ML20154Q438

Insp Repts 50-295/86-02 & 50-304/86-02 on 860104-0214. Violation Noted:Inoperability of Auxiliary Feedwater Pump 1B

ML20154Q438
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	03/13/1986
From:	Hehl C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20154Q435	List: ML20154Q430 ML20154Q438
References
50-295-86-02, 50-295-86-2, 50-304-86-02, 50-304-86-2, NUDOCS 8603210164
Download: ML20154Q438 (11)

See also: IR 05000295/1986002

Text

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. U. S. NUCLEAR REGULATORY COMMISSION

REGION III

Reports No. 50-295/86002(DRP); 50-304/86002(DRP)

Dccket Nos. 50-295; 50-304 License Nos. DPR-39;DPR-48

Licensee: Commonwealth Edison Company

P. O. Box 767

Chicago, IL 60690

Facility Name: Zion Nuclear Power Station, Units 1 and 2

Inspection At: Zion, IL

Inspection Conducted: January 4 through February 14, 1986

Inspectors: M. M. Holzmer

L. E. Kanter

J. N. Kish

Approved By: Hehl, Chief

Reactor Projects Section 2A

3//

Da'te

Inspection Summary

Inspection on January 4 through February 14, 1986

(Reports No. 50-295/86002(DRP); 50-304/86002(DRP))

Areas Inspected: Routine, unannounced resident inspection of auxiliary

electrical rooms; control rod drive motor generator rooms; review of

electrical distribution prints for reactor trip breaker modifications;

Unit 2 containment tour prior to its closure; operational safety and

engineered safety feature (ESF) system walkdown; surveillance; maintenance;

and licensee event reports (LERs). The inspection involved a total of 274

inspector-hours onsite, including 57 inspector-hours onsite during off-shifts.

Results: Of the eight areas inspected, one violation was identified in one

area. This violation, the inoperability of 18 Auxiliary Feedwater Pump, was

referred to a Region III enforcement board to determine whether escalated

enforcement is appropriate.

G603210164 e60317

PDR ADOCK 05000295

o PDR

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! . DETAILS

1. Persons Contacted

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l *G. Plim1, Station Manager

i *E. Fuerst, Superintendent, Production

• T. Rieck, Superintendent, Services

R. Johnson, Assistant Station Superintendent, Maintenance

L. Pruett, Unit 1 Operating Engineer

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J. Gilmore, Unit 2 Operating Engineer

N. Valos, Rad Waste Operating Engineer

R. Budowle, Assistant Superintendent, Technical Services

M. Carnahan, Training Supervisor

, R. Cascarano, Technical Staff Supervisor

i .A. Ockert, Assistant Technical Staff Supervisor

*C. Schultz, Regulatory Assurance Administrator

R. Aker, Station Health Physicist

J. Ballard, Quality Control Supervisor

'

. D. Kaley, Quality Control Engineer

• W. Stone, Quality Assurance Supervisor

D. McHenamin, Quality Assurance Engineer

• T. Printz, Assistant Technical Staff Supervisor

• W. Kurth, Assistant Superintendent Operating

• Indicates persons present at exit interview.

. 2. Summary of Operations

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Unit 1

The unit operated at power levels up to 100% throughout the inspection

period.

Unit 2

j The unit remained shutdown for refueling and the 10 year in-service

inspection for the first part of the reporting period,

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On January 1,1986, Safeguards Bus 248 was deenergized due to the loss of

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the normal supply from non-vital Bus 243. This resulted in an automatic

start of the 2A diesel generator. Paragraph 3 contains further details

on this event.

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On January 22, 1986, the licensee was performing PT-5 and 5A (Reactor

Protection Logic Tests) when the Train B Reactor Trip Breaker opened.

Paragraph 5 contains further details on this event.

Initial criticality for the cycle was achieved at 9

55 p.m. on January 26,

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1986, and the unit was tied to the grid at 5:30 a.m. on February 4, 1986,

i and operated at power levels up to 60%.

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. 3. Bus Drop

On January 17, 1986 at about 8:05 a.m., with Unit 2 in cold shutdown

a (Mode 5), Safeguards Bus 248 was deenergized due to the loss of the

normal supply from non-vital Bus 243. The event resulted in an automatic

start of the 2A diesel generator (DG) which functioned as designed.

Bus 243 was supplied from the system auxiliary transformer through 4160

volt breaker 2432. The alternate supply, from the unit auxiliary

transformer, through breaker 2431 was not available because the unit was

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shutdown. Breaker 2432 opened during naintenance on the red " breaker

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closed" indication light socket on the main control board. The apparent

cause was the defective socket. When breaker 2432 opened, the bus tie

between Bus 243 and Bus 248 opened on undervoltage, deenergizing Bus 248.

