ML20082K187

Responds to NRC Re Violations Noted in Insp Repts 50-413/90-201 & 50-414/90-201.Corrective Actions:Procedure MP/O/A/7450/26 Changed to Give Better step-by-step Guidance for Corrective Maint on Control Room Area Air Handling

ML20082K187
Person / Time
Site:	Catawba
Issue date:	08/22/1991
From:	Tuckman M DUKE POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9108290248
Download: ML20082K187 (28)

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t'  %' s ' ' , s j ouxcpowen August 22,1991 U. S. Nuclear Regulatory Commission A'lTN: Document Control Desk Washington, D.C. 20555

Subject:

Catawba Nuclear Station, Units I and 2 Docket Nos. 50-413, 414 NRC Inspection Report Nos. 50-413, 414/90 201 Reply to a Notice of Violation Enclosed is the response to the Notice of Violation issued June 24,1991 by Luis A.

Reyes concerning maintenance activities at Catawba Nuclear Station. A response to Unresolved item 413,414/90-201-08 is also enclosed. No response is provided for item D concerning station procedure review periods exceeding two years. Discussions held with te Catawba Senior Resident inspector and hit. Al Belisle of Region 11, concludet his item was previously identified and addressed in our response dated February 7,1991 to Violation 413,414/90 32-01. It is requested that this violation be withdrawr yrom the Notice of Violation.

Very truly ! ours,

(\.S. i C m hi. S. Tuckman xe: hir. S. D. Ebneter Regional Administrator, Region 11 hir. W. T. Orders Senior Resident Inspector hir. R. E. h1artin, ONRR 1 ..

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. DUKE POJER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 A. 10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," and the liconaco's accepted ,

Quality Assuranco (QA) Program (" Duke Power Company '

Topical Report, Quality Assuranco Program, Duko-1-A"), i Section 17.2.5, collectively coquiro that activities affecting quality bo prescribed by documented [

instructions or procedures appropriate to the  !

circumstances and shall be accomplished in accordanco j with these procedures or instructions. Instructions or :

procedures shall include appropriato quantitativo or  !

qualitative acceptanco criteria for datormining that l important activities have been satisfactorily l accomplished. j i

contrary to the above during the Maintenance Team Inspection during November 12 through 16, 1990 and November 26 through 30, 1990, it was discovered thatt  ;

1. The program document for vendor manual control, i Station Directivo 2.1.4, Revision 1, did not ,

provide instructions on the incorporation of vendor manual maintenance specifications into applicable sito maintenanco procedures. This resulted in the licensee's failure to include i vendor manual requirements in Procedurc '

MP/0/A/7450/26, " Westinghouse 8000 Series Fans Corrective Maintenance," Change 1, utilized during Work Request 3725MES. The procedure was inadequate in that it lacked details on torquing i requirements; acceptance criteria for chaft sizo; I bearing clearance requirements, and belt tension j criteria. This resulted in improper setting of  !

the bearing clearances for the Control Room arca air-handling units and failure to properly torque i the bearing cap fasteners.

2. Procedure MP/0/A/7650/63, "On-Line Leak Repair Corrective Maintenance," was inadequato in that <

the procedure lacked clear instructions not to >

exceed the minimum wall thickness provided; lacked ,

instructions on how to obtain and verify thread engagement for the injection valve; failed to '

treat the injection pump as measuring and test

• equipment; failed to clearly distinguish between

(

system and component design pressures; and, lacked instructions for determining the actual injection l pressure.

l l 3. Procedure PT/0/A/4971/12/R, " Routine Test

• Procedure; RIS Type 90634-100 Under-voltage Sensor  !

with C-H M300 Auxiliary Relay," did not provide  ;

sufficient guidance for obtaining input voltage and control voltage and did not provide i instructions concerning installation of the test  ;

, DUKE PO2ER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 set-up. Craft personnel had to perform actions not procedurally delineated to satisfactorily complete the maintenance activition.

M EPRHRE8 e

1. ReAnon_far__Yiglation A.1. Maintenance Technicians woro working on the control Room Area Air Handling Unit B using Proceduro MP/0/A/7450/26. Station Directivo (SD) 2.1.4, Revision 1, does not provide guidance on the incorporation of vendor muaual maintenance specifications into applicable sito maintenance procedures. However, SD 4.2.1 " Development, Approval and Use of Station Proceduros" does provide guidance in incorporating applicable reference material such as technical manuals, manufacturor's instruction manuals, etc. This directivo also specifies that proceduros shall be written to a lovel of detail sufficient for a qualified person to perform the task with no direct supervision required. Proceduro MP/0/A/7450/26 as written did not comply with the requirements of SD 4.2.1.

A.2. This incident was attributed to inadequate proceduro detail due to familiarity of MES and vendor personnel with the repair process. This resulted in lack of clear instructions for certain activities performed under this procedure.

A.3. Procedure PT/O f A/4971/12/R did not provide sufficient guidance for obtaining cortain readings l and did not provido adequato instructions pertaining to installation of the test set up.

