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#REDIRECT [[IR 05000298/1998022]]
{{Adams
| number = ML20199E169
| issue date = 01/07/1999
| title = Insp Rept 50-298/98-22 on 981116-1208.Violations Noted.Major Areas Inspected:Licensee Performance in Completing Engineering Strategy Action Item 3.2.e
| author name =
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
| addressee name =
| addressee affiliation =
| docket = 05000298
| license number =
| contact person =
| document report number = 50-298-98-22, NUDOCS 9901200342
| package number = ML20199E157
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 31
}}
See also: [[see also::IR 05000298/1998022]]
 
=Text=
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                                                                  ENCLOSURE 2
                                                                                                            {
                                                                                                              l
                                  U.S. NUCLEAR REGULATORY COMMISSION                                          i
                                                                      REGION IV                            '
        -
                                                                                                            i
            Docket No.:        50-298
                                                                                                              1
            License No.:        DPR 46                                                                      i
            Report No.:        50-298/98-22
            Licensee:          Nebraska Public Power District                                              !
                                                                                                            i
            Facility:          Cooper Nuclear Station                                                        i
                                                                                                              l
            Location:          P.O. Box 98
                                Brownville, Nebraska
            Dates:              November 16 through December 8,1998
            Inspectors:        David P. Loveless, Sr. Project Engineer
                                William M. McNeill, Reactor Engineer
                                James F. Melfi, Project Engineer
            Approved By:        Charles S. Marschall, Chief
                                Project Branch C
l                              Division of Reactor Projects
f
l          ATTACHMENTS:
;          Attachment 1      Supplemental Information
            Attachment 2      Work Item Sample Selections Reviewed
!
j          Attachment 3      Documents Reviewed
            Attachment 4      Unauthorized Modification Review Program
i
  ~
!
!
                                                                                                              '
i
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                                                                                                              l
1
                                                  ,
          9901200342 990107
-
          PDR      ADOCK 05000298
          G                    PDR                                                                            l
i                                                                                                            i
s
 
      -.-    -.      - . - - ~ -              - - -. - - - .                        ..~ -_- - -      . - -
  ~
                                                                                                              .
  .
                                            EXECUTIVE SUMMARY
                                            Cooper Nuclear Station
                                      NRC Inspection Report 50-298/98-22
    This focus inspection was conducted to evaluate the licensee's performance in completing
    Engineering Strategy Action item 3.2.e," Complete the Unauthorized Modification Review," as                1
                                                                                                              '
    documented in the Cooper Nuclear Station Strategy for Achieving Engineering Excellence,
    Revision 2. This program had been created to correct deficiencies identified in previous
    escalated enforcement. This focus inspection was the first inspection of a completed
    engineering improvement strategy item. The team identified that the program had not identified
    all unauthorized modifications, nor had all identified unauthorized modifications been properly
    evaluated and dispositioned. The specific safety significance of items identified by the team              '
    was considered to be relatively low. However, the findings indicated a lack of adequate                    1
    management oversight of the program. Corrective actions to prevent recurrence of
    unauthorized modifications via the maintenance work order process were effective.                          4
    Maintenance
    =
            The licensee's changes made to their procedures and processes for handling                        I
            maintenance work requests (MWRs) effectively precluded unauthorized modifications.                  !
l          The work planners and maintenance craftsmen were sensitive to potential configuration              '
            changes, and a review of recently completed MWRs did not identify any unauthorized
l          modifications (Section M3.1).
    *
            The existence of 318 items identified by the licensee as potential unauthorized
            modifications, that had not been identified through MWR review, indicated that past
          weaknesses in other licensee programs may have also resulted in unauthorized
            modifications (Section M3.1).
j  Enaineerina
    =
            Licensee personnel had failed to identify seven unauthorized modifications identified by
            the team. This failure was the first example of a violation for the failure to take adequate
            corrective actions to the problem identified as Violation 50-298/9604-1013. The safety
            significance of the items identified by the team was low. However, the findings indicated
            a lack of program oversight (Section E1.1).
    *      Licensee engineers failed to properly evaluate all of the conditions adverse to quality
            identified by the unauthorized modification review program. This failure was an
            additional example of a violation for the failure to take adequate corrective actions
            regarding Violation 50-298/9604-1013. The safety significance of items identified by the
l          team was low (Section E1.2).
;
!  *      Licensee management oversight for the unauthorized modification review program was
!          insufficient to identify and correct problems identified by the team. Licensee engineers
            failed to utilize their design control process in resolving a majority of the unauthorized
            modifications documented. This failure resulted in one example of a violation. Also,
j          program coordinators made a decision to leave the backlog items open without a
;
;
!
i
!
                                                                                                              ,
 
      . . , - . . . .                    - _ .                . - -          - --      -. . - . - - - - -
    .
    .
                                                            2-
                      complete understanding of the scope and potentialimpact of each item
                      (Sections E1.1, E1.2, and E7.1).
l
f
!
l
l
,
l
2
4
  i
W
 
    -  ---._-.,- - - -.- - -                                                    - -.    -- _ _          _ - - - . _
      .
                                                                Report Details
                                                                ll. Maintenance
        M3                  Maintenance Procedures and Documentation
        M3.1 Maintenance Proaram Chanaes to Prevent Unauthorized Modifications                                          ;
          a.                Inspection Scope (62702)
                            The team reviewed the changes made to maintenance procedures and processes to
                            assess if these changes should preclude future unauthorized modifications. Interviews
                            were conducted with maintenance department working level personnel. The team
l                          evaluated a random sample of MWRs completed after corrective actions were                  i
                            implemented to determine if they contained unauthorized modifications.                      l
          *                Backaround                                                                                  i
                                                                                                                        l
                            On November 8,1995, the NRC team identified that the main steam tunnel blowout
I                          panel sections did not appear to be consistent with diagrams in applicable design          l
                            calculations. A structurally significant coating had been placed on the secondary          1
l                          containment side of the panel sections, potentially altering their material characteristics
l                          and strengthening the blowout panel . sections. Increased structural strength would have    ,
                            been nonconservative for the blowout panel's design basis function. In addition, the        '
                            design configuration of the panel sections had not been maintained in associated
                            documents and drawings. An apparent violation was identified for the failure of the
                            licensee to pedorm an evaluation in accordance with 10 CFR 50.59 on this modification
                            to the steam tunnel blowout panel sections. The resulting enforcement action issued
                            Notice of Violation 96004-01013.
                          The licensee's response dated May 17,1996, committed to review MWRs according to
                            a sampling plan. The review would detect modifications installed without performance of
                            safety evaluations. The sample size initially consisted of 10 percent of a se!ecteo
                            population of MWRs from 1974 to 1996. The review of this sample of 2090 MWRs
                            resulted in the identification of 128 unauthorized modifications.
                            As a result of these findings, the licensee expanded the scope of their sampling to
                            include all of the remaining MWRs from 1973 - 1996. In an effort to identify all
                            unauthorized modifications in the plant, the licensee established a population of
l                          95,736 MWRs written since initial licensing until June 12,1996. June 12,1996, was the
(                          date of implementation of the corrective actions to eliminate the possibility of making an
;                          unauthorized modification by means of the MWR process. The licensee divided these
.                          MWRs into two groups. One group of 22,834 MWRs written before 1980 were available
j                          on microfilm. A second group of 72,902 MWRs written after 1980 were available on
;                          microfilm copy and documented in an electronic data base. The electronic data base
i                          allowed the licensee to do a " key word' search of those MWRs written after 1980. From
j                          the keyword search, the 72,902 MWRs were reduced by 51,994 MWRs to
;                            20,908 MWRs.
  !
!
;
 
    ___                                                            __                  .
1 -
                                                                                                      1
                                                                                                      1
  .
                                                    -2-                                                i
                                                                                                      l
                                                                                                      1
          Licensee personnel screened 14,740 of the 20,908 MWRs by evaluating whether the            ,
          documents contained changes that may have been unauthorized modifications. This            l
          was referred to as the first screening criteria. Approximately 5,712 MWRs were
          screened, utilizing the same criteria, by contract personnel. Of the 20,908 MWRs
          screened,2,956 were considered to be potential unauthorized modifications.
l
          In addition to the MWR review, the licensee also evaluated past problem identification      l
l          reports (PIRs) to determine if any documented potential unauthorized modifications. An
          additional 318 items were considered to be examples of potential unauthorized
          modifications. However, it was not determined if these were associated with MWRs.
          The team considered the existence of 318 items considered potential unauthorized
,
          modifications to be a serious question of the logic used by the licensee. It was originally
l          assumed by the licensee that all unauthorized modifications were associated with
          weaknesses in the MWR process. Therefore, an exhaustive review of MWRs should
          have revealed all unauthorized modifications. Licensee management committed to
          further review and evaluate the cause of the unauthorized modifications documented in
          these 318 PIRs.
          In accordance with the licensee's program, all potential unauthorized modifications were    j
          given a second, more detailed screening. Of the 3,274 potential unauthorized                !
          modifications (2,956 MWRs and 318 PIRs), project personnel concluded that 1,023 did        l
          not document unauthorized modifications. This resulted in a final tally of 2,251            1
          unauthorized modifications identified by the project and requiring disposition. The team    i
          documented an accounting of the screening process discussed above in Attachment 4.
        b. Observations and Findinas
          As corrective action to prevent recurrence of the unauthorized modification problem,
          licensee personnel combined the requirements of several procedures. Maintenance
          personnel deleted Procedures 7.0.1.3," Maintenance Work Request Planning -
          Documentation of Work," and 7.0.1.6, " Maintenance Work Request - Minor
          Maintenance." For unauthorized modifications, the licensee changed Administrative
          Procedure 0.40, " Work Control Program," combining these requirements into this
          procedure. The licensee also added instructions into Maintenance Procedure 7.0.4,
          " Conduct of Maintenance," to obtain an engineering evaluation for configuration control
          changes.
          The maintenance craftsmen interviewed were cognizant of the unauthorized
          modification issues and the need to verify that replacement components were exactly
          the same. If the components were different, the maintenance craft would obtain an
          engineering evaluation for the change.
          The team observed portions of the work planning process to verify that an unauthorized
          modification would not occur. The work planners properly evaluated potential
          configuration changes and used a planners' desk guide to prescreen MWRs for those
          requiring an engineering review. The team also observed the planners' discussion at a
l
l
 
  _ _ _ _ _ _ _          ---
                              _ _ _ _ _ _ _ _ _ -..                  _____ _ _ _ _ __            _ _ _ .. _    _ . _ _
      .
      .
                                                                  -3-
                      routine meeting to review emergent work. The personnel at the meeting were sensitive
                      to the potential for unauthorized configuration changes and the need for engineering
                      review of these changes.
                      To verify that these procedure changes were effective and the knowledge of the workers            i
                      was adequate, the team reviewed a random sample of 60 MWRs completed after these
                      procedure changes were implemented. A listing of the MWRs is included in
                      Attachment 2. The team did not identify any unauthorized modifications documented
                      within this sample.
                c.    Coriciusions
                      The team concluded that the changes made to licensee procedures and processes for
                      MWRs effectively precluded unauthorized modifications. The work planners and
                      maintenance craft were sensitive to potential configuration changes, and a review of
                      recent MWRs did not identify any unauthorized modifications. However, the team found
                      that the existence of 318 items identified by the licensee as potential unauthorized
                      modifications, that had not been identified through MWR review, indicated that past
                      weaknesses in other licensee programs may have resulted in unauthorized
                      modifications.
                                                          Ill. Engineering
                E1    Conduct of Engineering
                E1.1  Review of MWRs for Unauthorized Modifications
                a.    Inspection Scope (37551)
                      The team assessed the scope and quality of the licensee's efforts involving the                    1
l                      unauthorized modification review program as defined in "CNS Strategy for Achieving
                      Engineering Excellence," Revision 2, dated July 8,1998. Samples of MWRs were
                      ovaluated to determine if they contained unauthorized modifications not identified by the
                      licensee's efforts. The team also conducted interviews with key personnel and
                      management involved in the review,
                b.    Observations and Findinos
,                      The team selected statistically significant samples from each of five populations
l                      according to the method utilized by licensee personnelin determining if unauthorized
i                      modifications existed. The populations are described end the specific examples listed in
i                      Attachment 2 to this inspection report. The following are the findings of the team related
l                      to each sample:
                      1.        The team drew a sample (Sample 1) of 60 MWRs from the population of
                                  22,834 MWRs worked prior to mid 1980 to verify proper sorting of the MWRs.
                                  The goal of the team was to review only those MWRs determined by the licensee
                    _                    _        --
 
  . . . . .      _        .._    . -          - - - - - . _ - . - - - . - .                . -    - - -
                                                                                                            i
                                                                                                            l
                                                                                                            '
                                                          -4-
                not to include unauthorized modifications (rejected). However, the total
                population of 22,834 MWRs was sampled because the project coordinators had
                not tracked the exact number of MWRs rejected from this population. The team
6
                sampled the entire population, and the 3 MWRs previously identified by licensee
                personnel to document unauthorized modifications were verified to be included                j
                on the list of 2,251 unauthorized modifications identified by the licensee.                  j
                                                                                                            l
                a      The team identified one MWR from Sample 1 that represented an                        1
                        unauthorized modification. Based on the team's sampling method, the
                        identification of one MWR documenting an unauthorized modification that
                        had not been identified by the licensee's process was statistically
l                        significant. The MWR identified was worked on May 11,1978. At that
I
                        time, craftsmen manufactured and installed a guard over the fire system
l
                        flushing pump ventilation openings to prevent recurrence of bird's nests.
                        Licensee personnel concurred with the team's findings and issued
                        PIR 3-40350 to document the failure to identify and correct this specific
                        unauthorized modification.
            2. The team drew a sample (Sample 2) of 60 MWRs from the population of
,
'
                51,994 MWRs. These MWRs represented the population of MWRs that were
                screened by computer searching techniques and determined not to be
                unauthorized modifications. Licensee personnel had utilized a keyword search
                to identify MWRs that were likely to have involved changes to the facility, while
                ruling out those that were properly authorized by appropriate design change
                documents. No unauthorized modifications were identified by the team from
                Sample 2.
                The team used a statistical tolerance sampling plan with a minium sample size
                that would give a high degree of assurance that the licensee's screening process
                was effective. The lack of identified unauthorized modifications from Sample 2
                indicated a 95 percent confidence that 95 percent of the population did not
                contain unauthorized modifications.
            3. The team drew two samples (Samples 3 and 4, respectively) from the population
                of 20,462 MWRs. These represented the MWRs from 1980 through 1996 that
                had not been rejected via computer screening techniques, but were not
                considered potential unauthorized modifications by the licensee staff making the
,
                reviews. These items had been rejected using the licensee's first screening
l              criteria as defined in Section M3.1.b of this inspection report. Sample 3                    i
i              consisted of 60 MWRs selected from those screened by permanent plant
l              personnel. Sample 4 consisted of 60 MWRs selected from those screened by
i
                the licensce's contractor. No unauthorized modifications were identified by the
i              team from Sample 3.
i            4. The team identified four MWRs from Sample 4 that represented unauthorized
                modifications. Based on the team's sampling method, the identification of four
{                                                                                                          .
!
i
4
                                                                                                          __
                                                                            . _ _ _              _
 