The normal breaker alignment was restored at 9

00 a.m. the same day.

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The bus drop resulted in the temporary loss of the 28 RHR pump, the 2B

service water pump, and the A reactor containment fan cooler. Four con-

tainment isolation valves also stroked. The necessary NRC notifications

were made pursuant to 10CFR 50.72.

4. Inoperability of IB Auxiliary Feedwater Pump

1 On December 21, 1985, a service water system hydrostatic test was being

conducted during the Unit 2 outage. The valve lineup for the test shut

ISW 0660, a manual valve which normally supplies the 18 auxiliary

feedwater (AFW) pump lube oil cooler from the Unit 2 side of the service

water (SW) system. The valve lineup neglected to open 1SW 0659, which

would have supplied the IB AFW pump from the Unit 1 side of the SW system.

As a result, SW to the IB AFW pump oil cooler was isolated, rendering the

pump inoperable.

On December 28, 1985, as part of the Unit 2 outage, work on 2MOV-SW101,

which supplies service water to the 2B AFW pump suction, had been

attempted, but the licensee was unable to get the header drained so that

repairs could proceed. The shift engineer directed the radwaste foreman

on shift to connect a hose to the flange between the SW header and

2SW 0656 to help drain the header. This was done, and after observing

the drainage flow, the foreman felt that there was pump head somewhere

. on the header. In an attempt to determine the source, he closed ISW 0656.

He stated that he felt that this valve was allowing SW flow from the Unit 1

side to be cross connected to the Unit 2 side, thus preventing the SW

header from draining. At this time, both valve 1SW 0656 and valve 1SW 0660

were cut of position (closed) isolating normal SW to the 1B AFW pump oil

cooler.

!

When his shift had ended,-the radwaste foreman told the oncoming shift

engineer that he isolated the cross connect from Unit 1 to Unit 2. The

i oncoming shift engineer understood this to mean a SW crossconnect, and

felt that there would not be any impact on Unit 1, being unaware that

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. Unit 2 SW was the normal supply to the IB AFW pump lube oil cooler. He

also thought, as a result of his turnover with the off going shift

engineer, that the 2MOV SW101 maintenance team would be requesting

operator assistance later in the shift, and he would then send the shift

foreman to ensure that the lineup was correct. In addition, he assumed

that the hydrostatic test return to service valve lineup or the startup

valve lineup would assure that the cross connect valve would get to the

correct position before it was needed for Unit 2 operations. As a result,

he did not initiate a "non-routine valve line-up" sheet.

Non-routine valve line-up sheets, as stated in Zion Administrative

Procedure (ZAP) 3-51-4B, " Procedure for Non-routine Valve Line-ups" are

applicable for " changes made in valve line-ups of safety related systems,

that are not covered in the out of service (005) card system and last for

a duration greater than one shift, which differ from the routine valve

line-ups as stated in the Zion Station System Operating Instructions."

On January 6, 1986, the Unit 2 hydrostatic test return to service valve

line-up was completed, and ISW 0660 was opened. The valve may have been

opened earlier, but this cannot be conclusively shown from the valve

line-up. The sheet only shows that the valve line-up was completed on

i January, 6, 1986. Since manual valve ISW CC55 had been closed as

described above and was not addressed on the hydrostatic test valve

line-up, SW to the 18 AFW pump oil cooler remained isolated.

1 On January 12, 1986, with Unit 2 still in cold shutdown, a B-operator on

j' normal rounds identified the need to remove the header drain hose which

had been connected to facilitate repair of valve 2MOV SW101. In the

process of determining how to go about disconnecting and removing the

a hose, it was discovered that both valves ISW 0656 and ISW 0659 were

closed. ISW 0656 was immediately opened, restoring the IB AFW pump to

operability.

l Root Cause Analysis

The following root causes or contributors to this event were identified:

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An error in the Unit 2 SW hydrostatic test procedure valve line-up

caused the isolation of the IB AFW pump oil cooler. (1SW 0660 was

shut without opening ISW 0659)

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The radwaste foreman shut ISW 0656, and neither he nor the oncoming

shift engineer initiated a non routine valve line-up sheet to track

or document this activity.

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Communications between the radwaste foreman and the oncoming shift '

engineer were vague, and unspecific. This probably contributed to

the feelings of the shift engineer that there was no urgency

associated with the repositioning of ISW 0656.

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Some shift engineers were unaware of the normal line-up for the AFW

, lube oil coolers, which is that some components are normally

supplied from the opposite unit. This apparently contributed to the

misconception that shutting "a crosstie" would not normally affect

the other unit.