2. gojtrectiye h_91LORs__T_alRA AD_dEAMLts Achigle4:

(. A.1. Proceduro MP/0/A/7450/26 has been changed to givo l better step-by-stop guidance for corrective maintenance on Control Room Area Air Handling Units. The changes made were only to cover tho l

work in progress at the time of the violation.

1

! The section manager has covered with the HVAC crew l the nood to immediately identify any deficiencies found in the procedures and to suspend work until corrections have becn mado.

1 A.2. MES promptly evaluated each concern addressed with Maintenance Procedure MP/0/A/7650/63, "On-Lino Leak Scaling," and the following actions were taken

, . DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 On November 27, 1990, the Maintenanco Proceduro was revised to incorporate / clarify information on j minimum wall thickness, thread engagement for tho  ;

injection fitting, and method for datormining L actual injection pressure. The intent of those  ;

changos was to onhance/ clarify the proceduro.

Following the MES ovaluation, it was determined that no action was required for the remaining two items. One item, " Failure to treat the injection l pnmp as test equipment", is not felt to bo j necessary or feasible. The required volume of scalant can not bo dotormined to a high degree of  :

accuracy due to tne unknown size of void and  ;

compressible naturo of scalant materials. Design l Engineering specifies in the repair procedure the  !

approximato (nominal and maximum) amount of i scalant material used to control the volume of i scalant that will be injected, thus minimizing possible scalant extrusion into the 1.focess lino.

• Thoroforo, there is no nood to use an injection pump with test equipment accuracy.  !

The last item of concern,"Failuro to clearly distinguish betwoon system and component design  !

pressures," may be a misunderstanding of -

terminology. System pressure is the piping design pressure from the flow diagram and pipe specification. Component pressuro is the actual ,

design pressure of the individual component to be  !

repaired. For examplo, a piping system designed r for 150 pound class service may have a valvo installed which is rated for 600 pound service. i MES and Design Engincoring perform reviews for e each leak scaling repair in addition to vendor l engineering / final review. Completion of the i reviews and 10CFR50.59 ovaluations are required by >

Procedure MP/0/A/7650/63. MES fools the pressure values are adequatoly identificd and reforoaced in the procedure.

A.3. PT/0/A/4971/12/R will be replaced with two now procedures, a PT that performs the monthly Tech Spec test and an IP that performs the la month

relay calibration and acceptance tost. The IP is l

in the initial preparation stage and is being re-written to address the NRC concerns outlined in  !'

the Notice of Violation. This procedure will be approved before September 30, 1991. The new PT no longer measures input and control voltage. Tho ,

measurements are not required to determino Toch Spec operability and were not included in the new L

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I DUKE POWER COMPANY j REPLY TO NOTICE OF VIOLATION 413, 414/90-201 procedure. Nevertheless, the latest revision of this procedure includes test cetup connection information and improved procedure text. The latest revision of this pT was apprnved in December, 1990.

In general, catawba has taken a broad approach to the resolution of the concerns ideritified during the Maintenance Team Inspection, and has made improvements to several proceduro upgrade proarams. These programs are being implemented in the Instrument and Electrical (IAE) section, the Mechanical Maintenance (M/M) ocction and the Power Delivery Department.

lAE reorganized their procedure upgrade effort during the first quarter ot 1991, making technicians with assigned systems responsible for the technical content of procedures during the upgrades. The responsible technicians will generate the procedurer, and the procedure crew will review them for buman factors considerations.

In addition, the field technicians reviewed all procedures for readability. This review was completed in April, 1991.

Detailed meetings were conducted in the first quarter of 1991 with all IAE supervision and technicians to rcomphasize the criticality of proper procedure usage. The meetings focused on when to have procedures in hand and stressed that if procedures are not correct, they shall be corrected before proceeding with the work.

Ownership and responsibility for power Delivery procedurc writing, upgrade and revision have been shifted from the General Office to the site Power Delivery Team effective March, 1991. This provides quicker turn around on changes and facilitates direct input from field personnel.

The last two year review cycle was completed in March, 1991 and included all relaying, switchgear, and motor maintenance procedures.

Mechanical Maintenance is in the process of rewriting Maintenance Management Procedure (MMP) 6.4, "Use of Mechanical Maintenance Procedures."

This rewrite will emphasize using only controlled information while performing work, and discontinuing work if an error is found in a procedure until the procedure can be corrected.

Training will then be conducted on the revised MMP. The revision and training will be completed

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DUKE POWER COMPANY REPLY TO NOTICC OF VIOLATION 413, 414/90-201 by September 30, 1991.

3. cprtop_tive_A9119na_to_be laken_to_hy_qid_further Yiohti9.no :

A.1. Procedure MP/0/A/7450/26 has undergone a complete re-write and is currently in the final review stages. Proceduro MP/0/A/7450/26 Retype #2 will be approved by October 31, 1991. A systematic review o' all HVAC Maintenance Procedures began on July 8, 1991, and an experienced technician has been assigned to assist in this effort. At present there are 35 HVAC related procedures for safety related equipment. During th review process all of these procedures will be evaluated and an additional ten or so new procedures will be written. The review will be completed by March 31, 1993.

