IR 05000344/1989005: Difference between revisions

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{{Adams
{{Adams
| number = ML20246D896
| number = ML20247Q976
| issue date = 04/19/1989
| issue date = 06/01/1989
| title = Insp Rept 50-344/89-05 on 890212-0325.Violations Noted.Major Areas Inspected:Safety Verification,Maint,Surveillance,Event Followup,Design Engineering & Open Item Followup
| title = Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-344/89-05
| author name = Barr R, Mendonca M, Obrien J, Suh G, Wagner W
| author name = Mendonca M
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
| addressee name =  
| addressee name = Cockfield D
| addressee affiliation =  
| addressee affiliation = PORTLAND GENERAL ELECTRIC CO.
| docket = 05000344
| docket = 05000344
| license number =  
| license number =  
| contact person =  
| contact person =  
| document report number = 50-344-89-05, 50-344-89-5, NUDOCS 8905110081
| document report number = NUDOCS 8906070101
| package number = ML20246D887
| title reference date = 05-19-1989
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| document type = CORRESPONDENCE-LETTERS, NRC TO UTILITY, OUTGOING CORRESPONDENCE
| page count = 26
| page count = 1
}}
}}


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,    .U.:.S. NUCLEAR REGULATORY COMMISSION
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      ' REGION V
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   > Docket' No. ; 50-344 t
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  . Report N y 50-344/89-0 ] Docket'No.-
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  - Licensee':  Portland General. Electric Company  "
121.S.W. Salmon Street r    Portland, OR 9720 ,
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Facility Name: Trojan
  . Inspection at: Rainier, Oregon Inspection conducted:  February 12 - March 25, 1989 Inspectors:  % In t ^  I //P h f R. C. Barr  (/  Date Signed-
     . Senior. Resident Inspector--
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Y. Suh
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r  Yhf/Py Date-Signed Resident Inspector n %  %-  '~ f  V//f//)
J. P. O'Brien-   Date Signed Reactor Project Inspector-  [
W.,7f Wagner // '
hm1W  .#YffF37 0#te 5(gned R Mctor Inspedtor Approved By:
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M. M. Mendonca, Chief    .Date Signed ~
Reactor Projects Section 1 Summary; Inspection on February 12 - March 25, 1989 (Report 50-344/89-05)
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. Areas Inspected; Routine' inspection of operational safety verificatio f  maintenance, surveillance, event follow-up, design engineering, and open item follow-up. Inspection procedures 30702,~30703, 37200, 37702, 38703, 61726, 62703, 71707, 90712, 92700,'92701 and 93702 were used as guidance during the conduct of the inspection.
 
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    -2-Results: This inspection identified six violations of NRC requirement Paragraph 3 discusses log keeping practices including the failure to log an entry into containment while at powe Paragraph 6 discusses inadequate work instructions of a maintenance request for calibrating reactor plant control instrument Paragraph 6 also discusses the requirements set forth in Regulatory Guide 1.33 for calibration procedures for each instrument covered by Technical Specification Paragraph 6 also discusses the need for supervisors to conduct detailed pre-work briefing, particularly when work scope or work plans chang Paragraph 7 discusses an instance where the reporting requirements of 10 CFR 50.73 for a 30 day Licensee Event Report was exceede Paragraph 10 discusses the failure to follow procedural requirements in the
  . control of top tier drawing ' Paragraph 11 discusses the failure to follow QA procedures for processing a Non-Conformance Report (NCR) that allowed non-conforming weld filler material to be used, and inadequate documentation of its us The subjects of these violations, quality of Maintenance work instructions, procedural compliance and detailed supervisory and management involvement with routine activities and off-normal events has our heightened concer There appears to be a reluctance by both line and quality reviewers to challenge low quality work instruction Additionally Managements' actions and follow-up for improving the quality of work instructions, as exemplified by the steam generator water level transient event, has been only partially effectiv As a result of recent events, the licensee has taken action to lower the threshold for when and how soon critiques will be held following off-normal event _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - -
 
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e          3 DETAILS
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, Persons Contacted
  +*D. W. Cockfield, Vice President, Nuclear
  +*C. P. Yundt, Plant General Manager
  +*T. D. Walt, General Manager, Technical Functions
  + L. W.-Erickson, Manager,. Nuclear Quality Assurance
  * R. P. Schmitt, Manager, Operations and Maintenance        ,
  +*D. W. Swan, Manager, Technical Services
  *A. N. Roller, Manager, Nuclear Plant Engineering M. J. Singh, Manager, Plant Modifications J. D. Reid, Manager, Plant Services
  *J. W. Lentsch, Manager, Personnel Protection
  *J. M. Anderson, Manager, Material Services M. D. Gatlin, Warehouse Supervisor
  *A. R. Ankrum, Manager, Nuclear Security
  +*M. R. Snook, Manager, Quality Support Services R. E. Susee, Manager, Planning and Scheduling D. F. . Levin, Supervisor, Plant Modifications E. A. Curtis, Procurement Supervisor
  *A. M. Puzey, Office Supervisor P. A. Morton, Branch. Manager, Plant Systems Engineering R. L. Russell, Operations Supervisor R. H. Budzeck, Assistant Operations Supervisor D. L. Bennett, Maintenance Supervisor R. A. Reinart, Instrument and Control Supervisor T. O. Meek, Radiation Protection Supervisor R. W. Ritschard, Security Supervisor
  + C. H. Brown, Operations Branch Manager, Quality Assurance
  * D. L. Nordstrom, Nuclear. Engineer, Nuclear Safety and Regulation
  + D. Wheeler, Quality Inspection Branch Manager
  + R. Prewitt, Quality Systems Supervisor
  + G. A. Zimmerman, Manager NSRD
  + 0. A. Desmarais, Mechanical Engineer, NPE
  + S. A. Bauer, Manager, Nuclear Regulation Branch
  + J. Carter, Metallur0 i st, NPE
  + M. Hoffman, Manager, Mechanical Branch, WPE
  + A. Ciapanno, Welding Engineer / Specialist The inspectors also interviewed and talked with other licensee employees during the course of the inspection. These included shift supervisors, reactor and auxiliary operators, maintenance personnel, plant technicians, engineers, and quality assurance personne ,
  + Denotes those attending the exit interview on March 9, 198 * Denotes those attending the exit interview on March 23, 198 . Elant Status The plant operated at 100% power from February 12 through February 24, 1989. From 8:05 a.m. February 25,1989 to 5:16 a.m. February 26, 1989,
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  . Portland' General / Electric Company
 
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121lSW Salmon' Street', TB-17
 
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  . Portland, Oregon 97204,
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  , iAttention: 'Mr.- David'W..Cockfield


