ML20129E933
| ML20129E933 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 09/26/1996 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20129E922 | List: |
| References | |
| 50-341-96-06, 50-341-96-6, NUDOCS 9610040005 | |
| Download: ML20129E933 (35) | |
See also: IR 05000341/1996006
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U.S. NUCLEAR REGULATORY COMISSION ,
REGION 3
Docket No: 50-341 l
License No:
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Report No: 50-341/96006
Licensee: Detroit Edison Company (Deco) .
Facility: Enrico Fermi, Unit 2
Location: 6400 N. Dixie Hwy.
Newport, MI 48166
Dates: June 29 - August 2, 1996
Inspectors: A. Vegel, Senior Resident Inspector
C. O'Keefe, Resident Inspector :
P. Lougheed, Lead Engineering Inspector, RIII
A. Dunlop, Reactor Inspector, RIII
J. Neisler, Reactor Inspector, RIII
R. Jickling, EP Analyst, Region III
A. McQueen, EP Analyst, Region IV
J. Lusher, EP Specialist, Region I
R. Glinski, RP Specialist, Region III
R. Doornbos, Operator Examiner, Region III
Approved by: Mike Jordan, Chief, Branch 7
Division of Reactor Projects
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9610040005 960926
G ADOCK 05000341
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EXECUTIVE SUMMARY
Enrico Fermi, Unit 2
NRC Inspection Report 50-341/96006
This integrated inspection
ing, maintenance, included aspects of licensee operations, engineer-
and plant support.
resident inspection; in addition, it includes the results of an evaluatedThe report
the service water systems, and inspections by regional special .
Operations
e
during an Emergency Diesel Generator 12 surveillance.A near mis
to
(01.2)detail and the absence of a pre-job brief contributed to the event. Lack of attention
e
Inspectors identified an example of an inadequate system operating
procedure for Residual Heat Removal Service Water in that all system
valves were not included in the system lineup verification. Inadequate
procedures continued to be an area of concern.
e (03.1 and E7.1.1)
Control room operators and a chemistry technician were unaware of the
draw a sample for the emergency exercise. abnormal Post Accident Sam
When flow could not be
shut for almost 2 months. established, operators discovered that the flow path had
(04.1)
e
and good coordination and teamwork in the simulator dur
session and the Fermi Emergency Preparedness Exercise. (05.1)
Maintenance
o
Preparation
of for outages,
safety system and execution
declined. of work, particularly during performance
between organizations. assignment of outage managers, parts availabilit
(M1.3)
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has had a positive impact on the corrective maintenance b
other maintenance groups adherence to the maintenance schedule.
o (M1.2)
A series of general service water pump problems resulted in having one
pump unavailable or in reduced status, during most of the inspection
period.
Lack of coordination within maintenance and among supporting
groups
reducedcontributed
capability. to the extended period this important system was at a
(M2.2 and M2.3)
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EXECUTIVE SUMMARY
Enrico Fermi, Unit 2
NRC Inspection Report 50-341/96006
This integrated inspection included aspects of licensee operations, engineer-
ing, maintenance, and plant support. The report covers a 5-week period of
resident inspection; in addition, it includes the results of an evaluated
emergency preparedness exercise, followup of the licensee's self-assessment of
the service water systems, and inspections by regional specialist inspectors.
Ooerations
e A near miss occurred on Technical Specification action statement entry
during an Emergency Diesel Generator 12 surveillance. Lack of attention
to detail and the absence of a pre-job brief contributed to the event.
(01.2)
e Inspectors identified an example of an inadequate system operating
procedure for Residual Heat Removal Service Water in that all system
valves were not included in the system lineup verification. Inadequate
procedures continued to be an area cf concern. (03.1 and E7.1.1)
e Control room operators and a chemistry technician were unaware of the
abnormal Post Accident Sampling System lineup when they attempted to
draw a sample for the emergency exercise. When flow could not be
established, operators discovered that the flow path had been tagged
shut for almost 2 months. (04.1)
P
e Inspectors observed proper use of procedures and emergency declarations,
and good coordination and teamwork in the simulator during a training
session and the Fermi Emergency Preparedness Exercise. (05.1)
Maintenance
e Preparation for and execution of work, particularly during performance
of safety system outages, declined. Problems were identified in timely
assignment of outage managers, parts availability, and coordination
between organizations. (M1.3)
e The recent establishment of the Fermi Integrated Resource Support Team
has had a positive impact on the corrective maintenance backlog and
other maintenance groups adherence to the maintenance schedule. (M1.2)
e A series of general service water pump problems resulted in having one
pump unavailable or in reduced status, during most of the inspection
period. Lack of coordination within maintenance and among supporting
groups contributed to the extended pericd this important system was at a
reduced capability. (M2.2 and M2.3)
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- Restoration from High Pressure Coolant Injection (HPCI) motor operated-
valve testing resulted in a delay in returning HPCI back to service.-
Two bolts were not installed on the valve actuator cover housing. This
required the valve actuator to be disassembled to check for damage and -
to restore the actuator to a normal operation. No damage was detected.
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Enaineerina ,
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e A drain line for the Division 1 safety related_ service water common :
return line to the mechanical draft cooling towers was found by the !
inspectors to be partially plugged for the second time in four monta;. 1
Corrective actions for Violation 341/96004-03 failed to identify this ;
repeat occurrence. (E2.1) j
e The root cause investigation of the fire in the Reactor Water Cleanup
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Filter Demineralizer control panel was timely and thorough, and j
supported a prompt repair and return to service without adversely j
impacting reactor water chemistry. (E2.2) l
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j e NRC followup inspection of the licensee-performed Service Water System
l Operational Performance Inspection found some creas which were not
l covered by the licensee team. However, the NRC identified no additional
l concerns and concluded that the licensee self assessment was adequate. ;
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L Plant Suncort ;
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e Instrumentation and Controls workers performed surveillance' activities
l on the scram discharge volume instruments under the wrong Radiation Work
Permit, and a radiation protection supervisor missed an opportunity to ;
catch the error. (RI.1) i
e Two instances were identified where personnel new to the site violated !
site radiological controls. While the consequences of the events were l
minor, the adequacy of radiation worker trair.ing was of concern, _!
especially in light of the upcoming refueling outage. (R5.1) o
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e The spent fuel pool cleanout project was performed conservatively.