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The procedure for non-routine valve line-ups has not been consistently

applied, and is in need of review and possible revision.

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During the review of the event, it was discovered that the Unit 1 SW

hydrostatic test procedure which had been used earlier that year

also isolated the 28 AFW pump oil cooler in a similar manner to that

described above. However, the error was immediately identified and

corrected by a temporary procedure change initiated during the Unit 1

j SW hydro. This change was not made permanent.

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Immediate Corrective Actions

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ISW 0656 was opened immediately after identification.

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The shift engineer immediately ordered a verification of the line-up

of the SW valves supplying all Unit 1 AFW pump oil coolers. The

same valves on Unit 2 were also checked, although there was no

immediate need to do so

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Performance tests were performed on all 3 unit 1 AFW pumps on the

shift following discovery, as these tests were previously scheduled

for performance during that time period.

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Long Term Corrective Actions

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The SW hydrostatic test procedure will be corrected to ensure that

SW is provided to both motor driven AFW pumps on the operating unit

the next time the procedure is used.

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A copy of the Potentially Significant Event notification which was

given to the corporate office will be routed to all personnel

l involved in hydrostatic test package review. A memo will accompany '

l the event description, to caution reviewers to give appropriate

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attention to detail during their reviews.

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A change to the ZAP will be initiated to require that all procedure

i changes clearly state the reason for the change. Training will be

provided for this ZAP change.

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The procedure for non-routine valve line-ups will be reviewed and

revised if necessary.

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Valve line-up checklists will be reviewed relative to components

supplied with SW from the opposite unit and changed as appropriate.

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There will be a review to determine whether it is necessary for one

unit's components to be normally supplied by SW from the opposite

unit.

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Alert all shift supervisors by memo that these cross connected

conditions exist and may potentially exist in other support

systems.

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Training will be provided to radwaste foremen on ZAP's which pertain

to operations. The training will emphasize procedure adherance.

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Off going maintenance supervisors will be required to provide a

status update to the shift engineer for jobs which were in progress.

This is to be done before leaving for the night.

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The radwaste foremen's desk will be moved to the shift engineer's

office, and radwaste foremen will be required to turnover there.

Safety Significance

FSAR section 6.7.1, AFW design basis, states, "One of the two motor-driven

auxiliary feedwater pumps supplying two of the four steam generators will

provide enough feedwater to safely cool the unit down to the temperature

, at which the residual heat removal system can be utilized. The single

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turbine-driven auxiliary feedwater pump has twice the capacity of either

j motor-driven pump." The 1A (turbine-driven) and the IC (motor-driven) AFW

f pumps and their associated support systems and power supplies were operable

while the IB AFW pump was out of service. The 1B AFW pump could have run

j for approximately 20 minutes with its lube oil cooler isolated, according

to the results of a test on the 1A AFW pump run several years ago.

The licensee performed about 58 hydrostatic tests in the last Unit I and

2 outages, and this is the only known example of a valve line-up error

which wasn't detected during the review process. As a result, this

appears to be an isolated case.

The licensee was slow to realize the significance of this event, in that

it was discovered on January 12, 1986, and was processed as a routine

deviation report (DVR) until approximately January 27, 1986, when the

Operating Assistant Superintendent determined that this event could have

represented a significant reduction in the margin of safety, and informed

the NRC resident inspector. The licensee usually informs the resident

j office immediately when significant events occur. The fact that the

licensee informed the resident inspector indicates that they were

beginning to treat this as a more serious matter.

Technical Specification (TS) 3.7.2.a precludes reactor operation in

Mode 1 for more than seven days with one motor-driven AFW pump inoperable.

Operation of Unit 1 in Mode 1 from December 21, 1985 until January 12,

j 1986, a period of approximately 22 days, with the IB motor-driven AFW

pump inoperable is a violation of TS 3.7.2.a. (295/86002-01)

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. 5. Reactor Trip Breaker Opening

On January 22, 1986, at 11:31 a.m., with the unit in the hot shutdown

mode, the licensee was performing Periodic Test (PT) 5 and SA when the

Train B reactor trip breaker opened. The PT was being utilized as a

check to ensure proper installation of recently completed modifications

(Ring Bus and Shunt Trip) as well as for Generating Operating Procedure

(GOP) startup testing for the nearly concluded refueling outage. As part

l of its investigation, the licensee physically traced the conduit runs and

found them to be connected to the wrong trains (i.e., A to B and B to A).