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14    Vic6 President, Nuclear p,     .
i power was reduced to 55% to repair a circulating water to main condenser leak. On March 4,1989, with the reactor at 100% power, a water level transient occurred in all steam generators as a result of attempting an instrument calibration tnat could only be performed while shutdow Due to a higher than normal containment atmosphere activity, on March 9, 1989, with the reactor at 100% power, a containment entry was made to isolate an apparent leaking valve in the pressurizer vapor space sampling line. On March 25, 1989, the end of the inspection period, the reactor was at 100% power with the licensee preparing for the 1989 Refueling
s e Gentlemen:
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Outage that is scheduled to begin on April 6, 198 . Operational Safety Verification (71707)
Thank!you for your. letter ' dated May 19, 1989, in* response to our Notice'of Violation and   50-344/89-05,. dated April 19, 1989,
During this inspection period, the inspectors observed and examined activities to verify the operational safety of the licensee's facilit The observations and examinations of those activities were conducted on a daily, weekly or biweekly basi Daily, the inspectors observed control room activities to verify the licensee's adherence to limiting conditions for operation as prescribed in the facility Technical Specifications. Logs, instrumentation, recorder traces, and other operational records were examined to obtain information on plant conditions, trends, and compliance with regulation On occasions when a shift turnover was in progress, the turnover of information on plant status was observed to determine that pertinent information was relayed to the oncoming shift personne The inspectors identified that the containment entry of March 9,1989, was not recorded in the control operator lo The containment entry was logged in the Shift Supervisors log; however, neither the time nor duration of the entry was recorded. Further inspection identified that
"  informing'usfoInspection f the' steps Report you have No.taken to correct-the''-items which we brought
) the administrative procedure that establishes the requirements for containment entries, A0-3-11, " Containment Access, Integrity, Evaluation, and Inspections", Revision 21, dated January 12, 1989, was followed. The inspectors noted A0-3-11 did not require logging the entry of containment; however, Administrative Procedure, A0-3-6, " Conduct of Operations", Revision 17, dated March 3, 1988, section II.C.7. states for control operator logs that " Log entries shall include but not be limited to: ... Maintenance Activities that affect operations..." and " Performances of special inspections or checks (overspeed trips, oil filters, etc.)." The entry into containment while at power to perform maintenance and inspections clearly falls into these categories because reactor operations are restricted so as not to change reactivity and power, and the entry was to conduct a special inspectica and, if necessary, corrective maintenance. The inspectors concluded that the containment entry should have been logged in accordance with A0-3- This was identified to the licensee as an apparent Severity Level V violation (50-344/89-05-01). The inspectors also noted that frequently the control room log continues to be maintained on scratch paper for approximately an entire shift and then be transcribed to the legal record near the end of the shif This is contrary to the industry accepted standard that log entries should be made promptly. This practice had previously been discussed with licensee management. Operations Management acknowledged the inspector's findings and committed to provide
  .to.your. attention. .Your corrective actions;will be verified during af future
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Your cooperation with us isOppreciated.
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L additional guidance to the operating crews by clarifying A0-3-11 to h include the requirement to log all at power containment entrie f Additionally, the licensee conducted an evaluation of log keeping
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practices against the industry standard and is evaluating the need for further corrective actio 'l Each week the inspectors toured the accessible areas of the facility to observe the following items:
  (a) General' plant and equipment condition (b) Maintenance requests and repair (c) Fire hazards and fire fighting equipmen (d) Ignition sourcesJand flammable material contro (e) Conduct of activities in accordance with the licensee's administrative controls and approved procedure (f) Interiors of electrical and control panel (g) Implementation of +.he licensee's physical security plu (h) Radiation protection control <
  (i) Plant housekeeping and cleanlines ,
  (j) Radioactive waste system (k)= Proper storage of compressed gas bottle Weekly, the inspectors examined the licensee's equipment clearance control with respect to removal of equipment from service to determine that the licensee complied with technical specification limiting conditions for operatio Active clearances were spot-checked to ensure, *
that their issuance was consistent with plant status and maintenance evolutions. Logs of jumpers, bypasses, caution and test tags were examined by the irispector Each week the inspectors conversed with operators in the control room, and with other plant personne The discussions centered on pertinent topics relating to general plant conditions, procedures, security, training and other topics related to in progress work activitie s The inspectors examined the licensee's nonconformance reports (NCRs) to confirm that deficiencies were identified and tracked by the system and that these nonconformances were being tracked and followed to the completion of corrective actio Further details are provided in paragraph 1 ,
Routine inspections of the licensee's physical security program were performed in the areas of access control, organization and staffing, and detection and assessment system The inspectors observed the access control measures used at the entrance to the protected area, verified the integrity of portions of the protected area barrier and vital area barriers, and observed in several instances the implementation of compensatory measures upon breach of vital area barrier The inspectors noted that the licensee installed new monitors for detecting explosive materials. Portions of the isolation zone were verified to be free of obstructions. Functioning of central and secondary alarm stations (including the use of CCTV monitors) was observed. On a sampling basis, the inspectors verified that the required minimum number of armed guards and individuals authorized to direct security activities were on sit .
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:s The inspectors conducted routine inspections of selected activities of the. licensee's radiological protection progra A sampling of. radiation work permits'(RWP) was reviewed for completeness and adequacy of
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' . 4 information. During the course of inspection activities and periodic tours of plant areas, the inspectors verified proper use of personnel monitoring equipment,' observed individuals leaving the radiation controlled area and signing out on appropriate RWP's, and observed the posting of radiation areas and contaminated area Posted radiation levels at locations within the fuel and auxiliary buildings were verified using both NRC and licensee portable survey meters. The involvement of health physics supervisors and engineers and their awareness of significant plant activities was assessed through conversations and
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review of RWP sign-in record The inspectors verified the' operability of selected engineered safety features.' This was done by direct visual verification of the correct position of valves, availability of power, cocling water supply, system integrity and general condition of equipment, as applicabl Portions of the Emergency Diesel Generating System were verified operable during this inspection perio One apparent violation and no deviations were identifie . Maintenance (62703, 92701)
The inspectors observed the performance of annual preventive maintenance
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for the "C" service water booster pump moto The work was controlled by maintenance request MR 89-0587 and included physical inspection of the electric motor, lubrication of the motor shaft bearings, and measurement of the motor insulation resistance. The work was performed by two electrical maintenance personnel and was further controlled by      !
radiological work permit RWP 89-2 The inspectors reviewed the associated clearance, verified that applicable tagouts had been made and verified that measuring and test equipment calibrations were curren In the lubrication of the motor shaft bearings, the maintenance personnel      l connected a grease gun to the grease fittings and delivered approximately two pumps of the grease gun to each bearing. The drain plug was not removed during grease addition. In conversations with maintenance technicians and supervisory personnel, the inspectors understood that the observed method may be the standard practice. Review of the manufacturer's technical manual showed that the manufacturer recommended
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a different annual lubrication practice which included cleaning of the drain plug area, addition of grease until new grease is forced out the drain, and motor operation for 30 minutes prior to replacing the drain plu The lubrication survey provided by the grease manufacturer also recommended a similar lubrication practice for electric motor bearing The inspectors' review of the equipment history file for the period of 1983 through 1989 of the service water booster pump motors did not reveal bearing failures, but did indicate come history of bearing lubrication problem At the exit licensee management committed to evaluate the lubrication progra The inspectors will follow-up on this issue during routine inspection activit .__ _______  -
 
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l No violations or deviations were identifie ,
_ Surveillance (61726)
The inspectors observed the performance of portions of the inservice testing of the "A" containment spray pum The test was conducted by operations personnel and was controlled by Periodic Operating Test POT-4-1, titled " Pump and Valve Inservice Testing / Eductor Performance,"
Revision 19, dated November 7, 1988. POT-4-1 included testing of the containment spray pumps, full stroke exercising of the eductor check valve, and part stroke exercising of the refueling water storage tank check valve in accordance with the licensee's topical report PGE-1048, titled " Inservice Testing Program for Pumps and Valves Second Ten-Year Interval." The scope of the present inspection was limited to inservice testing of the "A" containment spray pum ~The inspectors noted that test personnel had copies of the test procedure and data sheets in hand during conduct of the test, and verified that an independent verification was performed for the final position of valves in the locked valve program. Calibration of test equipmer.t and instrumentation was verified to be current by review of completed calibration sheets. A review of completed POT-4-1 data sheets for 1988 and 1989 indicated that required test frequencies were being met, and showed no significant changes in pump performance. The inspectors also reviewed the test procedure for conformance with the requirements of technical specifications 4.0.5 and 3/4.6.2.1 and with the requirements of Section XI of the ASME Boiler and Pressure Vessel (B&PV) Cod In the review of the test procedure to the requirements of Section XI of the B&PV Code, the inspectors identified the following item First, paragraph IWP-3220 of Section XI required that all test data be analyzed within 96 hours after completion of a tes POT-4-1 required that the  ,
operations shift supervisor check test data against the value/ range
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denoted on the data sheets within 96 hours but does not specify a time limit for review of the test data by the test enginee POT-4-1 apparently provided the required action range for test quantities, but did not provide the acceptable range limits or alert ranges for use by the shift supervisor in his review. The concern was whether the shift supervisor review met the intent of the IWP-3220 requirement. Second, POT-4-1 does not provide any allowable ranges for bearing temperatures on the applicable data sheet which was required to be checked by the shift supervisor within 96 hour This created the possibility that bearing temperature test data may not have been analyzed in a timely manne Third, review of completed vibration amplitude meter calibration sheets indicated that the instrument accuracy requirements specified in Table IWP-4110-1 of Section XI may not have been met. The inspectors discussed these items and other questions with test engineering personnel and requested further informatio This is considered an unresolveu item (50-344/89-05-02).
 
