either before or after the event. After '

discussions with the inspectors, a member of operations department management stated that the condition clearly met the program's definition. Repairs to the cycled condensate valves were completed prior to the end of the inspectio The inspectors reviewed standing order OSO-089, " Operator Workarounds," Revision 1, to determine the program requirements for workarounds. The inspectors noted that OSO-089 specified a narrowly focused definition of an operator workaround in that it limited workarounds to problems which impaired the operators ability to respond to plant transients in a effective manner. The inspectors also noted that workarounds were not

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identified as MWRs were written or problems occurred, and there was no specified frequency at which outstanding MWRs were to be reviewed for the presence of workaround Revision 2 of OSO-089, issued on July 2,1997, expanded the definition of operator workarounds, directed operations personnel to identify potential operator workarounds and initiate the appropriate resolution documents on an ongoing basis rather than by periodic review, and specified monthly reviews of open items to identify operator workarounds which might be missed by the ongcing review _ Conclusions Untimely resolution of the seat leakage past RT Valves 1G33F045 and 1G33F046 resulted in a an undocumented operator workaround and overflow of the RT resin addition tan A revision to the standing order covering the identification and tracking of operator workarounds provided improved programmatic control .3 Eailure to Consult Drawina Results in RT System isolation Ln_spection Scope (71707)

The inspectors reviewed the circumstances surrounding the June 24,1997, inadvertent isolation of the RT syste , Observations and Findinas At approximately 11:05 a.m.. contiol room operators received an annunciator indicating a ground on safety related Motor Control Center (MCC) 1 A. Through the performance of troubleshooting, electrical maintenance determined that the feeder breaker to terminal cabinet 1H12-P7068. Breaker 23 of MCC 1 A. had caused the ground. Operators decided to open Breaker 23 to clear the ground condition. Prior to opening the breaker, operators reviewed CPS 4201.01C001, ' Loss of 125VDC MCC 1A Load Impact List." to determine the impact of opening Breaker 23. The procedure checklist only indicated that the safety relief valves and automatic depressurization valves would be effecte _ _ . . _ - _ __ - . _ _ _ _ _ __ _ _ _ _ _ _ _ ___

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Upon opening Breaker 23, the non-regenerative heat exchanger outlet temperature failed high causing RT Suction Outboard Isolation Valve 1G33-F004 to close. Consequently, RT Pumps A & B tripped and RT Suction inboard Isolation Valve 1G33-F001 closed resulting in an inadvertent isolation of the RT syste ,

The inspectors noted that the load impact list included a caution note which stated that:

(1) the load impact list only captures significant items of operational concem, (2) depending on be severity of the event, other loads not explicitly identified may be impacted, and (3) the listings should be used as an aid in assessing the impact, and source EO2/3s (electrical diagrams) referred to as needed for a detailed evaluation cf the even The inspectors interviewed the shift supervisor and determined that operators had not consulted electrical diagrams to verify the impact prior to opening Breaker 23. During a subsequent review of the applicable diagram, the licensee was able to identify the impact on the RT system from opening Breaker 23. The failure to adhere to the caution statement in a procedure which directed operations to refer to the electrical diagrams resulted in an inadvertent actuation of a RT system containment isolation valve and is a Technical Specification 5.4.1.a violation (50 461/97014-01a). The inspectors considered this violation to have potential generic significance because of the human factors implications in the licensee's policy of maintaining partially comprehensive impact list Operations submitted a comment control form to ensure that the information given in the load impact list for Breaker 23 was accurate. The assistant plant manager for operations informed the inspectors that shift briefs would be performed to reenforce management expectations that station drawings be referred to in addition to load impact lists prior to performing ground isolation activities, Conclusions A violation was identified for the inadvertent actuation of a RT system containment isolation valve due the failure to refer to the electrical diagrams as required by a caution statement in a load impact lis O2 Operational Status of Facilities and Equipment O Fire Protection Iniection System Auft The inspectors reviewed the Updated Safety Analysis Report (USAR). Emergency Operating Procedure 4411.03, "EOP Injection / Flooding Sources," Revision 2, piping and instrumentation drawings (P&lOs), performed a field observation, and inspected spare parts staged for the system. The inspectors determined that the fire protection injection system was maintained consistent with the USAR and plant procedure O2.2 Sionificant Reduction of Main Control Room Deficiencies (71707/62707)

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The inspectors observed a significant reduction in the number of main control room I

(MCR) deficiencies duing . the sixth refuehng outage. The licensee had committed to review their MCR deficiencies in response to NRC Confirmatory Action Letters (CALs)

dated September 11,1996, and January 9.1997 (see inspection Report 50-461/97012).

