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{{Adams | |||
| number = ML20199D462 | |||
| issue date = 11/07/1997 | |||
| title = Corrected Pages for Insp Rept 50-213/97-03 on 970408-0707 & 0805 | |||
| author name = | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) | |||
| addressee name = | |||
| addressee affiliation = | |||
| docket = 05000213 | |||
| license number = | |||
| contact person = | |||
| document report number = 50-213-97-03, 50-213-97-3, NUDOCS 9711200341 | |||
| package number = ML20199D451 | |||
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS | |||
| page count = 8 | |||
}} | |||
See also: [[see also::IR 05000213/1997003]] | |||
=Text= | |||
{{#Wiki_filter:- - _ - - - . - - ~ - . .. - - .---.- .. -- | |||
* | |||
I | |||
9 | |||
U.S. NUCLEAR REGULATORY COMMISSION ! | |||
REGION I l | |||
' | |||
Docket No.: 50 213 | |||
License No.: DPR 61 | |||
: | |||
Report No.: 50 213/97 03 | |||
Licensee: Connecticut Yankee Atomic Power Company | |||
P. O. Box 270 | |||
Hartford, CT 061410270 | |||
Facility: Heddam Neck Station | |||
Loc, $ ,on: - Hiddam, Connecticut | |||
' Dates: April 8 July 7,1997, and August 5,1997 _. | |||
Inspectors: William J. Raymond, Senior Resident inspector | |||
John H. cusher, Emergency Preparedness Specialist i | |||
! | |||
Approved by: Richard J. Conte, Ch'ef, Projects Branch 8 | |||
Division of Reactor Projects | |||
i | |||
; | |||
~ | |||
9711200341.971107 | |||
PDR ADOCK 05000213 | |||
8 PDR | |||
. . . - ..- - . -. .. . . . - . - .. . | |||
- _ | |||
. ; | |||
, | |||
.. | |||
; | |||
' | |||
! | |||
8 | |||
level alarms provide an indirect backup means to check the operability of the flood | |||
detection circuits. | |||
Similarly, there is only one channel to monitor total plant stack flow rate. However, i | |||
the following alarms would provide indirect methods for the operator to verify the l | |||
1 | |||
operability of the stack flow rate: PAB supply and purge air flow low, total stack , | |||
flow low, and fans not running. Any of the alarms would alert the operator to , | |||
check for problems with the PAB ventilation system, including the stack flow rate. | |||
- Finally, the following localindicators could also be used to check the operability of i | |||
the total stack flow rate: flow to the stack as measured on HIC 1101: PAB exhaust i | |||
flow per HIC 1102; containment purge flow per HIC 1103; and, waste gas exhaust | |||
flow per F11105A, t | |||
Based on the above, the inspector concluded that the licensee had alternate means j | |||
L to check the operability of stack flow rate and flood detection circuits, and that the - | |||
. | |||
.i | |||
alternate methods were suitable to meet the technical specification definition of | |||
performing channel che<:ks to the extent possible. This item is closed. | |||
08.3 (Closed) VIO 97 0102: Confiauration Control | |||
, | |||
The licensee responded to inspection 97 01 by letter dated June 6,1997 (CY 97- | |||
059), which described actions to address each deficiency noted in the inspection, | |||
and tn reduce personnel errors and improve human performance. While the licensee | |||
completed actions as specified in the June 6 submittal, the corrective actions were | |||
not effective in preventing a recurrence of operator errors while testing the diesels. ' | |||
This matter is discussed further in Section M4.1 below. NRC concerns in this area | |||
will be tracked as part of Enforcement Action (EA) 97-366. This item is closed. | |||
' | |||
l | |||
08.4 (Closed) UR!J4;27-02: Hydrazine Release | |||
J' | |||
This item was open pending the completion of an investigation of the source of the , | |||
_ | |||
hydrazine leak into the auxiliary building. The root cause investigation was ! | |||
*' | |||
completed as part of the followup to PIR 95-09, and was approved by the PORC on | |||
April 27,1995. The licensee found that the hydrazine leak occurred due to | |||
mispositioned valves from in the ventilation connection to the PAB process plenum. | |||
The cause of the mispositioned valves was not determined. There were no | |||
subsequent leaks of hydrazine during clant operations. The hydrarine originated | |||
' | |||
from the steam jet air ejector exhaust, which is no longer a source with the plant | |||
permanently shutdown. This item is closed, | |||
t | |||
08.5 (Closed) IFl 94-05-04: Service Water System lineuos | |||
; This item concerned an error in filing procedure changes in the control room, which | |||
, | |||
resulted in the completion of SUR 5.1-152 with a page missing. The corrective | |||
actions were documented in response to PIR 94 057, and included an audit of all > | |||
working copies of procedures in the control room and counseling operators to j | |||
' | |||
ensure all pages of a procedure are present when performing a task. No further | |||
similar discrepancies were subsequently noted. This item is closed. . | |||
t | |||
t | |||
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m.r,-e | |||
M J- i-.-.-.--. A - ; k n_ -- .*,.2-,--2-,---. -42 4e. __,;p %_- ,, an.. .a1.a_a_.Awh_s:2 .d_,__ ------.4 m_a - - a4__ _ . - ...m. w _- | |||
. | |||
.. | |||
14 | |||
following a postulated seismic event. Licensee actions were in progress to repair or | |||
replace the printer unit. The seismic monitoring system has a history of repetitive , | |||