No violations or deviations were identifie ;
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l 6 .' Event Follow-up (62703, 92701, 93702)
Steam Generator Water Level Transient At approximately 10:59 a.m. on March 4, 1989, while conducting calibration of reactor plant control instrumentation, referred to by licensee, instrument technicians as Hagan (the instrumentation manufacturer) Cals, a steam generator (SG) level transient from a normal operating level of 44% (narrow range-NR) to a transient level of 58% (NR)
occurred. At the time of the event the cause of the SG water level transient was.not obvious to the instrument technicians performitig the calibrations or the operating crew, even though that crew had released the instrument calibration-work to be performed. As soon as the transient was terminated, the shift' supervisor discontinued all possible work activity that coulu have caused the transient until the event could be understood sufficiently to restart acintenance activities without inciden Subsequent operating crew and-instrument technician evaluation determined that an instrument technician had momentarily removed a fuse while establishing conditions necessary to check the calibration of the lead-lag module (LY-505-E) for first stage turbine impulse pressure signal conditioning;-and that LY-505-E should not have been attempted to be calibrated at power since that module was required for controlling SG water level with the reactor at power. When the Shift Supervisor concluded he understood the cause of the event, he contacted the Duty Plant General Manager and informed.him of the plant transient. The Duty Plant General Manager concluded the event did riot require immediate critique since to him it appeared the Shift Supervisor was taking conservative actions. On March 6, 1989, the Plant General Manager decided an event report and a critique were required to expeditiously gather the event fact The inspectors conducted a detailed assessrint of this event from March 6-10, 1989. The following paragraphs describe the inspectors' finding On February 8, 1983, Maintenanc.e Reque;t (MR) 89-1538, a Preventive Mair;tenance work request tc perform annual calibrations of approximately 450 reactor control instrument inodules, was processed by the acting Work '
Group Craft Supervisor. The inspectors noted that the MR did not have a list of the instruments to be calibrated or a clear indication of the scope of the work to be performed. The MR desc*ibed the work to be conducted as " Calibrate Hagan Modules in protection racks, control racks and associated control board inaicators." The MR work instructions were: Obtain permission from C0 and shift supervisor Remove from service using appropriate PICT Check calib of modules Return modules to service These work instructions were insufficient to prevent the performance of  t the calibration of LY-505-E while in an operating condition that would not support its calibratio LY-505-E calibration is part of " Shutdown  i folder 22." Shutdown folder 22 62 alt with the calibration of 18 modules
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including a turbine impulse pressure instrumentation circui The inspectors reviewed applicable interconnecting wiring diagrams and held discussions with engineering and maintenance personnel. Based on this review, the following modules appeared to be in the safety related portion of the instrumentation circuit: signal summator PY-505 B (used in computation for high steam flow), signal isolator PY-505A (used in isolation from steam dump control), signal,comparator PB-505C (used for rod block signal), and signal comparator PB-505 AB (used as input to low power permissive signals). The inspectors found that the licensee program for calibrating instruments relies on the knowledge of the instrument technician, and his use of electrical diagrams, vendor manuals and calibration data cards. Only several formal pre-written procedures for each individual calibration have been developed to direct the    ,
craftsman while performing instrument calibration '
The MR and its work instructions were developed by the acting Work Group Craft Superviso In discussions with the individual, the inspectors ascertained that the method used to develop the work instructions were similar to the method used for the calibrations conducted in previous year Besides not including a list of the instruments to be calibrated, the MR also did not include a list of the procedures to be used by the technicians performing the calibrations or special precautions to be observed while performing the calibration The calibration activity  was segmented into approximately thirty folders, referred to as shutdown folders by the technicians, each containing from one to sixty-four instruments for calibration. Four of the shutdown folders, folders 8, 9, 12 and 22, contained instruments that could be calibrated while operating or shutdown, and instruments that could only be calibrated.while shutdown. The other folders contained instruments that could be calibrated either at power or shutdow Inspector' discussions with the Instrument and Controls Technician Work Group Supervisor (WGS) revealed that the technicians had been provided with an uncontrolled, marked-up, computerized copy of the instruments to be calibrated within the scope of the MR and that the list had not been attached to the MR when it was routed for review and approva The WGS
  - further noted that the work was divided into groupings referred to as
" shutdown folders" and that the technicians used these in the performance of the calibration He continued by noting that the cover sheet to each  j shutdown folder listed all'the instruments in the folder and the general maintenance procedures the technician should refer to when calibrating those instruments. He also noted that the tect:icians were required to
- be knowledgeable of the procedures used to caliorate the instruments on which he was working. However, the inspectors verified through interview with the instrument technician that was conducting the calibrations that he had not reviewed the general calibration procedures immediately prior to conducting the calibrations nor did he have these procedures or the vendor manual at the job site with him. The inspectors also noted the technicians had not been periodically required to recertify their knowledge of tnese procedures and that one of the technicians performing the calibrations had not co7 ducted these calibrations during the last four year _ _ _ _ _ _ _ _ - _ _ -
 
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r bec w/ copy of[' letter dated 5/19/89:      1-Docket File    <
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The licensee does have Maintenance Procedures that provide general guidance to.the technician on conducting calibration In interviews with the Maintenance Manager and the I & C Work Group Supervisor, the inspectors concluded the licensee justification of this methodology is:
Resident Inspector Project Inspector
Maintenance Procedure (MP) 2-5, Revision 5, " Electrical Analog Instrumentation", implements the standard for inspection and maintenance of this equipment. Additionally, this procedure references other-maintenance procedures and vendor technical manuals with which the technician should refer when conducting instrument maintenance and calibrations. However, the inspectors found that the vendor technical manuals do not provide plant specific direction for the calibration of all instrument Additionally for this specific set of instrument calibrations, general procedure, MP-2-1, "Hagan Process Control and Protection Equipment", Revision 6, identifies the steps necessary to safely isolate, perform maintenance, test and return to service plant instrumentation and control equipment. It should be noted that during the SG water level transient of March 4,1989, the technicians performing the calibrations did not have nor had they reviewed this procedure immediately prior to conducting the calibration Knowledge of these procedures has been considered by the licensee to be within the skill level of the craftsma In the review of MR 89-1538 the inspectors also noted, in acco/ dance with licensee Administrative Order (AO) 3-9, Revision 30, " Maintenance Requests", other licensee reviews were required prior to releasing the work to be performe For this MR the other reviews were conducted by the Initiating Supervisor, a Quality Control Reviewer, the Cognizant Supervisor (who in this case was also the initiator of the MR), and a Shift Superviso In reference to the Quality review, a portion of the QA review requires, per Quality Support Ser/ ices 8 ranch Procedure,
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  " Quality Review - Work Packages / Documents," Revision 0, that the Quality Reviewer assure " Applicable procedures are referenced". While the review was conducted, the reviewer failed to identify that no procedures had been referenced. Additionally, discussions with the reviewer indicated to the inspectors that the review was superficial in that the reviewer thought that the scope of the work was to have calibrated between three and five instruments. Since the MR did not have a list of the instruments to be calibrated, it was understandable the QA Reviewer did not realize the scope of the MR; however, the instructions did indicate multiple calibrations were to be performed and should have generated      ,
0 .A. Johnson'    .
additional questions on the part of the Quality Reviewe As a result of   l the reviewer not understanding the scope of the MR, the reviewer did not schedule inspection hold points or observations of these calibrations by the Quality Assurance organization.
  , B. Faulkenberry J. Martin-    1 LFMB-State of Oregon-I ' '
  ; bec w/o , copy. of letter' dated 5/19/89:
M. Smith Ll
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L  The QA department reviewed the work instructions with responsible individuals and assured appropriate understanding. Additionally, based on this review a change to the QA procedure has been initiated to provide clarification.
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l As noted previously, prior to work authorization the MR was also reviewed by an Operations representative, who is also a licensed senior reactor operator and also a shift supervisor. This reviewer recognized the full
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mumme 5 Portland General Electric C0ii vis or
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David W. Cockfield Vice President, Nuclear May 19, 1989 Trojan Nuclear Plant Docket 50-344 License NPP-1 U.S. Nuclear Regulatory Commission.


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ATTN: Document Contrcl Desk Washington DC 20555
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scope of the work; however, he did not challenge the quality of the work instructions nor the absence of a list of instruments to be calibrate He also did not refer to Maintenance Procedure (MP) 2-1, "Hagen Process Control and Protection Equipment", to evaluate the need for additional precautions which in section III states: "There are a few instruments in the control racks that maintenance cannot be performed on unless the plant is shutdown." Therefore, no additions were made to the work instructions to alert the shift supervisors that some calibrations within the Hagan Process Control Racks could only be performed while shutdow '
The Operations Department determined that operators were given confidence
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by discussions with I&C which indicated work was to be conductd in accordance with approved procedures. Operators relied on I&C knowledg The licensee determined that operations personnel acted appropriately and that the bulk of the corrective action was required in the maintenance control and instruction are Based on the above, the licensee does not have appropriate, specific procedures for each calibration of instruments called out in the Technical Specifications as required by Regulatory Guide 1.3 This is an apparent violation (50-344/89-05-03).


Subsequent to the reviews the MR was authorized and released to be worked by Operations. Each week the Planning and Scheduling organization conducts a planning meeting with all planners present to schedule the maintenance activities to be conducted for the next week and over the weekend. For the weekend of March 4, 1989, the calibration of the instruments associated with ' shutdown folders' 16 and 23 were to be performed. However, on Saturday March 4, 1989, when the technicians went to the control room and requested permission from the Shift Supervisor to conduct the scheduled calibrations, the Shift Supervisor would not i release the MR since the plant conditions, due to previously planned and
==Dear Sirs:==
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Reply to a Notice of Violation Your letter of April 19, 1989 transmitted a Notice of Violation associated with Nuclecr Regulatory Commission Inspection Report 50-344/89-05.
scheduled maintenance not being completed, were not compatible with the calibrations to be conducted. The technicians then returned to the instrument shop and discussed with the Work Group Supervisor the alternative of conducting the calibrations associated with another
  ' shutdown folder' (folder 22). The WGS directed the technicians to perform calibrations associated with Protection Set 1 (PICT-3-1, ' shutdown folder' 22). Licensee procedure A0-3-9, Revision 30,
  ' Maintenance Requests,' section 4.5.1 states in part, " The Work Group Craft Supervisor shall:...b. Review the work instructions with the craftsman / technician prior to the start of work and establish safety requirements for the job." This review was conducted for the scheduled work; however, whcn the planned work was deferred a review in accordance with A0-3-9 was not conducted for the fill-in work. This is an apparent violation (50-344/89-05-05).


The technicians returned to the control room and requested permission from the shift supervisor to conduct calibrations on the Hagan control racks associated with Protection Set I. The shift supervisor's review of the work he released did not ascertain that the shutdown folder had instruments within it that could only be calibrated when shutdow Although the licensee concluded that operation's response was appropriate, the licensee needs to assure that operations personnel assume a sense of ownership and a leadership role in assuring work activities are appropriate.
Attached is our response to that Notice of Violation.