                                                    _ _ _ _ _ _ _ _ _ _
                                        5-
    MWRs documenting unauthorized modifications that had not been identified by
    the licensee's process was statistically significant. The following represents the
    unauthorized modifications identified by the team:
    *
              MWR 94-4167 documented an unauthorized modification to computer
              consoles in the main control room. On January 10,1992, craftsmen
              installed a 9% foot section of 1-inch square tube steelin the center of the
              main control room. The tube steel was installed as a protective barrier to
              existing power cables. Licansee personnel concurred with the team's
              findings and issued PIR 4-00022 to document the failure to identify and
              correct this specific unauthorized modification.
    *
              MWR 90-2588 documented an unauthorized modification to an indicator
              isolation valve in the auxiliary steam system. On May 23,1990,
              craftsmen replaced a leaking auxiliary steam petcock with a needle valve.
              The MWR documented that a different type of valve was used and that
              the equipment data file needed to be updated. After NRC identification,
              licensee review found that they failed to update the equipment data file.
            The valve installed was similarly rated for system pressure and the
            system was not safety related. Licensee personnel concurred with the
            team's findings and issued PIR 3-40341 to document the failure to
            identify and correct this specific unauthorized modification.
  *
            MWR 86-2979 documented an unauthorized modification to a pump
            instrument rack in the spent fuel pool cooling system. On August 7,
            1986, craftsmen installed two pipe clamps to fix vibrating instrument and
            controls piping. Licensee personnel concurred with the team's findings
            and issued PIR 3-40338 to document the failure to identify and correct
            this specific unauthorized modification.
  *
            MWR 91-4738 documented an unauthorized modification to a steam
            tunnel fire protection suppression piping hanger. On August 23,1994,
            craftsmen reinstalled a pipe hanger utilizing instructions provided by the
            planner. The component was modified by relocating the hanger,
            enlarging the support plate holes, drilling holes in the steam tunnel wall,
            and using larger anchor bolts. Licensee personnel concurred with the
            team's findings and issued PIR 3-40351 to document the failure to
            identify and correct this specific unauthorized modification.
5. The licensee's program prompted engineers to perform a second screening of
  the potential unauthorized modifications identified by the first screening utilizing
  different criteria. During the second screening, engineers reviewed the
  3,274 items identified as potential unauthorized modifications, reducing the total
  to 2,251 considered by the licensee as documenting unauthorized modifications.
  The team sampled 60 MWRs (Sample 5) from the 1,023 MWRs rejected to verify
  the effectiveness of the second screening process. The team identified two
  MWRs from Sample 4 that represented unauthorized modifications. Based on
  the team's sampling method, the identification of two MWRs documenting
 
    _ _ _.    ~.        . _ _    _ . _ - . _ - _ _ _ _                              . . _    _ - - - _ - . -
      -
                                                                                                                  .
                                                                                                                  !
      .
                                                                                                                  :
                                                                                                                  '
                                                              .6-
                            unauthorized modifications that had not been identified by the licensee's process
                            was statistically significant. The following represents the unauthorized
                            modifications identified by the team:                                                j
                            *
                                    MWR 76-3-71 documented an unauthorized modification to the drywell              I
                                    high pressure annunciator associated with the drywell pump-around
                                    system. Setpoints for the system air compressor automatic function and
                                    the associated annunciator were changed. This system has been
                                    abandoned in place except for testing purposes. Licensee personnel
                                    disagreed with the team's findings because the changing of setpoints on
                                    an abandoned system was not considered to constitute an unauthorized
                                    modification under the licensee's review process. However, the team
                                    determined that the setpoint changes had been made without appropriate
                                    design controls. PIR 3-53069 was issued to document the team's finding
                                    and to further evaluate the concern.
                                                                                                                  1
                            *
                                    MWR 79-5-51 documented an unauthorized modification to the reactor            )
                                                                                                                  '
                                    high water level turbine trip circuitry. On May 18,1979, craftsmen
;                                  installed a capacitor in parallel with a reactor feedwater pump control
l                                  circuit. The capacitor was installed to reduce noite in the control
l                                  circuitry. The engineers performing tha second level screening had
                                    decided that this was not an unauthorized modification because they
                                    thought that the capacitor had been removed in accordance with an              i
.
                                    approved design modification. However, in response to the team's
l                                  questions, engineers performed additional visual inspections, revealing        ,
)                                  that a capacitor had been installed and remained in the circuitry.
l                                  Licensee personnel disagreed with the team's findings because the item
i                                  had been addressed by the " white paper." However, the team noted that
                                    the item was clearly documented in the " white paper" as not being an
,                                  unauthorized modification when the addition of a capacitor to the circuit
I
'
                                    met the definition of an unauthorized modification. Licensee engineers
                                    documented the team's findings on PIR 3-40352 to further evaluate the
                                    concern.
                  During the review of Samples 1 through 5, the team identified seven unauthorized
                  modifications that had not been identified by the licensee's review process. These
                  seven were identified from three populations with a sample of 60 MWRs from each
                  population. This represented an error rate greater than 2 percent from the total
                  300 MWRs reviewed by the team members. The evaluation of MWRs in Samples 2 and
                  3 produced no unauthorized modifications not previously identified by the licensee. This
,
                  indicated a high level of confidence in the computerized screening process and in those
i
  .
                  initially screened directly by licensee personnel. To the contrary, the team identified
l                seven MWRs from Samples 1,4, and 5 that represented unauthorized modifications.
:                Based on the team's sampling method, the identification of these seven MWRs
    ;            documenting unauthorized modifications that had not been identified by the licensee's
  i              process was statistically significant. The safety significance of the seven unauthorized
'
                  modifications identified by the team was low. However, the findings indicated a lack of
                  program oversight.
i
1
F
            n-      n  ,            -g:-                                                                        -
 
  _ _ _ ___      __...___.____-.____._______m._
                                                                                                                  '
    .
    .
                                                                  -7-                                            +
                                                                                                                  i
                    The team concluded that the failure of the licensee's program to identify these seven
                    unauthorized modifications constituted inadequate corrective action taken as a result of
                    Violation 50-298/9604-1013. This failure to take adequate corrective action is the first
                    example of a violation (50-298/9822-01). This violation is being cited because it was
                    identified by the inspectors and, th 3refore, does not meet the criteria for discretion as
                    documented in the NRC Enforcement Criteria. A response is required for this violation        i
                    because the issue was not entered into the licensee's corrective action program until
                    after the inspection was complete. Additionally, the licensee's corrective actions will be
                    reviewed for applicability to the closure of other engineering strategy items.
                                                                                                                  i
            c.    Conclusions
                                                                                                                  i
                    The team identified seven unauthorized modifications from three populations with              l
                    samples of 60 MWRs from each population. This represented a greater than 2 percent            I
                    hit rate from the total 300 MWRs the team members reviewed. The failure of licensee
                    personnel to identify these unauthorized modifications during their review was the first
                    example of a violation for the failure to take adequate corrective actions for the problem    :
l                  identified as Violation 50-298/9604-1013. The safety significance of the items identified      I
                    by the team was low. However, the findings indicated a lack of program oversight.              !
l                                                                                                                  l
            E1.2    Evaluation of Identified Unauthorized Modifications
!
            a.    Inspection Scope (37551,37001)
                                                                                                                  l
                    The team reviewed samples of items identified by the licensee as being unauthorized
                    modifications. Th9 adequacy of the licensee's evaluation and corrective actions for
l                  these identified una Jthorized modifications were assessed. Team members reviewed
                    documentation and ,mocedures, performed visual inspections of plant components, and
                    interviewed person iel t<> assess the adequacy of the licensee's review.
            b.    Observations and Findinas
                    The team selected statistically significant samples from each of three populations
                    according to the method utilized by licensee personnel in evaluating and dispositioning
                    the identified unauthorized modifications. The three populations were categorized as:
                    (1) unauthorized modifications dispositioned by the licensee's generic " white paper;"
                    (2) items dispositioned by generic engineering evaluations addressing multiple
                    unauthorized modifications; and (3) unauthorized modifications dispositioned by item
                    specific evaluations or reviews. The team described the populations and listed the
(                  specific examples in Attachment 2. The following are the findings of the team related to
                    each sample:
,                    1.            The team drew a sample of 60 MWRs (Sample 6) from the population of 1,107
l                                  unauthorized modifications that were dispositioned by the " white paper."
l                                  Program coordinators had grouped potential unauthorized modifications into one
;                                  of seven categories. Each category was then resolved on a generic basis.
j                                  While reviewing Sample 6, the team identified three examples of inadequate
j                                  resolution of design documentation errors that resulted from the unauthorized
i
                                                                                                                    I
                                                                            , , - - - -
 
      - .      . _ .  .    -.        _- -          . . . .    _ - . _ -          .      - - . - .      _ - _ - .
    *
l
    .                                                                                                              ;
l                                                            -8-                                                    :
                    modification. These represented examples of unauthorized modifications
                    identified by the licensee that were not properly dispositioned.                              i
                                                                                                                    i
                    Also, during the team's review of Sample 6, the licensee staff issued
                    PIR 3-40349 to identify that the " white paper" was not a controlled design                    ,
                    document nor were the dispositions of all MWRs associated with the " white                    I
                    paper" resolved in accordance with the design process. The failure to use an                  l
                    approved design process to make or accept design modifications was in violation
!                    of 10 CFR Part 50 Appendix B, Criterion Ill. However, the specific examples
                    identified by the team were cited in the Notice of Violation as a failure to take
                    adequate corrective action. The following documents the specific issues
                    identified by the team:
;
                    *
                              MWR 76-4-108 documented an unauthorized modification of an offgas
                              control room ventilation system solenoid. On April 30,1976, craftsmen
                              installed two snubbers on the cooling water lines. This was identified by
                              the licensee as an unauthorized modification. However, the current
i                              drawings were not updated to reflect the change. Engineers had
!
                              determined, as documented in the " white paper," that no documentation
l                              changes were required. The licensee agreed that this condition was
                              improperly evaluated and issued PIR 3-40353 to document and correct it.
                    *
                              MWR 76-6-13 documented an unauthorized modification of a
l                              temperature control valve temperature element in the main generator
                              exciter. On October 15,1976, craftsmen relocated a temperature
                              element in the main generator exciter to improve the sensing capability of
                              the element. However, the current drawings still do not reflect the
!
'
                              change. The expert panel had determined that no documentation
                              changes were required. The licensee agreed that this condition was
                              improperly evaluated and issued PlR 4-00020 to document and correct
                              the condition.
                    *
                              MWR 77-3-158 documented an unauthorized modification of the air wash
l                              systems for various plant ventilation systems. On March 28,1977,                      l
l
'
                              craftsmen removed from the reactor building, turbine, and other buildings'            l
                              ventilation systems an air wash subsystem that did not work. These
l
                              subsystems were designed to remove particulate from the air supply.
                              This was identified by the licensee as an unauthorized modification.
                              However, the associated drawings have not been consistently updated.
                              Currently, this is a configuration control problem, but the disposition
                              stated that no configuration documents required updates. The licensee
                              agreed that this condition was improperly evaluated and issued PIR 4-
                              00068 to document and correct the condition.
i          2.      The team drew a sample of 88 MWRs (Sample 7) from the population of
                    approximately 545 unauthorized modifications that were dispositioned by generic
  j                  engineering evaluations. The team determined that these MWRs were
                    associated with the 15 engineering evaluations documented in Table S-7.1 in
r
I
i
                                                                                                                    I
          .
 