Planning and coordination for the project was meticulous. (R2.1) l
e Overall performance during the 1996 emergency preparedness exercise was
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very good and as indica +ed by the following observations. Emergency ;
l classifications and notifications to offsite authorities were made in a -
timely manner. Technical Support Center staff rapidly evaluated plant
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conditions and made appropriate emergency classifications. Command and -
control and offsite communications were very good in the Emergency ;
Operations Facility. (P4.1) l
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Report Details
So-ary of Plant Status
Unit 2 operated between 85 and 89 percent power throughout this inspection
period, except for power reductions on June 28-29 and August 2, for control
rod pattern adjustments.
I. Operations
01 Conduct of Operations
01.1 General Comments (71707)
Using Inspection Procedure 71707, the inspectors conducted frequent
reviews of ongoing plant operations. In general, the conduct of opera-
tions was professional and safety-conscious; specific events and
noteworthy observations are detailed in.the sections below.
Operations observed in the control room and out in the plant were
performed well. The focus on procedure adherence has resulted in the
identification of a number of corrections. However, the inspectors
noted that the majority of the problems identified during evolutions
monitored by the inspectors were found during performance, rather than
during the pre-job review.
The inspectors noted that on July 5, the control room log entry for
Surveillance 44.020.232, "NS4 Reactor Coolant Injection System (RCIC)
Steam Line Flow Division 2 Functional Test," was incomplete in that only
one of the three Technical Specification (TS) action statements
applicable was listed. This gave the appearance that RCIC system was
not recognized as inoperable during that surveillance until it was found
that the Nuclear Shift Supervisor (NSS) log entry was complete regarding
the TS action statements entered. Inattention to detail was evident in
this instance, and was of concern because the control room practice was
that frequently the NSS log is updated from the control room log ,
entries. l
On July 18, inspectors observed the pre-job brief and performance of
Surveillance 24.202.01, "High Pressure Coolant Injection (HPCI) Pump
Time Response and Operability at 1025 PSI." The brief was detailed and '
thorough, including expected radiological conditions and As Low As
Reasonably Achievable (ALARA) consid0 rations. Operators were assigned
in pairs to provide peer checking, which contributed to a fairly smooth
surveillance run. During the brief, a licensed operator alertly
questioned whether a change in plan to calibrate an instrument if
necessary during the surveillance would invalidate the surveillance
results. This question was resolved prior to beginning. Several minor
procedure problems were identified during the surveillance which were
appropriately resolved by operating shift supervision.
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01.2 Near-miss on Technical Soecification Entry for Fearaency Diesel
Generator (EDG) 12
a. Insoection Scone (61726) l
The inspectors observed the shift turnover brief for the day shift on
July 11. The
cycling drywe?.-torus pre-job brief and
vacuum performance
breakers of thein surveillance
was observed for
the control room;
during this time the below events transpired. Follou p discussions with
the operators involved and the EDG system engineer were conducted
following initial problem identification. The condition of equipment
and course of action were discussed with the system engineer and the
NSS.
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b. Observations and Findinas
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On July 11, operators and maintenance personnel prepared to perform a
Fast Start of EDG 12, Surveillance Procedure 24.307.15. The shift had
planned to perform this surveillance following the cycling of drywell-
torus vacuum breakers. The latter surveillance was in progress while
personnel in the field made preparations for the EDG surveillance. The
i vacuum breaker surveillance required the attention of the Nuclear
l Assistant Shift Supervisor (NASS). When he began to review the EDG
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surveillance procedure he identified that Precaution 2.8 indicated that
Swing Bus 72CF automatic throw-over would be disabled during the
surveillance, which was required to be operable per TS 3.8.3.1.a.3. At
about the same time, operators in the field radioed the control room
that the diesel was being pre-lubricated, allowed by TS, and requested
an announcement for starting the EDG.
The NASS ordered the operators in the field not to start the EDG and
discussed the situation with the NSS and the system engineer. The
action statement for TS 3.8.3.1 wa entered and the surveillance was
l performed without further inddent.
The inspectors determined that no pre-evolution briefing was conducted. I
Operators stated that EDG surveillance runs were performed every week, i
and no briefing was necessary.
The operators routinely reviewed the impact statements attached to the
surveillance procedures to determine TS actions required. In this case,
the impact statement did not include TS 3.8.3.1.a.3. l
c. Conclusions
The inspectors considered this event to be a near-miss avoidance of
I recognizing an entry into a TS requirement. Considering the
surveillance to be routine, operators did not perform a briefing or
review of the procedure sufficiently in advance to identify all the
required actions. Additionally, the operating shift deviated from the
plan to perform the two surveillances sequentially; operators making
preparations in the field progressed into the time-critical starting
sequence tefore the containment vacuum breaker surveillance was
complete.
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02 Operational Status of Facilities and Equipment
02.1 Enaineered Safety Feature (ESF) System Walkdowns (71707) r
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The inspectors used Inspection Procedure 71707 to walk down accessible
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portions of the following ESF systems:
. EDGs 11, 12, 13, and 14
. Standby Liquid Control System j
. Residual Heat Removal (RHR) System
. RHR Service Water (RHRSW) System
. Core Spray System ,
. HPCI System ;
. Primary Containment Nitrogen Inerting System ;
Equipment operability and material condition were acceptable in all
cases. Several minor discrepancies were brought to the licensee's ,
attention and were corrected.' The inspectors identified no substantive ;
concerns as a result of these walkdowns.
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Housekeeping in the HPCI room following the system outage was poor.
Several days after the outage, the inspectors identified outage related
debris in the HPCi room, a ; mall valve packing leak in E41-F031, and two :
valves in series with seat leakage (E41-F055 and E41-F056).