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Sincerely,
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Attachment      [;
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c: . John B. Martin    ro Regional Administrator, Region V
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P U.S. Nuclear Regulatory Commission    y E
        .. .; H Mr. William T. Dixon    a
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l State of Oregon    e Department of Energy Mr. R. C. Barr NRC Resident Inspector Trojan Nuclear Plant l
l 121 S W Salmon S9eet Potat O'egan 97204    1 A C A :r o L tv i cm      I
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Dock;t 50-344    Attachment
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At the time of the event the technicians were calibrating instruments contained within ' shutdown folder' 22. The technicians, because the work instructions were of inadequate detail, the required pre-work briefing was not conducted per procedures and the shutdown folder's instrument list did not identify plant conditions required to calibrate each instrument, attempted to calibrate LY-505-E, an instrument that should only be calibrated while shutdown. When the technician deenergized the lead-lag module for calibration by momentarily removing a fuse, the transient occurred. The technician, because he felt uncomfortable with what he was doing, immediately reenergized the lead-lag module, thereby minimizing che transient. The inspectors also noted that the circuit diagram the technician was using when establishing the conditions to check the calibration of LY-505-E was an uncontrolled, out-of-date, partial print maintained within the Hagan control rack doo In summary, without more detailed work instructions and an att:ched list
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of instruments to be calibrated the MR reviewers, the technicians, and the operating staff could not determine the scope of the work being conducted. Without adequate work instructions, an adequate pre-work briefing and proper segregation of work to be performed for the appropriate plant conditions, the technicians could not perform work acceptably. This event represents a breakdown of work control practices within the Maintenance Program. This event is very similar to a previous citation (50-344/88-40-03), where a reactor trip resulted from an instrument technician performing an instrument calibration without adequate work instruction The inspectors reviewed their findings and conclusions of this event with plant managemen Plant management acknowledged the findings and committed to implement the following corrective actions:
License NPF-1    May 19, 1989
  - Generate a separate MR to address all Hagan modules and instruments calibrated under an individual PICT. A separate MR will be written each time an instrument to be calibrated requires the use
  . Page 1 of 4 REPLY TO A NOTICE OF VIOLATION Title 10 of the Code of Federal Regulations, Part 50 (10 CFR 50),
  .of a different PICT to take them out of service and return them to servic Generate a list of each specific instrument to be calibrated via an MR and attached it to the applicable MR and state that only these instruments are to be calibrated under that M ,
Appendix B Criterion V, s' cates, in part:
  " Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings."
 
VIOLATION A Nuclear Division Procedure (NDP) 600-1, Revision 4, dated February 10, 1987 entitled, " Control of Nonconforming Materials, Parts, and Components," Section 1.0, states in part, "This procedure establishes measures to assure that nonconforming materials, parts, and components will be adequately documented and controlled . . . ".
Contrary to the above, during the 1987 outage, nonconforming weld filler
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material was identified and documented on a Noncenformance Report (NCR)    i form, but the NCR was not processed in accordance with the established Quality Assurance (QA) Program procedures.


  - Notes will be added to the applicable I&C-4 data sheets to state that calibration of this module is not to be performed while operating. I&C-4 data sheets will also be updated to include notes to designate if they must be deenergized to perform the calibratio Conduct a Lessons Learned training session with the I&C shop led  .
This is a Severity Level IV violation (Supplement 1).     ]
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REPLY TO VIOLATION A Portland General Electric Company (PGE) acknowledges the violation:    !
by the involved technician Move to Sundays the schedule date for Hagan cals to allow return to the original intent which was to perform these activities when no other maintenance is in progress.
1. Reason for Violation:      j The reason for this violation was personnel error. An NCR was initiated, but the initiator's supervisor failed to follow Nuclear    j Division Procedure (NDP) 600-1, " Control of Nonconforming Materials,    4 Parts, and Components," by not assuring the NCR was processed    I through to the Nuclear Quality Assurance Department (NQAD). An NCR was clearly necessary to document and evaluate the deficient j
characteristics of the filler material.


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  , " Docket 50-344    Attachmsnt License' NPF-1    May 19, 1989 Page 2 of 4 2. Corrective Steps Taken and Results Achieved:
a. The weld filler material of concern was placed on hold in the warehouse under NCR tags. This was completed on February 6, 1989. This action ensures that the wold filler material will not be issued for use While the NCR is being dispositioned, b. The original NCR was properly transmitted to NQAD, assigned number 89-172 on May 10, 1989, and is being properly processed in accordance with NDP 600-1. The disposition of the NCR will address any use of the weld filler material onsite before it was placed on hold under NCR tags.


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c. Nuclear Division nanagement has placed additional continuing emphasis on procedural compliance in the time since the occurrence of this violation. On December 21, 1980, the Vice President, Nuclear, issued to his managers the " Nuclear Division Mission and 1989 Goals," which included emphasis on procedural compliance. These goals have since been disseminated to Nuclear Division employees at all levels, d. The supervisor responsible for not transmitting the NCR has left PGE. Therefore, no specific disciplinary action was taken for this employee. Procedural compliance has been emphasized to employees in General Employee Training (CET).
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3. Corrective Steps That Will Be Taken to Avoid Further Violations:
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All corrective steps have been completed.


  - An MR with appropriate instructions and prior reviews, including the requisite pre-job briefings, will be prepared, reviewed, approved, and scheduled for each train of the Hagan rac In the long term, a review of all Hagan rack modules will be conducted and all modules requiring the plant to be shutdown will be separated into different folders and scheduling group MRs used to initiate preventative maintenance will insure that adequate direction is'provided to bound all plant conditions and will list specific equipment to be worked under that individual M Two apparent violations and no deviations were identifie . Follow-up of Licensee Event Reports (92700, 90712)- The following LER is closed based on in-office review, inspector verification of the implementation of selected corrective actions and licensee commitment to perform future corrective actions:
4. Date Wheu Full Compliance Will Be Achieved:
LER 88-26, Revision 0 and Revision 1, (Closed), " Reactor Trip on Low Reactor Coolant Loop Flow Signal Due to a Technician's Procedural Error". This LER and its revision discussed a reactor trip that resulted from technician error, inadequate work instructions and ineffective supervisory involvement and oversight. A detailed discussion of the event was included in inspection report 50-344/88-4 All NRC open items associated with this event have been previously close The following LERs are closed based on inspector. follow-up that included discussions with licensee representatives, detailed event evaluation, verification of appropriateness and implementation of corrective actions and licensee commitment to perform future corrective action:
Full complianew was achieved with the issuance of NCR 89-172.
LER 88-05, Revision 1, (Closed), " Surveillance Interval for Valves Exceeded Due to Personnel Procedural Error." This LER discussed two separate instances where surveillance associated with in-service testing were missed. The first event, identified by NRC inspectors and reported in Inspection Report 50-344/88-13, discussed exceeding the surveillance interval for testing Chilled Water return valves CV-10015 and CV-1001 Additionally during licensee assessment of the event, five other cases were identified where valves had not been tested within'the required surveillance interval. The licensee attributed personnel error to be the cause of the missed surveillance for these cases, since an engineer incorrectly logged dates of testing performance and an inadequate procedure, PET 9-4, provided insufficient detail for performing equipment testing at-increased frequency. As corrective actions, the licensee confirmed that testing had been done in the six cases and revised PET 9-4 to clarify testing at an increased frequenc Subsequent to the submittal of Revision 0 of this LER, the licensee identified another instance of a missed surveillance in the area of
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I in-service testin POT-2-3-DD, ' Safety Injection System, ECCS
>  Valve Quarterly In-Service Test' was missed as a result of errors on the part of two operations staff member First, the operations clerk provided the wrong surveillance, POT-2-3-DB, ' Safety Injection System, ECCS Valve Monthly In-Service Test' instead of POT-2-3-DD,
  ' Safety Injection System, ECCS Valve Quarterly In-Service Test' to the control operator for performanc Second, the shift supervisor, who had the responsibility for ensuring the correct surveillance, were performed and recorded, failed to recognize that the incorrect surveillance was performe The inspectors noted the shift supervisor reviewed POT-2-3-DB and incorrectly annotated that POT-2-3-DD had been performe As corrective actions, the licensee counseled the personnel involved and performed P0T-2-3-D The licensee Project Review Board (PRB) on May 4, 1988, determined this most recent identified missed surveillance was reportabl Because the event was similar in subject to LER 88-05, Revision 0, the PRB incorrectly ' decided to revise LER 88-05 vice submit a new'
Licensee Event Report. The practice of adding additional events to an already submitted LER is appropriate only when a continuing review of a previous event identifies additional instances of the same event with the same root cause. In those cases, to comply with 10 CFR 50.73, the licensee is required to submit the revised LER within thirty (30) days. Therefore, the licensee should have submitted a new LER vice LER 88-05 Revision 1, and in any event the revised LER should have been submitted within thirty days from discovery. This was identified to the licensee as an apparent Severity Level V violation (50-344/89-05-06). At the exit the licensee stated that the PRB is now assigning each event its own separate event report number and as such amending previously reported events has been discontinue LER 88-45, Revision 0, (Closed), " Reactor Coolant System Check Valve Leak Rate Not Measured Due to Construction Error". This LER discussed the invalid performance of leek rate testing for the "C" reactor coolant loop first-off pressure isolation check valve (894]C) due to not drilling an orifice in a fitting of a section of the safety injection test line associated with check valve 8948 Therefore with the test line blocked, the leak rate tests performed from 1977-1982 and from 1984-1988 were invalid. In July 1983, a valid leak rate test was conducted yielding a leak rate of 2.9 gp In November of 1988, another valid leak rate was performed yielding a leak rate of 4.1 gp From this data the licensee concluded from 1977-1988 that the leak rate had not exceeded the technical specification limit of 5.0 gp On three occasions the licensee had the opportunity to identify that a blockage existed in the test lin In 1983 the licensee suspected the test line was blocked and conducted an alternate test. No attempt was made at that time to identify the cause of the blockag In 1984 an attempt, blowing air tnrough the test line, was made to clear the blockag Plant personnel concluded the blockage was
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cleared, but no test was performed to verify the blockage had been cleared. In July 1988, the method of performing the leak rate testing was changed and the test results indicated a blockage; however, neither the operator nor the engineer that reviewed the test recognized the test indicated a blockage existe As a corrective action when the licensee recognized the orifice had not been drilled, the licensee performed valid leak rate testin Additionally, the_ licensee considered drilling an orifice in the test line fittin The licensee concluded for radiological and mechanical consideration not to drill the orifice, but to continue testing by an alternate metho LER 88-25, Revision 0, (Closed), " Construction Activity Inadvertently Disturbs Archeological Site"   This event occurred as a result of the licensee not conducting a timely safety evaluation, as required by 10 CFR 50.59. In November 1987, NRC conducted a management meeting with the licensee to clarify when safety evaluations should be conducted. During this meeting examples were presented that were similar to the activity that resulted in this event. However, the licensee believed that an effective safety evaluation program had been implemented and, therefore, did not review the safety evaluation program for weaknesses. As a result of this event, the licensee conducted a review of the safety evaluation associated with facility modifications not directly related to the:
   ' L3 cense NPF-1   fly 19, 1989
reactor plant cnd implemented improvements stated in the LE One apparent violation-and no deviations were identifie . Follow-up on Notices of Violations and Deviations (91700, 92701)
The following open items are closed based on a review of licensee response to Notices of Violation and/or Deviation, the licensee's in-depth root cause analysis, and inspector follow-up and verification of licensee committed action Open Item 87-18-02, (Closed), Violation of Procedural Compliance While Sluicing Between Safety Injection (SI) Cold Leg Accumulators. This violation described a procedural noncompliance during the transfer of water between SI cold leg accumulator Since the event the licensee has emphasized coroliance with procedures by conducting both formal and informal meeting. with all levels of management and supervisio Additionally, the licensee has initiated the Quality Operations Rover progra Weekly, a member of the Quality Assurance Organization evaluates various aspects of nuclear plant operation, including procedural compliance, to assess the plant staffs' compliance with procedures. The Rovers' evaluations indicate improved compliance with procedures. The inspectors' evaluations have also indicated improved compliance with procedures by plant operators. The inspectors will continue to evaluate procedural compliance by all plant personnel during      ]
routine inspectio Open Item 87-18-05, (Closed), Violation of procedural Compliance to Post Quality Control (QC) Hold Tags for Defective Equipment. This violation I
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Page 3 of 4 VIOLATION B Nuclear Plant' Engineering Procedure (NPEP) 200-6, Revision 3, dated May 29, 1985, entitled, " Preparation of Engineering Drawings," requires, in part, that drawing change notices (DCNs) be incorporated in new or l
 