.
. .
                                            9
        Attachment 2. The team reviewed the engineering evaluations for adequacy and
        assessed the adequacy of these evMuations to address the unauthorized
        modifications documented in the ar,s:)ciated MWRs. The team identified one
        problem with the adequacy of assumptions used in an engineering evaluation in
        Sample 7. This was an additional example of an unauthorized modification
        identified by the licensee that was not properly dispositioned. The following
      documents the specific issue identified by the team:
      a
                item E97-0244 documented a visualinspection of plant anchor bolt
                installations that had been conducted by licensee engineers. One of
                these anchor bolt installations was the mounting for a reactor building
                room partition that was not part of the original design. This had been
                identified by the licensee as an unauthorized modification. Engineering
                Evaluation 98-048 concluded that Calculation NEDC 97-093 was
                adequate to address and resolve this unauthorized modification.
                Calculation NEDC 97-093 addressed the partition and determined that it
                was acceptable for a use-as-is disposition. This acceptance was despite
                the indication that the anchor bolts in the partition were inadequate
                because an assumption was made that the partition would not hit any
                safety-related equipment should it fall over. A team visual inspection
                revealed that the 7-foot tall partition was less than 5 feet from a hydrogen
                analyzer. The licensee has agreed that this condition was improperly
                evaluated and initiated PIR 3-40342.
    3. The team drew a sample of 60 MWRs (Sample 8) from the population of an
      estimated 599 unauthorized modifications that were dispositioned by item-
      specific evaluations and assessments. Three problems were identified in
      Sample 8 associated with the licensee's proper identification of the design basis.
      These were additional examples of unauthonzcd modifications identified by the
      licenseo that were not properly dispositioned. The fo!!owing documents the
      specific issues identified by the team:
      a
                item E97-0101 documented an unauthorized modification to multiple
                plant components consisting of the attachment of drip pans. Licensee
                engineers had reviewed multiple installations of drip pans attached
                directly to plant process components. A calculation had been prepared
                for the resolution of pans attached to nonsafety-related equipment.
                However, the subject closure package stated that the calculation was
                also applicable to the resolution of safety-related penetrations. The team
                noted that the calculation only addressed Seismic Category 11 component
                interactions as opposed to the more stringent requirements of Seismic      I
                Category I applied to safety-related components. The licensee agreed
                that the results were inconclusive and that specific locations were not
                evaluated, and PIR 4-00029 was issued to further review the problem.        l
      *
                MWR 75-4-228 documented an unauthorized modification to the residual
                heat removal system pump seal water lines. Craftsmen had fabricated
                and installed two stiffener brackets. Although the licensee identified this
 
                                            -10-
                  as an unauthorized modification, they determined that no additional
                  corrective action was required solely because the resolution was
                  addressed in a General Electric service information letter. The closure
                  documentation stated that the expert panel determined the service
                  information letter to be the design basis. The licensee has concurred that
                  vendor information does not become part of the design basis without an      ,
                                                                                              '
                  appropriate review and safety evaluation. The licensee planned to
                  address this as a generic problem with their process for handling service
                  information letters. They documented the concern in PIR 4-00041.
          =      MWR 77-11-68 documented an unauthorized modification to the refueling
                  machine fuel handling grapple. Craftsmen had modified the fuel grapple
                  by removing the support spring and replacing several other components.
                  Although the licensee identified this as an unauthorized modification, they
                  determined that no additional corrective action was required solely
                  because the resolution was addressed in a General Electric service
                  information letter. The closure documentation stated that the expert
                  panel determined the service letter to be the design basis. The licensee
                  concurred that vendor information does not become part of the design
                  basis without an appropriate review and safety evaluation. This concern
                  was documented in PIR 4-00041. As stated previously, the licensee
                  planned to address a generic problem with the handling of service
                  information letters.
  During the review of MWRs and associated items included in Samples 6,7, and 8, the
  team identified seven items that the licensee had not properly evaluated once they
  identified that an unauthorized modification existed. The team identified problems with
  items in each sample, indicating a lack of confidence in each of the statistically
  significant samples. The team found that the safety significance of inadequate
  evaluation of these seven items was low. However, the findings indicated a lack of
  program oversight.
  The team concluded that the failure of the licensee to properly evaluate and resolve
j these seven unauthorized modifications constituted inadequate corrective actions taken
  as a result of the problem identified as Violation 50-298/9604-1013. This failure to take
'
  adequate corrective action is a second example of a violation (50-298/9822-02).
  Additionally, the team reviewed the licensee's backlog of items to be completed
  following closure of the unauthorized modification review program. The team evaluated
  those unauthorized modifications from Sample 6 that contained backlog items, as
! documented in Table S-6 of Attachment 2. The program coordinators had characterized
  the backlog as requiring only minor procedural or drawing updates. However, the team
  found that many items required visual inspection to fully assess the scope of the
  problem and that the coordinators required contractor support to better explain the open
  issues. The team concluded that the licensee's decision to leave the backlog open was
  made without a complete understanding of the scope and potentialimpact of each item.
  The program coordinators initiated PIR 3-40348 to document this issue and evaluate the
 
    _ . _ _ _ _ - _          _ ___-                        _ ._-      ___        - . _ . _ . _      _ _ _ _ . _ _ _ . _ . .
  .
  -
                                                                  -11-
                                                                                                                                l
                                                                                                                                i
                        need for corrective action, including properly identifying the scope of work remaining to
                        close each action.
l
                    c.  Conclusions
l
l                        The team identified seven MWRs that were not properly evaluated once the licensee
;                        determined that they documented unauthorized modifications. The engineers' failure to
l                        properly evaluate and correct the conditions adverse to quality identified by the
l                        unauthorized modification review program was an additional example of a violation for
l                        the failure to take adequate corrective actions for the problems identified as
                                                                                                                                )
l                        Violation 50-298/9604-1013. The safety significance of items identified by the team was
                        low. However, the findings indicated a lack of program oversight. The lack of proper
                        design control for the issues resolved by the " white paper" and the licensee's decision to
                        leave the backlog items open having been made without a complete understanding of
                        the scope and potentialimpact of each item were considered additional examples of a
                        lack of program oversight.
                    E7  Quality Assurance in Engineering Activities
                    E7.1 Oversiaht of the Unauthorized Modification Review Proaram and the Enaineerina
                        Strateav
                    a.  Inspection Scope (37551)
                        The team reviewed and evaluated documented licensee assessments of the
                        unauthorized modification review program. Line management involved in the oversight
                        and closure review of the process were interviewed. Additionally, the team observed
                        routine engineering strategy review meetings.
                    b.  Observations and Findinas
                        Following NRC identification of an unauthorized modification associated with the steam
                        tunnel blowout panel and other related problems, the quality assurance organization                    ;
                        conducted a special audit to determine the nature and scope of the problems. This
                        special audit resulted in a review of MWRs for potential unauthorized modifications. The
                        team reviewed those quality assurance audits and surveillances documented in
                        Attachment 3 to this inspection report. Additionally, the team summarized the scope
                        and findings of each review as documented in Attachment 3.
                        Licensee personnel had conducted quality assurance audits and performed
                        management oversight of the unauthorized modification review program. Problems with
                        the first-level screening of MWRs conducted by the contractor were identified during one
                        surveillance and corrective actions were proposed. A followup surveillance activity,
                        performed about 6 weeks later, conc;uded that the problems had been corrected. No
i                        other significant items were noted in the audits or surveillances. However, quality
l                        assurance auditors did not further evaluate the effectiveness of corrective actions
!
                                      _    -_-
 
                                    _ - _____________ _ ___-__
  k
                                                              -12-
                    throughout the process. The team noted that the final quality assurance audit of the
                    program completion had not been performed at the time of the onsite inspection.
                    A required part of the team's sample selection process, documented in Soctions E1.1
                  and E1.2 of this inspection report, was to fully understand and characterize the
                    populations of MWRs and the screening, processing, or evaluation techniques used for
                    each. It took program coordinators, working with contract personnel several days to
                    fully charactenze the disposition and size of each population listed in Attachment 4 to
                  this inspection report. The team also noted problems in characterizing the extent of the
                  backlog and the proper design control of unauthorized modifications dispositioned in the
                  " white paper." The team concluded that oversight of the program End the contractor's
                  activities associated with the unauthorized modification review program was weak.
                  To better understand the oversight provided for the unauthorized modification review
                  program, the team observed a routine engineering strategy review meeting. The status,
                  preparation, schedule, and support needed for the implementation of each item was
                discussed by the strategy owner. This discussion and the feedback from other strategy
                item owners indicated a questioning attitude and a continuous evaluation of
                implementation.
                Through interviews, the team evaluated the reviews conducted by the task owner,
                strategy owner, and independent reviewer on the unauthorized modification review
                program, Engineering Strategy Action item 3.2.e. The task owner and strategy owner
                reviews were both probing supervisory-level reviews of the package contents. The
                independent reviewer had not been directly involved in the program and conaucted a
                review of the closure package, including an evaluation of the appropriateness of actions
                conducted. However, no independent evaluation of the process, input, or data of the
                issue were conducted. The team found it positive, based on the issues identified during
              this inspection, that the program closure package had not made it through the senior
              engineering manager's closure process.
    c.        Conclusions
              The team concluded that licensee management had provided some level of oversight
              over the unauthorized modification review program. However, the team identified
              several problems, in addition to two examples of a violation, that indicated insufficient
              program oversight.
    E8        Miscellaneous Engineering issues
    E8.1      Evaluation of Special Test Procedures (37001)
                10 CFR 50.59 allows licensees to make changes to their plants without prior NRC
              approval, provided certain conditions are satisfied such as an evaluation to establish
              that an unreviewed safety question does not exist. The unauthorized modifications
              review reviewed MWRs to identify modifications made to the plant that were not
              authorized and not reviewed in accordance with 10 CFR 50.59. During this inspection,
f        -----____ _
 
            _-                                _ _ _ _ _ _ _ _ _ _ _ _ _
b
?
                                                                        -13-
      the team selected and reviewed a sample of 30 procedure changes and 30 special test
      procedures previously performed that had required evaluation in accordance with
      10 CFR 50.59. The team identified that eight of the special test procedures did not have
      a record of a 10 CFR 50.59 safety evaluation. These procedures had been performed
      prior to 1979, indicating that the programmatic problems were not current. The
      procedures reviewed were documented in Attachment 3 to this inspection report.
      Licensee staff issued PIR 3-40340 to document the problem of not being able to provide
      evidence that 10 CFR 50.59 safety evaluations were performed for these eight
      procedures. The failure to conduct and document safety evaluations for these tests is
      considered unresolved (50-298/9822-02).
                                          V. Management Meetings
  X1  Exit Meeting Summary
    The team presented the interim inspection results to members of licensee management
    at an exit meeting on November 20,1998. A final exit meeting was conducted via
    telecon on December 8 to discuss the findings contained in the report and additional
    issues identified in the interim.
    The team asked the licensee whether any materials examined during the inspection
    should be considered proprietary. No proprietary information was identified.
  X3 Focus Meeting Summary
    On December 17,1998, a focus meeting was conducted between members of licensee
    management and the NRC staff to discuss the status of the licensee's engineering
    improvement strategy. During that meeting, licensee management discussed the
    findings of this inspection and their preliminary conclusions. The exchange of
    information during the meeting was candid and informative.
                          _ _ _ _ _ _ _ _
 
                                            _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ - _
.
.
                                                  ATTACHMENT 1
                              PARTIAL LIST OF PERSONS CONTACTED
  Licensee
    *P. Adelung, Senior Civil / Structural Engineer
    *K. Billesbach, Quality Assurance Assessment Auditor i
    M. Boyce, Plant Engineering Manager
  *P. Caudill, General Manager, Technical Services
    J. Dykstra, Senior Quality Assurance Engineer
  *T. Gifford, Design Engineering Manager
  *B. Houston, Nuclear Licensing and Safety Manager
    M. Kaul, Shift Supervisor / Operations
    D. Kunsemiller, Consultant, Licensing
    J. Long, Nuclear Projects Manager
  *D. Mangan, Licensing Engineer
    R. Pearson, Lead Project Controls Engineer, Enercon
  *B. Rash, Senior Manager of Engineering
  *N. Sanjanwala, Acting Civil Design Engineering Supervisor
    B. Toline, Quality Assurance Auditor Supervisor
  NRC
  C. Marschall, Chief, Project Branch C, Region IV
  V. Gaddy, Senior Resident inspector, Acting
  C. Skinner, Resident inspector
  * Indicates persons attending both the November 20 and December 8 meetings.
                                  INSPECTION PROCEDURES USED
  IP 37551: Onsite Engineering
  IP 37001: 10 CFR 50.59 Evaluations
  IP 62702: Maintenance Observation
  IP 92903: Followup - Engineering
                            ITEMS OPENED, CLOSED, AND DISCUSSED
  Opened
  50-298/9822-01          VIO    Inadequate corrective action regarding the implementation of the
                                  unauthorized modification review program (Sections E1.1 and
                                  E1.2)
  50-298/9822 02          URI    Performance of special tests without a documented safety
                                  evaluation (Section E8.1)
 
.
.
                                      ATTACHMENT 2
                                                                    .
                      WORK ITEM SAMPLE SELECTIONS REVIEWED
                                          Table S-1
                                  Maintenance Work Orders
  Samole 1:
  Population: 22,834 MWRs written prior to mid 1980.
  Sample Size: 60
  73-12-170            75-4-58                  76-12 86  78-2-189
  74-2-37              75-7-3                  76-12-103 78-3-161
  74-3-36              75-9-33                  77-1-102  78-4-107
  74-4-180            75-10-173                77-1-189  78-5-122
  74-5-248            75-11-129                77-5-259  78-6-25
  74-6-114            75-12-47                77-8-3    78-6-38
  74-6-294            75-12-283                77-8-49  78-9-147
  74-8-292            76-1-141                77-8-250  N79-1 63  ;
  74-9-125            76-1-184                77-9-172  79-1-141
  74-9-153            76-2-48                  77-10-1  79-1-148
  74-9-188            76-3-165                77-10-35  79-4-148  l
  74-11-64            76-5-166                77-10-215 N79-9-30
  75-1-47              76-6-197                77-10-359 79-9-147
  75-1-106            76-8-61                  77-12-193 80-9 13
  75-3-229            76-8-184                78-1-127  N80-10-9  l
                                                                      l
                                                                      l
                                                                      !
 
    . . . _ .        . - . .      .
                                                    . ~ . .      -        . -      . .    . _ - - . - - - . . _ - . _ - - . . .        _ - .
                                                                                  2-
                                                                              Table S-2
                                                                    Maintenance Work Orders
                    Samole 2:
              ',
                    Population: 51,994 MWRs rejected by computer search.
                    Sample Size: 60
                    80-0040                                86-0502                    90-1136                                94-2522
                    81-1184                                86-2921                    90-2344                                94-0711
                    82-0857                                86-4081                    90-3472                                94-5585
                    83-0611                                86-5257                    91-0033                                94-1031
                    83-2070                                87-0744                  91-1255                                95-1023
                    84-0233                                87-0611                  91-2519                                95-0204
                    84-1377                                87-3111                  91-3669                                95-1665
                    84-2506                                88-1547                  92-0538
  '
                                                                                                                              95-0525
l                    85-0266                                88-2810                  92-2139                                95-2406
                    85-1437                                88-3954                  92-3307                                95-0901
                    85-2593                                89-0045                  93-0683                                95-3821
                    85-3690                                89-1265                  93-1927                                95-4239
                    86-0064                                89-2504                  93-0820                                96-0432
l                    86-0226                                89-3609                  93-4276                                96-1024
                                                                                                                                              !
                    86-0231                                89-4638                  94-1131                                96-0700          '
l'
                                                                                                                                              i
!                                                                                                                                              l
;                                                                                                                                              l
                                                                                                                                              I
,
;.                                                                                                                                            ,
t
1
i                                                                                                                                            :
<
                                                                                                                                              !
>
i
:
                  _      __          _ _ _ . . _ _                _ _ _        .      -                ..                  ._    ,.
 