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- The inspectors observed that MCR deficiencies received a high degree of management ,

. attention and were tracked continually during the sixth fueling outagei During the initial ;

review of this CAL item, the inspectors noted that the licensee had not formalized any controls for the identification, disposition, and tracking of new MCR defx:iencies identified

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after the conclusion of ine refueling outage. Subsequently, on July 2,1997, operations _

issued Revision 2 to OSO-089 which incorporated the methods to be used when identifying, dispositioning or tracking MCR deficienciesi 04 - Operator Knowledge and Performance -

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'04.1 = Weak Ooorator Knowledae cG_eak Detection Systems (71707)

The inspectors interviewed two licensed operators with regard to their knowledge of the leak det9ction calculation method developed during the sixth refueling outage. The operators were aware that a new computer screen had been developed for the process computer. However, since the system was not yet operational, the operators stated they were not familiar with its use. Although both operators remembered having been trained on the system, the operators did not remember the limitations associated with its us The inspectors concluded that the operators knowledge and familiarity with the leak

' detection calculation method as incorporated into the process computer was weak. On July 8, the assistant plant manager for operations informed the inspectors that additional crew briefings to reinforce previous training would be performed prior to startu Miscellaneous Operations issues 08.1 Assessment of Impediments to Effective Resolution of Performance Deficiencies a Clinton Power Statior1 _

a, . Insoection Scqps At the time of this inspection, the Clinton Power Station (CPS) had demonstrated poor c performance in the areas of procedure adequacy, procedure adherence, human performance, and programmatic compliance with various NRC requirements since at least September 1996. This performance was documented in laspection Reports (irs) '

50 461/96009,96010,96011,96012,96015, and 97003. The inspection objective was to

, evaluate the potentialimpediments to the licensee's effective resolution of this broad

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range of performance deficiencies. The inspectors conducted interviews with licensee management and staff to identify the conditions and apparent contributing factors to the -

observed performance deficiencie Observations cnd Findinas

- During interviews with plant staff and management, the inspectors noted several perceived conditions at CPS that could impact CPS's ability to effectively resolve

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,e performance deficiencies and maintain safe and reliable operations. The inspection findings are grouped into the following broad areas: (1) management oversight,

(2) decision making and safety focus, and (3) organizational interface i l

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- Management Oversight

Inspector observations in the area of management oversight were related to the _ extent to which supervisory personnel were cognizant of plant staff activities and ensured such -

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activities were performed in accordance with management expectation '

- Supervisory Oversight and Direction:

q Interviews with Control and instrumentation (C&l) and Electrical Maintenance workers and Engineering personnel indicated that the plant staff lacked contact with, and direction from, management. ." Management-by-walking-around" was perceived as minimal, it was

indicated during several interviews that the prevalent management style was either management by implied threat or management bymemo. The inspectors did not identify any specific examples or references to harassment and intimidation during the course nf .

these conversation irs for the 6 months prior to this inspection suggested supervisory oversight of -

operations had been weak. The reports documented that control room decorum was crew dependent, tumovers did not always address changes in plant equipment status, control room traffic was not minimized during shift tumovers, and wednesses in log keeping practices compromised adequate supervisory reviewc Weaknesses in supervisory oversight in Radiation Protection were also evident in inspection finding The findings included the failure to radiologically evaluate work sites and specify appropriate controls, poor control of radiological areas, evidence of eating, drinking, and sleeping in radiological areas, and failure to review vendor procedures on a periodic basis.

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Accountability:

Many of the individuals interviewed believed that personnel were not being held 4'

accountable fcr their poor performance and that a lack of accountability existed in all organizationallevels at CPS. Several persons interviewed stated that they had not been given a performance appraisal in well over a year and for many individuals the last performance appraisal was perceived as an effort that was only conducted to support the most recent "down-sizing" initiative. - Another individual cited an instance of employees receiving performance awards even though administrative controls were bypassed to accomplish the work (no violations of NRC requirements were identified). The failure to hold personnel accountable for poor performance or to recognize good performance was

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! considered by some to be leading to decreased morale among plant staf Inspection findings that demonstrated a failure to hold personnel accountable included; the failure of a Line Assistant Shift Supervisor (LASS) to counsel a licensed reactor

. operator (RO) or write a Condition Report (CR) after determining that the RO had left the

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at the controls area without proper relief, and a failure to inform an operator that ho had

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increased radwaste inputs by failing to perform specific procedural step Performance Monitoring:

< The inspectors interviewed CPS personnel conceming the methods used at the site to

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monitor performance and identify performance trends. The CR process was the primary

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l process used at CPS for documenting adverse conditions and events for assessment, tracking, and corrective action. In response to inspection findings documented in IR 50-461/96003, the licensee substantially revised the manner in which CRSs were coded and trended to capture the human performance contributors in the CR databas However, the team reviewed the results of a lic(nsee survey, known as the " Cultural index"which polled the opinions of 682 CPS employees on a wide range of itsue Analysis of the 50-item survey indicated that four of the top five concems at the station .