maintenance problems and was difficult to maintain because of obsolete ! | |||
components. Engineering was reviewing a request to identify options upgrade the | |||
system for implementation of the nuclear island. 1 | |||
l | |||
M1.3 Conclusions for Maintenance Activities | |||
' | |||
< Plant personnel performed routine and non routine activities wellin resolving | |||
problems, including the special test of a new check valve in the SW system, the | |||
calibration of radiation effluent monitors, and troubleshooting problems in diesel fire | |||
water pump, the EG 2A shutdown circuit and the seismic monitors. Plant personnel | |||
completed routine tests of plant equipment well, recognized degraded conditions, i | |||
and initiated actions to complete troubleshooting and repairs. Good work controls | |||
were noted, including good pre-job briefs, control of tagouts, adherence to work | |||
packages and work plans. There was good coordination with and support from | |||
health physics and engineering support personnel. Workers demonstrated good | |||
skills and knowledge of systems under test or repair. The persistence of some | |||
problems remalris a csncern, such as the problems on the diesel fire pump, and the | |||
EG 2A shutdown sequence. As in the past, poor plant material conditions challenge | |||
plant operators and impede the succes'sful completion of testing. | |||
M4 Maintenance Staff Knowledge and Performance | |||
l M4.1 Emeraency Diesel Generay, Testina (EA 97-386-01023) | |||
a. insoection Scone (71707) | |||
The inspector reviewed licensee action to test emergency diesel generator EG 2A on | |||
May 21,1997. | |||
b. Observations and Findinas | |||
Following scheduled preventive maintenance on EG 2A, the licensee tested the | |||
diesel on May 21,1997 in accordance with procedures ENG 1.7114 (heat | |||
exchanger performance), PMP 9.1-31 (pre start lacking and in leakage checks), and | |||
SUR 5.1 17A (operability run). Operators operated EG 2A from the local excitation | |||
panel, which started 6:58 p.m. and ran successfully. However, the licensee did not | |||
complete the planned one hour test run. After starting the engine, a control | |||
operator identified an unusual noise and discovered that the jacking gear was still | |||
installed on the engine. The operators informed the shift manager and shutdown | |||
EG 2A. The Shift Manager responded to the scene to supervise recovery actions, | |||
and later prepared adverse condition report (ACR) 97 252 to describe the event. | |||
. The nuclear side operator (NSO) who performed PMP 9.1-31 had left the jacking | |||
' | |||
gear mechanism installed after Jacking the engine. EG 2A was jacked per steps | |||
6.1,10 through 6.1.12 of PMP 9.131, which is classified as a continuous use | |||
procedure which must be in hand during the conduct of the test and signed off as | |||
P | |||
s- -- ,rm..., - | |||
- . ,- ,-,- - m --. , - | |||
4 | |||
. | |||
15 | |||
each step is completed. Af ter installing the tool and jacking the engine, the NSO | |||
had signed step 6.1.12 as completo, indicating that the crank tool had been | |||
removed and placed on its storage bracket inside the engine room. in fact, only the | |||
electric motor portion of the tool had been stored and the gear mechanism was lef t | |||
installed on the engine. The NSO failed to notice the gear as he reinstalled the | |||
cover over the Jacking area inside the engine compartment. The NSO f ailed to | |||
complete step 6.1.10 of PMP 9.131 because of a personnel error in his failure to | |||
assure the step was completed in accordance with the procedure requirements. | |||
The licensee's investigation found damage to EG-2A, which remained unavailable | |||
for service until May 28,1997. Licensee actions to address the damage are | |||
described in Section M1.1 above (AWO 97 2028). The immediate corrective | |||
actions included: relieving the NSO from duty pending a review of the event the | |||
NSO was subsequently reassigned duties outside of operations; changed procedure | |||
PMP 9.131 (along with procedures SUR 5.1 17A, SUR 5.1-17B, NOP 2.1-16a and | |||
2.1 168) to require double verification that the jacking tool is removed prior to | |||
running a diosol generator; and, conducting a brief of the event with each operating | |||
crew. The licensee also conducted a root cause investigation of the May 21 event | |||
to identify contributing causes to the operator error. The licensee planned further | |||
actions to prevent recurrence of the event, including procedure changes to improve | |||
the clarity of the instructions to Jack the engine, and a plan to modify the jacking | |||
tool so to make it impossible to reinstall the gear ring cover with the jacking tool | |||
installed. | |||
The inspector identified no inadequacies regarding the immediate corrective actions, | |||
nor in the licensee's conclusions regarding the cause of the event. The f ailure to | |||
follow PMP 9.131 during the conduct of EG 2A testing on May 21 was a violation | |||
of Technical Specification 6.8.1 that was identified by the licensee. The May 21 | |||
event was a repeat occurrence of this problem in that a similar event occurred on | |||
November 27,1996 (ACR 961322),which was the subject of an NRC enforcement | |||
action (VIO 96 13-01). This event was another example of a recurring problem of | |||