    ._ __    __ - ._ .        _ . _ _ _ . . . - _ - . .          _ _ _ . _ . _ _ _ . _ . _ . . _ . _ _ _ _ _ _ . _ . _ _ . _ _ _
                                                                                                                                            ,
                                                                                                                                            '
o
  4
                                                                      -3-
                                                                                                                                            1
                                                                Table S-3                                                                    ,
                                                                                                                                              '
                                                          Maintenance Work Orders
            Samole 3:
            Population: 14,750 MWRs rejected from first screening by NPPD
            Sample Size: 70
                                                                                                                                              i
            0-09155                  86-1135                              89-2328                                              92-2833    I
            1-24148                  86-2172                              89-3194                                              92-3496      l
            81-0244                  86-3201                              89-3998                                              93-0468
                                                                                                                                              i
            81-1869                  86-4211                              90-0075                                              93-1095      l
                                                                                                                                            ;
            82-0695                  86-5033                              90-0825                                              93-1759
            82-2260                  87-0492                              90-1706                                              93-2303      ,
                                                                                                                                            4
            83-1068                  87-1390                              90-2593                                              93-2925
            83-1996                  87-2318                              90-3397                                              93-3591
            84-0085                  87-3184                              90-4295                                              93-4169      l
                                                                                                                                            1
            84-1071                  88-0180                              91-0606                                              94-0120
            84-2070                  "20986                              91-1334                                              94-0722
            84-2976                  88-1713                              91-2076                                              94-1294
'
            85-0509                  88-2476                              91-2896                                              94-1937
            85-1367                  88 3311                              91-3671                                              94-2525
            85 2249                  88-4185                              92-0179                                              94-3155
            85-3097                  88-5015                              92-0910                                              94-3839
l
            85-4077                  89-0641                              92-1543
,
            86-0337                  89-1521                              92-2284
l
i
?        .                                                                                                                              _-
 
.o
.
                                                -4-
                                            Table S-4
                                  Maintenance Work Orders
  Samole 4:
  Population: =5,712 MWRs rejected from first screening by Enercon
  Sample Size: 63
    0-07309              92-1936                  94-6534          95-2100
    82-0691              92-3234                  94-6713          95-2334
    84-2058              93-0649                  94-6897          95-2606
    85-1303              93-2691                  94-6967          95-2832
    85-4074              94-4089                  94-7040          95-2875
    86-1134              94-4267                  95-0041          95-3003
    86-2979              94-4548                  95-0255          95-3183
    88-2456              94-4738                  95-0460          95-3396
    89-0639              94 4914                  95-0700          95-3545
    90-0720              94-5104                  95-0904          95-3724
    90-2588              94-5312                  95-1099          95-3988
    90-3054              94-5551                  95-1305          95-4299
    91-3288              94-5643                  95-1317          95-4570
    91-3670              94-5792                  95-1480          96-0017
    91-4167              94-6062                  95-1642          96-0267
    92-0699              94-6269                  95-1882          96-0755
                                                                            1
                                                                            ,
                                                                            f
 
    . - . -    . - --.-_  -    .-    ..=...--- - -- -...-..                                  .. - - - -                        - -- - --
o
            .
a                                                                                                                                        .
                                                                                                                                          i
                                                                                  5
                                                                                                                                          i
                                                                    Table S-5
                                                            Maintenance Work Orders                                                      ,
                                                                                                                                          ,
                Samole 5:
              . Population: 1,023 MWRs rejected from second level screening                                                              !
                Sample Size: 60
                                                                                                                                          i
                    74-2-142            75 8-123                                  76-3-141                      78-9-148                l
                    74-2-211            75-8-216                                  76-3-260                      79-5-51
                    74-6-314            75-9-23                                    77-2-10                        N79-10-98
                    74-8-292            75-9-152                                  77-3-161                      80-4-4
                    75-1-139            75-9-318                                  77-4-343                      N80-245                l
                    75-3-36            75-10-14                                    77-6-54                      83-1735
l
l                  75-3-126            75-10-60                                    77-6-121                      84-0562
i                                                                                                                                        .
L                  75-4-224            75-10-68                                    77-6-214                      84-1805
<
                    75-4-247            75-10-132                                  77-12-101                    89-1538
l.                  75-6-13            75-10-323                                  78-1-158                    89-1658
!                  75-6-215            75-12-92                                    78-3-34                      91-0311
                    75-7-56              76-1-285                                  78-4-251                      91-2256
                    75-7-263            76-1-353                                  78-5-149                      91-4099
                    75-7-328            76-2-187                                  78-5-178                      92-1660
                    75-8-15            76-3-71                                    78-7-196                      93-2773
i
r
                                                                                                                                          I
!. '                                                                                                                                        I
  r
  ).
*i
?
l                                                                                                                                          ,
                                                                                                                                          '
i
:
.
      - - -                ,      -                          .-  . - ~ . . . -  ,            - - , , y-- -
                                                                                                                r.      _    -w
 
    . _. _. _..      . . . _ . - . . _ . _ _ _ . _ _ _ .
                                    -
                                                                    . . . . . _ _ . _ . _ . _ .. _ _ .. _ . _ _ _ . _ _ .. _ - _ _ _ _ ... ._
O
    , .
                                                                                -6-                                                                  !
                                                                                                                                                    !
                                                                        Table S-6
                                                                                                                                                    '
                                                                Unauthorized Modifications
            Samole 6:
            Population: 1,107 ltems resolved by the White Paper                                                                                    l
            Sample Size: 60
                                                                                                                                              .
              74-1-235                                76-6-13                      N79-7-41                                        91-0249*
              74-1-87                                76-9-44                      N80-3-58                                        91-0911
                                                                                                                                                    '
              74-12-317                              76-10-30                      N80-6-111                                      92-0667
              74-2-100                                76-11-239'                    N80-9-161                                      92-2295
              74-4-424                                77-3 158                      81-1816                                        93-0140
              74-4-546                                77-4-70                      82-1223*                                      93-3758
              74-6-226                                77-6-212*                    83-1044                                        94-2353          I
              74-7-406                                77-7-134                      83-2677                                        95-0027
i
L            74-8-66*                                77-10-327                    84-0629                                        97-0017*        i
!
l
.
              74-9-127*                                77-12-103                    84-3244                                        E97-0072
              75-3-280                                78-3-49                      85-3126                                        E97-0174*
I
              75-6-30                                  78-4-208'                    86-3044                                        E97-0279*
              75-9-46                                  78-8-147                      89-3910                                        E97-0300*
l            75-10-294                                78-10-170                    90-1916*                                      E97-0371
!
              76-4-108                                79-4-94                      90-2425                                        E97-0378*
            * Items with open issues, " Backlog'
l
t
i
!
,
  (
.
4
i
i
!
<
                                                                                                        -.                                      -
                                                                                                                                                  e
 
  -        . - - . - - . . .          -      - _ - . .  .  - _ ._ -    _    - ... -.. - - -. - --  _
                                                                                                        l
                                                      -7-
                                                  Table S-7
                                                                                                        '
                                        Unauthorized Modifications
l                                                                                                        i
  Samole 7:
  Population: 545 Items resolved by generic engineering evaluations
  Sample Size: 88
    74-2-67                    78-5-42                  82-1604          92-0131
    74-2-360                  78-6-167                  83-0355          92-3034
    74-3-23                    78-9-119                  83-0918          94-0957
    74-9-204                  78-10-133                83-1689          94-4396
    75-5-149                , N79-1-6                  83-2214          94-4919
    75-7-184                  79-4-61                  83-2561          95-0774
    75-10-85                  79-5-5                    84-0844          95-1347
    76-11-253                  N79-5-195                84-2181          E97-0028
    76-2-259                  79-12-33                  84-2794          E97-0093
    76-5-176                  79-12-39                  85-0524          E97-0082
    76-6-118                  80-3-3                    85-3169          E97-0106
    77-1-151                  80-3-49                  86-1603          E97-0113
    77-4-121                  N80-3-90                  86-5330          E97-0117
    77-5-117                  80-5-7                    87-2933          E97-0171
  77 6-4                      80-0180                  88-2041          E97-0182
    77-8-352                  80-0340                  88-3648          E97-0200
  77-8 357                    81-0176                  89-4464          E97-0224
  77-12-104                  81-0668                  89-4486          E97-0242
  78-2-76                    81-1372                  90-1258          E97-0244
  78-2-104                    81-1898                  90-1941          E97-0255
  78-3-168                    81-2407                  90-2885          E97-0356
  78-4-236                    82-1005                  91-2573          E97-0364
l
l
!
!
                                                                      ,.                            ,
 
        .  .. . -..        . -- _        _ _ . - . - - - . - -          - -          . . - . - . .--
..
.o
+
                                                              8-
                                                Table S-7.1
                                        Enaineerino Evaluations
.a
.
  Generic engineering evaluations associated with Sample 7 MWRs
l  Sample Size: 15
    Engineering      Title / Description:
    Evaluation:
    98-136          Evaluation of Miscellaneous Essential Electrical and I&C Unauthorized
                                                                                                        '
                    Modifications                                                                      !
i
    98-132          Evaluation of Miscellaneous Essential Mechanical Unauthorized
                    Modifications
    98-098          Packing Replacements                                                              l
    98-032          Adding Load to Motor Control Centers MCC-LX & MCC-TX
    98-010          Qualify Existing 1/4" Tubing Betv'een Valves DW-V-147 and HPCI-V-284.
    98-009          Evaluation of Miscellaneous Essent;al Civil Unauthorized Modifications
    97-265          Nonseismic Bracing for 5 Hydraulic Control Units
    97-256          Nonessential Unauthorized Mechanical Modifications
    97-253          Various Self-Contained Breathing Apparatus installations in the Plant
    97-217          Chain Welded to Valve RF-V-29
    97-210          Temperature Indicators Mounted in the 125/250 VDC Battery Rooms                    i
    97-173          Rework of Hoist to the Main Lubricating Oil piping above the Reservoir
    97-094          Evaluation of Locked High Radiation Area Gates
    97-093          Unauthorized Concrete Anchor Installations
                                                                                                        i
    97-071          Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement                  i
 
  -.- . . . -              - - . - . - - -                - _    _ - . - - - -          _ . - -        . . . . - . . . . _
  o
i
b9
                                                                    -8-
:
1
                                                                Table S-7.1
;                                                      Enaineerina Evaluations
                                                                                                                              i
i
i              Generic engineering evaluations associated with Sarnple 7 MWRs
i              Sample Size: 15
)              Engineering        Title / Description:                                                                      '
>
                Evaluation:
i
                98-136              Evaluation of Miscellaneous Essential Electrical and l&C Unauthorized
                                    Modifications
                98-132              Evaluation of Miscellaneous Essential Mechanical Unauthorized
                                    Modifications
                98-098              Packing Replacements
                98-032              Adding Load to Motor Control Centers MCC-LX & MCC-TX
                98-010              Qualify Existing 1/4" Tubing Between Valves DW-V-147 and HPCI-V-284.                      l
                98-009              Evaluation of Miscellaneous Essential Civil Unauthorized Modifications
                                                                                                                              l
                97-265              Nonseismic Bracing for 5 Hydraulic Control Units                                          j
                97-256              Nonessential Unauthorized Mechanical Modifications
                97-253              Various Self-Contained Breathing Apparatus installations in the Plant
                97-217              Chain Welded to Valve RF-V-29
                97-210              Temperature Indicators Mounted in the 125/250 VDC Battery Rooms
                97-173              Rework of Hoist to the Main Lubricating Oil piping above the Reservoir
                97-094              Evaluation of Locked High Radiation Area Gates
                97-093              Unauthorized Concrete Anchor installations
                97-071              Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement
                                                                                                                              l
                                                                    _
 
    . _ _ _ __._._ _        ._              . . _ . _ . _ . - .          . . . . - _ _ . _ . _ . - _ -  ___ ._ . _ _    _ _ . _ . - .
                                                                                                                                        !
                                                                                    .g.
                                                                                                                                        *
                                                                          Table S-8
                                                        Unauthorized Modifications                                                        .
                                                                                                                                        !
          Samole 8:                                                                                                                      >
          Population: 599 Items with item-specific resolutions
          Sample Size: 57
                                                                                                                                        i
                                                                                                                                        !
            73-12-137              76-9-248                                              85-1753        E97-0101                        ,
            74-11-138            77-11-68                                              85-2363        E97-0119                        i
            74-3 198              77-3-42                                                86-4123        E97-0178
            74-3-391              77-8-253                                              88-0192        E97-0214
            74-5-185              77-9-269                                              89-1595        E97-0216
                                                                                                                                          !
            74-7-301              78-3-160                                              90-1226        E97-0263                        )
                                                                                                                                        I
i
            74-8-176.            78-4-149                                              92-0285        E97-0360
            75-11-218            78-7-88                                                92-1759        E97-0381
;          75-3-127              78-9-76                                                93-0512        N79-5-156
            75-4-228              79-7-2                                                94-0107        N79-5-75
l          75-8-230              80-0598                                                95-1305        N80-9-23
l          75-8-231              80-8-18                                                CR96-0020      TR80-0499
            76-12-154            81-1557                                                E97-0026
            76-5-300              83-1735                                                E97-0054                                        !
            76-8-178              83-2370                                              E97-0068
L
$
$
  '
:
.
                                    . . . . _ - . _ .          . - - - . ,      ,                                    - _        --
 
  .. .  -  -        . .      - - . . _                  _    . . _ -      - - -  . - - _ . - . . -  - - .- . -        _ - ..-
p
a
0
                                                                          -10-                                                      ;
                                                                                                                                    ;
                                                                  Table S-9
                                                          Maintenance Work Reauests                                                  l
                                                                                                                                    l
                                                                                                                                    !
        Samole 9:
        Population: 4,071 Corrective ma'ntenance MWRs worked following corrective actions
        Sample Size: 60
        96-1030                          96-2062                            97-0622                  97-2840
        96-1105                          96-2129                            97-0731                  97-2913
        96-1433                          96-2197                            97-0872                  97-3011
        97-0157                          96-2264                            97-0939                  98-0134                    l
        96-1300                          96-2331                            97-0972                  98-0448
                                                                                                                                    :
l        96-1384                          96-2400                            97-1175                  98-0677
        96-1426                          96-2465                            97-1132                  98-0636
        96-1635                          97-0341                            97-0824                  98-0998
!
        96-1574                          97-0136                            97-2015                  98-1344
        96-1626                          97-0294                            97-1433                  98-1535                    i
>
                                                                                                                                    !
                                                                                                                                    '
        96-1921                          97-0301                            97-1509                  98-1792
        96-1715                          97-0388                            97-2251                  98-1990                    l
        96-1832                          97-1111                            97-3057                  98-2382
'
        96-1977                          97-0522                            97-2638                  98-2868
        96-1969                          97-1256                            97-2739                  98-3171
i
i
h
l
:
<
                          . , , .            .  . . _ _ .                .._
                                                                                                                    .....m.
 