related to the Condition Report process. The CR process was perceived as burdensome, resulting in unnecessary corrective actions, and ineffective in investigating and taking corrective action for " organizational and programmatic breakdowns" and for " human performance" problems. Although the opinions of the CPS personnel may reflect their perception of the CR process before the rev'.sion, the inspectors were concemed that the widespread negative perception of the CR process might impede acceptance of the CR program over time and might inhibit the reporting of conditions adverse to quality. The inspectors noted that, at the time of the inspection, the number of CRs being generated on a monthly basis was increasing and appeared to be comparable to other one unit facilities. An inspection follow-up system item,50-461/97011-10, was subsequently opened to track the reporting and trending of material deficiencies adverse to qualit Interviews were also conducted with personnel responsible for the development and implementation of leading indicators of performance. Operations crew performance observations and the Task Performance Checklist for maintenance activities were discussed. Both of these programs were previously implemented but the implementation was not consistent and the programs were allowed to lapse. Although the licensee had plans to revitalize these programs it was not clear at the time of this inspection that the licensee had established clear expectations for the use of these indicators and the maintenance of the performance indicator program Revie.y of inspection findings from the 6 months prior to this inspection indicated that the NRC inspectors had identified long standing procedure and equipment deficiencies that were not identified by the licensee's tracking and trending systems. Also, several inspection findings had been identified relating to ineffective or untimely corrective action Decision Making and Safety Focus inspector observations in the area of decision making and safety focus concemed the extent to which: (1) decisions reflected safety as the primary objective and (2) an environment existed that encouraged the reporting and resolution of safety concem Production Versus safety:

Interviews with plant staff reflected a concem that efftrts to remain competitive were being given more emphasis at CPE than the safe generation of electricity. Some CPS Liaff members suggested that the message they are getting is "do it any way possible" and * remain competitive." The inspectors observed a meeting of senior site managers concerning CPS's Strategic Recovery Plen. The inspectors' perceptions of this meeting were that the managers were more focused on resources and the impact on plant restart date than evaluating the technical merits o' the plan for identifying and resolving concems. The Strategic Recovery Plan was approved for implementation despite four-

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senior managers, including the plant manager, voting that they did not have technic confidence in the pla The inspectors reviewed NRC inspection findings from the six month period prior to the inspection and found several issues that raised concems regarding an emphasis on production over safety. These findings relate to the scheduling of maintenance and corrective actions, the prominence of the safety message in guidelines and job cescriptions, and routine decisions or actions that appeared non-conservative or suggested that safety was compromised by efforts to perform jobs quickl Questioning Attitude:

During the inspection an inspector observed a conversation between a shift supervisor and a C&l supervisor conceming a failed surveillance test. The C&l supervisor proposed the use of an attemative gauge as a means for getting the equipment to pass surveillance. Neither the C&l supervisor nor the shift supervisor questioned the appropriateness of using an attemative gauge as the solo means for resolving the failed surveillance. The inspector was concemed that the individ'Jals appeared to be focused on getting acceptable results rather than exhibiting a questioning 9ttitude conceming the cause of the surveillance failure. The inspectors did not identify any violations of NRC requirements with respect to the surveillance discussed abov During interviews, several workers stated that they were afraid to make an "on-the-job" mistake. They recounted an incident where co-workers were given time off (without pay)

after reporting a "near miss" (electrical shock), in other interviews individuals stated that dissension and opposing views were not encouraged. This view is consistent with the inspectors perception of the meeting of CPS senior managers conceming the Strategic Recovery pla Review of inspection report findings from the 6 months prior to this inspection provided several examples of a weak questioning attitude. These examples included operators failing to challenge other operators during shift tumovers, operators not questioning the safety of stacking annunciator response books over control panels, engineers not questioning the safety implications of inoperable water-tight doors, and radiation protection technicians failing to determine if a hose was pressurized prior to disconnecting the hos Organizational Interfaces Management Teamwork: j inspector observations and interviews indicated a lack of teamwork between CPS i

departments and managers. During a meeting observed by the inspectors, a senior management participant stated that "[T]he site is broken down into silos; everyone is hunkered down in their own bunkers." Another individual stated that there is disbelief on the pad of tt,a operators that management can work together to make the recovery effor1 successful. During interviews, individuals expressed the opinion the management

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effectiveness and credibility had suffered from behavior they perceived as " infighting" or l "temtorial." i i

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A lack of communication between management was evident at the Strategic Recovery Plan meeting. Some members of senior management were surprised by the plan. They repeatedly stated that it was not what they expected and some voiced a concem that the plan did not reflect a coordination of issue owners. The inspectors considered consensus building at this meeting to be weak. The Strategic Recovery Plan was formally adopted despite several high level managers voting that did not have technical" buy-in."

Perceptions conceming the ability of CPS management to work effectively as a team are widespread among the CPS staff One of the top five issues identified through the

" Cultural Index" conducted at CPS was that station personnel did not believe that management worked well together without defensiveness, interview results suggested that ineffective teamwork between the Operations and Plant -

Support Departments contributed to the slow resolution of problems with the site's procedural adherence policy. Other individuals bolieved that the engineering staff lacked the respect of many personnelin the Operations Department. Consequently, the expertise of personnel such as the shift technical advisor were not being effectively utilized. Inspection reports documented several examples of weak engineering support of operations, failums of operations to effectively use plant resources, and a lack of support of other departments for the Operations Departmen .