A.2. An Engineering review of on-line leak repairs is continuing and further enhancement of maintenance procedures is beir.g performed when necessary. The present method for identifying allowable injection pressure is based upon the industry recognized standard approach which is the best available information at present. MES plans a be involved with and follow industry / vendor efforts in this area and incorporate new methods as they develop.

A 3. Power Delivery will review similar procedures and address the concerns raised in this Notice of Violation. This procedure review, and necessary revisions, will be completed by October 15, 1991.

In general, Duke Power currently hes a Procedure Policy Review Group which spans groups at all three nuclear stations, the General Office, Power Delivery, Production Support and Construction and Maintenance Department. The goals of this team are to review existing procedure adherence policies and make recommendations to the Human Performance Excellence *eam for a clearly defined, comprehensive procedure adherence policy. The team is studying the INPO Good Practice on Procedure Use and Adherence, as well as guidelines from other nuclear plants. After the policy is defined and communicated, training and procedure reviews will be completed.

The status of the IAE procedure upgrade is as follows: j

.S.

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4 DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 Priority 1: 248 total, 236 completed. Commitment for completion is December 31, 1991. Defined as having a high potential for reactor trip or personnel injury.

Priority 2t 661 total, 478 completed. Commitment for completion is August 1, 1992. Defined as having a high potential for challenging a safety system, or being a regulatory required orocedure.

Priority 3: 548 total, 48 completed. Commitment for completion is August 1, 1994. Defined as having a potential impact on plant reliability or performance.

Effective June 1, 1991, a customer review of a model Mechanical Maintenance procedure began.

Each supervisor will provide feedback on the leve) of technical detail needed for this procedure.

This review will be concluded by August 31, 1991.

Effective September 1, 1991, all Mechanical Maintenance procedures which will be up-graded, revised, or re-written will incorporate the quality features including appr opriate levels of detail containcd in the model procedure.

The status of the M/M pro;edure upgrado program is as follows:

Priority 1: 260 total, 205 complete. Commitment for completion is April 1, 1992. Defined as involving critical path or potential critical path work and Tech Spec work.

Priority 2: 143 total, 88 complete. Commitment for completion is April 1, 1992. Defined as involving industrial safety and non-outage items related to plant reliability.

In addition to improvements in existing procedures, a need for new procedures, including non-safety related procedures on certain systems and components has been identified by the Power Delivery Team. The goal of the review and upgrade is to have procedures that are user-friendly, more consistent and contain improved IcVel of detail.

Following is the schedule for review and upgrade of existing procedures and creation of new procedures in the Power Delivery Group:

Priority 1: 20 upgrades, 5 new. Estimated completion December 31, 1991. Defined as safety-related procedures with the greatest need for improvement and new safety-related procodures to

, , DUKE PODER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 enhance existing snaintenance activities.  !

Priority 2: 35 upgrades, 5 now. Estiraated completion December 31, 1992. Defined as othcr safety-related procedures with editorial related changes needed.

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4. p_ ate of Full Complia_nga A.1. Procedure changes were initiated immediately following identification and completed on November 27, 1990. Duke Pouer in now in full compliance.

A.2. Procedure changes were initiated immediately following identification and completed on November 29, 1990. Duke Power is now in full compliance.

A.3. Duke Power will be in full compliance by October 15, 1991.

a. . . .

6 DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 B. Technical Specification 6.8.1 states that written procedures shall be established, implemented and maintained covering the activities and applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2.

Contrary to the above, instances were noted where personnel failed to follow approved procedures during the performance of work.

1. Chemical cleaning of the Nuclear Service Water System motor and pump components was being performed in accordance with Work Requests 007238 SWR and 007240 SWR and procedures MMP 1.6,

" Housekeeping Requirements During Maintenance Activities on Open Systems and Components," and an associated vendor procedure entitled "DSI (Vendor)". These procedures require the following:

a. Vendor procedure Step B.1 required flushing each component at a rate of 1 gallon every five minutes with 25 gallons of fluid supplied to each component being cleaned.

However, means were not provided to measure flow and total volume to each component,

b. Vendor Procedure Steps B.1 and C.1 required rotating pump shafts by hand while flushing and rinsing. This was not being performed.

c. Procedure Step C required the temperature of the rinse water to be 125* F. The maximum temperature observed during rinsing was 102'F.

d. Procedure MMP 1.6, " Housekeeping Requirements During Maintenance Activities on Open Systems and Components", requirements for Housekeeping Zone III controls were not adhered to regarding maintenance of a materials and personnel log.

2. Procedure 0/B/7650/115, " Building / Erection and Removal of Scaffolding", Section 11.6.8 states that scaffolding should not be placed within 2 feet of items that could be damaged during a seismic event. Scaffold No. 41932, erected on October 16, 1990, in Containment Spray Pump Room 1B blocked the manual-operator of motor-operated valve MOVINS03B, and provided insufficient clearance for scaffold movement during a seismic event to ensure ' hat the operator electrical cables would not be damaged.

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DUKE POWEP. COMPANY REPLY TO NOTICf. OF VIOLATION 413, 414 / f> 0-2 01 RESIONSEt

1. Reapo.n_for_Y_jpla11on t B.1. This incident occurred as a result of a performr.nce deficiency. The procedure being used did not meet the standards of our procedures and the persons involved did not recognize the steps in the document as binding procedure steps. In fact, some of the steps could not be performed due to physical limitations.