  . - . . _ .          -.
k
b
                                                      ATTACHMENT 3
                                                  DOCUMENTS REVIEWED
              SPECIAL TEST PROCEDURES
l
'
              NUMBER      DESCRIPTION                                                    REVISION
l            73-2          " Diesel Generator Reliability Testing Program,"                December 1,1973
L
              75-8          " Test Procedure for Lifting Adapter Assembly,"                March 16,1982
              76-1          " Drywall to Torus Leak Rate,"                                  February 27,1976  i
,
                                                                                                              I
,
              76-14        " Testing for Stuck Reed Relays in ARM Averaging cards September 16,1976          i
                                                                                                                '
                              in the Neutron Monitoring System,"
              77-17        "Taking Transformer Loss Compensator Out of Service," February 11,1982
                                                                                                              :
              77-28        * Recirculation Pump Start Without Bypass Valves,"              Date unknown      I
              77-4          "HPCI Run Test,"                                              January 28,1977
                                                                                                                l
              78-1          "RHR-MO-25 Valve Operability,"                                January 20,1978
              QUALITY ASSURANCE AUDITS AND SURVEILLANCES                                                      I
              DATE        AUDIT / SURVEILLANCE        GENERAL FINDINGS / COMMENTS
                                                                                                              .
                                                                                                                l
              4/30/96    96-07a, Unauthorized        Special audit of unauthorized modifications, resulting
                          Modifications                in 3 significant findings at the beginning of
                                                        unauthorized modification review program
              7/17/96    97-07, Design Control        Part of audit was to resolve design controlissues and
                                                        Updated Safety Analysis Report inaccuracies.
              9/4/97      S301-9701,                  Surveillance to assess the status of the unauthorized
                          Unauthorized                modification project. Identified several MWRs that
                          Modifications                were not properly screened.
              10/15/97    E301-9701                    Emergent Surveillance on Unauthorized
                                                        Modifications, to assess problems identified in
                                                        Surveillance S301-9701.
              10/22/97    97-15," Design Control"      Encouragement to complete screening on remaining
.
                                                        MWRs.
              9/10/98    98-14, " Engineering /      Status of unauthorized modification project. Note
                          Special Programs            that an audit will be done later to evaluate
                                                        effectiveness.
I
 
,. . - . - . .    __    - ... -.. _ - . -.~ -- - -_._--- . -          . . . . _ - - .          . . . . . - . . - .
i
'
P
b
b:                                                                                                                      i
I
ro
                                                                                                                      i
                                                                2                                                    )
              MAINTENANCE PROCEDURES REVIEWED
l              PROCEDURE NUMBER    PROCEDURE TITLE                                      REVISION                      .
                                                                                                                      1
i
'
                                                                                                                      :
              Procedure 0.40      Work Control Program                                Revision 15
                                                                                                                      1
                                                                                                                      ,
                                                                                                                      i
!              Procedure 7.0.4      Conduct of Maintenance                              Revision 12                  i
;
                                                                                                                      !
i
l                                                                                                                      l
I
                                                                                                                        l
!
!
!
                                                                                                                        l
!
!
!
!
!.
                                          - - ,              .  , _ .  . _ - -        , - _
 
  _ _ _ . .    ~
                          ,        .-          _. __-._.._____.._ _ _ _ _                    __-..._ . _ . . . _ . _ . _ . _._-
                                                      ATTACllMENT 4
                                      Unauthorized Modification Review Program
            Accounting of Maintenance Work Requests (MWRs):
                                                                                                                                  l
                    MWRs from 1973 - 1980                                22,834'                                                  1
                    MWRs from 1980 - 1996                                72,902
                                                                                                                                  i
            Total Population:                                                            95,736
                                                                                                                                  ]
                                                                                                                                  l
                    Screened via Keyword Search: (51,994)*
                            Exclude MDC, DC
            Total Documents Reviewed:                                                    43,742
                    Pre 1980 = 22,834
                    Post 1980 = 20,908
                    Initial Screening (1st) Criteria: (40,786)                                                                    i
                            NPPD:          (14,750)*                                                                            ;
                            Enercon:                      (~5,712)*                                                              l
                            Pre-1980                    (20,324)                                                                  !
,          Problem Identification Reports Added:                                          318
!
l          Potential Unauthorized Modifications:                                      3,274                                      l
                            Enercon:              2,828                                                                          !
                            NPPD:          128                                                                                    i
                            PIR (Non-MWR)          318                                                                          j
l
                    Non-safety significant (2nd) Criteria:                (1,023)*
            Unauthorized Modification Population:                                        2 2_51
                    White Paper Resolved:                1,107'
                    (Sample included verification of backlog)
                    Engineering Evaluation Resolved:                        545'
                    Other Resolution:                                      599*
!
            Total MWR Population 6/12/96 - Present:                              4,071*
                    (Corrective Maintenance Completed)
            * Samples selected from these populations as documented in Attachment 2 to this inspection
            report.
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:
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Latest revision as of 06:30, 15 December 2020

Insp Rept 50-298/98-22 on 981116-1208.Violations Noted.Major Areas Inspected:Licensee Performance in Completing Engineering Strategy Action Item 3.2.e
ML20199E169
Person / Time
Site: Cooper Entergy icon.png
Issue date: 01/07/1999
From:
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20199E157 List:
References
50-298-98-22, NUDOCS 9901200342
Download: ML20199E169 (31)


See also: IR 05000298/1998022

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ENCLOSURE 2

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U.S. NUCLEAR REGULATORY COMMISSION i

REGION IV '

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Docket No.: 50-298

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License No.: DPR 46 i

Report No.: 50-298/98-22

Licensee: Nebraska Public Power District  !

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Facility: Cooper Nuclear Station i

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Location: P.O. Box 98

Brownville, Nebraska

Dates: November 16 through December 8,1998

Inspectors: David P. Loveless, Sr. Project Engineer

William M. McNeill, Reactor Engineer

James F. Melfi, Project Engineer

Approved By: Charles S. Marschall, Chief

Project Branch C

l Division of Reactor Projects

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l ATTACHMENTS:

Attachment 1 Supplemental Information

Attachment 2 Work Item Sample Selections Reviewed

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j Attachment 3 Documents Reviewed

Attachment 4 Unauthorized Modification Review Program

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9901200342 990107

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PDR ADOCK 05000298

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EXECUTIVE SUMMARY

Cooper Nuclear Station

NRC Inspection Report 50-298/98-22

This focus inspection was conducted to evaluate the licensee's performance in completing

Engineering Strategy Action item 3.2.e," Complete the Unauthorized Modification Review," as 1

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documented in the Cooper Nuclear Station Strategy for Achieving Engineering Excellence,

Revision 2. This program had been created to correct deficiencies identified in previous

escalated enforcement. This focus inspection was the first inspection of a completed

engineering improvement strategy item. The team identified that the program had not identified

all unauthorized modifications, nor had all identified unauthorized modifications been properly

evaluated and dispositioned. The specific safety significance of items identified by the team '

was considered to be relatively low. However, the findings indicated a lack of adequate 1

management oversight of the program. Corrective actions to prevent recurrence of

unauthorized modifications via the maintenance work order process were effective. 4

Maintenance

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The licensee's changes made to their procedures and processes for handling I

maintenance work requests (MWRs) effectively precluded unauthorized modifications.  !

l The work planners and maintenance craftsmen were sensitive to potential configuration '

changes, and a review of recently completed MWRs did not identify any unauthorized

l modifications (Section M3.1).

The existence of 318 items identified by the licensee as potential unauthorized

modifications, that had not been identified through MWR review, indicated that past

weaknesses in other licensee programs may have also resulted in unauthorized

modifications (Section M3.1).

j Enaineerina

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Licensee personnel had failed to identify seven unauthorized modifications identified by

the team. This failure was the first example of a violation for the failure to take adequate

corrective actions to the problem identified as Violation 50-298/9604-1013. The safety

significance of the items identified by the team was low. However, the findings indicated

a lack of program oversight (Section E1.1).

identified by the unauthorized modification review program. This failure was an

additional example of a violation for the failure to take adequate corrective actions

regarding Violation 50-298/9604-1013. The safety significance of items identified by the

l team was low (Section E1.2).

! * Licensee management oversight for the unauthorized modification review program was

! insufficient to identify and correct problems identified by the team. Licensee engineers

failed to utilize their design control process in resolving a majority of the unauthorized

modifications documented. This failure resulted in one example of a violation. Also,

j program coordinators made a decision to leave the backlog items open without a

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complete understanding of the scope and potentialimpact of each item

(Sections E1.1, E1.2, and E7.1).

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Report Details

ll. Maintenance

M3 Maintenance Procedures and Documentation

M3.1 Maintenance Proaram Chanaes to Prevent Unauthorized Modifications  ;

a. Inspection Scope (62702)

The team reviewed the changes made to maintenance procedures and processes to

assess if these changes should preclude future unauthorized modifications. Interviews

were conducted with maintenance department working level personnel. The team

l evaluated a random sample of MWRs completed after corrective actions were i

implemented to determine if they contained unauthorized modifications. l

  • Backaround i

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On November 8,1995, the NRC team identified that the main steam tunnel blowout

I panel sections did not appear to be consistent with diagrams in applicable design l

calculations. A structurally significant coating had been placed on the secondary 1

l containment side of the panel sections, potentially altering their material characteristics

l and strengthening the blowout panel . sections. Increased structural strength would have ,

been nonconservative for the blowout panel's design basis function. In addition, the '

design configuration of the panel sections had not been maintained in associated

documents and drawings. An apparent violation was identified for the failure of the

licensee to pedorm an evaluation in accordance with 10 CFR 50.59 on this modification

to the steam tunnel blowout panel sections. The resulting enforcement action issued

Notice of Violation 96004-01013.

The licensee's response dated May 17,1996, committed to review MWRs according to

a sampling plan. The review would detect modifications installed without performance of

safety evaluations. The sample size initially consisted of 10 percent of a se!ecteo

population of MWRs from 1974 to 1996. The review of this sample of 2090 MWRs

resulted in the identification of 128 unauthorized modifications.

As a result of these findings, the licensee expanded the scope of their sampling to

include all of the remaining MWRs from 1973 - 1996. In an effort to identify all

unauthorized modifications in the plant, the licensee established a population of

l 95,736 MWRs written since initial licensing until June 12,1996. June 12,1996, was the

( date of implementation of the corrective actions to eliminate the possibility of making an

unauthorized modification by means of the MWR process. The licensee divided these

. MWRs into two groups. One group of 22,834 MWRs written before 1980 were available

j on microfilm. A second group of 72,902 MWRs written after 1980 were available on

microfilm copy and documented in an electronic data base. The electronic data base

i allowed the licensee to do a " key word' search of those MWRs written after 1980. From

j the keyword search, the 72,902 MWRs were reduced by 51,994 MWRs to

20,908 MWRs.

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Licensee personnel screened 14,740 of the 20,908 MWRs by evaluating whether the ,

documents contained changes that may have been unauthorized modifications. This l

was referred to as the first screening criteria. Approximately 5,712 MWRs were

screened, utilizing the same criteria, by contract personnel. Of the 20,908 MWRs

screened,2,956 were considered to be potential unauthorized modifications.

l

In addition to the MWR review, the licensee also evaluated past problem identification l

l reports (PIRs) to determine if any documented potential unauthorized modifications. An

additional 318 items were considered to be examples of potential unauthorized

modifications. However, it was not determined if these were associated with MWRs.

The team considered the existence of 318 items considered potential unauthorized

,

modifications to be a serious question of the logic used by the licensee. It was originally

l assumed by the licensee that all unauthorized modifications were associated with

weaknesses in the MWR process. Therefore, an exhaustive review of MWRs should

have revealed all unauthorized modifications. Licensee management committed to

further review and evaluate the cause of the unauthorized modifications documented in

these 318 PIRs.

In accordance with the licensee's program, all potential unauthorized modifications were j

given a second, more detailed screening. Of the 3,274 potential unauthorized  !

modifications (2,956 MWRs and 318 PIRs), project personnel concluded that 1,023 did l

not document unauthorized modifications. This resulted in a final tally of 2,251 1

unauthorized modifications identified by the project and requiring disposition. The team i

documented an accounting of the screening process discussed above in Attachment 4.

b. Observations and Findinas

As corrective action to prevent recurrence of the unauthorized modification problem,

licensee personnel combined the requirements of several procedures. Maintenance

personnel deleted Procedures 7.0.1.3," Maintenance Work Request Planning -

Documentation of Work," and 7.0.1.6, " Maintenance Work Request - Minor

Maintenance." For unauthorized modifications, the licensee changed Administrative

Procedure 0.40, " Work Control Program," combining these requirements into this

procedure. The licensee also added instructions into Maintenance Procedure 7.0.4,

" Conduct of Maintenance," to obtain an engineering evaluation for configuration control

changes.

The maintenance craftsmen interviewed were cognizant of the unauthorized

modification issues and the need to verify that replacement components were exactly

the same. If the components were different, the maintenance craft would obtain an

engineering evaluation for the change.

The team observed portions of the work planning process to verify that an unauthorized

modification would not occur. The work planners properly evaluated potential

configuration changes and used a planners' desk guide to prescreen MWRs for those

requiring an engineering review. The team also observed the planners' discussion at a

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routine meeting to review emergent work. The personnel at the meeting were sensitive

to the potential for unauthorized configuration changes and the need for engineering

review of these changes.