Vertical Communications:

Interviews indicated that many CPS personnel believed they had minimal contact with plant management and that the flow of information up and down the chain of command was limited. Frequent changes in management and management direction were considered by some to contribute to an unclear sense of direction. The inspectors found that specifics on the Strategic Recovery Plan (SRP) had not been well communicated to personnel on site at the time of the inspection. The inspectors observed the SRP Overview Training and found that it consisted mostly of a " pep talk" and discussions of alternative actions, e.g., management comoany could be hired to assist in recovery and the potential for job losse Work Prioritization, Planning, and Scheduling:

Some of the individuals interviewed described weaknesses in the prioritization of emergent and planned work and a lack of communication between the schedulers and the people responsible for performing the work. Other individuals stated that jobs had not consistently been walked down by planners or craft personnel prior to the start of the job, and job prere quisites had act always been adequately specified in the procedure or work package. These concems were perceived as contributing to the current work backlogs in Maintenance, Engineering, and Plant Support (procedures).

NRC inspection reports from the 6 months prior to this inspection contained several findings conceming inadequate prioritization of work, timeliness of corrective actions, and a lack of clear goals. Additional report findings were identified related to pre-job planning including examples of test procedures lacking guidance, operating crews failing to identify out-of service equipment prior to test start, and increased personnel exposures caused by inadequate pre-job plannin . .

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suits of 1989 Inspection e NRC conducted an Operational Safety Team inspection (OSTI) in 1989

. 50-461/89030), The 1989 OSTl found that: (1) operating practices at CPS appeared developing a culture of "getting around" specifications, crocedures, or operational lnditions versus making them correct; (2) engineering ims. lvement in solving operational o' blems appeared to be slow; (3) an inability of CPS staff te understand personnel

tions contributed to an apparent low morale situation, (4) tl ere was a lack of trust

> tween Illinois power mansgement and the work force at tht Clinton Station, and (5) the

s: amwork concept which management was trying to foster had not yet taken hold etween management and staff,

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he inspectors concluded that the identified causal factors for performance deficiencies t CPS during the six months prior to this inspection, and the results of interviews and bservations conducted during this inspection, reflected similar issues underpinning the erformance problems documented in the 1989 OSTI. In evaluating these inspection

<ndings, CPS should evaluate the effectiveness of the actions taken following the 1989

>STI to ensure cyclic performance does not recur, iclusions cst nterview results and NRC inspection findings for the six months prior to the inspection-1.2, Cnd ,ndicated weaknesses in management oversight of activities at CPS. Specifically, formal methods for monitoring performance (e.g., Condition Reports, routine structured observations) had been weak or applied inconsistently in the past. Informal methods (e.g., " management by walking around") were described by CPS personal as minimal, in addition, many of the individuals interviewed did not believe that personnel were recognized for good performance and held accountable for poor performance. In general, the interviews indicated that morale was low at CPS and that a rift had developed the .between staff and managemen The emphasis on cost savings and remaining competitive was perceived by some staff at

. CPS to have resulted in a lack of focus on safety. The NRC had observed a pattem of l performance since September 19% which indicated an inconsistent questioning attitude y conceming safety matters and a willingness to make decisions or take actions that Che appear non-conservative from a safety perspective. The inspectors were concerned that the widespread frustration with the Condition Report process would further discourage

. .t Personnel from exhibiting a strong questioning attitude and pursuing problem resolution, p on Je Weak teamwork between CPS departments and department managers was perceived by t, CPS staff and managers to be a principle contributor to performance problems. The d inspectora were concemed that this perception, and resulting skepticism, in conjunction with apparent weaknesses in vertical communications, could be an impediment to obtaining the support necessary from the staff to effectively resolve past performance problems and maintain long-term commitment to the safe operation of the facilit . - ,

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ll. Maintenance M1 Conduct of Maintenance M General Comments Lnspection Scooe f62707/61726)

The inspectors reviewed or observed all or portions of the following work activities:

D72903 Troubleshoot and Repair of Division ll Inverter-D50185 Intermittent Erroneous Indication on LCLC Tank -

-D71553 Troubleshoot and Repair of Waste Sludge Tank B Recirculation Valve OWXO318-CPS 9051.01 HPCS System Pump Operability-CPS 9333.41 Division ill 4.16KV Undervoltage Relay Logic System Functional Test in addition, see the specific discussions of maintenance observed under M1.1, M1.2, and M1.3 belo M1.2 Overflow of Low Crud Low Conductivity Tank ( a inspection Scone (62707)

The inspectors reviewed the circumstances involving the June 3,1997, overflow of the Low Crud Low Conductivity (LCLC) Tan Observations and Findinas Operations initiated CR 1-96-07-012 and MWR D50185 in July 1996, to document an overflow caused by levelindication problems. Job step (2) of the MWR stated that the levelindication ;,roblems may hPve been caused by a dirty or corroded capacitance probe. However, troubleshooting efforts focussed on the instrument loop and did not address the possibility of capacitance probe failure. Because maintenance focussed on the incorrect components, the level indication problems could not be recreated and the MWR was scheduled to be performed at a later date. Following the June 3,1907 event, the licensee dedicated workers to resolve the level indication problems and determined that the levelindication problems were caused by a failed capacitance prob Disregarding the test of the capacitance probe during trouble shooting activities was considered a poor maintenance work practic Conclusions See Section M _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ - _ _ _ _

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- M1,3 - Initiation of Work on Wrona component Inspection Scope (62707)

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The inspectors performed a review of the circumstances involving the June 3,1997, initiation of maintenance activities on Waste Sludge Tank B Bottom Discharge Valve OWX331B, instead of Waste Sludge Tank B Recirculation Valve OWX031 Observations and Findinos On June 3,1997, Cal technicians attempted to locate Valve OWXO318 prior to performing work. Upon entering the work area, one of the C&l technicians noted that the valve was not clearly labeled. To help identify the valve, ice technician asked the radwaste operations center operator to stroke the valve. As the valve stroked, the technician believed he correctly identified the component to be worked and noticed that the identified valve had 318 written on the limit switch. As the technician removed the instrument air line to the valve, the radwaste operations center operator noticed that the indication for Valve OWX3318 changed. A non-licensed operator immediately informed the technician that he had begun work on the wrong componen The inspectors leamed that the technician had consulted plant drawings to aid in identifying the valve, however, positive identification could not be made due to poor drawing quality. Instead of referencing additional documents, the technician requested the valve be stroked as a method of positive identification. The inspectors determined that the commencement of work on a component without positive identification a poor maintenance work practic Conclusions See Section M M1.4 - Uso of Uncontrolled Documents Durina Maintenance Inspection Scope (62707)

The inspectors observed trouble shooting and repair activities in progress on the Division 11 power inverter in accordance with MWR D72903. The inspection focused on the documentation found and utilized in the field during the maintenance activity, Observations and Findinas The inspectors performed a review of supporting documentation at the job location and noted several discrepancies. CPS Procedure 1005.03, " Control, DistriLution and Statusing of Station Procedures and Documents," Revision 17, Section 8.2, stated that-only controlled, official working or approved for work copies of CPS procedures shall be utilized to perform activities. Section 3.4 specified that holders of documents are responsible for maintaining operating manuals current in accordance Records Management System (RMS) Standard 4 01, " Standard for the Receipt, Control, Distribution, and Maintenance of Controlled Documents." RMS Standard 4.01, Section 3.9.1.b. stated that documents requested for a work activity shall be processed 14 _

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by documsnt control as follows: Documents shall be stamped " Approved For Work" in red ink on the controlling pag The inspectors noted three discrepancies involving the use of controlled documentatio First, the working copy of Procedure CPS 3509.01, " Instrument Power System," did not-

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have any markings indicating the procedure was an approved official working copy. The inspectors later determined that the correct revision of the procedure was being utilize Second, four drawings (542-002-62 Revision J,642105-60 Revision D, 642108-60 Revision I and 642-107-60 Revision F) were in use at the job site, but were not stamped b/ document control as officialworking copies. A review of the controlled copy of the vendor manual for Elgar inverters, K28010144, Revision 32, bdicated that:

(1) drawing 542-002-62, Revision J, and drawing 642105-60, Revision D, were the proper revision, (2) drawing 642-108-60, Revision I, was the current revision, however, the licensee's " controlled copy" was outdated (still Revision B), and (3) drawing 642107-60 was currently on Revision Third, vendor manual K2801-0144, Revision 21, was found open and in use in the field with the words " Controlled Copy" lined out. Document control logs specified the current revision as Revision 3 Interviews with maintenance management following discovery of these examples indicated that the correct revision of K2801-0144 was available at the job location as part of the MWR. Nevertheless, the inspectors noted that the incorrect document was in use and the correct document revision was wrapped in a plastic bag. The failure to ensure approved documents are used for maintenance activities is a 10 CFR 50, Appendix B, Criterion Vi violation (50-461/97014-02). Conclusions One violation was identified for the failure to use official working copy procedures and document M1.5 Conclusions on Conduct of Maintenance During the inspection period, the inspectors noted several poor maintenance work practices involving an insdvertent isolation of RT, an overflow of the LCLC tank, initiation of maintenance on the wrong component, and the use of uncontrolled documents during trouble shooting of the Division 11 inverte Prior to the inspection period, the inspectors documented several additional poor maintenance work practices which resulted in damage to plant components or inadvertent actuations of plant systems. Specific examples included: (1) damage to the reactor core isolation cooling (RCIC) system exhaust vacuum breaker outboard isolation valve due to the failure to communicate the position of the motor operated valve test prep switch during tumover between maintenance shifts, (2) contamination of an individual due to the reuse of a flexitalic gasket on the containment equipment drain system, (3) an l

inadvertent initiation of the standby gas treatment system due to inputting a trip signal to Channel A without verifying a trip signal existed on Channel D, and (4) an inadvertent i