deficiencies in worker performance during the conduct of routine activities, as noted | |||
in Inspection 9613 and 97-01. | |||
The licensee corrective actions to addrets human performance errors were in the | |||
process of development and implementation when the May 21 ovent occurred. | |||
However, the May 21 event should have been prevented by a more thorough or | |||
timely licensee review and response to the November 1996 event. The f ailure to | |||
correct a condition adverse tt quality was one of two viciations of 10 CFR 50 | |||
l Appendix B, Criterion XVI (EA 97 366-01023). Also see section E2.1. | |||
Human Performance issues Personnel Errors | |||
Several recent inspection issues (Inspection items 9613-01,97-0102) concerned | |||
the occurrence of personnel errors and the failure to follow procedures over a wide | |||
spectrum of plant activities. The licensee was requested to respond to inspection | |||
item 97-01-02 by NRC letter dated May 8,1997. Other examples of poor | |||
personnel performance were noted during the period which involved the | |||
- . .-. - -- . ..- ~ - - . ._ - . . -- | |||
. | |||
. | |||
16 | |||
performance by various plant personnel, including operators. The licensee First | |||
Quarter 1997 Trend Report (CYCA 97-014) issued on June 10,1997, found that | |||
personnel error and procedure noncompliance was the most frequent reason for- , | |||
in:tiating ACRs during the first three months of 1997 (i.e.,32 of 162 ACRs). | |||
The licensee responded to inspection 97 01 by letter dated June 6,1997 (CY 97- , | |||
058), which described actions to reduce personnel errors and improve human | |||
performance. NRC concerns regarding human performance in routine operations . | |||
and maintenance activities were discussed in a meeting with licensee management t | |||
at the NRC Regional Office on May 28,1997. The NRC concerns regarding | |||
personnel errors and procedure noncompliance remain, | |||
c. Conclusions | |||
a | |||
Poor procedural adherenco was demonstrated during a test of EG 28 on May 21, | |||
1997. Licensee corrective actions to address a similar error during a test of EG 28 | |||
in November 1996 were ineffective. The occurrence of personnel performance | |||
errors in the conduct of routine activities remains an NRC concern that warrants | |||
furtPer licensee action. | |||
* | |||
M8 Status of Previous inspection Findir gs (92902) | |||
M8,1 (Closed) VIO 98-13 01: Diesel Run with Crank Toolinstt] iga | |||
; _ This item concerned an problem on November 27,1996 when an operator failed to | |||
follow a test procedure, resulting in the operation of EG 2B with a jacking tool | |||
installed. The licensee responded to this matter by letter dated February 25,1997 | |||
to describe the corrective actions taken relative to the individual involved in the | |||
event. The licensee considered the November 27 incident to be an isolated event. | |||
During this inspection on May 21, an operator f ailed to follow a test procedure, | |||
resulting in the running of EG-2A with the jacking tool installed and damage to the | |||
EG 2A ring gear, causing the diesel to remain unavailable for service for 7 days (See | |||
Section M4.1 above). The error on May 21 was a continuation of past performance | |||
problems, and demonstrated that past licensee corrective actions were ineffective. | |||
NRC concerns regarding the correct performance of routine activities were | |||
addressed in inspection item 97-0102 and were the subject of a management | |||
meeting with the licensee on May 28,1996. Licensee action to address human | |||
l performance ssues will be tracked as part of EA 97 366. This item is closed.' | |||
M8.2 (Closed) URI 96-06-Q5: Actions to Address MIC Corrosion | |||
- This item was open pending further NRC reviev/ of licensee actions to implement | |||
the MIC mitigation program and to address degraded conditions. This area was | |||
- reviewed in inspection 97 01 and Section M1 above. Improvements were noted in " | |||
the licensee efforts to monitor MIC degraded pipe sections and to make timely | |||
operability determinations for adverse findings. The licensee began startup and - | |||
operation of the Bulaab injection system to rnitigate the MIC problem. The licensee | |||
, | |||
e | |||
v me-- yr v vy - - +e. | |||
' | |||
M | |||
. . . - - . - - - . . . . , . .. - . . - . | |||
, | |||
, | |||
. | |||
' | |||
, | |||
19 | |||
requirements of ENG 1.7-156. The inspector concurred with the licensee's | |||
deten..inations that no unreviewed safety questions were created by the changes to - , | |||
the f acility as described in the UFSAR. | |||
c.- Conclusions | |||
- | |||
Engineering provided timely and effective support to plant operations through the | |||
development and implementstion of ENG 1.7156 to assist in the smooth | |||
transitioning to the decommissioning mode. | |||
E2 Engineering Support of Facilities and Equipment | |||
i E2.1. Service Water System Waterhammer (EA 97-366-01013) | |||
: | |||
a. Insaection Scoce (37551) | |||
The purpose of this inspection was to review the licensee evaluations and resolution | |||
of potential two phase flow problems in the service water (SW) system, and to | |||
complete modifications to preclude postulated waterhammer events, | |||
b. Observation and Findirias | |||