To verify that these procedure changes were effective and the knowledge of the workers i

was adequate, the team reviewed a random sample of 60 MWRs completed after these

procedure changes were implemented. A listing of the MWRs is included in

Attachment 2. The team did not identify any unauthorized modifications documented

within this sample.

c. Coriciusions

The team concluded that the changes made to licensee procedures and processes for

MWRs effectively precluded unauthorized modifications. The work planners and

maintenance craft were sensitive to potential configuration changes, and a review of

recent MWRs did not identify any unauthorized modifications. However, the team found

that the existence of 318 items identified by the licensee as potential unauthorized

modifications, that had not been identified through MWR review, indicated that past

weaknesses in other licensee programs may have resulted in unauthorized

modifications.

Ill. Engineering

E1 Conduct of Engineering

E1.1 Review of MWRs for Unauthorized Modifications

a. Inspection Scope (37551)

The team assessed the scope and quality of the licensee's efforts involving the 1

l unauthorized modification review program as defined in "CNS Strategy for Achieving

Engineering Excellence," Revision 2, dated July 8,1998. Samples of MWRs were

ovaluated to determine if they contained unauthorized modifications not identified by the

licensee's efforts. The team also conducted interviews with key personnel and

management involved in the review,

b. Observations and Findinos

, The team selected statistically significant samples from each of five populations

l according to the method utilized by licensee personnelin determining if unauthorized

i modifications existed. The populations are described end the specific examples listed in

i Attachment 2 to this inspection report. The following are the findings of the team related

l to each sample:

1. The team drew a sample (Sample 1) of 60 MWRs from the population of

22,834 MWRs worked prior to mid 1980 to verify proper sorting of the MWRs.

The goal of the team was to review only those MWRs determined by the licensee

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not to include unauthorized modifications (rejected). However, the total

population of 22,834 MWRs was sampled because the project coordinators had

not tracked the exact number of MWRs rejected from this population. The team

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sampled the entire population, and the 3 MWRs previously identified by licensee

personnel to document unauthorized modifications were verified to be included j

on the list of 2,251 unauthorized modifications identified by the licensee. j

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a The team identified one MWR from Sample 1 that represented an 1

unauthorized modification. Based on the team's sampling method, the

identification of one MWR documenting an unauthorized modification that

had not been identified by the licensee's process was statistically

l significant. The MWR identified was worked on May 11,1978. At that

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time, craftsmen manufactured and installed a guard over the fire system

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flushing pump ventilation openings to prevent recurrence of bird's nests.

Licensee personnel concurred with the team's findings and issued

PIR 3-40350 to document the failure to identify and correct this specific

unauthorized modification.

2. The team drew a sample (Sample 2) of 60 MWRs from the population of

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51,994 MWRs. These MWRs represented the population of MWRs that were

screened by computer searching techniques and determined not to be

unauthorized modifications. Licensee personnel had utilized a keyword search

to identify MWRs that were likely to have involved changes to the facility, while

ruling out those that were properly authorized by appropriate design change

documents. No unauthorized modifications were identified by the team from

Sample 2.

The team used a statistical tolerance sampling plan with a minium sample size

that would give a high degree of assurance that the licensee's screening process

was effective. The lack of identified unauthorized modifications from Sample 2

indicated a 95 percent confidence that 95 percent of the population did not

contain unauthorized modifications.

3. The team drew two samples (Samples 3 and 4, respectively) from the population

of 20,462 MWRs. These represented the MWRs from 1980 through 1996 that

had not been rejected via computer screening techniques, but were not

considered potential unauthorized modifications by the licensee staff making the

,

reviews. These items had been rejected using the licensee's first screening

l criteria as defined in Section M3.1.b of this inspection report. Sample 3 i

i consisted of 60 MWRs selected from those screened by permanent plant

l personnel. Sample 4 consisted of 60 MWRs selected from those screened by

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the licensce's contractor. No unauthorized modifications were identified by the

i team from Sample 3.

i 4. The team identified four MWRs from Sample 4 that represented unauthorized

modifications. Based on the team's sampling method, the identification of four

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MWRs documenting unauthorized modifications that had not been identified by

the licensee's process was statistically significant. The following represents the

unauthorized modifications identified by the team:

MWR 94-4167 documented an unauthorized modification to computer

consoles in the main control room. On January 10,1992, craftsmen

installed a 9% foot section of 1-inch square tube steelin the center of the

main control room. The tube steel was installed as a protective barrier to

existing power cables. Licansee personnel concurred with the team's

findings and issued PIR 4-00022 to document the failure to identify and

correct this specific unauthorized modification.

MWR 90-2588 documented an unauthorized modification to an indicator

isolation valve in the auxiliary steam system. On May 23,1990,

craftsmen replaced a leaking auxiliary steam petcock with a needle valve.

The MWR documented that a different type of valve was used and that

the equipment data file needed to be updated. After NRC identification,

licensee review found that they failed to update the equipment data file.

The valve installed was similarly rated for system pressure and the

system was not safety related. Licensee personnel concurred with the

team's findings and issued PIR 3-40341 to document the failure to

identify and correct this specific unauthorized modification.

MWR 86-2979 documented an unauthorized modification to a pump

instrument rack in the spent fuel pool cooling system. On August 7,

1986, craftsmen installed two pipe clamps to fix vibrating instrument and

controls piping. Licensee personnel concurred with the team's findings

and issued PIR 3-40338 to document the failure to identify and correct

this specific unauthorized modification.

MWR 91-4738 documented an unauthorized modification to a steam

tunnel fire protection suppression piping hanger. On August 23,1994,

craftsmen reinstalled a pipe hanger utilizing instructions provided by the

planner. The component was modified by relocating the hanger,

enlarging the support plate holes, drilling holes in the steam tunnel wall,

and using larger anchor bolts. Licensee personnel concurred with the

team's findings and issued PIR 3-40351 to document the failure to

identify and correct this specific unauthorized modification.

5. The licensee's program prompted engineers to perform a second screening of

the potential unauthorized modifications identified by the first screening utilizing

different criteria. During the second screening, engineers reviewed the

3,274 items identified as potential unauthorized modifications, reducing the total

to 2,251 considered by the licensee as documenting unauthorized modifications.

The team sampled 60 MWRs (Sample 5) from the 1,023 MWRs rejected to verify

the effectiveness of the second screening process. The team identified two

MWRs from Sample 4 that represented unauthorized modifications. Based on

the team's sampling method, the identification of two MWRs documenting

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unauthorized modifications that had not been identified by the licensee's process

was statistically significant. The following represents the unauthorized

modifications identified by the team: j

MWR 76-3-71 documented an unauthorized modification to the drywell I

high pressure annunciator associated with the drywell pump-around

system. Setpoints for the system air compressor automatic function and

the associated annunciator were changed. This system has been

abandoned in place except for testing purposes. Licensee personnel

disagreed with the team's findings because the changing of setpoints on

an abandoned system was not considered to constitute an unauthorized

modification under the licensee's review process. However, the team

determined that the setpoint changes had been made without appropriate

design controls. PIR 3-53069 was issued to document the team's finding

and to further evaluate the concern.

1

MWR 79-5-51 documented an unauthorized modification to the reactor )

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high water level turbine trip circuitry. On May 18,1979, craftsmen

installed a capacitor in parallel with a reactor feedwater pump control

l circuit. The capacitor was installed to reduce noite in the control

l circuitry. The engineers performing tha second level screening had

decided that this was not an unauthorized modification because they

thought that the capacitor had been removed in accordance with an i

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approved design modification. However, in response to the team's

l questions, engineers performed additional visual inspections, revealing ,

) that a capacitor had been installed and remained in the circuitry.

l Licensee personnel disagreed with the team's findings because the item

i had been addressed by the " white paper." However, the team noted that

the item was clearly documented in the " white paper" as not being an

, unauthorized modification when the addition of a capacitor to the circuit

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met the definition of an unauthorized modification. Licensee engineers

documented the team's findings on PIR 3-40352 to further evaluate the

concern.

During the review of Samples 1 through 5, the team identified seven unauthorized

modifications that had not been identified by the licensee's review process. These

seven were identified from three populations with a sample of 60 MWRs from each

population. This represented an error rate greater than 2 percent from the total

300 MWRs reviewed by the team members. The evaluation of MWRs in Samples 2 and

3 produced no unauthorized modifications not previously identified by the licensee. This

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indicated a high level of confidence in the computerized screening process and in those

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initially screened directly by licensee personnel. To the contrary, the team identified

l seven MWRs from Samples 1,4, and 5 that represented unauthorized modifications.

Based on the team's sampling method, the identification of these seven MWRs
documenting unauthorized modifications that had not been identified by the licensee's

i process was statistically significant. The safety significance of the seven unauthorized

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modifications identified by the team was low. However, the findings indicated a lack of

program oversight.

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The team concluded that the failure of the licensee's program to identify these seven

unauthorized modifications constituted inadequate corrective action taken as a result of

Violation 50-298/9604-1013. This failure to take adequate corrective action is the first

example of a violation (50-298/9822-01). This violation is being cited because it was

identified by the inspectors and, th 3refore, does not meet the criteria for discretion as

documented in the NRC Enforcement Criteria. A response is required for this violation i

because the issue was not entered into the licensee's corrective action program until

after the inspection was complete. Additionally, the licensee's corrective actions will be

reviewed for applicability to the closure of other engineering strategy items.

i

c. Conclusions

i

The team identified seven unauthorized modifications from three populations with l

samples of 60 MWRs from each population. This represented a greater than 2 percent I

hit rate from the total 300 MWRs the team members reviewed. The failure of licensee

personnel to identify these unauthorized modifications during their review was the first

example of a violation for the failure to take adequate corrective actions for the problem  :

l identified as Violation 50-298/9604-1013. The safety significance of the items identified I

by the team was low. However, the findings indicated a lack of program oversight.  !

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E1.2 Evaluation of Identified Unauthorized Modifications

!

a. Inspection Scope (37551,37001)

l

The team reviewed samples of items identified by the licensee as being unauthorized

modifications. Th9 adequacy of the licensee's evaluation and corrective actions for

l these identified una Jthorized modifications were assessed. Team members reviewed

documentation and ,mocedures, performed visual inspections of plant components, and

interviewed person iel t<> assess the adequacy of the licensee's review.

b. Observations and Findinas

The team selected statistically significant samples from each of three populations

according to the method utilized by licensee personnel in evaluating and dispositioning

the identified unauthorized modifications. The three populations were categorized as:

(1) unauthorized modifications dispositioned by the licensee's generic " white paper;"

(2) items dispositioned by generic engineering evaluations addressing multiple

unauthorized modifications; and (3) unauthorized modifications dispositioned by item

specific evaluations or reviews. The team described the populations and listed the

( specific examples in Attachment 2. The following are the findings of the team related to

each sample:

, 1. The team drew a sample of 60 MWRs (Sample 6) from the population of 1,107

l unauthorized modifications that were dispositioned by the " white paper."

l Program coordinators had grouped potential unauthorized modifications into one

of seven categories. Each category was then resolved on a generic basis.

j While reviewing Sample 6, the team identified three examples of inadequate

j resolution of design documentation errors that resulted from the unauthorized

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modification. These represented examples of unauthorized modifications

identified by the licensee that were not properly dispositioned. i

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Also, during the team's review of Sample 6, the licensee staff issued

PIR 3-40349 to identify that the " white paper" was not a controlled design ,

document nor were the dispositions of all MWRs associated with the " white I

paper" resolved in accordance with the design process. The failure to use an l

approved design process to make or accept design modifications was in violation

! of 10 CFR Part 50 Appendix B, Criterion Ill. However, the specific examples

identified by the team were cited in the Notice of Violation as a failure to take

adequate corrective action. The following documents the specific issues

identified by the team:

MWR 76-4-108 documented an unauthorized modification of an offgas

control room ventilation system solenoid. On April 30,1976, craftsmen

installed two snubbers on the cooling water lines. This was identified by

the licensee as an unauthorized modification. However, the current

i drawings were not updated to reflect the change. Engineers had

!

determined, as documented in the " white paper," that no documentation

l changes were required. The licensee agreed that this condition was

improperly evaluated and issued PIR 3-40353 to document and correct it.

MWR 76-6-13 documented an unauthorized modification of a

l temperature control valve temperature element in the main generator

exciter. On October 15,1976, craftsmen relocated a temperature

element in the main generator exciter to improve the sensing capability of

the element. However, the current drawings still do not reflect the

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change. The expert panel had determined that no documentation

changes were required. The licensee agreed that this condition was

improperly evaluated and issued PlR 4-00020 to document and correct

the condition.

MWR 77-3-158 documented an unauthorized modification of the air wash

l systems for various plant ventilation systems. On March 28,1977, l

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craftsmen removed from the reactor building, turbine, and other buildings' l

ventilation systems an air wash subsystem that did not work. These

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subsystems were designed to remove particulate from the air supply.

This was identified by the licensee as an unauthorized modification.

However, the associated drawings have not been consistently updated.

Currently, this is a configuration control problem, but the disposition

stated that no configuration documents required updates. The licensee

agreed that this condition was improperly evaluated and issued PIR 4-

00068 to document and correct the condition.

i 2. The team drew a sample of 88 MWRs (Sample 7) from the population of

approximately 545 unauthorized modifications that were dispositioned by generic

j engineering evaluations. The team determined that these MWRs were

associated with the 15 engineering evaluations documented in Table S-7.1 in

r

I

i

I

.

.

. .

9

Attachment 2. The team reviewed the engineering evaluations for adequacy and

assessed the adequacy of these evMuations to address the unauthorized

modifications documented in the ar,s:)ciated MWRs. The team identified one

problem with the adequacy of assumptions used in an engineering evaluation in

Sample 7. This was an additional example of an unauthorized modification

identified by the licensee that was not properly dispositioned. The following

documents the specific issue identified by the team:

a

item E97-0244 documented a visualinspection of plant anchor bolt

installations that had been conducted by licensee engineers. One of

these anchor bolt installations was the mounting for a reactor building

room partition that was not part of the original design. This had been

identified by the licensee as an unauthorized modification. Engineering

Evaluation 98-048 concluded that Calculation NEDC 97-093 was

adequate to address and resolve this unauthorized modification.