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i recirculation flow control valve run-back due to not verifying the impact of lifting an -

additional set of leads during a feedwater instrument loop calibration, in response tu the poor maintenance work practices, maintenance initiated CR 197-06165 on June 16,1997, to document a declining trend in the performance of maintenance activities. The CR stated that there have been numerous occurrences of maintenance activities being performed which have not met the licensee's expectation In response to the CR, the Assistant Plant Manager for Maintenance assigned a supervisor to each shift to provide oversight of work activities and requested the independent analysis group to perform a detailed root cause evaluation to determine the causes of the declining trend. As of July 8, no action had been taken to identify the root cause of this declin!.f tren Conclusiont Several examples of inadvertent actuations, tank overflows, and damage to equipment indicate a decline in the maintenance area due to poor maintenance work practice Ill. Ennineerina E1 Conduct of Engineering E Fatiaue Monitorino Procram Inspection Scope (37551)

The inspectors performed a review of licensee identified problems with the fatigue monitoring program for Class 1 components and the licensee's corrective action Observations and Findinas Engineers identified that problems existed in the program for monitoring the fatigue life of Class 1 components, and initiated CR 1-97-05-075 on May 7,1997. Specifically, the RCIC injection piping was found to be approaching its allowable lifetime fatigue cycle limit when previously unidentified fatigue cycles were accounted for. The CR also oocumented that a programmatic failure to identify all fatigue cycles for Class 1 components existe The inspectors reviewed CR 1-97-05-075 and noted that the CR had been properly classified as a mode restraint. The inspectors found that the Engineering Department .

had reconstituted the fatigue cycle history of involved components, reviewed the plant's authorization and design bases, determined that the RCIC lifetime fatigue cycle limit could be extended, and identified the program weaknesses which had led to the failure to identify all fatigue cycles on Class 1 components. The inspectors determined that the licensee appeared to use conservative methodology in determining fatigue cycles and assessed the condition in a proactive manne _ _ _ - _ _ - _ _ _ _ _ _ _ _ - _ _ _ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ -_ _ _ - - _ _ -

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. Conclusions The Engineering Department's response to the identification of deficiencies in the fatigue monitoring program was prompt and conservativ E2 Engineering Support of Facilities and Equipment E Containment Protective Coatinas Inspection Scope f37551)

The inspectors reviewed the licensee's actions in response to a June 9,1997, NRC Confirmatory Action Letter for degraded coating Observations and Findinas Test Site Selection The Engineering Department selected a number of test sites to support certification that

protective coatings within the containment and drywell were qualified. The inspectors evaluated engineering's selection of test sites by review of preliminary test documentation and inspection of accessible test sites inside containmen The test sites included areas with original coatings, areas repaired during construction, and areas recoated since 1990. The inspectors determined that the test sites were representative of locations throughout containment with two exception The inspectors noted that none of the test sites established or planned included areas

adjacent to weldments on the containment liner, The inspectors observed that many of j the areas where protective coating failures occurred originated from locations where

! structural members had been welded to the containment liner. After the inspectors i pointed out the lack of test sites near weldments, engineering personnel added two test sites to gather additional data. In addition, none of the test sites established or planned included areas adjacent to failures of protective coatings on concrete surfaces. After the

', inspectors had pointed out the lack of test sites near coating failures on concrete, engineering personnel added one test site on a concrete surface which had shown coating failure Recoatina Work The inspectors performed walkdowns of containment and observed that significant l

portions of the containment liner were being recoated from base metal. Specifically, all portions of the con'ainment liner six feet above the 828 foot elevation (refueling level) and a six foot band above the polar crane were recoated. In addition, most areas below the 828 foot elevation where degraded coating had been observed were stripped and recoated. The inspectors considered the actions to recoat areas where protective -

coating problems had been observed *o be good.

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. 1 i stina Criteria The inspectors reviewed test plan * CPS Coating Test Plan Service Level 1 Areas," j Revision 1, dated Ju3e 17,1997, and noted that the acceptance criteria for test sites i were consistent with ANSI N5.12, *Protwellve Costings (Paints) for the Nuclear Industry." Conclusions The selection of coating adhesion test sites did not initially represent all observed problem areas. After discussions with the inspectors, additional test sites which .

adequately represented observed problem areas were added. The protective coating  !

testing methodology was acceptat,l !

I! Qualificallpn of Rosemount Transmitters and Refiance Comoressor Motors jngection Scope (37551)

The inspectors reviewed the licensee's response to CR 19611325 regarding adequacy of environmental qualification of Rosemount pressure transmitters and Reliance compessor motors, ,

l Observations and Findinas OR 196113251nvolved a concem regarding Nuclear Station Engineering Department Procedure E.6 * Environmental Qualification."

Attachment E.61 state:d, in part, that "the first 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or actual operating time during accident shall be en ~ ,oped by test temperature and duration unless justifie Time / temperature following that, to 109 days (including margin) can be met using state-of the art technology for accelerated accident aging and Arrhenius method., ."