B.2. This incident occurred as a result of individual performance deficiency. MP/0/B/7650/115 does allow for scaffolding to be built within 2 feet of seismic components. However, if the 2 foot boundary is violated then the scaffold shall be secured to prevent movement. This is a standard requirement for seismic areas, and the scaffold builder failed to adhere to this requirement of the maintenance procedure.

2. C o r r o c_tlye Ac t ic np_Talt e n a nd_Re s uJLt a_Ag.hi s evedi B.1. The procedure DSI (Vendor), has been rewritten using the Duke Power procedure format and is now MP/0/A/7150/98, " Nuclear Service Water (RN) Pump and Motor Cooler Chemical F1 unt".

The requirement to adhere to procedures has been reemphasized to all Mechanical Maintenance personnel. The Section Manager met with Supervisors and representatives from the crews and discussed the requirement to adhere to procedures and to stop work i f t hc scope execr ded the procedure. Tha Supervisors and representatives have covered this information with the individual crews. All meetings emphasized the need to follow the established procedures or gign work and get a procedure changed if it is incorrect.

B.2. Research of the work in the NS Pump Room revealed that this scaffold was no longer needed and it was removed. As a follow up, MP/0/B/7650/115 has been revised to be clearer and more " user-friendly".

Additionally, all scaffold builders have been trained on both the revisions to the procedure and to the proper usage of the procedure. During the training, specific emphasis was placed on the importance of adhering to the requirements of the procedure data cheets which delineates seismic requirements and other special equipment

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 protection considerations.

In general, detailed meetings were conducted in the first quarter of 1991 with all IAE Supervisors and Technicians to reemphasize the criticality of proper procedure usage. The meetings focused on when to have procedures in hand and stressed that if procedures are not correct, they shall be corrected before proceeding .

with the work. l i

specific procedure use training and guidelines I were given to Power Delivery crew wno performed l work at Duke Power's Nuclear Str. cions. This i training stressed the importar.cc of following procedures exactly and the itaportance of changing a procedure if it does not fit the work scope.

3. Corrective Actions to be Tehen to Avoid Further

. Violations:

B.1. No further actions are planned at this time.

B.2. No furthe. actions are planned at this time.

4. p_ ate of 3 1) CoEpliaAce:

B . '. . Duke Power is now in full compliance.

B.2. Duke Power is now in full compliance, l

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DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 i

C. 10 CFR Part 50, Appendix B, Criterion V, " Instructions, l Procedures, and Drawings", and the licensee's accepted QA Program, Section 17.2.5, collectively require that activities affecting quality shall be accomplished in accordance with appropriate instructions and procedures.

Nuclear Production Department Directive 3.1.1,

" Independent Verification Requirements", Revision 4 and .

Station Directive 4.2.2, " Independent' Verification Requirements", Revision 2 require the appropriate '

completion of independent verification.

Procedures IP/0/A/3890/01, " Controlling Procedure for  !

Troubleshooting and Corrective Maintenance";  ;

i IP/2/A/3222/55A, NCS Pressure (Wide Range) Channel 4  ;

l Loop PT-403 (2NCPT5140)"; IP/2/A/3122/01B, " Inadequate Core Cooling Monitor System (ICCM-86) Walkdown Checklist Train B"; and IP/2/A/3122/03B, " Inadequate ,

Core Cooling Monitor System (ICCM-86) Analog / Digital Internal Loop Calibration Train B"; each require:

1. Before action is performed, two individuals acting independently will verify that component on which action is to be taken is correct. This will be done by comparing work requests, procedure, and equipment identification.

2. After action is performed, an individual, acting independently of person that performed action, will verify action has been completed correctly. '

Contrary to the above, technicians conducting tasks

! described in Procedures IP/0/A/3890/01,IP/2/A/?222/55A, l IP/2/A/3122/01B, and IP/2/A/3122/03B failed to adhere to the independent verification requirements in each of these procedures. Similar failures to follow independent verification requirements were identified with performance of procedure IP/1/A/3240/04I, l " Calibration Procedure for Power Range N-42 Analog l Channel Operability Test".  ;

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BESPONSE

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l L 1. Reason for Violation:

l The technicians actions met the requirements of NPD l Directive 3.1.1, CNS Directive 4.2.2 and CNS IAE Guideline #9.

al.a NRC Inspector observed two technicians performing a 1 maintenance activity by procedure. When the procedure reached a step that required an Independent Verification, one technician performed the step and ,

DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 signed that it had been performed. The second technician then verified that the step was performed correctly and signed the independent verification.

We believe that since the second technician did not perform the action, but did verify the accuracy of the action prior to its taking place and then the fact that action did take place, he was acting independently. The NRC Inspector felt that since the technicians were on the same job at the same time they could not act in an independent manner. This was the same concern on procedures referenced in the violation report.

2. Corrective Ap_tions Talep and _Results Achieved:

Individuals in the IAE section are initially trained in the requirements of CNS IAE Guideline #9. Emphasis was recently placed on understanding the reasons for and the importance of proper IV verification through additional training carried out by the IAE first line supervisors in July 1991.