Additionally, a hose directing oil leakage to a container did not reach
the container, and a spare step-off pad was loosely taped to the back of
the safety related HPCI room cool' r just above the cooler suction, such
that it could fall and bloch m i cs to the cooler. Once notified of -
the discrepancies, the liceria u prompt corrective action. The ,
inspectors concluded that furt..er attention to post maintenance i
housekeeping was required.
03 Operations Procedures and Documentation ,
03.1 Procedural Inadeauacies (TI 2515/118 Item 03.02.el) !
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a. Inspection Scope (40501)
NRC temporary instruction (TI) 2515/118 ites 03.02.el required that the {
reviewers walk through the system operating procedures and the system
piping and instrument diagrams with engineering and operations staff.
As this item was not performed during the service water, self-
assessment, the inspectors performed the walk through.
b. Observations and Findinas
The inspectors, together with an engineer and operations support person,
reviewed System Operating Procedure (SOP) 23.208 "RHR Complex Service
Water System" and Functional Operating Sketch 6M721-5706-3 "RHR Service
Water Makeup, Decant and Overflow Systems. The valve lineups and
procedure steps were traced out on the drawing and the rationale for the
step order was discussed. One discrepancy was identified: vent valve
E1100-F258, although shown on the drawing, was not identified in the
procedure. The operations staff initiated a DER, walked down the system
and initiated a temporary procedure change to incorporate that valve,
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and two others identified during the walkdown, into the procedure.
Based on the walkdown results, the operations staff also requested l
labels for several components. i
10 CFR Part 50, Appendix B, Criterion V, requires, in part, that
activities affecting quality be prescribed by documented instructions,
procedures or drawings, of a type appropriate to the circumstances.
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Failure to include all valves in the system lineup verification j
procedure in 50P 23.208 resulted in the procedure being inadequate and
was considered a violation of Criterion V (50-341-96-06-01).
c. Conclusions
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The inspectors identified that 50P 23.208 was inadequate in that it did
not ensure system configuration was maintained by including all system
valves in the system lineup verification. Another example of procedural
inadequacies was identified by plant operators, as discussed in Section
01.2. In this case, the inspectors were concerned that the problem was
, found during performance of the procedure rather during a pre-
performance review, where the problem could be more easily remedied.
. As previously documented in Inspection Report 96002, 96004, and 96005, a
number of procedure inadequacies have been identified. The inspectors
l were concerned that corrective actions to improve procedure quality have
yet to be completely effective.
04 Operator Knowledge and Performance
04.1 Post Accident Samolina System (PASS) Samole Attemoted with System
Isolated and Taaaed
On July 16 during the biennial emergency exercise, chemistry personnel
attempted to obtain a sample from the Post Accident Sampling System.
When proper flow could not be established, control room operators
realized that the sample flow path was isolated by tagged and locked
shut manual valve P34-F004. The manual valve was closed because of
problems with operating solenoid-operated valve P34-F401B " Division 1
Pressurized Reactor Coolant Sample Isolation Valve" in the same line.
This condition was identified by Limiting Condition for Operation 96-
0322, Safety Tagging Record C96-0884, and Control Room Instrument System
dot 111, all dated May 25, 1996.
Despite the available indications and paperwork, neither the chemistry
technician nor the control room operators were aware of the status of
the PASS system. Deviation Event Report (DER) 96-0809 documented this
event. For additional discussion of PASS system operation, see section
P4.1. The occurrence of this event indicated a weakness in control room
operator and chemistry technician cognizance of the status of plant
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equipment.
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04.2 Non-Licensed Doerator Knowledae of Service Water Reauirements (TI
2515/118 Ites 03.02.e)
a. Insoection Scone (40501)
TI 2515/118 ites 03.02.e also required verification that service water
system components and equipment were accessible for normal and emergency
operation, including determination that any special equipment required
to perform the procedures was available and in good working order. It
further required verification of the operators' knowledge of equipment
location and operation.
b. Observations and Findinas
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The inspectors accompanied a nuclear power plant operator (nonlicensed)
on a tour of the general service water (GSW), residual heat removal
service water (RHRSW), diesel generator service water (DGSW) and
emergency equipment service water (EESW) systems. During the tour, the
operator explained what equipmot would be locally operated and under
what conditions. The operator described how he would obtain the
necessary equipment (ie ladders) to perform the procedures. The
operator independently confirmed information discussed in the training
lesson plans and was knowledgeable of a recent emergency equipment
cooling water system modification.
c. Conclusions
The nonlicensed operator was very knowledgeable of service water system
requirements and equipment locations. Besides knowing where equipment
was located, he understood why it needed to be operated and the purpose
of the equipment. No problems were identified during this walkdown.
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05 Operator Training and Qualification
05.1 Simulator Observations l
The inspectors observed simulator training sessions on July 11 and July
16 during the Fermi Emergency Preparedness Exercise.
One scenario run for training was the loss of one reactor recirculation !
pump. This was intended as refresher training due to having one of the
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reactor recirculation motor generator lube oil pumps out of service for '
repairs. The inspectors considered this training to be timely and
pertinent to current operating conditions of the plant.
The balance of simulator scenarios observed were plant casualty i
sessions. Use of procedures and emergency declarations were proper, and
communication and teamwork among operators was excellent. Crews ,
observed did a good job discussing priorities, options, and
recommendations. For additional discussion of operator performance
during the exercise, see section P4.1. !
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05.2 Ooerator Trainino on Service Water (TI 2515/118 Item 03.02.c)
a. Inspection Scone (40501)
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TI 2515/118 item 03.02.c required that the reviewers evaluate operator
training for the service water systems, focusing on the technical
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completeness and accuracy of the training manual and lesson plans. It
further required verification that the lesson plans reflect system
modifications and that the licensed operators have been trained on these j
modifications. I
b. Observations and Findinas
The inspectors reviewed the lesson plans for both licensed and l
nonlicensed operators for initial and continuing training. The lesson !
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plans were determined to be complete and accurate. The inspectors l
reviewed the lesson plan for a recent EECW modification and discussed ;
the modification with the training instructors. The lesson plan !
