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#REDIRECT [[IR 05000213/1997003]]
{{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
    - - y..  ..E.,y_.-.%_  .e-y -r,v,    ,,v-g.-. , , . -p.e...m.cy,-,,_m u.ww.,--n .m.    ,,...--c-.----,,... ,,,,..E.,.,,.-m.-,w-.--er ,_-w<  --
                                                                                                                                                    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

Corrected Pages for Insp Rept 50-213/97-03 on 970408-0707 & 0805
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. .

t

t

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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

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 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

__. . _ . . . _. _

. ,

.

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