In response to this violation, we have reviewed NPD Directive 3.1.1 " Independent Verification Requirements", Revision 4 and Catawba Directive 4.2.2

" Independent Verification Requirements", Revision 2, and have determined that the Independent Verification Program should be evaluated to determine where enhancements should be made.

3. . Corrective Actions to be Taken to Avoid Further Violations A. Regulatory Compliance will review NPD Directive 3.1.1 using INPO OP-214 Good Practice dated June 1991, as guidance to determine changes needed in the existing Independent Verification Program.

Recommended changes will be incorporated into NPD Directive 3.1.1 by December 31, 1991.

B. Using the revised NPD Directive 3.1.1, each station will incorporate Independent Verification Program changes into the Station Directive on Independent Verification, revise applicable station procedures and provide training to all appropriate station personnel concerning Station Directive and procedure changes.

C. Duke Power Company's Human Performance Excellence Team (HPET) is currently evaluating station implementation of the Independent Verification Program to determine where improvements are needed. HPET recommendations will be reviewed by

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DUKE POWER COMPAMY I REPLY TO NOTICE OF TIOLATION 413, 41#./90-201 station and department management and approved changes will be incorporated in the Program.

4. pate of Full Qompliance:

Full compliance will be achieved upon station implementation of Independent Verification Program changes at each station. Recommended changes to the Independent Verification Program will be incorporated into NPD Directive 3.1.1 by December 31, 1991. The implementation date will be determined by each station after the scope of changes is identified.

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, DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 D. Technical Specification Section 6.8.2 required that applicable procedures identified in Appendix A to Regulatory Guide 1.33, " Quality Assurance Program Requirements (Operation)," Revision 2, shall be reviewed periodically. Station Directive 4.2.1,

" Development, Approval and Use of Station Procedures,"

required that all station procedures shall be reviewed at intervals not exceeding two years.

Contrary to the above, the following Station Directive Procedures had not received periodic reviews: 2.4.3,

" Control of Materials, Parts and Components"; 2.12.7,

" Fire Detection and Protection"; 3.3.1, " Determination of QA Condition for Structures, Systems, and Components"; 3.3.3, " Preventive Maintenance Program".

This list is not intended to be all inclusive.

RESPONSE

No response is provided. Discussions held with the Catawba Senior Resident Inspector and Mr. Al Belisle of Region II, concluded this item was previously identified and addressed in our response dated February 27, 1991 to Violation 413, 414/90-32-01. It is requested that this violation be withdrawn from the Notice Of Violation.

l DUKE PODER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 E. 10 CFR 50.73 ( A) (2) (1) (B) requires that the licensee report via an LER any operation or condition prohibited by the Technical Specifications which includes missed surveillance or technical requirements. Also, 10CFR50.73 (a)(1) requires that LER's be submitted within 30 days of the discovery of the event.

Contrary to the above, one LER was not issued and another was not submitted within the required 30-day time period as follows:

1. Certain auxiliary feedwater cncck valves vert added to the Catawba Inservice Testing Program in May 1989 but procedures were not changed to include the test requirements. This was discovered in December 1989. The missed surveillance was not reported on an LER within 30 days of discovery as required.

2. A violation of Technical Specification Table 3.3-4, item 10.b concerning 4KV bus undervoltage-grid degraded voltr.ge instrumentation occurred in November 1989. However, LER 90-012-00 was not written until March 2, 1990.

RESPONSE

1. Reason for violation:

E.1. The person who evaluated this item for reportability did not consider the requirements of TS 4.0.5. The focus of the reportability evaluation was on whether the valve was a containment isolation valve. The requirements of TS 4.0.5 were overlooked.

E.2. This item was discovered by a QA Auditor. Several weeks of research passed before it was realized that a Technical Specification Violation had occurred. When this fact was realized the item was determined reportable and an LER was initiated.

2. Corrective Actions Taken and Results Actieved:

E.1. Personnel who make reportability evaluations were reminded to consider all applicable parts of Technical Specifications when making reportability determinations.

E.2. Quality Assurance personnel were instructed on the impcrtance of reporting possible Technical Specification violations via the Problem Investigation Process so that Operability and

DUKE PODER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 Reportability Evaluations can be made promptly.

Transmission personnel recalibrated all affected relays to comply with Technical Specification requirements. Transmission procedures were revised to comply with Technical Specification requirements.

New or rewritten Safety Related Transmission Department Procedurcs will receive a cross-disciplinary review by Nuclear Production Department personnel to ensure compliance with Technical Specification requirements.

A letter was sent to QA, Transmission and Site Design personnel requesting that each group be made aware of the need for prompt action when a discrepancy with Technical Specifications and associated procedures is suspected.

3. Corrective Actions to be Taken to Avoid Further violatiens:

E.1 & E.2 No further corrective actions other than those descrioed in Item 2 (above) will be taken.