, appeared to adequately address the modification. '
The inspectors also observed several simulator scenarios where the
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operators had to respond to various service water related transients )
such as failure of a general service water pump, start of the EECW and {
EESW systems and start of the DGSW pumps. The operators responded to !
the various service water alarms appropriately. '
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c. Conclusions
The technical adequacy of the operator training on service water
appeared satisfactory. Lesson plans adequately covered operation of the i
systems under normal and abnormal conditions and were updated to address
i system modifications and that operators were appropriately trained.
The effectiveness of the training was supported by a nonlicensed
operator's understanding of the service water systems and a recent
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modification, as discussed in section 04.2.
l 07 Quality Assurance in Operations Activities
07.1 Followuo Inspection for the Service Water System Self-Assessment
a. Insoection Scope (40501)
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From February 28 through March 29, 1996, the licensee conducted a self-
assessment of the service water system in accordance with TI 2515/118
" Service Water System Operational Performance Inspection (SWSOPI)" and
inspection procedure 40501 " Licensee Self-Assessments Related to Team
Inspections." In accordance with the requirements of 40501, the
inspectors performed a followup inspection on the self-assessment in
order to evaluate (1) whether. the inspection requirements of TI 2515/118
were adequately met by the assessment team and (2) the effectiveness of
- the licensee's responses to the issues raised by the assessment team.
The inspectors reviewed a draft copy of the self-assessment report and
determined that Items 03.01.e, 03.02.c, 03.02.e, 03.03.g and 03.03.h of
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the TI were either not performed or not documented. Therefore, the
inspectors performed an independent inspection of those requirements.
As documented in inspection report 96003, the inspectors had concerns
with the responsiveness of the licensee to some of the assessment team's
issues during performance of the self-assessment. For that reason, the
inspectors independently completed Item 03.04.e of TI 2515/118 to assess
the effectiveness of the assessment team.
Finally, the inspectors reviewed the licensee's responses to all the
issues raised by the assessment team to ensure that the concerns were
being adequately addressed and that no operability concerns existed,
b. Observations and Findinas
Review of the above TI inspection requirements is documented in the
following sections: TI 03.01.e - Section El.1, TI 03.02.c - Section
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. 04.2 TI 03.02.e - Sections 03.1 and 05.2, TI 03.03g - Section M4.4,
l TI 03.03h - Section M5.1, and TI 03.04.e - Section El.2. One violation
l was identified, as discussed in Section 03.1.
Review of the responses to assessment team issues is documented as
follows: maintenance and surveillance and testing - Sections M7.3 &
M7.4, engineering - Section E7.1, and operations - Section 07.2. One
inspection followup issue was identified.
The inspectors reviewed the self-assessment final report, issued
July 19, 1996, 11 weeks after the assessment team exit. While the final
report was much improved over the draft version, the inspectors noted
that there were still some problems. For example, item 03.01.e, on page
C.3, stated that pump runout was addressed by issues 5 and 41. However,
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when the inspectors reviewed these issues, they determined the subject
to be heat exchanger fouling rather than pump runout.
c. Conclusions
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Overall, the inspectors concluded that the self-assessment was
adequately performed. The assessment team covered the majority of the
areas contained in the TI, with only a few items not documented. These
areas were independently reviewed by the inspectors and only one
procedural inadequacy issue was identified. After an initial delay, the
licensee took adequate action to resolve the issues identified by the
assessment team. The inspectors identified one minor concern regarding
stroke time testing, as described in section M7.4. The self-assessment
final report was minimally satisfactory due to the length of time to
issue the report, inspector identification of missed assessment areas, l
and overall weak content of the report. However, the requirements of TI '
2515/118 were met, and the TI is closed.
07.2 Review of Service Water System Self-Assessment Issues
The inspectors reviewed the responses to the four self-assessment issues
! that were within the operations area. All four items were resolved by ;
! procedural clarifications. The inspectors noted the documented response
to issue 31, on RHR reservoir level, did not appear complete 1,n that the
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alarm response procedure did not clearly describe how reservoir level !
was to be verified upon failure of normal instrumentation. Per the !
operations response team member, the intent was to have a power plant
operator measure the distance from the top of the grating to the water i
level using a standard tape measure. Following the discussion, the
liceasee revised the appropriate alarm response procedure to reflect the
above clarification. With this clarification, all of the operational
issues appeared to be resolved in a reasonable manner. The inspectors i
had no concerns with the licensee's responses to the assessment team j
issues in the operations area.
II. Maintenance
M1 Conduct of Maintenance
M1.1 General Comments
a. Inspection Scone (62703)
The inspectors observed all or portions of the following work
activities:
. HPCI Valve E4150-F004 Work
. HPCI Operability Surveillance
. Primary Containment Integrity Verification Surveillance
. Fire Wrap Installation in Control Air Compressor Room
. Drywell - Torus Vacuum Breaker Operability Surveillance
. Emergency Diesel Generator (EDG) 12 Fast Start
b. Observations and Findinos
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As discussed on section 02.1 above, housekeeping and post-maintenance
cleanup were observed to be poor following the HPCI system outage.
L Additionally, test batteries and a cart were left unattended and
l unrestrained in a safety battery room following maintenance (see Section
M4.3). !
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M1.2 First Team Imolementation (62703) !
Inspectors reviewed licensee documents, observed maintenance activities-
and interviewed licensee personnel to assess the effectiveness of
Fermi's Integrated Resource Support Team (F.I.R.S. Team) implementation.
The licensee developed the F.I.R.S. Team to address minor maintenance !
issues. The goals of the team were to perform minor corrective i
maintenance tasks to reduce the maintenance backlog while reducing the l
burden on other maintenance groups. In addition, since the F.I.R.S. Team
was performing emergent corrective maintenance tasks, other maintenance
l organizations were able to focus on maintaining the maintenance
schedule. Since implementation of the F.I.R.S. Team in early June,1996,
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the corrective maintenance backlog had been reduced by approximately 100
] tasks. Also, approximately 38 percent of all work requests written in
July were addressed by the team. The inspectors concluded that the
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F.I.R.S. Team has had a positive impact on the effectiveness of the
licensee's maintenance program.