The CR raised a concem that the qualifications of the Rosemount transmitters and the Reliance motors were non-conservative since Pey were based on equivalent temperatures using Arrhenius methodology and not based on the actual accident temperatures during the first 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after the acciden The inspectors reviewed the en@evring evaluatior's and calculations performed by Sargent & Lundy. The licen'.oe's environmental qualification engineers and Sargent & Lundy (in cale'..ation CMED-060288) concluded ' hat the post-LOCA qualification of Rosemcant 1iS3, Series 8 transmitters was .:cceptable. This calculation also mentioned that ino qualification by equivalency utilizing the Arrhenius methodology was accepted by the manufacturers, IEEE, and other utilities. The calculation indicated that the test temperature of 318"F for the first six hours was much larger than the post- i

. accident temperature of 204*F in Zone H-40. The calculation also indicated that the test results exceeded the equivalent temperature and duration of the post accident conditions, after including the + 15"F margin for temperature and +10% margin for duration, as per IEEE 323197 i 18 . _ -. .. - --- --- - -- -- - - - ~

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The inspectors also reviewed calculation No. EQ CLO59 regarding the qualification of the Reliance motors. This calculation concluded that the test conditions used to qualify these motors adequately enveloped the plant loss of coolant accident temperature Based on the review of these qualification reports and industry practices, the inspectors agreed with the licensee's conclusion that the Rosemount transmitters and Reliance motors were adequately qualified for the applications in the plant. The licensee engineers agreed that some ambiguity existed a:. per the present wording of Attachment E.6-1 regarding the first 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> testing at actual accident temperatures. The Engineering Department felt that the Arrhenius method was acceptable due to the words "unless justified"in the procedure. However, the licensee decided to clarify that testing at the equivalent temperatures / times was acceptable in the ne# blannual revision of this

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procedure, c. ponclusions Engineering evaluations and calculations provided reasonable assurance to ensure that Rosemount pressure transmitters and Reliance motors would satisfactorily perform after postulated accident E Impfomentation of Temporary Modificatign1 Inspection Scope (37551)

The inspectors reviewed open temporary modifications as well as those closed in the last 18 months. In addition, a walkdown of the facility was performed to determine if any temporary modifications existed which were not controlled by the licensee. No significant deficiencies were noted in the review of licensee designated temporary modification Qbservations and Findinas CPS Procedure 1014.03," Temporary Modifications," Revision 18, Section 2.2.2, d6 fined a Temporary Modification as any short term alteration made to plant systems, structures, or equipment that does not conform with approved drawings or other design document Section 8,1.1 required that a Temporary Modification Permit be used to initiate temporary modification On June 18,1997, the inspectors observed that temporary lighting had been installed through the frames for the Main Control Room Environmental Boundary Doors 501 and 524. However, the temporary lighting was not identified or controlled as a temporary modificatio 1 to the facility. The failure to initiate a Temporary Modification Request is a Technical Specification 5.4.1.a violation (50-461/97014-01b).

In response to the discrepancy, the licensee iridiated a CR on June 19,1997, to document the condition. On June 27,1997, a temporary modification request was submitted for the installation of the temporary lighting. Because a full safety evaluation was neoc'ed to Nstify the temporary modification, the lights were removed during the day shift on June 28,1997. Later the same day, the licensee issued temporary modification 97 044 and reinstalled the lights The assistant plant managers for operations and

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t maintenance stated that the delay in performing the safety evaluation resulted from a miscommunication between operations and maintenance departments, Conclusions

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t One violation was identified for the installation of a temporary modification which breached the main control room envelope boundary. No deficiencies were identified l during the review of open temporary modification l f

N. Plant Suonort

R1 Radiological Protection and Chemistry (RP&C) Controls R1,1 Uncontrolled Radioactive Malertal  ; Inspection Scope (71750)

The inspectors performed tours of the redlologically controlled areas to detennine the adequacy of radiological postings and control of radioactive material. Observed radiological postings were adequate. Examples of weak radiological practices regarding ,

the labeling of bags containing radioactive material were identified by the inspectors and

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licensee, Observations and Findinas On June 23,1997, the inspectors observed an unlabeled and unsealed yellow plastic bootie on the 712' elevation of the fuel building which contained used gloves and paper towels. Along with the bootle were tools and equipment for maintenance work which had been performed by C&l technicians. Additionally, the inspectors observed an unlabeled and unsealed bag of wet towels and water on the flooring near the bag on the 755' elevation of containmen At the request of the inspectors, the radiologicci protection (RP) supervisor evalcated the fuel building work area and determined that the gloves and towels in the bootie were contaminated at approximately 3.000 dpm. This quantity was below 10 CFR Part 20.1905 levels required for labeling radioactive material. Nevertheless, the RP supervisorinitiated a CR to document the presence of the radioactive material. The RP supervisor stated that had C&linformed RP of the activity, the deficiency would not have occurre The RP supervisor sent a technician to evaluate the discrepancies in containment. The technician identified additional deficiencies including improperly sealed vacuum attachments and an unlabeled and unsealed radioactive material tool bag. The technician identified a maximum level of 2,000 dpm on the items. The RP supervisor initiated another DR to document these deficiencies as wel ,