4. Date of Full Compliacce: i Duke Power is now in full compliance, l

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DUKE PODER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 F. Licensee Conditions 2.C.(8) and 3.C.(6) for Catawba Units 1 and 2, respectively, require the licensee to maintain in effect all provisions of the approved fire protection program, including emergency lighting, as described in the Final Safety Analysis Report and as approved in the Safety Evaluation Report through supplement 6.

Contrary to the above, the licensee failed to maintain in effect the fire protection program in that numerous battery pack emergency lighting units required by 10 CFR Part 50, Appendix R, and Catawba FSAR Section 9.5.3.2 were found inoperable during annual and monthly testing from July through November, 1990. Work requests were issued for repairs, but as of November 27, 1990, about 33 percent of the FSAR-required emergency lights remained out-of-service.

BESPONSE:

1. Reason for Violation:

The excessive failure rate of the emergency battery pack lighting was attributed to an inadequate maintenance and testing program. The system and parts in stock could not provide and maintain the emergency battery pack lights for 100 percent of the required illumination time.

2. Corrective Actions Taken and Results Achieved:

The controlling procedure for maintenance and testing of the emergency battery pack lights, IF/0/B/3540/02, has been revised to perform a 100 percent capacity test annually and an operability test monthly on ALL the emergency battery pack lighting units. A program is in place to ensure replacement parts and spares are in stock, including replacement batteries on trickle charge, so that failed units may be repaired or replaced and retested when performing either test. All emergency battery pack lights have been tagged with their_ design number for maintenance and testing data collection.

3. Corrective Actions to be Taken to Avoid Further Violations:

Complete battery replacement of all emergency battery pack lights, including a 100 percent capacity retest, is in progress and will be completed by December 1, 1991.

The maintenance and testing program will be reviewed by April 1, 1992 to evaluate the program's effectiveness

DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201 in increasing the reliability of the emergency battery pack lighting. If any revisions are necessary, the maintenance and testing program will be revised accordingly.

4. p_ ate oL Full Contpliange t Duke Power is now in full compliance.

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i DUKE POWER COMPANY

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REPLY TO NOTICE OF VIOLATION 413, 414/90-201 G. 10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action," and the licensco's accepted QA Program, '

Section 17.2.16, collectively require that measures be _

established to assure that conditions adverse to  !

quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.

In the case of significant conditions adverse to l quality, the cause of the condition shall be determined and corrective action taken to preclude repetition. For significant conditions adverse to quality both the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels ,

of management.

Stt ion Directive 2.8.1, " Problem Investigation Process and Regulatory Reporting," describes the process for identification, evaluation, reporting, and correction  ;

of problems which may not meet regulatory requirements and requires that problem investigation reports be initiated as soon as practical after identifying any situation which is not expected, does not meet requirements, or is not the result of normal wear.

Maintenance Management Procedura 1.0, " Work Request '

Praparation," states that work request should be .

initiated when maintenance action is needed.

Contrary to the above, instances were identified in which licensee personnel failed to initiate deficiency reports (work requests or problem investigation report) when conditions adverse to quality occurred.

1. On October 17, 1990, during the performance of procedura PT/1/A/4200/52A," Partial Stroke Test >

1FW-28," a significant spill occurred because a '

valve was out of position.

2. On August 25, 1990, 20 to 30 gallons of water were spilled from the containment spray ring as a -

result of Engineered Safeguard Features testing.

3. On September 7, 1990, during reactor coolant system heatup, the 25V-1-S/G 2D power-operated relief valve lifted prematurely at 1020 psig resulting in a 5 degree cooldown as steam pressure dropped to 960 psig.

RESPONSE

1. Reason _for Violation:

Operations was not sufficiently sensitive to when a PIR is required.

1 DUKE POWER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201

2. C_pgrective Actions o __TaXen_ add Results Achiev_ed:

The Operations philosophy on generation of PIRs was initially discussed with all shifts at the Shift Supervisors meeting on December 7, 1990. It was discussed that we need to increase our sensitivity to initiating PIRs. If there is any doubt on the need for a PIR, then write one.

A representative from the Compliance groap attended the Shift Supervisor's meeting of January 4, 1991. The PIR threshold was discussed by all present. It was re-emphasized that PIRs would be generated, as required, based upon the judgement of the shift involved.

The number of PIRs generated has shown a dramatic increase over the past several months due to the increased sensitivity of the need to generate PIRs.

3. Corrective Aq.t_io3s to be Taken to Ay_o_id_Lurihor Violations:

No further corrective actions are necessary.

4. Date of Full CompJ_iaAco:

Duke Power is now in full compliance.

.. DUKE POWER COMPANY REPLY TO NOTICE OF VIULATION 413, 414/90-201 H. 10CRF Part 50, Appendix B, Criterion VIII,

" Identification and Control of Materials, Parts, and

_ Components," and the Licensee's accepted QA Program, Section 17.2.8, collectively require that measures be established for the identification and control of materials, parts and components to prevent the use of incorrect or defective material, parts and components.

Contrary to the above, licensee procedures governing the shelf-life program for materials used in safety-related equipment did not contain adequate instructions for. control and handling of expired shelf-life material such that expired material could be issued without an engineering evaluation. This resulted in 21 expired material issuances of QA-related 0-rings (P/N 1126-00568N) being used in environmentally sealed electronic transmitter covers and one expired material issuance of a QA-related gasket (P/N21710811n) for use in environmentally sealing Limitorque housing covers.