in February 1997, inspection 97 01 provided the NRC review of licensee actions to | |||
address potential waterhammer in the SW cooling lines to the SFPCS. Actions were | |||
completed during this period to prevent water hammer by the installation of a check | |||
valve in th, common SW supply line to the SFPCS, Check Valve SW-CV 963 and | |||
associated ust connections were installed and demonstrated to be operable per | |||
design change request DCR 97-002. The safety and technical evaluations for DCR | |||
97-002 showed that waterhammer would be prevented as long as water leakage | |||
back through SW CV 963 was less than 2 gpm during the 45 second period | |||
following a loss of normal power (LN.') event while the emergency diesels started. | |||
The check valve leakage was measured at much less that 2 gpm. | |||
Inspection item 97 01-07 was open pending actions to resola the design | |||
discrepancy, complete a review of the causes, and make a report under 50.73. LER | |||
97 07 dated April 23,1997 reported the event and provided the licensee's | |||
assessment of the significance of the uncorrected design discrepancy. The licensee | |||
reported the discrepancy per 50.73(a)(ii)B and (a)(i)B as operation outside the | |||
design basis and a condition prchibited by the technical specifications. | |||
A delay in resolving this technical issue occurred from the time the issue was | |||
identified to the engineering staff rm August 14,1996 (upon receipt of Report TM- | |||
1788a) until the development of an appropriate operability and reportability | |||
evaluation in March 1997 following NRC review of the matter. The licensee's root | |||
cause investigation was completed on April 16,1997. The causes for the untimely | |||
_ | |||
followup included assigning the work as a low priority, weaknesses in the CAP | |||
(issue tracking), and poor control of work turnover during the period of staff | |||
instability after the decision to decommission the plant, | |||
s | |||
-m - r _ - | |||
, | |||
. | |||
20 | |||
Following the identification of the design discrepancy in February 1997, the licensee | |||
took timely and appropriate corrective actions to review other NRC open issues and | |||
engineering department open Action Requests. This review showed that no other | |||
safety significant discrepancies were had been overlooked during the transition in | |||
station staff. As shown in the key performance indicators for engineering, progress | |||
has been made to reduce the backlog of open engineering work (the backlog | |||
reduced from greater than 200 to less than 100 items in July 1997). | |||
CY concluded from an engineering assessment that the SW cooling lines to the | |||
SFPCS could not be shown to remain operable under the postulated design basis | |||
transient (LNP). The safety significance of the event was deemed to be low based | |||
on the low (current) decay heat rate in the SFP (1.5 f/hr) and the tima available to | |||
implement compensatory measures (34 hours) prior to reaching 150 degrees. The | |||
LER safety assessment addressed the present heat load. This matter was discussed | |||
with the licensee, who stated that it was expected that the analysis in License | |||
Amendment #188 for totalloss of SFP cooling under worst case heat load | |||
conditions was bounding for the postulated f ailure. During the exit meeting on July | |||
15, the Site Director stated that an LER supplement would be issued to addrest, this | |||
assessment. | |||
This original design deficiency resulted in the SFPCS being inoperable under certain | |||
conditions, and resulted in plant operation contrary to TS 3.9.15. However, the | |||
delay from August 1996, resulted in operation with the deficiency during the full | |||
core offload in November 1996. The untimely licensee response was a violation | |||
l (second of two) of 10 CFR 50, Appendix B, Criterion XVI (EA 97 366-01013).(See | |||
section M4.1) | |||
CY initiated an ACR to address the problem of delay on these corrective actions. | |||
The ACR root cause analysis produced adequate corrective actions for the following | |||
underlying problems: 1) the department engineering supervisor's failure to follow | |||
administrative control procedure for ACR by not writing an ACR when the issue | |||
came in the summer of 1996; 2) the previous action tracking system not effective | |||
in that the specific task assignment for this problem was never acknowledged (for | |||
unknown reasons) and the process was cumbersome to use. This analysis also | |||
noted that the department supervisor's staff turnover (leaving the organization due | |||
to decommissioning status of the plant) was not effective in assuring the issue was | |||
properly resolved in a timely manner. However, the ACR does not address | |||
corrective actions related to the staff turnover problem, | |||
c, .Qonclusions | |||
Ergineering support was effective this period to complete evaluations in support of | |||
a design change to eliminate the potential for waterhammer in the SW system, and | |||
to complete corrective actions once the design discrepancy was realized. Past | |||
engineering support was poor resulting in inadequate control of the plant design. | |||
The f ailura to complete timely operability and reportability evaluations following | |||