M1.3 Conclusions on Conduct of Maintenance
Performance in-the area of preparation and execution of planned
maintenance activities, particularly safety system outages, continued to
decline during this inspection period. Poor coordination and a lack of
thorough planning contributed to the continued occurrence of problems
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during the execution of planned maintenance activities.
Of particular concern was an apparent difficulty in identifying and
assigning system outage managers with sufficient lead time to set the
outage scope and coordinate preparations. For example, the RHR system
outage manager was assigned less than a week before the start of the
outage, and the planning meeting was scheduled less than four days
before the outage start date. Even though the RHR system outage was
considered by the licensee to be of greatest risk significance of all
planned system outages in 1996, the adequacy of preparations did not
appear consistent with the risk significance of the outage Most of
the system outages during this inspection period were assigned in a
similar fashion. The consequence of this late planning will be
evaluated in the next report after the completion on the outage.
Continued problems in restoring Number 2 General Service Water (GSW)
Pump to reliable service highlighted problems with work planning and
coordination, parts availability, and vendor oversight as discussed in
Section M2.1 below.
Following the system outage problems in June 1996, the licensee
instituted a new policy to enhance coordination between organizations in i
support of system outages and' ensure preparation in adequate detail. '
Changes included holding briefings attended by all appropriate
organizations prior to system outages to discuss status of preparations,
parts, tagouts, and to resolve any problems. The scope of the outage
was set at this meeting, about a week in advance of the outap. A post-
outage critique was also instituted to document problems and help
prepare for future outages. However, outage scope changes continued to
be made just prior to or during system outages.
An overall effort to improve how work was scheduled and performed was
- underway, headed by the Superintendents of Work Control, Operations and
Maintenance. Some changes have been made in the process and increased !
management attention was evident. However, the inspectors were )
concerned by the work performance problems observed this report period. j
M2 Maintenance and Material Condition of Facilities and Equipment
M2.1 General Service Water Pumo Maintenance Problems
l
a. Inspection Scope (92903) i
The inspectors followed the progress of GSW pump maintenance
difficulties. Maintenance and engineering personnel were interviewed to
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determine the technical and coordination difficulties and failed l
investigation results. '
b. Observations and Findinas
On June 24, the Number 2 GSW pump motor grounded and failed. It was
replaced with a new motor from a different vendor on July 5. Difficulty
in mounting and aligning the motor to the pump was encountered due to
differences in the mating surface geometry. Following return to
service, GSW Pump 2 experienced packing binding. The licensee
determined that the packing was no longer evenly distributed, which
maintenance corrected twice.
On July 14, GSW Pump Number 2 pump shaft sheared just below the motor-
pump shaft coupling. The licensee determined that the shaft failed due
to high cycle fatigue caused by shaft misalignment after about six hours
of run time. This was believed by the licensee to have been caused by
the new motor having the wrong mating surface geometry. The maintenance
l engineer believed that the initial motor to pump alignment was difficuit
l and a misalignment developed because the motor seat did not have the
- proper bevel. The fact that the motor mount was different than previous
motors was not recognized until the motor was first installed.
Maintenance replaced the pump and motor using the original motor which
failed earlier. The motor had been rewound by a vendor not normally
used by the licensee. Following installation, the motor-pump
combination exhibited vibration above the acceptable range,
necessitating the use of the pump only in emergencies. Maintenance
records indicated that the licensee accepted the rewound motor with
vibration levels at the high end of the acceptable range; when coupled
l to the pump, vibration was above the acceptable range. Vendor testing
l of the motor was not observed by the licensee, as was the usual
l practice.
On August 6 the motor was replaced with the motor which previously broke i
the pump shaft. The mating surfaces of the motor had been machined to
produce a better fit and improve the ease of alignment, and the lower l
bearing had been replaced and lubricated by a vendor. During the motor
l installation, maintenance personnel discovered that two dissimilar types
of grease had been used to lubricate the lower motor bearing (DER 96-
1 0905), and that required parts were not available on site for making the
l
electrical connections. Installation was delayed several days due to
- coordination problems within maintenance, and several hours due to
problems among operations, maintenance, and inservice inspection
engineers in coordinating tagging and taking vibration measurements.
l During most of the period of June 24 through August 6, Number 2 GSW Pump
l was considered in a restricted use condition. In the past hot weather
i conditions during this season required the running of all five GSW
- pumps. However, conditions during this period were mild, and all five
j GSW pumps were not required.
The GSW system was ranked the eighth most important system by the
i licensee's Probablistic Risk Assessment (PRA). During this same period,
( GSW Pumps 4 and 5 also required corrective maintenance.
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- c. Conclusions
! This sequence of events represented poor work coordination and a lack of
planning and attention to detail. Inadequate oversight of vendors
, resulted in accepting motors with the wrong lubricant and with high
j vibration. Poor oversight and control of vendors was of concern with
the upcoming refueling outage and the large numbers of contract
- personnel planned to be brought onsite,
i
j The inspectors considered that the coordination and planning involved in.
l this series of repairs fell short of the importance of this system from
! a PRA and Maintenance. Rule perspective. During this period of five
j weeks,. in a season which historically required all available GSW flow,
i maximum capability was not effectively maintained. Had such flow been
j required, operators would have been forced to choose between reducing
j power or running a degraded pump. I
f M2.3 GSW Pi=a Motor Work Performed by Vendor Without Authorization
} I
In an attempt to dete:mine the source of vibration in Number 2 GSW Pump,
'
l
! a representative of the vendor that rewound the motor visited the site
l on July 31. In company with licensee engineers, he went to the motor
'
expecting to find test equip;aent installed in place of the upper motor l
! bearing cover, as was arranged. When it was not installed, he asked if ;
l the motor was tagged out, was told it was, then proceeded to remove the !
j' cover and install the test equipment without authorization. l
l When a maintenance engineer returned from checking the status of work
i package authorization (it was not yet authorized), he found work in
j progress, he ordered work stopped and informed the control room. j
.