RESPONSE

1. Beason for Violation:

Weakness in our Shelf Life procedure.

2. Corrective Action Taken and Results Achieved:

A revision to the Shelf Life procedure added a new tag to better identify such expired shelf-life materials in storage, and Operability Reviews have been completed on all components affected by the improper issue of the o-rings with the expired shelf-life.

l 3. Corrective Actions to be Taken to Avoid Further violations:

An audit of the entire shelf-life program has been completed and all items meet the requirements of the revised procedure.

4. Date of Full Compliance:

Duke Power is now in full compliance.

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DUKE POWER COMPANY I REPLY TO NOTICE OF VIOLATION 413, 414/90-201 I. 10 CFR Part 50, Appendix B, Criterion VI, " Document Control" and the licensee's accepted QA Program, Section 17.2.6, collectively require that measures be established to control the issuance of documents such as procedures and drawings, including changes thereto, which prescribe all activities affecting quality.

Contrary to the above, these measures were not implemented for the following examples:

1. During the bearing replacement on the control room air handling unit associated with work request 3725MES, craft personnel utilized an unapproved procedure (i.e., manufacturer's instructions enclosed with the purchased replacement Lsaring) to accomplish the maintenance activities.

2. During implementation of work request 543870PS, maintenance personnel used an uncontrolled drawing of the control circuit located inside of the air-handling unit 1TB-AHU-3 control panel.

RESPONSE

1. Reason for Violation:

I.1. This incident occurred as a result of employee performance deficiencies. The revision of MP/0/A/7450/026 that was current at the time of thic work was lacking in sufficient detail to perform the required task. Since the work was being performed at night, engineering support personnel were not available on site. The technicians improperly used the only other information that was currently available to them.

I.2. IAE technicians were sent to investigate a problem with 1-TB-AHU-3. General troubleshooting procedure IP/0/A/3890/01 was used during the investigation of the problem. The IAE technician went to the AHU panel to verify voltage was present in the panel. While doing this, an IAE technician noticed a print was located on the inside cover of the panel. The IAE technician looked at the print and questioned why it was there, but the technician did not use nor intend to use this print as part of his troubleshooting process. A drawing was not required for the technician to simply verify that voltage was present in the panel. Also, it is not a common

! practice for IAE personnel to use uncontrolled i documents to perform work.

DUKE PODER COMPANY REPLY TO NOTICE OF VIOLATION 413, 414/90-201

2. Corrective. Aclions Talt_e.!Ln_and Regul_t_s_Lnhiey.2d.:

I.1. The supervisor determined that the procedure contained major deficiencies, and he stopped work on the job. Appropriate engineering support personnel were consulted, and the procedure was rewritten'to incorporate sufficient detail to complete the maintenance activities. Additionally, the supervisor and his crew were counseled by the i general cupervisor and the maintenance manager on proper procedure usage.

I.2. The IAE technicians involved, immediately removed the uncontrolled print from the panel and disposed ,

of it. Appropriate supervision und Maintenance Engineering Services were informed about ,

uncontrolled documents and the potential for their use, ,

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3. Carrectire Actions to be Taken to Avoid Furthgg Etolatioma:

I.1. Previous employee training has been conducted on both Station Directive 4.2.1 and Maintenance Management Procedure 6.4 to address procedure usage. However, Maintenance Management Procedure 6.4 concerning Mechanical Maintenance procedure usage is being rewritten. This revision will .

provide further emphasis on proper procedore and controlled document usage. Once approved, we will provide training to all Mechanical Maintenance personnel to ensure that each person completely understands proper procedure usage. This effort will be completed by September 30, 1991.

Additionally, further revisions to MP/0/A/7450/026 are currently being developed. These revisions will provide additional levels of detail to further enhance the techniques of performing the i task and will make the MP clearer and more -

logically organized. This effort will be completed by August 15, 1991.

I.2. Maintenance Engineering Services has taken the responsibility for locating all uncontrolled documents within inside covers of equipment and removing and destroying them. Work request  ;

9106825701 has been written to inspect all AHU cabinets and panels. All inspections will be completed by November 1, 1991.

In addition, station management will emphasize the  ;

need for personnel to strictly adhere to Station Directive 2.1.5 " Drawing Distribution and DUKE POWER COMPANY j

• REPLY TO NOTICE OF VIOLATION 413, 414/90-201 Control", concerning the use of controlled drawings to perform work.

4. pate of Full Comp _liance l

1.1. Duke Power is now in full compliance.

I.2. Duke Power is now in full compliance.

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DUKE POWER COMPANY REPLY TO UNRESOLVED ITEM 413,414/90-201-08 10 CFR Part 50, Appendix B, Critorion V requires that activities affecting quality shall be prescribed by ,

documented instructions or procedures of a type appropriate .

to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. l

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Instructions, procedures, or drawings shall include appropriate quantitative and qualitative acceptance criteria  !

for determining that Jmportant activities have been satisfactorily accomplished.

Contrary to the above, during the Maintenance Team .

Inspection: .