discovery of the technicalissue in August,1996 was an example of a violation of | |||
regulatory requirements. The related ACR thoroughly identified underlying causes | |||
__. . _ . . . _. _ | |||
. , | |||
. | |||
51 | |||
INSPECTION PROCEDURES USED | |||
IP 40500: . Effectiveness of Licensee Controls in identifying, Resolving, and Preventing | |||
Problems . | |||
* | |||
IP 62703: Maintenance Observation | |||
IP 64704: Fire Protec'Sn Program | |||
IP 71707: Plant Operations | |||
IP 73051: Inservice inspection Review of Program | |||
IP 73753: Inservice inspection | |||
IP 93729: Occupational Exposure During Extended Outages | |||
IP 83750: Occupational Exposure | |||
-IP 92700: Onsite Followup of Written Reports of Nonroutine Events at Power Reactor | |||
Facilities | |||
IP 92902: Followup - Engineering - | |||
IP 92903: Followup - Maintenance | |||
IP 92904: Followup - Plant Support | |||
IP 93702: Prompt Onsite Response to Events at Operating Power Reactors | |||
ITEMS OPEN, CLOSED, AND DISCUSSED | |||
Ooened | |||
l 97 366 EA Inadequate Corrective Action - EDG Testing (01023), | |||
l SW Water Hammer (01013) | |||
l 97-03-04 URI Degraded SFP Heat Exchanger Performance - TS Change | |||
97-03-05 URI Degraded SFP Heat Exchanger Performance - Corrective Action | |||
Closed - New | |||
97-03-01 NCV inadequate SFP Procedure | |||
97 03-02 NCV Failure to Maintain PORC Composition | |||
97 03-06 NCV Inadequate NPSH for SFP Cooling Pumps | |||
97-03-07 NCV Inadequate Safety Evaluation - Operator Action | |||
Closed - Previoua | |||
95-27-02 IFl RCS Leak Rate Determinations | |||
95 27-01 IFl Daily Technical Specification Channel Checks | |||
97-01-02 VIO Configuration Control | |||
94-27 02- URI Hydrazine Release | |||
94-05 04 IFl Service Water System Lineups | |||
95-02-02 ' lFI | |||
. Diesel Tagging Error Causes Flood | |||
96-13-01 VIO Diesel Run with Crank Tool Installed | |||
96-06-05 URI Actions to Address MIC Corrosion | |||
94-21-01 LER Reactor Shutdown Due to IRPl inaccuracies | |||
96-14-01 LER High inverter Temperatures | |||
96-17 LER Main Stack Sample Performed Late | |||
}} |
Latest revision as of 05:36, 15 December 2020
ML20199D462 | |
Person / Time | |
---|---|
Site: | Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png |
Issue date: | 11/07/1997 |
From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
To: | |
Shared Package | |
ML20199D451 | List: |
References | |
50-213-97-03, 50-213-97-3, NUDOCS 9711200341 | |
Download: ML20199D462 (8) | |
See also: IR 05000213/1997003
Text
- - _ - - - . - - ~ - . .. - - .---.- .. --
I
9
U.S. NUCLEAR REGULATORY COMMISSION !
REGION I l
'
Docket No.: 50 213
License No.: DPR 61
Report No.: 50 213/97 03
Licensee: Connecticut Yankee Atomic Power Company
P. O. Box 270
Hartford, CT 061410270
Facility: Heddam Neck Station
Loc, $ ,on: - Hiddam, Connecticut
' Dates: April 8 July 7,1997, and August 5,1997 _.
Inspectors: William J. Raymond, Senior Resident inspector
John H. cusher, Emergency Preparedness Specialist i
!
Approved by: Richard J. Conte, Ch'ef, Projects Branch 8
Division of Reactor Projects
i
~
9711200341.971107
PDR ADOCK 05000213
8 PDR
. . . - ..- - . -. .. . . . - . - .. .
- _
. ;
,
..
'
!
8
level alarms provide an indirect backup means to check the operability of the flood
detection circuits.
Similarly, there is only one channel to monitor total plant stack flow rate. However, i
the following alarms would provide indirect methods for the operator to verify the l
1
operability of the stack flow rate: PAB supply and purge air flow low, total stack ,
flow low, and fans not running. Any of the alarms would alert the operator to ,
check for problems with the PAB ventilation system, including the stack flow rate.
- Finally, the following localindicators could also be used to check the operability of i
the total stack flow rate: flow to the stack as measured on HIC 1101: PAB exhaust i
flow per HIC 1102; containment purge flow per HIC 1103; and, waste gas exhaust
flow per F11105A, t
Based on the above, the inspector concluded that the licensee had alternate means j
L to check the operability of stack flow rate and flood detection circuits, and that the -
.
.i
alternate methods were suitable to meet the technical specification definition of
performing channel che<:ks to the extent possible. This item is closed.
08.3 (Closed) VIO 97 0102: Confiauration Control
,
The licensee responded to inspection 97 01 by letter dated June 6,1997 (CY 97-
059), which described actions to address each deficiency noted in the inspection,
and tn reduce personnel errors and improve human performance. While the licensee
completed actions as specified in the June 6 submittal, the corrective actions were
not effective in preventing a recurrence of operator errors while testing the diesels. '
This matter is discussed further in Section M4.1 below. NRC concerns in this area
will be tracked as part of Enforcement Action (EA)97-366. This item is closed.
'
l
08.4 (Closed) UR!J4;27-02: Hydrazine Release
J'
This item was open pending the completion of an investigation of the source of the ,
_
hydrazine leak into the auxiliary building. The root cause investigation was !
- '
completed as part of the followup to PIR 95-09, and was approved by the PORC on
April 27,1995. The licensee found that the hydrazine leak occurred due to
mispositioned valves from in the ventilation connection to the PAB process plenum.