Calculation NEDC 97-093 addressed the partition and determined that it

was acceptable for a use-as-is disposition. This acceptance was despite

the indication that the anchor bolts in the partition were inadequate

because an assumption was made that the partition would not hit any

safety-related equipment should it fall over. A team visual inspection

revealed that the 7-foot tall partition was less than 5 feet from a hydrogen

analyzer. The licensee has agreed that this condition was improperly

evaluated and initiated PIR 3-40342.

3. The team drew a sample of 60 MWRs (Sample 8) from the population of an

estimated 599 unauthorized modifications that were dispositioned by item-

specific evaluations and assessments. Three problems were identified in

Sample 8 associated with the licensee's proper identification of the design basis.

These were additional examples of unauthonzcd modifications identified by the

licenseo that were not properly dispositioned. The fo!!owing documents the

specific issues identified by the team:

a

item E97-0101 documented an unauthorized modification to multiple

plant components consisting of the attachment of drip pans. Licensee

engineers had reviewed multiple installations of drip pans attached

directly to plant process components. A calculation had been prepared

for the resolution of pans attached to nonsafety-related equipment.

However, the subject closure package stated that the calculation was

also applicable to the resolution of safety-related penetrations. The team

noted that the calculation only addressed Seismic Category 11 component

interactions as opposed to the more stringent requirements of Seismic I

Category I applied to safety-related components. The licensee agreed

that the results were inconclusive and that specific locations were not

evaluated, and PIR 4-00029 was issued to further review the problem. l

MWR 75-4-228 documented an unauthorized modification to the residual

heat removal system pump seal water lines. Craftsmen had fabricated

and installed two stiffener brackets. Although the licensee identified this

-10-

as an unauthorized modification, they determined that no additional

corrective action was required solely because the resolution was

addressed in a General Electric service information letter. The closure

documentation stated that the expert panel determined the service

information letter to be the design basis. The licensee has concurred that

vendor information does not become part of the design basis without an ,

'

appropriate review and safety evaluation. The licensee planned to

address this as a generic problem with their process for handling service

information letters. They documented the concern in PIR 4-00041.

= MWR 77-11-68 documented an unauthorized modification to the refueling

machine fuel handling grapple. Craftsmen had modified the fuel grapple

by removing the support spring and replacing several other components.

Although the licensee identified this as an unauthorized modification, they

determined that no additional corrective action was required solely

because the resolution was addressed in a General Electric service

information letter. The closure documentation stated that the expert

panel determined the service letter to be the design basis. The licensee

concurred that vendor information does not become part of the design

basis without an appropriate review and safety evaluation. This concern

was documented in PIR 4-00041. As stated previously, the licensee

planned to address a generic problem with the handling of service

information letters.

During the review of MWRs and associated items included in Samples 6,7, and 8, the

team identified seven items that the licensee had not properly evaluated once they

identified that an unauthorized modification existed. The team identified problems with

items in each sample, indicating a lack of confidence in each of the statistically

significant samples. The team found that the safety significance of inadequate

evaluation of these seven items was low. However, the findings indicated a lack of

program oversight.

The team concluded that the failure of the licensee to properly evaluate and resolve

j these seven unauthorized modifications constituted inadequate corrective actions taken

as a result of the problem identified as Violation 50-298/9604-1013. This failure to take

'

adequate corrective action is a second example of a violation (50-298/9822-02).

Additionally, the team reviewed the licensee's backlog of items to be completed

following closure of the unauthorized modification review program. The team evaluated

those unauthorized modifications from Sample 6 that contained backlog items, as

! documented in Table S-6 of Attachment 2. The program coordinators had characterized

the backlog as requiring only minor procedural or drawing updates. However, the team

found that many items required visual inspection to fully assess the scope of the

problem and that the coordinators required contractor support to better explain the open

issues. The team concluded that the licensee's decision to leave the backlog open was

made without a complete understanding of the scope and potentialimpact of each item.

The program coordinators initiated PIR 3-40348 to document this issue and evaluate the

_ . _ _ _ _ - _ _ ___- _ ._- ___ - . _ . _ . _ _ _ _ _ . _ _ _ . _ . .

.

-

-11-

l

i

need for corrective action, including properly identifying the scope of work remaining to

close each action.

l

c. Conclusions

l

l The team identified seven MWRs that were not properly evaluated once the licensee

determined that they documented unauthorized modifications. The engineers' failure to

l properly evaluate and correct the conditions adverse to quality identified by the

l unauthorized modification review program was an additional example of a violation for

l the failure to take adequate corrective actions for the problems identified as

)

l Violation 50-298/9604-1013. The safety significance of items identified by the team was

low. However, the findings indicated a lack of program oversight. The lack of proper

design control for the issues resolved by the " white paper" and the licensee's decision to

leave the backlog items open having been made without a complete understanding of

the scope and potentialimpact of each item were considered additional examples of a

lack of program oversight.

E7 Quality Assurance in Engineering Activities

E7.1 Oversiaht of the Unauthorized Modification Review Proaram and the Enaineerina

Strateav

a. Inspection Scope (37551)

The team reviewed and evaluated documented licensee assessments of the

unauthorized modification review program. Line management involved in the oversight

and closure review of the process were interviewed. Additionally, the team observed

routine engineering strategy review meetings.

b. Observations and Findinas

Following NRC identification of an unauthorized modification associated with the steam

tunnel blowout panel and other related problems, the quality assurance organization  ;

conducted a special audit to determine the nature and scope of the problems. This

special audit resulted in a review of MWRs for potential unauthorized modifications. The

team reviewed those quality assurance audits and surveillances documented in

Attachment 3 to this inspection report. Additionally, the team summarized the scope

and findings of each review as documented in Attachment 3.

Licensee personnel had conducted quality assurance audits and performed

management oversight of the unauthorized modification review program. Problems with

the first-level screening of MWRs conducted by the contractor were identified during one

surveillance and corrective actions were proposed. A followup surveillance activity,

performed about 6 weeks later, conc;uded that the problems had been corrected. No

i other significant items were noted in the audits or surveillances. However, quality

l assurance auditors did not further evaluate the effectiveness of corrective actions

!

_ -_-

_ - _____________ _ ___-__

k

-12-

throughout the process. The team noted that the final quality assurance audit of the

program completion had not been performed at the time of the onsite inspection.

A required part of the team's sample selection process, documented in Soctions E1.1

and E1.2 of this inspection report, was to fully understand and characterize the

populations of MWRs and the screening, processing, or evaluation techniques used for

each. It took program coordinators, working with contract personnel several days to

fully charactenze the disposition and size of each population listed in Attachment 4 to

this inspection report. The team also noted problems in characterizing the extent of the

backlog and the proper design control of unauthorized modifications dispositioned in the

" white paper." The team concluded that oversight of the program End the contractor's

activities associated with the unauthorized modification review program was weak.

To better understand the oversight provided for the unauthorized modification review

program, the team observed a routine engineering strategy review meeting. The status,

preparation, schedule, and support needed for the implementation of each item was

discussed by the strategy owner. This discussion and the feedback from other strategy

item owners indicated a questioning attitude and a continuous evaluation of

implementation.

Through interviews, the team evaluated the reviews conducted by the task owner,

strategy owner, and independent reviewer on the unauthorized modification review

program, Engineering Strategy Action item 3.2.e. The task owner and strategy owner

reviews were both probing supervisory-level reviews of the package contents. The

independent reviewer had not been directly involved in the program and conaucted a

review of the closure package, including an evaluation of the appropriateness of actions

conducted. However, no independent evaluation of the process, input, or data of the

issue were conducted. The team found it positive, based on the issues identified during

this inspection, that the program closure package had not made it through the senior

engineering manager's closure process.

c. Conclusions

The team concluded that licensee management had provided some level of oversight

over the unauthorized modification review program. However, the team identified

several problems, in addition to two examples of a violation, that indicated insufficient

program oversight.

E8 Miscellaneous Engineering issues

E8.1 Evaluation of Special Test Procedures (37001)

10 CFR 50.59 allows licensees to make changes to their plants without prior NRC

approval, provided certain conditions are satisfied such as an evaluation to establish

that an unreviewed safety question does not exist. The unauthorized modifications

review reviewed MWRs to identify modifications made to the plant that were not

authorized and not reviewed in accordance with 10 CFR 50.59. During this inspection,

f -----____ _

_- _ _ _ _ _ _ _ _ _ _ _ _ _

b

?

-13-

the team selected and reviewed a sample of 30 procedure changes and 30 special test

procedures previously performed that had required evaluation in accordance with

10 CFR 50.59. The team identified that eight of the special test procedures did not have

a record of a 10 CFR 50.59 safety evaluation. These procedures had been performed

prior to 1979, indicating that the programmatic problems were not current. The

procedures reviewed were documented in Attachment 3 to this inspection report.

Licensee staff issued PIR 3-40340 to document the problem of not being able to provide

evidence that 10 CFR 50.59 safety evaluations were performed for these eight

procedures. The failure to conduct and document safety evaluations for these tests is

considered unresolved (50-298/9822-02).

V. Management Meetings

X1 Exit Meeting Summary

The team presented the interim inspection results to members of licensee management

at an exit meeting on November 20,1998. A final exit meeting was conducted via

telecon on December 8 to discuss the findings contained in the report and additional

issues identified in the interim.

The team asked the licensee whether any materials examined during the inspection

should be considered proprietary. No proprietary information was identified.

X3 Focus Meeting Summary

On December 17,1998, a focus meeting was conducted between members of licensee

management and the NRC staff to discuss the status of the licensee's engineering

improvement strategy. During that meeting, licensee management discussed the

findings of this inspection and their preliminary conclusions. The exchange of

information during the meeting was candid and informative.

_ _ _ _ _ _ _ _

_ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ - _

.

.

ATTACHMENT 1

PARTIAL LIST OF PERSONS CONTACTED

Licensee

  • P. Adelung, Senior Civil / Structural Engineer
  • K. Billesbach, Quality Assurance Assessment Auditor i

M. Boyce, Plant Engineering Manager

  • P. Caudill, General Manager, Technical Services

J. Dykstra, Senior Quality Assurance Engineer

  • T. Gifford, Design Engineering Manager
  • B. Houston, Nuclear Licensing and Safety Manager

M. Kaul, Shift Supervisor / Operations

D. Kunsemiller, Consultant, Licensing

J. Long, Nuclear Projects Manager

  • D. Mangan, Licensing Engineer

R. Pearson, Lead Project Controls Engineer, Enercon

  • B. Rash, Senior Manager of Engineering
  • N. Sanjanwala, Acting Civil Design Engineering Supervisor

B. Toline, Quality Assurance Auditor Supervisor

NRC

C. Marschall, Chief, Project Branch C, Region IV

V. Gaddy, Senior Resident inspector, Acting

C. Skinner, Resident inspector

  • Indicates persons attending both the November 20 and December 8 meetings.

INSPECTION PROCEDURES USED

IP 37551: Onsite Engineering

IP 37001: 10 CFR 50.59 Evaluations

IP 62702: Maintenance Observation

IP 92903: Followup - Engineering

ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

50-298/9822-01 VIO Inadequate corrective action regarding the implementation of the

unauthorized modification review program (Sections E1.1 and

E1.2)

50-298/9822 02 URI Performance of special tests without a documented safety

evaluation (Section E8.1)

.

.

ATTACHMENT 2

.

WORK ITEM SAMPLE SELECTIONS REVIEWED

Table S-1

Maintenance Work Orders

Samole 1:

Population: 22,834 MWRs written prior to mid 1980.

Sample Size: 60

73-12-170 75-4-58 76-12 86 78-2-189

74-2-37 75-7-3 76-12-103 78-3-161

74-3-36 75-9-33 77-1-102 78-4-107

74-4-180 75-10-173 77-1-189 78-5-122

74-5-248 75-11-129 77-5-259 78-6-25

74-6-114 75-12-47 77-8-3 78-6-38

74-6-294 75-12-283 77-8-49 78-9-147

74-8-292 76-1-141 77-8-250 N79-1 63  ;

74-9-125 76-1-184 77-9-172 79-1-141

74-9-153 76-2-48 77-10-1 79-1-148

74-9-188 76-3-165 77-10-35 79-4-148 l

74-11-64 76-5-166 77-10-215 N79-9-30

75-1-47 76-6-197 77-10-359 79-9-147

75-1-106 76-8-61 77-12-193 80-9 13

75-3-229 76-8-184 78-1-127 N80-10-9 l

l

l

!

. . . _ . . - . . .

. ~ . . - . - . . . _ - - . - - - . . _ - . _ - - . . . _ - .

2-

Table S-2

Maintenance Work Orders

Samole 2:

',

Population: 51,994 MWRs rejected by computer search.

Sample Size: 60

80-0040 86-0502 90-1136 94-2522

81-1184 86-2921 90-2344 94-0711

82-0857 86-4081 90-3472 94-5585

83-0611 86-5257 91-0033 94-1031

83-2070 87-0744 91-1255 95-1023

84-0233 87-0611 91-2519 95-0204

84-1377 87-3111 91-3669 95-1665

84-2506 88-1547 92-0538

'

95-0525

l 85-0266 88-2810 92-2139 95-2406

85-1437 88-3954 92-3307 95-0901

85-2593 89-0045 93-0683 95-3821

85-3690 89-1265 93-1927 95-4239

86-0064 89-2504 93-0820 96-0432

l 86-0226 89-3609 93-4276 96-1024

!

86-0231 89-4638 94-1131 96-0700 '

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_ __ _ _ _ . . _ _ _ _ _ . - .. ._ ,.