[ An investigation by the NSS determined that the tagout was hung but not i
! verified at the time work was performed, and the engineers involved were
i not knowledgeable in contractor control procedures. The vendor was
l directed to leave the sits, the tagout was completed, and work was
performed by licensee maintenance personnel. DER 96-0813 was written to 4
! document the event and track corrective actions. The engineers involved i
- were trained on vendor control procedures and tagout requirements, and
l management expectations in this regard were stressed. i
! In response to this event, the licensee was in the process of conducting
i training on control of vendors for engineering and maintenance personnel
l at the conclusion of this inspection period.
4
Failure to follow procedures for work control and safety tagging was
l considered a violation. However, this will not be cited as the
requirements of the Enforcement Policy,Section VII were met (NCV 50-
, 341-96-06-02).
i
! M4 Maintenance Staff Knowledge and Performance
!
- M4.1 HPCI Suction Path Swanoed Inadvertent 1v Durina Unrelated Maintenance
On July 19, Instrumentation and Control technicians were preparing to
i calibrate the Condensate Storage Tank (CST) level instrument. While
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setting up'at the CST instrument cabinet, the telephone jack was found
l to be inoperable. Radios were then used to establish communications
with the control room. At about the same time, the control room ;
identified that the HPCI suctioni path swapped from the CST to the I
suppression pool..
1
Investigation revealed that CST water level was steady'at 22.5 feet
- during the event, which was.well above the 27 inch low water level
, swapover setpoint.
l
l Work was stopped to determine the cause of the event. The suction path l
l
was returned to normal when CST water level was verified. DER 96-0804 l
was written to document event occurrence and track corrective actions. !
!
The NRC Operations Center was notified in accordance with 50.72 based on
l
the actuation of an ESF system.
!
A Licensee Event Report (LER) investigation was conducted for this '
event. The team concluded that keying of the maintenance worker's radio
approximately six feet away from the CST water level transmitter caused
a false low 13 vel signal four. separate times in a brief period. This
, finding was consistent with testing performed by the licensee following
L a similar event documented by DER 93-0581. Corrective actions for DER
93-0581 included posting the areas around transmitters determined to be
potentially sensitive to radio transmissions with warning signs. This
action did not include the CST level transmitter cabinet. ;
The inspectors will follow up on this event and assess licensee
corrective actions under LER 341/96-010.
M4.2 HPCI Valve Work Error Delays System Restoration
a. Inspection Scope (92503)
The inspectors observed disassembly and inspection of the actuator for
E4150-F004, " Booster Pump CST Suction Isolation Valve ," following
actuator problems. The conditions of work leading to the problems were
discussed with maintenance personnel.
b. Observations and Findinas
On July 17, valve thrust testing on E4150-F004 was performed during a
,
planned HPCI system outage. Test equipment was removod from the
actuator, but raintenance personnel did not reinstail two bolts on the
cover housing for the actuator spring pack. When the valve was
subsequently closed, the spring pack pushed the cover off at an angle
and cocked the declutch lever. This required removing the actuator
motor and partial actuator disassembly to inspect for damage and restore
,
the actuator to normal.
The inspectors observed actuator disassembly and inspection. No damage
was identified, and subsequent testing showed no problems. The
inspectors discussed the event with maintenance personnel, and
determined that no detailed procedure was used for the thrust testing or
test equipment installation and removal. This was because of the many
.
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valve configurations in the plant and because the work was considered :
. within the skill of the craft. '
i c. Conclusions
The inspectors consid eed that inattention to detail by sa'
'
l ince
, workers was the cause of the event, and that this work was i the
i skill of the craft. While no damage was sustained as a re the
j error, system restoration was delayed about 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.
M4.3 Control of Eauinment Durina Battery Charaer Maintenance
J
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a. Insoection Scone (92903)
On August 1, while conducting a walkdown of the Division 2 safety
related battery, inspectors identified that a metal cart and temporary
i
test batteries were left unattended and unsecured in the battery room.
Inspectors reviewed licensee documents including:
.
! . Work Request 000Z965158, Battery Charger 2B-1 Tripping on High
1 Voltage;
j . Operations Conduct Manual M0P 11, Revision 2, Fire Protection.
.
l Inspectors also discussed the' event with licensee maintenance and
operations personnel.
'
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b. Observations and Findinas
1
'
On August 1, during a routine inspection of the Division 2 safety
related battery in the Auxiliary Building, inspectors noted that
temporary test batteries and a metal cart were being stored in the
"
Division 2 Battery Room. The inspectors were concerned that the
l temporary batteries and the cart were not properly secured to prevent
i them from damaging safety related batteries in case of a seismic event.
'
Control room operators were notified and the metal cart was removed.
The temporary batteries and the metal cart were staged in support of
- corrective maintenance activities on the 28-1 battery charger. Work was
. commenced on August 1, and was completed on August 3. However, on
i August 5, inspectors noted that the temporary batteries were still
, stored in the Division 2 Battery Room. In response to the inspectors'
- concerns, the temporary batteries were removed later the same day.
Operations Conduct Manual Chapter ll, " Fire Protection," required, in <
j part, that a temporary plant space request (TPSR) be initiated when
i storing or staging equipment in the Auxiliary Building unless certain
4 requirements were met. Some of the requirements included:
. staging area is roped off and properly identified;
. all materials are properly secured (seismic) in the Reactor,
Auxiliary and RHR Buildings.
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1 The inspectors identified that the above requirements were not met and a j
! TPSR was not utilized when the temporary test batteries were staged in
.
the Division 2 Battery Room from August I to 3. In addition,
- maintenance personnel demonstrated poor housekeeping practices and
- insensitivity to the potential for the metal cart to impact the
1 functionality of Division 2 battery when they left the metal cart
unrestrained on August 1.
Licensee corrective actions included performing a seismic evaluation of
i storing temporary batteries in the Division 2 battery which concluded
i that the impact was. insignificant from a seismic standpoint. In
i addition, the electrical maintenance supervisor initiated. required
- reading on restraint of loose items for the electrical maintenance
i group.
! c. Conclusions
.