The cause of the mispositioned valves was not determined. There were no
subsequent leaks of hydrazine during clant operations. The hydrarine originated
'
from the steam jet air ejector exhaust, which is no longer a source with the plant
permanently shutdown. This item is closed,
t
08.5 (Closed) IFl 94-05-04: Service Water System lineuos
- This item concerned an error in filing procedure changes in the control room, which
,
resulted in the completion of SUR 5.1-152 with a page missing. The corrective
actions were documented in response to PIR 94 057, and included an audit of all >
working copies of procedures in the control room and counseling operators to j
'
ensure all pages of a procedure are present when performing a task. No further
similar discrepancies were subsequently noted. This item is closed. .
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14
following a postulated seismic event. Licensee actions were in progress to repair or
replace the printer unit. The seismic monitoring system has a history of repetitive ,
maintenance problems and was difficult to maintain because of obsolete !
components. Engineering was reviewing a request to identify options upgrade the
system for implementation of the nuclear island. 1
l
M1.3 Conclusions for Maintenance Activities
'
< Plant personnel performed routine and non routine activities wellin resolving
problems, including the special test of a new check valve in the SW system, the
calibration of radiation effluent monitors, and troubleshooting problems in diesel fire
water pump, the EG 2A shutdown circuit and the seismic monitors. Plant personnel
completed routine tests of plant equipment well, recognized degraded conditions, i
and initiated actions to complete troubleshooting and repairs. Good work controls
were noted, including good pre-job briefs, control of tagouts, adherence to work
packages and work plans. There was good coordination with and support from
health physics and engineering support personnel. Workers demonstrated good
skills and knowledge of systems under test or repair. The persistence of some
problems remalris a csncern, such as the problems on the diesel fire pump, and the
EG 2A shutdown sequence. As in the past, poor plant material conditions challenge
plant operators and impede the succes'sful completion of testing.
M4 Maintenance Staff Knowledge and Performance
l M4.1 Emeraency Diesel Generay, Testina (EA 97-386-01023)
a. insoection Scone (71707)
The inspector reviewed licensee action to test emergency diesel generator EG 2A on
May 21,1997.
b. Observations and Findinas
Following scheduled preventive maintenance on EG 2A, the licensee tested the
diesel on May 21,1997 in accordance with procedures ENG 1.7114 (heat
exchanger performance), PMP 9.1-31 (pre start lacking and in leakage checks), and
SUR 5.1 17A (operability run). Operators operated EG 2A from the local excitation
panel, which started 6:58 p.m. and ran successfully. However, the licensee did not
complete the planned one hour test run. After starting the engine, a control
operator identified an unusual noise and discovered that the jacking gear was still
installed on the engine. The operators informed the shift manager and shutdown
EG 2A. The Shift Manager responded to the scene to supervise recovery actions,
and later prepared adverse condition report (ACR) 97 252 to describe the event.
. The nuclear side operator (NSO) who performed PMP 9.1-31 had left the jacking
'
gear mechanism installed after Jacking the engine. EG 2A was jacked per steps
6.1,10 through 6.1.12 of PMP 9.131, which is classified as a continuous use
procedure which must be in hand during the conduct of the test and signed off as
P
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4
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15
each step is completed. Af ter installing the tool and jacking the engine, the NSO
had signed step 6.1.12 as completo, indicating that the crank tool had been
removed and placed on its storage bracket inside the engine room. in fact, only the
electric motor portion of the tool had been stored and the gear mechanism was lef t
installed on the engine. The NSO failed to notice the gear as he reinstalled the
cover over the Jacking area inside the engine compartment. The NSO f ailed to
complete step 6.1.10 of PMP 9.131 because of a personnel error in his failure to
assure the step was completed in accordance with the procedure requirements.
The licensee's investigation found damage to EG-2A, which remained unavailable
for service until May 28,1997. Licensee actions to address the damage are
described in Section M1.1 above (AWO 97 2028). The immediate corrective
actions included: relieving the NSO from duty pending a review of the event the
NSO was subsequently reassigned duties outside of operations; changed procedure
PMP 9.131 (along with procedures SUR 5.1 17A, SUR 5.1-17B, NOP 2.1-16a and
2.1 168) to require double verification that the jacking tool is removed prior to
running a diosol generator; and, conducting a brief of the event with each operating
crew. The licensee also conducted a root cause investigation of the May 21 event
to identify contributing causes to the operator error. The licensee planned further
actions to prevent recurrence of the event, including procedure changes to improve
the clarity of the instructions to Jack the engine, and a plan to modify the jacking
tool so to make it impossible to reinstall the gear ring cover with the jacking tool
installed.
The inspector identified no inadequacies regarding the immediate corrective actions,
nor in the licensee's conclusions regarding the cause of the event. The f ailure to
follow PMP 9.131 during the conduct of EG 2A testing on May 21 was a violation
of Technical Specification 6.8.1 that was identified by the licensee. The May 21
event was a repeat occurrence of this problem in that a similar event occurred on
November 27,1996 (ACR 961322),which was the subject of an NRC enforcement
action (VIO 96 13-01). This event was another example of a recurring problem of
deficiencies in worker performance during the conduct of routine activities, as noted
in Inspection 9613 and 97-01.