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A review of the same modification performed on Unit 1 during testing

refueling outage did not identify similar concerns. Later the same day,

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j the conduits were installed correctly and PT-5 was rerun and successfully

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completed at 3:20 a.m. on January 23, 1986.

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The licensee is presently looking into the possibility of an additional

verification test prior to performing their post modification check for

proper installation. (Note: this is just being considered since their

post modification test did perform its intended function.) This matter

. will be considered an Open Item pending further review by the resident

} inspectors into the root cause of the event (304/85002-01).

No violation or deviations were identified. One Open Item was identified.

6. Followuo of Region III Requests

!

! In a memorandum from E. G. Greenman dated November 7, 1985, all resident

I inspector offices were directed to provide information concerning the use

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of Licensed Reactor Operators in supervisory positions. In accordance

with the above request, the inspectors reviewed the appropriate Zion

Administrative Procedures (ZAP). A discussion with the operating

engineer on the subject was also conducted. Their procedures showed

compliance with requirements of 10CFR 50.54(m)(2) 111, 10 CFR 55.4(d) and

10 CFR55.4(e).

No violations or deviations were identified.

7. Followup of NRR Requests

In a maintenance questionaire from Harold R. Booher, all resident

, inspector offices were directed to obtain plant-specific primary data as

part of NRR's Maintenance and Surveillance Program. The survey is being

utilized to assist in the characterization of maintenance programs and

practices at each specific plant. In accordance with the above request

the questionaire was filled out without assistance from the licensee.

l The results of this survey will be presented in a report to the Executive

Director for Operations (EDO) in the spring of 1986.

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l 8. Emergency Preparedness Exercise

l The licensee conducted an emergency preparedness exercise on February 10,

j 1986, involving various federal and state agencies. The licensee

utilized Emergency Operating Procedures to mitigate the consequences of

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. the simulated event. Details of the exercise and evaluations thereof are

contained in Inspection Reports No. 295/86001(DRSS) and No. 304/86001(DRSS).

The resident inspector attended the exit for the exercise on February 11,

1986.

No violations or deviations were identified.

9. Operational Safety Verification and Engineered Safety Features

System Walkdown

The inspectors observed control room operations, reviewed applicable logs

and conducted discussions with control room operators from January 4,1986

through February 14, 1986. During these discussions and observations,

the inspectors ascertained that the operators were alert, fully cognizant

of plant conditions, attentive to changes in those conditions, and took

prompt action when appropriate. The inspectors verified the operability

of selected emergency systems, reviewed tagout records and verified

proper return to service of affected components. Tours of the auxiliary

and turbine buildings were conducted to observe plant equipment conditions,

including potential fire hazards, fluid leaks, and excessive vibrations

and to verify that maintenance requests had been initiated for equipment

in need of maintenance.

The inspectors, by observation and direct interview, verified that the

physical security activities were being implemented in accordance with

the station security plan.

The inspectors observed plant housekeeping / cleanliness conditions and

verified implementation of radiation protection controls. From January 4

to February 14, 1986, the inspectors walked down the accessible portions

, of the auxiliary feedwater system, component cooling system, and auxiliary

electrical and control rod drive motor generator rooms to verify

operability. The inspectors also witnessed portions of the radioactive

waste system controls associated with radwaste shipments and barreling.

These reviews and observations were conducted to verify that facility

operations were in conformance with the requirements established under

Technical Specifications, 10 CFR and administrative procedures.

No violations or deviations were identified.

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10. Monthly Surveillance Operation

The inspector observed Technical Specifications required surveillance

testing on the containment spray system and verified that testing was

performed in accordance with adequate procedures, that test instrumen-

tation was calibrated, that limiting conditions for operation were met,

that removal and restoration of the affected components were accomplished,

that test results conformed with technical specifications and procedure

requirements and were reviewed by personnel other than the individual

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. directing the test, and that any deficiencies identified during the

testing were properly reviewed and resolved by appropriate management

persor.nel.

The inspector also witnessed or reviewed portions of the following test

activities:

PT-6 Containment Spray Tests and Checks

PT-7B Auxiliary Feedwater Pump Service Water Valves Operability Check

(Last Two Months' Tests)

PT-27 Refueling Outage Miscellaneous Valve Tests

No violations or deviations were identified.

11. Monthly

o Maintenance Operation

Station maintenance activities on safety related systems and components

listed below were observed or reviewed to ascertain whether they were

conducted in accordance with approved procedures, regulatory guides,

industry codes or standards, and in conformance with Technical

Specifications.