revised drawings within 90 days of issuance or whenever the number of l
describes a procedural noncompliance in that QC Hold Tags were not posted on equipment damaged as the result of transferring water between SI accumulators prior to understanding and correcting the cause of the damag Since this event, the inspectors verified the licensee had strengthened Nuclear Division Procedure 600-1 " Control of Nonconforming Materials, Parts, and Components". The inspectors verified the licensee has extensively used QC Hold Tags to control significant equipment and component non onformances. A recent example was the hanging of QC Hold Tags on safety * elated nonconforming circuit breakers to alert operators i of the potentiai for certain plant circuit breakers not to be able to be remotely shut after a seismic even Open Item 67-31-01, (Closed), Deviation for Instrument Air System  ;
DCNs exceeds five in number for a particular drawing.
Deviations from UFSA The licensee determined that when the Su11 air j Compressor (C116) was installed, the subsequent FSAR revision did not I clarify that the "oilless compressor cylinder" referred only to the !
reciprocating compressors (C 102 A, B and C). As part of an action plan !
in response to NRC Generic Letter 88-14, the licensee has completed a detailed review of the as-built Instrument Air system as compared to descriptions in UFSAR, design bases document and PPID's. This review was completed 3/3/89, and appropriate UFSAR revisions are in progres Open Item 88-30-01, (Closed), Violation for Failure to Include Service ;
Water Pump Bearing Water Flow Indicators in the Preventive Maintenance Progra The licensee concluded personnel error was the cause of the violatio Because the gages could not be physically calibrated, they were not included in the calibration program; however, by oversight the vendor requirement to periodically inspect and clean the instrument to maintain instrument accuracy was omitted. As corrective action, the licensee committed to include the subject flow instruments in the Preventive Maintenance Program by May 1, 198 The instrument had been included in the PM program by the end of the reporting perio Additionally, one of the three instruments had been cleaned and inspected. These instruments will be cleaned prior to the end of the 1989 Refueling Outag The licensee also committed to evaluate the need for sending the instruments to the vendor for calibration by' July 1, 198 A search for other instruments of this type was made and none were identifie Open Item 88-30-02, (Closed), Violation for Inadequate Administrative Controls to Control Overtime of Maintenance Personne This violation describes an instance where overtime hours for maintenance personnel were not sufficiently controlled to prevent exceeding work hour limitation The licensee concluded that oersonnel error was the cause of the violation, in that the Maintenance Department supervisors did not adequately monitor the overtime of personne Also, Plant Management failed to implement lessons learned from a similar event during the 1989 refueling outage. The inspector verified that the corrective actions the ifcensee ccmmitted to in the LER, review what controls exist and to set up a system to assist Maintenance supervisors in maintaining control of work hours, had been implemented. Maintenance workers will report overtime daily to a clerk, who will check to determine if a risk of exceeding work-hour limits exists. When an individual approaches-the
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limits, the supervisor will be alerted. Also, the Plant General Manager
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issued a memoranuum directing all branch managers to review their
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< controls on work-hour limitations, and to establish measures appropriate i for their work functions to ensure limits are not; exceeded. The
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inspectors also reviewed a recent QA audit, that covered the last forced outage, that concluded adequate controls exist concerning control of work hour The NRC inspectors found that no formal written guidance existed for the
  '' established measures" for the' Maintenance Department on the control of work hours, that is,'no Maintenance Department procedure, no policy statement nor change to the job descriptions of the clerk or craft supervisors has been made. Also, the new " Conduct of Maintenance Manual" does not address the requirements for the individual worker to report their time daily, nor the Supervisors' responsibilities to monitor overtime. Without these formal documented measures the potential t again exceed work hour limitations appears likel Additionally, the absence of formal guidance on controlling work hour limitation appears to conflict with recent Management policy on clear definition of responsibility =and accountability. The inspectors will continue to closely assess licensee control of work hours during routine inspectio Open Item ~ 88-30-05, (Closed), Violation for Failure to Initiate and
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' Document Required Investigation for Recorder LR-5521 Out-of-Calibratio ,
The licensee concluded the cause.of this violation was personnel error on the part of the I & C Supervisor, in that he failed to use an instrument'
list for a quality related tes As a result of this error, an out-of-calibration' form was not generated, and therefore, did not prompt the required investigatio * A review of recent surveillance test data was performed, and the review indicated that since the last out-of-calibration occured in Febraury 1988, Periodic Operating Test (POT)-7-1 had since been performed with satisfactory results and with the LR-5521 in-calibratio The Systems Engineering Group performed the required out of-calibration evaluation..for this occurrence, and recommended the use of the 1986 instrument list be discontinued. This instrument list was compiled by Plant Engineering in.1986, and is not formally controlled or maintained curren Use of the list has been terminated, and the I & C Supervisor will prepare an out-of-calibration form for all quality related instruments that are out-of-calibration. The Systems engineering group will-perform the evaluations as appropriat Open Item 88-30-07, (Closed), Violation for Lack of Adequate Management Oversight to Ensure Maintenance Problems and Discrepancies Are Resolved q Before Proceedin The licensee determined that the root causes of the event were inadequate management oversight and the lack of a trending program for maintenance history. Contributing to this issue was an inadequate system for monitoring and tracking open MRs. An engineering evaluation by the licensee was conducted to address the~ low flow condition, and appropriate revisions to the Operating Instructions were implemented. An improved system for tracking and monitoring the status of open'MRs was developed and implemented on February 15, 198 A long term program to improve maintenance f.istory, and to trend equipment
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  ,i problems and maintenance request problems was implemented in March 198 The effectiveness of these later two items will be addressed in future NRC inspection Open Item 88-30-08, (Closed), Violation for Failure to Perform Preventive Maintenance (PMs) on Equipment in Storage. The license determined that the root cause of the violation was personnel error by warehouse employee Contributing to the procedural compliance deficiency were two factors: Lower-tier procedures established in 1987 were cumbersome and
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difficult to understan No formal support program was developed to ensure compliance (ie. QA audit, nor preventive maintenance scheduling system).


