IR 05000298/1998022
| ML20199E169 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| 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) | |
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ENCLOSURE 2
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l U.S. NUCLEAR REGULATORY COMMISSION i
REGION IV
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Docket No.:
50-298
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
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j Attachment 3 Documents Reviewed Attachment 4 Unauthorized Modification Review Program i
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9901200342 990107 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
documented in the Cooper Nuclear Station Strategy for Achieving Engineering Excellence,
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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
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was considered to be relatively low. However, the findings indicated a lack of adequate
management oversight of the program. Corrective actions to prevent recurrence of unauthorized modifications via the maintenance work order process were effective.
Maintenance The licensee's changes made to their procedures and processes for handling I
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maintenance work requests (MWRs) effectively precluded unauthorized modifications.
l The work planners and maintenance craftsmen were sensitive to potential configuration
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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
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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).
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Licensee management oversight for the unauthorized modification review program was
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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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2-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.
Backaround i
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 calculations. A structurally significant coating had been placed on the secondary
l containment side of the panel sections, potentially altering their material characteristics l
and strengthening the blowout panel. sections. Increased structural strength would have
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been nonconservative for the blowout panel's design basis function. In addition, the
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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
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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
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documents contained changes that may have been unauthorized modifications. This 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
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
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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 not document unauthorized modifications. This resulted in a final tally of 2,251
unauthorized modifications identified by the project and requiring disposition. The team 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
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-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
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
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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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-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 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 The team identified one MWR from Sample 1 that represented an
a 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
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51,994 MWRs. These MWRs represented the population of MWRs that were
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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
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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.
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The team identified four MWRs from Sample 4 that represented unauthorized
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modifications. Based on the team's sampling method, the identification of four
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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
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j MWR 76-3-71 documented an unauthorized modification to the drywell
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.
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
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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
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that a capacitor had been installed and remained in the circuitry.
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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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I met the definition of an unauthorized modification. Licensee engineers
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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 i
initially screened directly by licensee personnel. To the contrary, the team identified
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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
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program oversight.
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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.
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Conclusions i
The team identified seven unauthorized modifications from three populations with samples of 60 MWRs from each population. This represented a greater than 2 percent 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 by the team was low. However, the findings indicated a lack of program oversight.
l E1.2 Evaluation of Identified Unauthorized Modifications
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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
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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
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l-8-modification. These represented examples of unauthorized modifications identified by the licensee that were not properly dispositioned.
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
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document nor were the dispositions of all MWRs associated with the " white 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
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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
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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
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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
craftsmen removed from the reactor building, turbine, and other buildings'
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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.
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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
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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:
item E97-0244 documented a visualinspection of plant anchor bolt a
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:
item E97-0101 documented an unauthorized modification to multiple a
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.
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
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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
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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
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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
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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
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-11-i need for corrective action, including properly identifying the scope of work remaining to l
close each action.
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Conclusions 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
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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 other significant items were noted in the audits or surveillances. However, quality i
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 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
... _.
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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
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86-0231 89-4638 94-1131 96-0700 l'
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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
82-0695 86-5033 90-0825 93-1759 82-2260 87-0492 90-1706 93-2303
,
83-1068 87-1390 90-2593 93-2925 83-1996 87-2318 90-3397 93-3591 84-0085 87-3184 90-4295 93-4169
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 85-4077 89-0641 92-1543 l
,
86-0337 89-1521 92-2284 l
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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
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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 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
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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
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Table S-6
'
Unauthorized Modifications Samole 6:
Population: 1,107 ltems resolved by the White Paper 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*
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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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l-7-Table S-7 Unauthorized Modifications
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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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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 Replacements98-032 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
_
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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-284.98-009 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
. _ _
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- 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
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76-8-178 83-2370 E97-0068 L
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-10-Table S-9 Maintenance Work Reauests 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 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
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96-1921 97-0301 97-1509 98-1792 96-1715 97-0388 97-2251 98-1990 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
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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
,
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 77-4
"HPCI Run Test,"
January 28,1977 78-1
"RHR-MO-25 Valve Operability,"
January 20,1978 QUALITY ASSURANCE AUDITS AND SURVEILLANCES DATE AUDIT / SURVEILLANCE GENERAL FINDINGS / COMMENTS
.
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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MAINTENANCE PROCEDURES REVIEWED l
PROCEDURE NUMBER PROCEDURE TITLE REVISION
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Procedure 0.40 Work Control Program Revision 15
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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):
MWRs from 1973 - 1980 22,834'
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)*
Pre-1980 (20,324)
!
,
Problem Identification Reports Added:
318
!
l Potential Unauthorized Modifications:
3,274 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.
l
4