The on-line leak repair process was executed through  !

procedure MP/0/A/7650/63, "On-Line Leak Repair Corrective ,

Maintenance", which was based on the Electric Power Research l Institute (EPRI) d ocun.e nt , "NMAC: On Line Leak Repairing". [

The team noted a discrepancy between the EPRI document and the licensee's program in regard to injection pressure of  :

the sealant. The EPRI document stated that injection [

pressures should in most cases be less than system pressures to positively prevent extrusion into the line. In all on- L line Icak activities observed or reviewed, the injection pressure significantly exceeded the pressure of the system  !

under repair.

The licensee specified in it procedure (MP/0/A/7650/63) the  ;

maximum pressure to which the component can be subjected '

from the injection process and defined this pressure as the "maximur allowable dead head pressure". The licensee stated that the " maximum allowable dead head pressure" should ,

always be equa; to or less than the component design

! pressure. The pressure indicated by the injection pump gauge routinely exceeded the " maximum allowable dead head pressure". For example, the actual injection pressure for 4 the repair of valve 2CA-191 was recorded at 3400 psig which l the " maximum allowable dead head pressure" was 2400 psig. -

l When questioned, the licensee stated that the maximum l allowable pump gauge pressure was the sum of the " maximum  :

allowable dead head pressure" and the " static pressure".

l The licensee indicated that the " static pressure" was obtained prior to connecting the scalant pump fitting to the temporary valve fitting and was the pump gauge prensure required to initiate movement of the sealant. The " static pressure", which is a function of the particular sealant

• chosen, is not defined in the procedure nor is its value specified in the procedure. The procedure also did not r

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DUKE POWER' COMPANY REPLY TO UNRESOLVED ITEM 413,414/90-201-08 direct the_ craft personnel to subtract the " static pressure"

-from the maximum gauge reading to obtain the actual injection pressure. Further, as observed during the leak repair of valve 1SP-0097, the craft personnel understood the maximum pressure gauge reading to include the system pressure prior to injection contrary to the licensco's Ldefinition of " static pressure". The licensee maintained that during the process the cavity being filled does not experience pressures in excess of " maximum allowable dead headLpressure". The licensee has not adequately demonstrated that the injection pressure as read at the injection pump gauge did not result'in component internal pressures greater that the " maximum allowable dead head pressure" and/or their design ratings.

BE.sPRES_E The team.apparently had noted a discrepancy between an EPRI document and Catawba's on-line leak scaling program with regard to injection pressure of the sealant. The inspection team noted a statement from the document; "In most cases, injection pressures should be less than line pressures, which positively prevent extrusion into the process line."

From the. team's field observations, it was believed that Catawba's program was not following recommended maintenance practice and was overpressurizing plant equipment.

An engineering evaluation was initiated immediately following-the identification of the teams concern. From review of the EPRI Document, discussion with various vendor experts, and the experience of the_ responsible MES Engineer, it was determined that the' statement-noted above was taken out-of_ context. The paragraph that this statement was found isla summary of the injection process and_use of shut-off adapters _from the start of repair to completion. The statement;in question is describing an' intermediate step of the injection-process where the scalant retainer cavity is vented. Most injections (i.e. majority of the sealant material) is injected utilizing a vented cavity where injection' pressures are less than line pressure; however, the final injection pressure is normally in excess of line pressure..The additional pressure is'needed to overcome line pressure, fill the remaining void, and to compact / compress the; cured sealant. The final statements from the same paragraph.of the EPRI document indicate that additional pressure is required. The-current procedure at Catawba was in line with the EPRI recommendations and current industry practice.

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DUKE POWER COMPANY REPLY TO UNRESOLVED ITEM 413,414/90-201-08 The inspection team also identified concerns with clarity of the procedure in regard to the injection process. From MES review of the procedure, it was agreed that the clarity and the documentation of the injection process could be enhanced.

Procedure Mp/0/A/7650/63 was revised November 29, 1990 to show the field calculation of the actual dead head injection pressure and its " recognized" relationship to static pressure, gauge pressure and maximum allowable dead head injection pressure.

Determination of maximum dead head injection pressure involves a detailed review and calculation by-Design l Engineering. Their is no precise correlation between hydraulic gauge pressure and the actual pressure / stress induced at the component; however, assumptions can be made that will result in a conservative approximation of the injection pressure. The intent of this procedure is the l prevention of equipment over-pressure while minimizing the possibility of sealant extrusion. No failure or equipment damage has been documented at Catawba due to scalant injection process.

, On-Line Leak Scaling has been performed for over twenty l years and as proven to be a safe and effective temporary repair method when properly controlled. From review of vendor experts, the controls we require in our procedure are considered very conservative. The repair record at Catawba corroborates this judgement. Catawba has used the current practice of on-line leak sealing since commercial operatioa began.in 1985. Over 300 successful repairs have been performed and only one (1) failure. The single failure was

!' attributed to an unrelated cause and was corrected.

Based on engineering and vendor reviews in addition to an

! excellent track record of successful repairs at CNS, we feel that our methodology is sound. We plan to be involved with and follow industry / vendor efforts in this area and I incorporate now methods as they develop.

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