The inspector verified that the following interim corrective steps had been taken: All materials requiring desiccants had been inspected and where  i necessary, desiccants were replace This was completed on j October 6, 198 ;
Contrary to the above, DCNs 80 and 84 to Revision 8 of Drawing E-22, the electrical fuse schedule, were issued on August 23, 1988 and October 12, 1988, respectively, and were incorporated into Revision 9 of Drawing E-22 on February 14, 1989, which exceeded the 90-day requirement. DCNs 80 and 84 dealt with safety-related components of the auxiliary feedwater system (AFWS) and chemical and volume control system (CVCS), respectively. In addition, Drawing E-22 had 15 associated DCNs for Revision 8 before Revision 9 was issued.
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          ! Shaft rotation maintenance had been performed on all equipment and material requiring such preventive maintenance. This action was completed on October 6, 198 , Electrical energization of materials requiring such preventive maintenance was completed November 8, 198 Meggering of electrical motors requiring such preventiva maintenance was completed October 18, 198 Examination of inventory items for shelf-life was completed by December 31, 198 A review of the Trojan Materials Management Department improvement action plan was performed to identify any other programs which were not receiving the correct prioritie No other problems were identifie Procedures for a comprehensive preventive maintenance program were developed and fully implemented by January 16, 1989. These included lower-tier procedures which will provide clear l    direction for warehouse personne Training was provided for warehouse personnel prior to implementing the procedure The inspector also reviewed packages submitted to plant engineering for all storage items identified to require PM Engineering review is expected to include a review of applicable technical manuals and vendor recommendations for any additional required PMs (e.g. maintenance needed to extend shelf-life). The inspector also reviewed documents concerning a computerized system to track required PM actions. This program will provide a formalized notification process to alert maintenance crews and i
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This is a Severity Level IV violation (Supplement 1).
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REPLY TO VIOLATION B PGE acknowledges tho violation:
  ,    17 1 e warehouse management when action is require Follow-up of the revisions to the PM program, as a result of the engineering review, and effectiveness of the computerized tracking system will be addressed in future NRC inspection Open Item 88-30-09, (Closed), Violation for Failure to Perform and
1. Reason for Violation:
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The reason for this violation was inadequate management attention in overseeing the drawing change process. Noncompliance with the requirements for drawing revisions was limited to electrical drawings.
Document Leak Test per ASME Criteria for Service Water Strainer Gasket Replacement. The licensee's root cause analysis concluded the cause of the violation was personnel error due to the craftsman's failure to document that he performed the inspectio Licensee questioning of the craftsman determined that the craftsman did inspect the system for leakag Additionally, the licensee identified that the practice of revising a work request to include additional work, which has been since discontinued, prevented the reviewers from recognizing the inspection had not been documente Also, the licensee identified that in the process of generating the maintenance request (MR) the work group planner had not recognized the repair as an ASME code repair, and therefore,.did not require an inspection to be performed. The licensee reviewed the MR and the subject of code repairs with the planning staff to prevent recurrence. The NRC inspectors reviewed recent MRs to verify the practice of appending work requests with additional repairs had been discontinued. Additionally, a recent maintenance request associated with the service water system was assessed to verify the requirement to inspect for leakage had been include Open Item 88-30-10, (Closed), Unresolved Item Concerning Inablity to Retrieve Maintenance Request Package This concern was raised due to the inability of the work planning group to find seven of the eighty Maintenance Request packages asked for by the tea The licensee has since identified the problems in locating these package A review of the work planning procedures and issues raised in response to violation 50-344/88-30-07 has resulted in the licensee developing an improved system for tracking and monitoring the status of open MR This system was implemented on February 15, 1989. The effectiveness of this program will be observed during the 1989 refueling outage, and evaluated in future NRC inspection Open Item 88-43-03, (Closed), Violation for Quality Control (QC)
Inspector's Failure to Report a Nonconforming Activity (NCAR).


This violation resulted from the QC inspector's misconception that nonconformances were not required to be formally documented if a " circle Q", required observation, was not annotated on the work document; and Quality Assurance supervision discouraging the inspectors from initiating NCARs on inspector perceived " insignificant" procedure violations. To prevent recurrence, the licensee took the following corrective actions:
2. Corrective Steps Taken and Results Achieved:
initiated an NCAR, issued a memorandum outlining expectations on documentation of procedural non-compliances for Nuclear Quality Assurance Department (NQAD) personnel, and revised Quality Inspection Procedures to clarify the requirements for reporting and documenting procedural noncompliance. The inspectors verified Administrative Order (AO) 13-1,
a. Management attention to due dates for the revision of safety-related drawings has been elevated. The Nuclear Plant Engineering Department now receives a computer printout of all open DCNs and their associated due dates biweekly. Procedural-ization of this process was completed March 16, 1989. This printout provides engineering management with the means to oversee and control the incorporation of DCNs.
  " Inspection Control" had been revised (February 1, 1989) and that supplemental training had been provided to Quality Inspections personne Additionally, NRC inspectors have inspected maintenance that had been observed by the licensee Quality Control inspector An additional
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I instance of a QC inspector failing to document a procedural noncompliance
b. A review of all outstanding safety-related DCNs has been completed. No other safety-related DCNs were identified which had not been incorporated within the required time frame, nor were there any other safety-related drawings with more than five DCNs outstanding.
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was identified in NRC inspection report 50-344/89-0 It appears    '
additional licensee corrective action is required to ensure all    ;
inspectors are knowledgeable of documentation requirements. The licensee's corrective action to the Notice of Violation associated with inspection report 50-344/89-01 is being drafted and will be evaluated upon receip No violations or deviations were identifie . Follow-up on 10 CFR Part 21 Reports (92700, 92701)
10 CFR Part 21 Report on ASEA Brown Boveri K-Line Circuit Breakers (0 pen Item 89-08-P Closed): A Part 21 report was submitted which dealt with the need to install slow close lever rebound springs on various K-line circuit breakers to ensure proper operation after a seismic even The inspectors reviewed the licensee's actions in response to the information provided in the Part 21 repor Licensee review of drawings and technical manuals revealed that there were approximately ninety applicable K-Line circuit breakers installed in the plant. Of these, seven breakers had been purchased after July 197 According to the Part 21 report, breakers manufactured after July of 1974 were equipped with the rebound sprin Licensee inspection of breakers manufactured before and after July 1974 confirmed the need to install rebound springs on the older breaker ;
A nonconformance report, NCR 89-033, was initiated which concluded that continued use was acceptable. This was based upon the finding that the only safety-related equipment affected by the potential failure of the circuit breaker to close after a postulated seismic event and a loss of off-site power were the containment air cooler Licensee calculations concluded that the plant could be maintained in Mode 3, Hot Standby, for about eight hours without adversely affecting the environmental qualification of equipment inside containment assuming no containment air coolers were functioning. Rebound springs were being ordered at the time of inspection with plans to install them on safety related breakers in the 1989 refueling outage and on non-safety related breakers as preventive maintenance became due on each per the maintenance schedul The inspectors performed a sampling inspection to verify the licensee tabulation of applicable breakers, reviewed the nonconformance report, and discussed the supporting analysis with licensee engineering and    -
licensing personne A review of operating procedures verified that operators were instructed to start containment air coolers in response to  j a loss of offsite power even In addition, the inspectors observed a  !
demonstration that was attended by operations personnel of the necessary actions to reset the slow close leve Discussions with maintenance management indicated that electrical maintenance personnel would normally reset the slow close lever, if needed. The inspectors concluded licensee actions addressed the concerns raised in the Part 21 repor No violations or deviations were identifie _ _ _ _ _ _ - _ _ _ _ -