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,

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4

-3-

1

Table S-3 ,

'

Maintenance Work Orders

Samole 3:

Population: 14,750 MWRs rejected from first screening by NPPD

Sample Size: 70

i

0-09155 86-1135 89-2328 92-2833 I

1-24148 86-2172 89-3194 92-3496 l

81-0244 86-3201 89-3998 93-0468

i

81-1869 86-4211 90-0075 93-1095 l

82-0695 86-5033 90-0825 93-1759

82-2260 87-0492 90-1706 93-2303 ,

4

83-1068 87-1390 90-2593 93-2925

83-1996 87-2318 90-3397 93-3591

84-0085 87-3184 90-4295 93-4169 l

1

84-1071 88-0180 91-0606 94-0120

84-2070 "20986 91-1334 94-0722

84-2976 88-1713 91-2076 94-1294

'

85-0509 88-2476 91-2896 94-1937

85-1367 88 3311 91-3671 94-2525

85 2249 88-4185 92-0179 94-3155

85-3097 88-5015 92-0910 94-3839

l

85-4077 89-0641 92-1543

,

86-0337 89-1521 92-2284

l

i

? . _-

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.

-4-

Table S-4

Maintenance Work Orders

Samole 4:

Population: =5,712 MWRs rejected from first screening by Enercon

Sample Size: 63

0-07309 92-1936 94-6534 95-2100

82-0691 92-3234 94-6713 95-2334

84-2058 93-0649 94-6897 95-2606

85-1303 93-2691 94-6967 95-2832

85-4074 94-4089 94-7040 95-2875

86-1134 94-4267 95-0041 95-3003

86-2979 94-4548 95-0255 95-3183

88-2456 94-4738 95-0460 95-3396

89-0639 94 4914 95-0700 95-3545

90-0720 94-5104 95-0904 95-3724

90-2588 94-5312 95-1099 95-3988

90-3054 94-5551 95-1305 95-4299

91-3288 94-5643 95-1317 95-4570

91-3670 94-5792 95-1480 96-0017

91-4167 94-6062 95-1642 96-0267

92-0699 94-6269 95-1882 96-0755

1

,

f

. - . - . - --.-_ - .- ..=...--- - -- -...-.. .. - - - - - -- - --

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5

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Table S-5

Maintenance Work Orders ,

,

Samole 5:

. Population: 1,023 MWRs rejected from second level screening  !

Sample Size: 60

i

74-2-142 75 8-123 76-3-141 78-9-148 l

74-2-211 75-8-216 76-3-260 79-5-51

74-6-314 75-9-23 77-2-10 N79-10-98

74-8-292 75-9-152 77-3-161 80-4-4

75-1-139 75-9-318 77-4-343 N80-245 l

75-3-36 75-10-14 77-6-54 83-1735

l

l 75-3-126 75-10-60 77-6-121 84-0562

i .

L 75-4-224 75-10-68 77-6-214 84-1805

<

75-4-247 75-10-132 77-12-101 89-1538

l. 75-6-13 75-10-323 78-1-158 89-1658

! 75-6-215 75-12-92 78-3-34 91-0311

75-7-56 76-1-285 78-4-251 91-2256

75-7-263 76-1-353 78-5-149 91-4099

75-7-328 76-2-187 78-5-178 92-1660

75-8-15 76-3-71 78-7-196 93-2773

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. _. _. _.. . . . _ . - . . _ . _ _ _ . _ _ _ .

-

. . . . . _ _ . _ . _ . _ .. _ _ .. _ . _ _ _ . _ _ .. _ - _ _ _ _ ... ._

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, .

-6-  !

!

Table S-6

'

Unauthorized Modifications

Samole 6:

Population: 1,107 ltems resolved by the White Paper l

Sample Size: 60

.

74-1-235 76-6-13 N79-7-41 91-0249*

74-1-87 76-9-44 N80-3-58 91-0911

'

74-12-317 76-10-30 N80-6-111 92-0667

74-2-100 76-11-239' N80-9-161 92-2295

74-4-424 77-3 158 81-1816 93-0140

74-4-546 77-4-70 82-1223* 93-3758

74-6-226 77-6-212* 83-1044 94-2353 I

74-7-406 77-7-134 83-2677 95-0027

i

L 74-8-66* 77-10-327 84-0629 97-0017* i

!

l

.

74-9-127* 77-12-103 84-3244 E97-0072

75-3-280 78-3-49 85-3126 E97-0174*

I

75-6-30 78-4-208' 86-3044 E97-0279*

75-9-46 78-8-147 89-3910 E97-0300*

l 75-10-294 78-10-170 90-1916* E97-0371

!

76-4-108 79-4-94 90-2425 E97-0378*

  • Items with open issues, " Backlog'

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-. -

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- . - - . - - . . . - - _ - . . . - _ ._ - _ - ... -.. - - -. - -- _

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-7-

Table S-7

'

Unauthorized Modifications

l i

Samole 7:

Population: 545 Items resolved by generic engineering evaluations

Sample Size: 88

74-2-67 78-5-42 82-1604 92-0131

74-2-360 78-6-167 83-0355 92-3034

74-3-23 78-9-119 83-0918 94-0957

74-9-204 78-10-133 83-1689 94-4396

75-5-149 , N79-1-6 83-2214 94-4919

75-7-184 79-4-61 83-2561 95-0774

75-10-85 79-5-5 84-0844 95-1347

76-11-253 N79-5-195 84-2181 E97-0028

76-2-259 79-12-33 84-2794 E97-0093

76-5-176 79-12-39 85-0524 E97-0082

76-6-118 80-3-3 85-3169 E97-0106

77-1-151 80-3-49 86-1603 E97-0113

77-4-121 N80-3-90 86-5330 E97-0117

77-5-117 80-5-7 87-2933 E97-0171

77 6-4 80-0180 88-2041 E97-0182

77-8-352 80-0340 88-3648 E97-0200

77-8 357 81-0176 89-4464 E97-0224

77-12-104 81-0668 89-4486 E97-0242

78-2-76 81-1372 90-1258 E97-0244

78-2-104 81-1898 90-1941 E97-0255

78-3-168 81-2407 90-2885 E97-0356

78-4-236 82-1005 91-2573 E97-0364

l

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. .. . -.. . -- _ _ _ . - . - - - . - - - - . . - . - . .--

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8-

Table S-7.1

Enaineerino Evaluations

.a

.

Generic engineering evaluations associated with Sample 7 MWRs

l Sample Size: 15

Engineering Title / Description:

Evaluation:

98-136 Evaluation of Miscellaneous Essential Electrical and I&C Unauthorized

'

Modifications  !

i

98-132 Evaluation of Miscellaneous Essential Mechanical Unauthorized

Modifications98-098 Packing Replacements l

98-032 Adding Load to Motor Control Centers MCC-LX & MCC-TX

98-010 Qualify Existing 1/4" Tubing Betv'een Valves DW-V-147 and HPCI-V-284.98-009 Evaluation of Miscellaneous Essent;al Civil Unauthorized Modifications97-265 Nonseismic Bracing for 5 Hydraulic Control Units97-256 Nonessential Unauthorized Mechanical Modifications97-253 Various Self-Contained Breathing Apparatus installations in the Plant

97-217 Chain Welded to Valve RF-V-29

97-210 Temperature Indicators Mounted in the 125/250 VDC Battery Rooms i

97-173 Rework of Hoist to the Main Lubricating Oil piping above the Reservoir

97-094 Evaluation of Locked High Radiation Area Gates97-093 Unauthorized Concrete Anchor Installations

i

97-071 Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement i

-.- . . . - - - . - . - - - - _ _ - . - - - - _ . - - . . . . - . . . . _

o

i

b9

-8-

1

Table S-7.1

Enaineerina Evaluations

i

i

i Generic engineering evaluations associated with Sarnple 7 MWRs

i Sample Size: 15

) Engineering Title / Description: '

>

Evaluation:

i

98-136 Evaluation of Miscellaneous Essential Electrical and l&C Unauthorized

Modifications98-132 Evaluation of Miscellaneous Essential Mechanical Unauthorized

Modifications98-098 Packing Replacements98-032 Adding Load to Motor Control Centers MCC-LX & MCC-TX

98-010 Qualify Existing 1/4" Tubing Between Valves DW-V-147 and HPCI-V-284. l

98-009 Evaluation of Miscellaneous Essential Civil Unauthorized Modifications

l

97-265 Nonseismic Bracing for 5 Hydraulic Control Units j

97-256 Nonessential Unauthorized Mechanical Modifications97-253 Various Self-Contained Breathing Apparatus installations in the Plant

97-217 Chain Welded to Valve RF-V-29

97-210 Temperature Indicators Mounted in the 125/250 VDC Battery Rooms97-173 Rework of Hoist to the Main Lubricating Oil piping above the Reservoir

97-094 Evaluation of Locked High Radiation Area Gates97-093 Unauthorized Concrete Anchor installations97-071 Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement

l

_

. _ _ _ __._._ _ ._ . . _ . _ . _ . - . . . . . - _ _ . _ . _ . - _ - ___ ._ . _ _ _ _ . _ . - .

!

.g.

Table S-8

Unauthorized Modifications .

!

Samole 8: >

Population: 599 Items with item-specific resolutions

Sample Size: 57

i

!

73-12-137 76-9-248 85-1753 E97-0101 ,

74-11-138 77-11-68 85-2363 E97-0119 i

74-3 198 77-3-42 86-4123 E97-0178

74-3-391 77-8-253 88-0192 E97-0214

74-5-185 77-9-269 89-1595 E97-0216

!

74-7-301 78-3-160 90-1226 E97-0263 )

I

i

74-8-176. 78-4-149 92-0285 E97-0360

75-11-218 78-7-88 92-1759 E97-0381

75-3-127 78-9-76 93-0512 N79-5-156

75-4-228 79-7-2 94-0107 N79-5-75

l 75-8-230 80-0598 95-1305 N80-9-23

l 75-8-231 80-8-18 CR96-0020 TR80-0499

76-12-154 81-1557 E97-0026

76-5-300 83-1735 E97-0054  !

76-8-178 83-2370 E97-0068

L

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.. . - - . . - - . . _ _ . . _ - - - - . - - _ . - . . - - - .- . - _ - ..-

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-10-  ;

Table S-9

Maintenance Work Reauests l

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Samole 9:

Population: 4,071 Corrective ma'ntenance MWRs worked following corrective actions

Sample Size: 60

96-1030 96-2062 97-0622 97-2840

96-1105 96-2129 97-0731 97-2913

96-1433 96-2197 97-0872 97-3011

97-0157 96-2264 97-0939 98-0134 l

96-1300 96-2331 97-0972 98-0448

l 96-1384 96-2400 97-1175 98-0677

96-1426 96-2465 97-1132 98-0636

96-1635 97-0341 97-0824 98-0998

!

96-1574 97-0136 97-2015 98-1344

96-1626 97-0294 97-1433 98-1535 i

>

!

'

96-1921 97-0301 97-1509 98-1792

96-1715 97-0388 97-2251 98-1990 l

96-1832 97-1111 97-3057 98-2382

'

96-1977 97-0522 97-2638 98-2868

96-1969 97-1256 97-2739 98-3171

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.....m.

. - . . _ . -.

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ATTACHMENT 3

DOCUMENTS REVIEWED

SPECIAL TEST PROCEDURES

l

'

NUMBER DESCRIPTION REVISION

l 73-2 " Diesel Generator Reliability Testing Program," December 1,1973

L

75-8 " Test Procedure for Lifting Adapter Assembly," March 16,1982

76-1 " Drywall to Torus Leak Rate," February 27,1976 i

,

I

,

76-14 " Testing for Stuck Reed Relays in ARM Averaging cards September 16,1976 i

'

in the Neutron Monitoring System,"

77-17 "Taking Transformer Loss Compensator Out of Service," February 11,1982

77-28 * Recirculation Pump Start Without Bypass Valves," Date unknown I

77-4 "HPCI Run Test," January 28,1977

l

78-1 "RHR-MO-25 Valve Operability," January 20,1978

QUALITY ASSURANCE AUDITS AND SURVEILLANCES I

DATE AUDIT / SURVEILLANCE GENERAL FINDINGS / COMMENTS

.

l

4/30/96 96-07a, Unauthorized Special audit of unauthorized modifications, resulting

Modifications in 3 significant findings at the beginning of

unauthorized modification review program

7/17/96 97-07, Design Control Part of audit was to resolve design controlissues and

Updated Safety Analysis Report inaccuracies.

9/4/97 S301-9701, Surveillance to assess the status of the unauthorized

Unauthorized modification project. Identified several MWRs that

Modifications were not properly screened.

10/15/97 E301-9701 Emergent Surveillance on Unauthorized

Modifications, to assess problems identified in

Surveillance S301-9701.

10/22/97 97-15," Design Control" Encouragement to complete screening on remaining

.

MWRs.

9/10/98 98-14, " Engineering / Status of unauthorized modification project. Note

Special Programs that an audit will be done later to evaluate

effectiveness.

I

,. . - . - . . __ - ... -.. _ - . -.~ -- - -_._--- . - . . . . _ - - . . . . . . - . . - .

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2 )

MAINTENANCE PROCEDURES REVIEWED

l PROCEDURE NUMBER PROCEDURE TITLE REVISION .

1

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Procedure 0.40 Work Control Program Revision 15

1

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! Procedure 7.0.4 Conduct of Maintenance Revision 12 i

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_ _ _ . . ~

, .- _. __-._.._____.._ _ _ _ _ __-..._ . _ . . . _ . _ . _ . _._-

ATTACllMENT 4

Unauthorized Modification Review Program

Accounting of Maintenance Work Requests (MWRs):

l

MWRs from 1973 - 1980 22,834' 1

MWRs from 1980 - 1996 72,902

i

Total Population: 95,736

]

l

Screened via Keyword Search: (51,994)*

Exclude MDC, DC

Total Documents Reviewed: 43,742

Pre 1980 = 22,834

Post 1980 = 20,908

Initial Screening (1st) Criteria: (40,786) i

NPPD: (14,750)*  ;

Enercon: (~5,712)* l

Pre-1980 (20,324)  !

, Problem Identification Reports Added: 318

!

l Potential Unauthorized Modifications: 3,274 l

Enercon: 2,828  !

NPPD: 128 i

PIR (Non-MWR) 318 j

l

Non-safety significant (2nd) Criteria: (1,023)*

Unauthorized Modification Population: 2 2_51

White Paper Resolved: 1,107'

(Sample included verification of backlog)

Engineering Evaluation Resolved: 545'

Other Resolution: 599*

!

Total MWR Population 6/12/96 - Present: 4,071*

(Corrective Maintenance Completed)

  • Samples selected from these populations as documented in Attachment 2 to this inspection

report.

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