The inspectors were concerned that the electrical maintenance personnel
were not following site requirements for the restraint of temporarily
staged equipment in safety related rooms. Specifically, until prompted
. by the inspectors, the licensee staff did not recognize that the sei'saic
j restraining and staging requirements were not met.
1
i Failure to initiate a temporary plant space request on August 1, for
j staging of the temporary test. batteries in the Division 2 Battery Room,
as required by Operations Conduct Manual was a violation of 10 CFR Part
50, Appendix'B, Criteria V, " Instructions, Procedures, and Drawings,"
which states, in part, that activities affecting quality be accomplished
in accordance with prescribed procedures (50-341-96-06-03).
M4.4 Maintenance Personnel Knowledae of Service Water System Reautrements
(TI 2515/118 Ites 03.03.a)
TI 2515/118 item 03.02.c required that the inspectors conduct detailed
interviews with maintenance personnel to determine their technical
knowledge of how components were maintained, such as the setting of
limit switches, the alignment of pump couplings, cleaning and replacing
filters, and the maintenance of circuit breakers. The inspectors
conducted interviews; with four electrical and four mechanical
maintenance workers.
Based on the interviews, the maintenance workers were technically I
knowledgeable within their areas. All of the workers were experienced,
with an average of 8 years within their respective maintenance !
departments. The workers were able to adequately describe the methods l
used to set valve actuator limit switches and align pumps, for example. .
The technical detail of maintenance procedures appeared adequate for the !
craft skill. All the workers'were aware of the actions required by the
licensee's program if a procedure was unclear or incorrect.
.
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M5 Maintenance Staff Training and Qualification !
!
M5.1 Maintenance Trainino Pertainina to the Service Water System (TI 2515/118
Ites 03.03.h) i
TI 2515/118 ites 03.03.h required that the inspectors determine if
maintenance personnel received adequate training pertaining to the
service water system and if the degree of training provided is
consistent with the amount of technical detail in the procedures. 1
During the interviews with maintenance workers, the inspectors
questioned them about the amount of training received. The licensee ,
normally only provided maintenance workers with a brief system overview 1
during the initial "new worker" training. One electrician, who was
recently traresferred to the Fermi site, noted that the system training
covered a lot of systems in a very short period of time, such that he
would not really feel comfortable describing the systems. However, all
of the workers considered that the training they received for their jobs
was extensive and thorough. The workers stated that they received
frequent refresher training, especially in t. heir " specialty" area.
Discussions with the mechanical workers revealed that they were well
aware of microbiological 1y induced corrosion and piping locations and
system conditions that contributed to it.
The inspectors also reviewed sample lesson plans and discussed the j
continuing training program with a training instructor. The Fermi 1
maintenance training appeared to provide a good mixture of classroom l
training with hands-on applications. The instructor noted that there '
was a strong management emphasis on continuing maintenance training.
The inspectors concluded that the maintenance workers received adequate
training to perform maintenance on the service water systems.
M7 Quality Assurance in Saintenance Activities
M7.1 Licensee Self-Assessment of Safety System Outaaes
a. Inspection Scone (40500)
As discussed in Inspection Report 96005, system outages in June 1996 for
the control center heating ventilation and air conditioning (CCHVAC) and
diesel fire pump (DFP) systems encountered difficulties. At the
conclusion of that inspection period, licensee self assessments of these
outages were in progress.
The inspectors discussed the outages and licensee self-assessments with
responsible engineers,. and maintenance personnel, root cause evaluators,
and work control personnel, as well as reviewing system engineering
lessons learned and overall licensee investigation results.
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b. Obser"ations and Findinas f
l
(1) Diesel Fire Pump outage Self Assessment Results j
As documented in Inspection Report 96005, during performance of the 18 ,
month surveillance on the diesel driven fire pump a number of
difficulties were encountered that challenged maintenance, operations, :
and engineering. t
The safety engineering root cause investigation of problems with the DFP t
system outage was detailed and thorough. It identified that i
coordination among groups was lacking. Maintenance and work planning r
groups were unaware that a temporary pump was required, and as a result, :
the outage was scheduled for the day before the critical date. System l
engineering did not begin to prepare a temporary modification package
until 4 days before the' start of the outage, and the initial design was
found to be inadequate upon review. The late start on the modification
and procedure changes resulted in a number of changes to correct errors
prior to implementation of the modification, and contributed to work
being started with the previous revision of the surveillance procedure l
(NOV341/96002-21). Another safety system outage, Primary Containment
'
Monitoring System, was delayed about two months because planners had to
support the DFP scope change to include the installation of temporary
DFPs. Document changes required were not all identified during the
license change request process to allow performing the surveillance on
line. Despite the DFP being equipment covered by TS requirements, the
outage was handled as a balance of plant equipment outage. The lessons
learned included raising future DFP outages to the level of attention
given to safety systems.
DERs 96-0651, 96-0655 and 96-0656 were written to document and track !
corrective actions for problems related to this system outage.
(2) CCHVAC Outage Self-Assessment Results
The investigation into CCHVAC system outage problems was headed by work
control and supported by the Independent Safety Engineering Group. This
self assessment effort was slow to reach conclusions, although some
corrective actions were implemented promptly.,to support upcoming system
outages. These included:
. Getting system engineers more involved in preparation for outages
on their systems, including acting as outage manager in some
cases;
. Initiating system outage briefing meetings to discuss
preparations, tagouts, parts availability, plant impact, status,
contingencies, etc., among all concerned disciplines;
. Adding a backshift outage ::ianager to each system outage.
Lessons learned by system ongineering were developed promptly, and
appeared to be a good review. Engineering identified that the test
procedure for CCHVAC makeup filters was inadequate (NCV in 96005), test
equipment could be improved, and additional personnel required training
19
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to run that type of test. A review of inflatable damper boot seal
failures in CCHVAC dampers showed several failures in the previous year,
with none prior to that time. The seals were original equipment, with
no planned replacement interval and no spares on site. System
engineering was evaluating the seal failures as possibly age-related, t
and consideration was being given to establishing a planned interval for
periodic replacement of these seals based on discussions with the
vendor.