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, 1 Review of Design Change Program (37702, 92701)
The inspectors conducted a review of the' licensee's design change L  program. The program as described in the following procedures was reviewed for consistency with regulatory requirements set forth in the administrative control section of the technical specifications and with guidelines outlined in industry standards:
  -
Nuclear Division Procedure NDP 200-1, Revision 8, titled
  " Design Change Control"
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Nuclear Plant Engineering Procedure NPEP 200-14, Revision 7, titled " Detailed Construction Package Preparation and Control"
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Nuclear Plant Engineering Procedure NPEP 200-11, Revision 1, titled " Verification of Design"
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Nuclear Plant Engineering Procedure NPEP 200-15, Revision 7, titled " Processing of As-Built Packages"
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Nuclear Plant Engineering Procedure NPEP 200-6, Revision 3, titled " Preparation of Engineering Drawings" The above procedures discussed the licensee's request for design change (RDC) process which included preparation of a preliminary design, performance of independent design verifications, review and approval of the design change by engineering management and the Plant Review Board, preparation of a detailed construction package (DCP), implementation of the design change by the construction work group, and turnover to the ;
plant operations department. The procedures also addressed the process i by which the implemented design change is reflected on engineering drawings and document The inspectors reviewed two recently completed safety-related as-built design packages and discussed the design changes with engineering and plant modifications personnel. The design packages were RDC 85-052/DCP 13, which dealt with modifications to the remote shutdown station room and equipment base frame supports, and RDC 83-061/DCP 1, which controlled the replacement of 18 packless globe valves in various emergency core cooling systems and the reactor coolant syste RDC 85-052/DCP 13 involved a revision of the detailed construction packag In the review of the RDC's and DCP's, the inspectors verified that required independent design verifications were performed, that the need for system change descriptions which initiated changes to procedures and personnel training was addressed, and that appropriate reviews and approvals were obtained for DCP revisions. The inspectors also verified the review and approvals obtained for field changes to the detailed construction package No significant discrepancies were identified in the revie In the control of engineering drawings, the use of drawing change notices (DCN) was one method to show as-built changes to an existing nuclear plant design drawing. Per NPEP 200-6, DCNs were required to be incorporated in new or revised drawings within 90 days of issuance or whenever the number of DCNs against a particular drawing exceeds five in number. The inspectors reviewed a sample of control room drawings and noted that DCNs for piping and instrument diagrams appeared to meet the above requirement. Various electrical drawings, however, either had more i
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L l than five associated DCNs or had recent DCNs which were not closed within 90 days of issuance. Examples of findings are described belo Three of the electrical drawings were designated by the licensee as top documents which were defined in NPEP 200-15 as those design documents which are of prime interest to plant operations personne Drawing E-45 which dealt with 120 VAC safety relatec instrument bus panels had DCN 69 and 70 issued for revision 37 which were not closed within 90 days of issuance. Drawing E-46 which dealt with other 120 VAC instrument bus i panels had DCN 113, 114, and 115 for revision 63 which were not closed within 90 days of issuanc Drawing E-22, the electrical fuse schedule, had DCN 80, 81, 82, and 84 for Revision 8 which were not closed within 90 days of issuanc Drawing change notices 80 and 84 dealt with safety related components of the auxiliary fet dwater system and chemical and volume control system, respectively. L-45, E-46, and E-22 were designated us top documents per NPEP 200-1 In addition, E-22 had 15 associated DCNs for Revision 8 before llevision 9 was issue At the time of inspection, the following electrical drawings had more than five associated DCNs: E-29, Revinion 58, the pull and terminal box schedule with 17 DCN's; E-191, Revision 37, electrical raceway schedule with 37 DCNs; and E-192, Revision 36, the electrical circuit schedule with 53 DCN A number of these DCNs had also been issued in excess of e  90 day !
  'Trojcn NuclC r Plcnt   Document Contr31 Desk
   .These findings indicata the need for increased attention to assure compliance with procedtral requirements for drawing revision The inspectors consider the above findings to be an apparent violation (50-344/89-05-07).
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  - . Dock;t. 50-344   Attachment
One apparent violation and no deviations were identifie . Commercial Grade Procurement (38703)
  '..- License NPF-1
In response to a Region V request, the licensee, on February 21, 1989, I submitted additional information regarding commercial grade material use in the Main Feedwater system. This included a list of pressure-bearing materials, the approximate quantity installed, identification or heat number, manufacturer, supplier, and the physical and chemical test results to dat This list also identified all weld filler material used in the MFW piping replacemen In addition, the submittal documented the licensee's evaluation that the feedwater piping was acceptable for continued use until the 1989 refueling outag The inspector's technical evaluation of the licensee's submittal involved matching ASTM chemical and physical requirements to that specified on the Certified Material Test Reports and the licensee's laboratory test results. The MFW piping replacement was procured to standard specification ASTM A 106, Grade B or ASTM A 333 Grade The laboratory test provided independent mechanical and chemical test data as supporting i evidence that the critical characteristics of the installed piping materials conform to code requirement The ASTM material specifications, the CMTRs and the results of the licensee's independent testing were found to be within toleranc The licensee's hardness
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May 19, 1989 Page 4 of 4
 
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testing of materials supports the acceptability of materials where physical testing had not been conducted. In general, the licensee's review of the various manufacturers and suppliers found that they had QA programs of varied degrees with several having ASME Quality Systems Certificates (QSC). Most had been audited by organizations other than PG The below discussed items summarize the material that was relat-ively weakly addressed.
 
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  * . Flow Bend 14-inch elbows, heats 8278 and A403
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No independent chemical, physical, or hardness testing had been performed by the licensee to verify the associated CMTRs due to the unavailability of material sample No known manufacturer QA progra The inspector considered the material to be acceptable for the following reasons:
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Three other heats of Flow Bend elbews were independently tested by  '
the licensee and found to be satisfactory, indicating the validity of Flow Bend CMTR Bechtel audited Flow Bend in 1983, 1984, 1985, and 198 Flow Bend is considered by Bechtel to be a good commercial supplie Flow Bend is not known by the NRC to be an unacceptable supplie In process construction inspections and tests of the subject  i material indicate that it is acceptable materia l
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Additional testing will be performed during the 1989 outag Mills Iron 14 x 16 reducers (2), heat 80A
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No independent chemical, physical or hardness testing done had-been performed by the licensee to verify the validity of the associated CMTR The inspector considered the material acceptable for the following reasons:
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The raw steel was procured by Mills Iron from U.S. Stee I
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Two other Mills Iron fittings of a different heat in the  {
warehouse tested satisfactor I
 
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Mills Iron has a QA progra !
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The QA program has been favotably audited by Bechtel to NCA380 l I
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*    * Various small pieces' including:
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2 ft. of 4-inchipipe'from Nippo '
    .(4) 1-inch half. couplings.from Fuj . The'.. ins'pector considered the material acceptable f or the following -
l-    reasons: All of the material has been in ' service since 198 All of the material was subject to weld inspections and hydrostatic testin '
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Nippon has a QS ~' The small quantity and size involved minimize the potential of problem ~
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<.  ' Weld rod
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Generally no independent chemical or physical testing had been don Information. supporting the quality of the materials includes:
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    [All.boughtfrommanufacturerswithanASMEQualitySystems  '
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Certificate (QSC).
 
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E-7018 bought in sealed containers, thereby minimizing the possibility of supplier problems.
 
,    The inspector's independent evaluation of the information provided by the licensee, regarding the MFW piping and fittings, is that sufficient-evidence of quality in the subject material exists to conclude that this material was acceptable for continued use until the 1989 refueling outage. "The licensee has scheduled additional testing to restive any
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3. Corrective Steps That Will Be Taken to Avoid Further Violations:
remaining material concerns prior to completion of the 1989 refueling
All corrective steps have been completed.
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  . outag The quality of the weld filler materials were evaluated separatel In order to evaluate the acceptability of the weld material used in welding the MFW replacement piping, the inspector reviewed the
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radiographs associated with welds made on the feedwater pipe. The welds were :randcaly selected from design drawing numbers EBB-3-1 (Revision 13)
and EBB-3-2 (Revision 11). These drawings identify the weld numbers and
  ' locations within the applicable Steam Generator Loops (A, B, C and D).
 
.The radiographs reviewed were for the following welds: Weld No. P25923 from Loop A, Weld Nos. P25876 aGd P25972R4 from Loop B, Weld No P25991R1 and P25889 from Loop C, and Weld No. P25881R4 from Loop Intermittent radiographs were included in'the inspector's review; these are "information only" shots taken at various stages of the welding process to identify any deficiencies that would cause weld rejectio Rejected welds that required repair are identified by placing an R afte ,
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4. Date When Full Compliance Will Be Achieved:
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Full compliance has been achieved.
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,      .1 i-the weld number. For example, P25972R4 indicates that 4 repairs were made before the weld joint was determined to be acceptable in accordance with ASME Section XI requirements. For the radiographs of the weld joints reviewed, the inspector observed that.the weld repairs were always made to the weld root and, in each case, involved the use of 1/8" E705-2
  ' Heat No. 06550 Discussions with licensee personnel revealed an exp.assed concern, by the welding ar.d QC departments, on the use of this particular weld ro High levels of porosity were identified with the use of this weld rod which resulted in one MFW pipe weld root being cut
  .out,.and the failure'of previously qualified welders to qualify based on-radiographic rejection of the welders test coupon When questioned why this problem wasn't addressed on a Nonconformance Report (NCR), the inspector.was informed that on July 30, 1987 an NCR was initiated. A copy was~provided for the inspector's revie This NCR described the nonconforming condition as '/ Filler metal (Linde or L-Tec) E705-21/8" to 3/32" G.T.A,W. wire do not produce x-ray quality welds, for welder
<,  qualification and in plant requirements of piping components that.have to meet such criteria." This NCR, however, was not validated and assigned an NCR number. The Plant Modifications Manager, when informed, had the
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1/8" E70S-2 weld rod placed on hold in the warehouse;.but no NCR was generated to formally address the proble .
Although this nonconforming weld rod was not dispositioned through the NCR process, the inspector is satisfied that the MFW pipe welds selected for review were satisfetor This conclusion is based on the inspector's review of the intermittent
  - radiographs and the final radiographs taken of the repaired welds for code acceptabilit The failure to process the NCR in accordance with.the established QA  I program procedures to assure that the nonconforming weld rod is promptly identified, the root cause of the condition is determined and corrective action taken to preclude repetition is an apparent violation of 10 CFR 50, Appendix B, Criterion V (50-344/89-05-08).