The licensee corrective actions to addrets human performance errors were in the
process of development and implementation when the May 21 ovent occurred.
However, the May 21 event should have been prevented by a more thorough or
timely licensee review and response to the November 1996 event. The f ailure to
correct a condition adverse tt quality was one of two viciations of 10 CFR 50
l Appendix B, Criterion XVI (EA 97 366-01023). Also see section E2.1.
Human Performance issues Personnel Errors
Several recent inspection issues (Inspection items 9613-01,97-0102) concerned
the occurrence of personnel errors and the failure to follow procedures over a wide
spectrum of plant activities. The licensee was requested to respond to inspection
item 97-01-02 by NRC letter dated May 8,1997. Other examples of poor
personnel performance were noted during the period which involved the
- . .-. - -- . ..- ~ - - . ._ - . . --
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16
performance by various plant personnel, including operators. The licensee First
Quarter 1997 Trend Report (CYCA 97-014) issued on June 10,1997, found that
personnel error and procedure noncompliance was the most frequent reason for- ,
in:tiating ACRs during the first three months of 1997 (i.e.,32 of 162 ACRs).
The licensee responded to inspection 97 01 by letter dated June 6,1997 (CY 97- ,
058), which described actions to reduce personnel errors and improve human
performance. NRC concerns regarding human performance in routine operations .
and maintenance activities were discussed in a meeting with licensee management t
at the NRC Regional Office on May 28,1997. The NRC concerns regarding
personnel errors and procedure noncompliance remain,
c. Conclusions
a
Poor procedural adherenco was demonstrated during a test of EG 28 on May 21,
1997. Licensee corrective actions to address a similar error during a test of EG 28
in November 1996 were ineffective. The occurrence of personnel performance
errors in the conduct of routine activities remains an NRC concern that warrants
furtPer licensee action.
M8 Status of Previous inspection Findir gs (92902)
M8,1 (Closed) VIO 98-13 01: Diesel Run with Crank Toolinstt] iga
- _ This item concerned an problem on November 27,1996 when an operator failed to
follow a test procedure, resulting in the operation of EG 2B with a jacking tool
installed. The licensee responded to this matter by letter dated February 25,1997
to describe the corrective actions taken relative to the individual involved in the
event. The licensee considered the November 27 incident to be an isolated event.
During this inspection on May 21, an operator f ailed to follow a test procedure,
resulting in the running of EG-2A with the jacking tool installed and damage to the
EG 2A ring gear, causing the diesel to remain unavailable for service for 7 days (See
Section M4.1 above). The error on May 21 was a continuation of past performance
problems, and demonstrated that past licensee corrective actions were ineffective.
NRC concerns regarding the correct performance of routine activities were
addressed in inspection item 97-0102 and were the subject of a management
meeting with the licensee on May 28,1996. Licensee action to address human
l performance ssues will be tracked as part of EA 97 366. This item is closed.'
M8.2 (Closed) URI 96-06-Q5: Actions to Address MIC Corrosion
- This item was open pending further NRC reviev/ of licensee actions to implement
the MIC mitigation program and to address degraded conditions. This area was
- reviewed in inspection 97 01 and Section M1 above. Improvements were noted in "
the licensee efforts to monitor MIC degraded pipe sections and to make timely
operability determinations for adverse findings. The licensee began startup and -
operation of the Bulaab injection system to rnitigate the MIC problem. The licensee
,
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requirements of ENG 1.7-156. The inspector concurred with the licensee's
deten..inations that no unreviewed safety questions were created by the changes to - ,
the f acility as described in the UFSAR.
c.- Conclusions
-
Engineering provided timely and effective support to plant operations through the
development and implementstion of ENG 1.7156 to assist in the smooth
transitioning to the decommissioning mode.
E2 Engineering Support of Facilities and Equipment
i E2.1. Service Water System Waterhammer (EA 97-366-01013)
a. Insaection Scoce (37551)
The purpose of this inspection was to review the licensee evaluations and resolution
of potential two phase flow problems in the service water (SW) system, and to
complete modifications to preclude postulated waterhammer events,
b. Observation and Findirias
in February 1997, inspection 97 01 provided the NRC review of licensee actions to
address potential waterhammer in the SW cooling lines to the SFPCS. Actions were
completed during this period to prevent water hammer by the installation of a check
valve in th, common SW supply line to the SFPCS, Check Valve SW-CV 963 and
associated ust connections were installed and demonstrated to be operable per
design change request DCR 97-002. The safety and technical evaluations for DCR
97-002 showed that waterhammer would be prevented as long as water leakage
back through SW CV 963 was less than 2 gpm during the 45 second period
following a loss of normal power (LN.') event while the emergency diesels started.
The check valve leakage was measured at much less that 2 gpm.
Inspection item 97 01-07 was open pending actions to resola the design
discrepancy, complete a review of the causes, and make a report under 50.73. LER
97 07 dated April 23,1997 reported the event and provided the licensee's
assessment of the significance of the uncorrected design discrepancy. The licensee
reported the discrepancy per 50.73(a)(ii)B and (a)(i)B as operation outside the
design basis and a condition prchibited by the technical specifications.