The following items were considered during this review: the limiting

conditions for operation were met while components or systems were

removed from service; approvals were obtained prior to initiating the

work; activities were accomplished using approved procedures and were

inspected as applicable; functional testing and/or calibrations were

performed prior to returning components or systems to service; quality

control records were maintained; activities were accomplished by qualified

personnel; parts and materials used were properly certified; radiological

controls were implemented; and fire prevention controls were implemented.

Work requests were reviewed to determine status of outstanding jobs and

to assure that priority is assigned to safety related equipment maintenance

which may affect system performance.

The following maintenance activities were observed or reviewed:

20 Main Steam Isolation Valve Maintenance (MSIV)

Unit 2 Source Range Channel Maintenance

Unit 2 Intermediate Range Channel Maintenance

Review of Unit 1 and Unit 2 modification package for installation of an

annunciator in the control room for iodine sampling af ter a 15% power

change

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!. Review of Unit I and Unit 2 Shunt Trip Modification

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l No violations or deviations were identified.

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12. Licensee Event Reports (LER) Followup

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l Through direct observations, discussions with licensee personnel, and

! review of records, the following event reports were reviewed to determine

! that reportability requirements were fulfilled, immediate corrective

action was accomplished, and corrective action to prevent recurrence had

i been accomplished in accordance with Technical Specifications. The LERs

listed below are considered closed

Unit 1

LER No. Description

!

j 85-40 Automatic Start of Penetration Pressurization Air Compressors

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1 85-43 Automatic Start of Penetration Pressurization Air Compressors

f 85-44 Inadvertent Reactor Trip Due to Steam Flow Transmitter 1FT-512

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85-46 Failure of Both Source Range Channels Following Reactor Trip

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85-47 Missed Surveillance for Reactor Coolant Iodine Following 15%

Power Range

l Unit 2

i Ler No. Description

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85-29 Purge Isolation Due to Low Temperature and High Radiation

l Signal

86-001 Inadvertent Operation of the Pressurizer Power Operated

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Relief Valves

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Regarding LER's 295/85040 and 295/85-43, " Automatic Start of Penetration

Pressurization (PP) Air Compressors," the LER's will be closed. A

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naintenance program is being tracked by the station. The events were

reported per 10CFR50.72. Due to heightened emphasis on ESF actuation

l reporting requirements, it is most probable that these will not be

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reported in future occurrences per 50.72 since the PP air system is

started by a process signal. This decision was arrived at as a result of

i a meeting between the licensee and Region III personnel January 16, 1986.

j Regarding LER 295/85-44, " Inadvertent Reactor Trip Due to Steam Flow

j Transmitter 1FT-512," the LER will be closed. The trip was caused by

j a steam flow transmitter drifting out of tolerance (00T). The flow

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j , transmitter was a Fisher-Porter type and has had a history of drifting

4 00T. This type of transmitter will be replaced under a station modif t- ,

4 cation. For details on the trip refer to inspection report 50-295/85042; f

i 50-304/85043.

Regarding LER 295/85-047, " Missed Surveillance for Reactor Coolant Iodine

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Following 15% Power Change". This item is considered a licensee identified

} violation for which no citation will be given (50-295/86002-02).

An event of similar nature occurred on Unit 2 in August 1984. During this

! event, Radiation Protection (RP) was not notified of the 15% power change  !

l and corrective action included revision to the appropriate start-up ,

l procedures. In this present event, notification was made to RP but  :

! misunderstood. Corrective action will include a description of this event

i in the operators' required reading package and will also be distributed to

} RP personnel. In addition, a modification package which was initiated

i after the last event is being processed for both Unit 1 and Unit 2 to

t install an annunciator in the control room so in the future, iodine

j sampling will be performed in accordance with Technical Specifications.

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l Regarding LER 304/85-029, " Purge Isolation Due to Low Temperature and ,

High Radiation Signal," the LER will be closed. However, an Open Item

j will be issued pending further investigation into the root cause of the

j event (304/86002-02).

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j No violations or deviations were identified. One licensee identified

violation and one Open Item were identified.

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j 13. Open Items

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! Open Items are matters which have been discussed with the licensee, which

l will be reviewed further by the inspector, and which involve some action

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on the part of the NRC or licensee or both. Two Open Items disclosed

during this inspection are discussed in paragraphs 5 and 12,

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I 14. Exit Interview

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The inspectors met with licensee representatives (denoted in Paragraph 1) I

throughout the inspection period and at the conclusion of the inspection

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on January 4 through February 4,1986 to summarize the scope and findings

of the inspection activities. The licensee acknowledged the inspectors'

! comments. The inspectors also discussed the likely informational content

l of the inspection report with regard to documents or processes reviewed

! by the inspectors during the inspection. The licensee did not identify

any such documents or processes as proprietary. l

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