.At the inspector's request, the Materials Manager had the warehouse searched to identify if any of this weld rod was located onsit All of -
SAB/LCD/mr 3073W.0589
the 1/8" E705-2 Heat No. 065502-was removed from the warehouse and sent to local school However, the 3/32" E705-2 Heat No. 065472 was in stock;'this rod produced weld porosity although to a lesser extent than the 1/8" rod. The licensee stated they would try to determine if any of the 1/8" rod is still available and, if so, obtain some for testing. In
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3 the interim, the licensee committed to perform some tests on the existing supply of the 3/32" E70S-2 ro The inspector will review the results of j (  this, effort during a future inspection when evalurting licensee actions  '
(  taken'to address the nonprocessed NC . Unresolved Item
  .An unresolved item is a matter about which more information is required  >
to ascertain whether it is an acceptable item, a deviation, or a violatio An unresolved item is discussed in paragraph j
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1 Severity Level V Violations As stated in Section V.A of 10 CFR Part 2, Appendix C, " General Statement of Policy and Procedure for NRC Enforcement Actions," 53 Fed. Reg. 40019 (October 13, 1988), a Notice of Violation will not normally be issued for isolated Severity Level V violations provided that the licensee has initiated appropriate corrective actions before the inspection end Two apparent Severity Level V violations for which a Notice of Violation was not issued are discussed in paragraphs 3 and 7 of this repor . Exit Interview (30703)
The inspectors met with the licensee representatives denoted in paragraph 1 on March 9,1989. The inspectors summarized the scope and findings associated with the Commercial Grade Procurement follow-up inspection conducted March 8-9, 198 The inspectors met with the licensee representatives denoted in paragraph 1 on March 23, 1989, and with licensee management throughout the inspection perio In these meetings the inspectors summarized the scope and findings of the inspection activities.
 
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Latest revision as of 19:30, 30 January 2022

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-344/89-05
ML20247Q976
Person / Time
Site: Trojan File:Portland General Electric icon.png
Issue date: 06/01/1989
From: Mendonca M
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To: Cockfield D
PORTLAND GENERAL ELECTRIC CO.
References
NUDOCS 8906070101
Download: ML20247Q976 (1)


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, iAttention: 'Mr.- David'W..Cockfield

14 Vic6 President, Nuclear p, .

s e Gentlemen:

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Thank!you for your. letter ' dated May 19, 1989, in* response to our Notice'of Violation and 50-344/89-05,. dated April 19, 1989,

" informing'usfoInspection f the' steps Report you have No.taken to correct-the-items which we brought

.to.your. attention. .Your corrective actions;will be verified during af future

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Your cooperation with us isOppreciated.

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M. M. Mendonca, Acting" Chief =

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Resident Inspector Project Inspector

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mumme 5 Portland General Electric C0ii vis or

David W. Cockfield Vice President, Nuclear May 19, 1989 Trojan Nuclear Plant Docket 50-344 License NPP-1 U.S. Nuclear Regulatory Commission.

ATTN: Document Contrcl Desk Washington DC 20555

Dear Sirs:

Reply to a Notice of Violation Your letter of April 19, 1989 transmitted a Notice of Violation associated with Nuclecr Regulatory Commission Inspection Report 50-344/89-05.

Attached is our response to that Notice of Violation.

Sincerely,

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Attachment [;

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c: . John B. Martin ro Regional Administrator, Region V

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P U.S. Nuclear Regulatory Commission y E

.. .; H Mr. William T. Dixon a

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l State of Oregon e Department of Energy Mr. R. C. Barr NRC Resident Inspector Trojan Nuclear Plant l

l 121 S W Salmon S9eet Potat O'egan 97204 1 A C A :r o L tv i cm I

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Trojtn Nuciccr Plcnt Document Contr:1 Deck

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Dock;t 50-344 Attachment

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License NPF-1 May 19, 1989

. Page 1 of 4 REPLY TO A NOTICE OF VIOLATION Title 10 of the Code of Federal Regulations, Part 50 (10 CFR 50),

Appendix B Criterion V, s' cates, in part:

" Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings."

VIOLATION A Nuclear Division Procedure (NDP) 600-1, Revision 4, dated February 10, 1987 entitled, " Control of Nonconforming Materials, Parts, and Components," Section 1.0, states in part, "This procedure establishes measures to assure that nonconforming materials, parts, and components will be adequately documented and controlled . . . ".

Contrary to the above, during the 1987 outage, nonconforming weld filler

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material was identified and documented on a Noncenformance Report (NCR) i form, but the NCR was not processed in accordance with the established Quality Assurance (QA) Program procedures.

This is a Severity Level IV violation (Supplement 1). ]

REPLY TO VIOLATION A Portland General Electric Company (PGE) acknowledges the violation:  !

1. Reason for Violation: j The reason for this violation was personnel error. An NCR was initiated, but the initiator's supervisor failed to follow Nuclear j Division Procedure (NDP) 600-1, " Control of Nonconforming Materials, 4 Parts, and Components," by not assuring the NCR was processed I through to the Nuclear Quality Assurance Department (NQAD). An NCR was clearly necessary to document and evaluate the deficient j

characteristics of the filler material.

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, Trojan Nuclosr Plant Documsnt Control D3sk

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, " Docket 50-344 Attachmsnt License' NPF-1 May 19, 1989 Page 2 of 4 2. Corrective Steps Taken and Results Achieved:

a. The weld filler material of concern was placed on hold in the warehouse under NCR tags. This was completed on February 6, 1989. This action ensures that the wold filler material will not be issued for use While the NCR is being dispositioned, b. The original NCR was properly transmitted to NQAD, assigned number 89-172 on May 10, 1989, and is being properly processed in accordance with NDP 600-1. The disposition of the NCR will address any use of the weld filler material onsite before it was placed on hold under NCR tags.

c. Nuclear Division nanagement has placed additional continuing emphasis on procedural compliance in the time since the occurrence of this violation. On December 21, 1980, the Vice President, Nuclear, issued to his managers the " Nuclear Division Mission and 1989 Goals," which included emphasis on procedural compliance. These goals have since been disseminated to Nuclear Division employees at all levels, d. The supervisor responsible for not transmitting the NCR has left PGE. Therefore, no specific disciplinary action was taken for this employee. Procedural compliance has been emphasized to employees in General Employee Training (CET).

3. Corrective Steps That Will Be Taken to Avoid Further Violations:

All corrective steps have been completed.

4. Date Wheu Full Compliance Will Be Achieved:

Full complianew was achieved with the issuance of NCR 89-172.

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TrajCn NuclGar Plcnt Document Control D ck Et ,

Dockat 50-344 Attachment

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' L3 cense NPF-1 fly 19, 1989

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Page 3 of 4 VIOLATION B Nuclear Plant' Engineering Procedure (NPEP) 200-6, Revision 3, dated May 29, 1985, entitled, " Preparation of Engineering Drawings," requires, in part, that drawing change notices (DCNs) be incorporated in new or l

revised drawings within 90 days of issuance or whenever the number of l

DCNs exceeds five in number for a particular drawing.

Contrary to the above, DCNs 80 and 84 to Revision 8 of Drawing E-22, the electrical fuse schedule, were issued on August 23, 1988 and October 12, 1988, respectively, and were incorporated into Revision 9 of Drawing E-22 on February 14, 1989, which exceeded the 90-day requirement. DCNs 80 and 84 dealt with safety-related components of the auxiliary feedwater system (AFWS) and chemical and volume control system (CVCS), respectively. In addition, Drawing E-22 had 15 associated DCNs for Revision 8 before Revision 9 was issued.

This is a Severity Level IV violation (Supplement 1).

REPLY TO VIOLATION B PGE acknowledges tho violation:

1. Reason for Violation:

The reason for this violation was inadequate management attention in overseeing the drawing change process. Noncompliance with the requirements for drawing revisions was limited to electrical drawings.

2. Corrective Steps Taken and Results Achieved:

a. Management attention to due dates for the revision of safety-related drawings has been elevated. The Nuclear Plant Engineering Department now receives a computer printout of all open DCNs and their associated due dates biweekly. Procedural-ization of this process was completed March 16, 1989. This printout provides engineering management with the means to oversee and control the incorporation of DCNs.

b. A review of all outstanding safety-related DCNs has been completed. No other safety-related DCNs were identified which had not been incorporated within the required time frame, nor were there any other safety-related drawings with more than five DCNs outstanding.

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May 19, 1989 Page 4 of 4

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3. Corrective Steps That Will Be Taken to Avoid Further Violations:

All corrective steps have been completed.

4. Date When Full Compliance Will Be Achieved:

Full compliance has been achieved.

SAB/LCD/mr 3073W.0589

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