A delay in resolving this technical issue occurred from the time the issue was
identified to the engineering staff rm August 14,1996 (upon receipt of Report TM-
1788a) until the development of an appropriate operability and reportability
evaluation in March 1997 following NRC review of the matter. The licensee's root
cause investigation was completed on April 16,1997. The causes for the untimely
_
followup included assigning the work as a low priority, weaknesses in the CAP
(issue tracking), and poor control of work turnover during the period of staff
instability after the decision to decommission the plant,
s
-m - r _ -
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20
Following the identification of the design discrepancy in February 1997, the licensee
took timely and appropriate corrective actions to review other NRC open issues and
engineering department open Action Requests. This review showed that no other
safety significant discrepancies were had been overlooked during the transition in
station staff. As shown in the key performance indicators for engineering, progress
has been made to reduce the backlog of open engineering work (the backlog
reduced from greater than 200 to less than 100 items in July 1997).
CY concluded from an engineering assessment that the SW cooling lines to the
SFPCS could not be shown to remain operable under the postulated design basis
transient (LNP). The safety significance of the event was deemed to be low based
on the low (current) decay heat rate in the SFP (1.5 f/hr) and the tima available to
implement compensatory measures (34 hours3.935185e-4 days <br />0.00944 hours <br />5.621693e-5 weeks <br />1.2937e-5 months <br />) prior to reaching 150 degrees. The
LER safety assessment addressed the present heat load. This matter was discussed
with the licensee, who stated that it was expected that the analysis in License
Amendment #188 for totalloss of SFP cooling under worst case heat load
conditions was bounding for the postulated f ailure. During the exit meeting on July
15, the Site Director stated that an LER supplement would be issued to addrest, this
assessment.
This original design deficiency resulted in the SFPCS being inoperable under certain
conditions, and resulted in plant operation contrary to TS 3.9.15. However, the
delay from August 1996, resulted in operation with the deficiency during the full
core offload in November 1996. The untimely licensee response was a violation
l (second of two) of 10 CFR 50, Appendix B, Criterion XVI (EA 97 366-01013).(See
section M4.1)
CY initiated an ACR to address the problem of delay on these corrective actions.
The ACR root cause analysis produced adequate corrective actions for the following
underlying problems: 1) the department engineering supervisor's failure to follow
administrative control procedure for ACR by not writing an ACR when the issue
came in the summer of 1996; 2) the previous action tracking system not effective
in that the specific task assignment for this problem was never acknowledged (for
unknown reasons) and the process was cumbersome to use. This analysis also
noted that the department supervisor's staff turnover (leaving the organization due
to decommissioning status of the plant) was not effective in assuring the issue was
properly resolved in a timely manner. However, the ACR does not address
corrective actions related to the staff turnover problem,
c, .Qonclusions
Ergineering support was effective this period to complete evaluations in support of
a design change to eliminate the potential for waterhammer in the SW system, and
to complete corrective actions once the design discrepancy was realized. Past
engineering support was poor resulting in inadequate control of the plant design.
The f ailura to complete timely operability and reportability evaluations following
discovery of the technicalissue in August,1996 was an example of a violation of
regulatory requirements. The related ACR thoroughly identified underlying causes
__. . _ . . . _. _
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51
INSPECTION PROCEDURES USED
IP 40500: . Effectiveness of Licensee Controls in identifying, Resolving, and Preventing
Problems .
IP 62703: Maintenance Observation
IP 64704: Fire Protec'Sn Program
IP 71707: Plant Operations
IP 73051: Inservice inspection Review of Program
IP 73753: Inservice inspection
IP 93729: Occupational Exposure During Extended Outages
IP 83750: Occupational Exposure
-IP 92700: Onsite Followup of Written Reports of Nonroutine Events at Power Reactor
Facilities
IP 92902: Followup - Engineering -
IP 92903: Followup - Maintenance
IP 92904: Followup - Plant Support
IP 93702: Prompt Onsite Response to Events at Operating Power Reactors
ITEMS OPEN, CLOSED, AND DISCUSSED
Ooened
l 97 366 EA Inadequate Corrective Action - EDG Testing (01023),
l SW Water Hammer (01013)
l 97-03-04 URI Degraded SFP Heat Exchanger Performance - TS Change
97-03-05 URI Degraded SFP Heat Exchanger Performance - Corrective Action
Closed - New
97-03-01 NCV inadequate SFP Procedure
97 03-02 NCV Failure to Maintain PORC Composition
97 03-06 NCV Inadequate NPSH for SFP Cooling Pumps
97-03-07 NCV Inadequate Safety Evaluation - Operator Action
Closed - Previoua
95-27-02 IFl RCS Leak Rate Determinations
95 27-01 IFl Daily Technical Specification Channel Checks
97-01-02 VIO Configuration Control
94-27 02- URI Hydrazine Release
94-05 04 IFl Service Water System Lineups
95-02-02 ' lFI
. Diesel Tagging Error Causes Flood
96-13-01 VIO Diesel Run with Crank Tool Installed
96-06-05 URI Actions to Address MIC Corrosion
94-21-01 LER Reactor Shutdown Due to IRPl inaccuracies
96-14-01 LER High inverter Temperatures
96-17 LER Main Stack Sample Performed Late