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, - Ggnelut ions A weak radiological work practice and procedure was identified for not labeling two bags containing low level radioactive material. This item will be followed up dunng a subsequent inspection (IFl 50 401/97014 04). *

S1 Conduct of Security and Safcguardh Activities S Protected Area lilymination inspection Geor e f71750)

The inspectors performed tours to determine if zones within the protected area were

'tequately illuminated, Observations and Findinal On June 18,1997, the Inspectors toured ite exterior areas within the protected area and noted inadequate illumination levels adjacent to radioactive waste storage container The inspectors requested that security personnel perform a lighting survey during the evening shift to verify the amount of illumination. Lighting surveys performed by security personnel on June 19,1997, Indicated that five locations adjacent to radioactive waste conlainers ranged between 0.054 and 0.140 foot candles. Low illumination levels reduced the ability of the security organization to adequately monitor and observe the areas noted abov CPS Physical Security Plan, Revision 13, Section 4.3.1, requires the minimum illumination level throughout the protected area be 0.2 foot candles. The failure to ensure exterior areas within the protected area were sufficiently illuminated is a violation of License Condition 2.E (50 461/97014-03). Review of the security plan determined that illumination levels of less than 0.2 (shadow areas) are acceptable in some cases, however, the plan did not identify the area noted above. Evaluation by licensee security management determined that although the lighting level was below 0.2, observation of the area may have been possible. The lighting deficiency was more than of minor significance because it appeared a procedure, requiring officers to check " dark areas" was not complied with, and this was anoner example of the licensee's failing to follow a procedure In response to the inspectors observa' ion, the licensee provided temporary lighting in the affected areas, arranged the storage containers in a configuration to minimize the use of temporary lighting, and performed additional lighting surveys, Q_ongu}i.o u A violation was identified for the failure to ensure exterior areas within the protected area are illuminated to greater than 0.2 foot .andles i

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S,Mananoment Meetinas X1 Exit Meeting Sun.**.ary The inspectors presented the inspection results to members of licensee management at I

the conclusion of the inspection on July 8,1997. The licensee acknowledged the findings presente The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie X2 Management Meeting Summary On June 6,1997, Mr. Sam Collins, Director, Office of Nuclear Reactor Regulation, visited Clinton Power Station. In addition to a plant tour, Mr, Collins met with several members of licensee senior management to discuss restart issues and general observation On July 2,1997, Mr. A. B. Beach, Regional Administrator, Region Ill, and other NRC management members visited the Clinton site. In addition to a plant tour, the NRC managers met with licensee tranagement to present the results of the Systematic Assissment of Licensee Performance (sat.P) repor On July 3,1997, a management meeting was held at the Clinton site to discuss the status of the licensee's restart action plan. The licensee discussed the resolution of previously identified material condition deficiencie . . - - _ _ _ . - . - .. .- - .

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I PERSONS CONTACTED J. Cook, Senior Vice President W. Romberg, Assistant Vice President P. Yocum, Manager . Clinton r'9wer Station -

D. Thompson, Manager . Nuclear Station Engineering Department L Wigley, Assistant Manager. Nuclear Station Engineering Department R. Phares, Manager . Nuclear Safety and Performance improvement J. Palchak, Manager. Nucioar Training and Support G. Baker, Manager . Quality Assurance D. Morris, Director. Radiation Protection A. Mueller, Assistant Plant Manager. Maintenance M. Lyon, Assistant Plant Manager. Operations ,

W. Bousquet, Director Plant Support Services

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INSPECTION PROCEDURES USED IP 71707: Plant Operations IP 01726: Surveillance Observations IP 62707: Maintenance Observations IP 37551: Engineering Observations IP 71750: Plant Support Observations ITEMS OPENED, CLOSED, AND DISCUSSED Opened .

50-461/97014-01a VIO Fallare to refer to electrical diagrams during ground isolation activitie /97014-01b VIO Failure to initiate a temporary modification permit prior to installing a temporary modification which breached the control room environmental boundar /97014 'J2 VIO Failure to use controlled official working, or approved for work copies of procedures while performing maintenanc /97014-03 VIO Failure to adequately illuminate the protected are /97014 04 IFl Labeling / Tagging of Radioactive Material

O- 8 LIST OF ACRONYMS ANSI American National Standards Institute CAL Confirmatory Action Letter C&l Controls and instrumentation CPS Clinton Power Station CR Condition Report CY Cycled Condensate DRP Division of Reactor Projects FP Fke Protection IEEE institute of Electrical and Electronics Engineers LCLC Low Crud Low Conductivity .

MC Makeup Condensate MCR Main Control Room MOV Motor Operated Valve MWR Maintenance Work Request NRC Nuclear Regulatory Commission OSO Operations Standing Order PDR Public Document Room .

PalD Piping and instrumentation Diagram RClO Reactor Core Isolation Cooling RMS Records Management System RP - Radiation Protection RT Resin Tank TM Temporary Modification TS Technical Specification USAR Updated Safety Analysis Report WS Non Safety Related Service Water WX Solid Radweste Reprocessing i

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