A problem identified in the original testing was the lack of sufficient
system flow. The system engineering assessment identified that, if
, additional system leakage were required to establish required flows, the
door to the CCHVAC mechanical equipment room could be opened without the
,
'
security precautions associated with holding open a door to the control
room. System engineering also informed the inspectors that the retest
performed was not required following removal of the sample canister and
capping of the hole, and that past tests had found no problems; system ;
engineering had required the test as a conservative means to prove the
, main filter was not being bypassed, even though the vendor did not
i
specifically recommend such a test.
- c. Conclusions j
, The inspectors noted that many of the problems exhibited during these i
system outages continued to be problems during this inspection period,
. as discussed in section M1.3 above. Coordination and execution of !
high-visibility maintenance activities declined during this and the
previous inspection period. Self assessment efforts and improvements in
how work is planned and executed were focussed on fixing the process,
and will, therefore, be assessed as changes are implemented. The
assessments were self-critical and thorough.
M7.2 Comorehensive Intearated Technical Assessment (CITA) of Maintenance i
4
!
a. Insoection Scope (62703)
The inspectors reviewed the licensee's Maintenance CITA report and
discussed the results with the Director of Quality Assurance and i
Maintenance Superintendent. l
b. Observations and Findinas
This self assessment was performed by a multi-disciplined team which was
comprised of site personnel and industry peers. The CITA covered the
entire maintenance functional area.
The CITA team concluded that plant equipment was being maintained
appropriately. However, lingering issues, such as inadequate impact
statements and work instructions, procedure adherence, and lack of
sensitivity to housekeeping, which were previously identified still
remain. Improvements in the quality of maintenance technical procedures
were underway, and the focus on procedure adherence had reduced the
number of problems in this area.
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Adherence to the planned work schedule was identified as a problem.
'
Four-week look ahead scheduling meetings were found to be ineffective: +
organizational attendance was poor, attendees were not prepared, and '
- large numbers of activities were added or removed from the schedule
(greater than 25 percent). Late work package planning contributed to
a schedule changes and resulted in little time to walk down jobs prior to
working. -
, Staffing of craft supervisory positions was not always meeting the l
4
supervisor to worker ratio goal. As a result, pre-job briefings were
j suffering and priorities slipped. :
$
l c. Conclusions
4
The inspectors considered the Maintenance CITA to be a start at ,
3 identifying probleias in the maintenance functional area, which had not :
- had a recent self-assessment. However, this assessment primarily
- reiterated previously identified problems, did not identify many new
! areas of concerns, and provided few recommendations for improvements.
j Recent CITAs in Operations and Engineering had provided more detailed
i assessments and recommendations. As discussed in this report, the
{ inspectors concluded that concerns in maintenance and work control
4
continue to exist.
i
,
M7.3 Review of Service Water System Self-Assessment Maintenance Issues
4
, The inspectors reviewed the responses to the eight self-assessment
i issues that were within the maintenance area and discussed them with the
i maintenance response team member. All of the assessment team's issues
! appeared to be resolved in a reasonable manner.
M7.4 Review of Service Water System Self-Assessment Surveillance & Testina
Issues
The inspectors reviewed the responses to the eighteen self-assessment
issues that were within the surveillance area. These items wera divided
roughly between issues concerning the licensee's response to Generic
Letter (GL) 89-13 " Service Water System Problems Affecting Safety-
Related Equipment" and the inservice testing (IST) program. The
inspectors had no problems with the action plans to resolve the
surveillance issues, with the exception of one IST item. The assessment
team had questioned why the RHRSW, DGSW, and EESW pump minimum flow line 1
'
isolation valves and two EESW control valves (P4400-F400A/B) were not in
the IST program. The licensee's response to this issue was to l
incorporate the valves into the program. The inspectors noted that the
licensee had not made provisions to stroke time test the control valves,
nor had they been granted relief by NRC. This will be tracked as an
inspection followup item (50-341-96-06-04).
The self-assessment identified a number of weaknesses with the
licensee's response to GL 89-13, Action III, which concerned testing and I
inspection of heat exchangers. Because of the number of issues i
identified, the inspectors concluded that the licensee had not !
adequately addressed this portion of the GL. The inspectors reviewed
1 j
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the licensee's plan to correct the identified weaknesses and verified
that all the weaknesses were being addressed.
'
The remainder of the assessment team's issues appeared to be resolved in
a reasonable manner.
M8 Miscellaneous Maintenance Issues (92902)
M8.1 (closed) Insoection Follow-Uo Item 50-341/95011-01: Review of licensee
corrective actions in response to frequent control room indicator lamp
failure. The licensee determined the root cause failure to be due to
filament notching. The inspector ascertained that the licensee has
replaced the incandescent lamps, where possible, with light emitting
diodes in critical displays such as the full core display. Most other
ait. plays use dual lamp indicators. The licensee is continuing their
efforts to extend indicator lamp life. This item is closed.
111. Enaineerina
El Conduct of Engineering
El.1 Puma Runout Verification (TI 2515/118 Ites 03.01.e4)
TI 2515/118 item 03.01.e4 required that the inspectors verify that pump
runout conditions were not present with minimum number of pumps
operating with worst case alignment of non-safety related loads.
The inspectors reviewed the pump curves for the DGSW, EECW, EESW, and
RHRSW pumps. Of these systems, only RHRSW had the potential for a
runout condition, if operated with only a single pump running. For this
case, the inspectors determined that operator actions specified by
procedure (S0P 23.208) would prevent runout from occurring, as the
system was manually initiated and controlled. Therefore, the inspectors
concluded that the safety related service water pumps were adequately
protected against pump runout.
El.2 Inservice Test (IST) Proaram Review (TI 2515/118 Item 03.04.e)
TI 2515/118 item 03.04.e required review of the IST records for pumps
and valves in the service water systems, with an emphasis on the
technical adequacy of procedures, trending of test results and recurrent
failures and review of the IST program for completeness.
The inspectors reviewed records of recently completed IST surveillances
and noted one deficiency: On June 19, 1996, during performance an IST
surveillance on EESW pump 'B', the initial test results indicated the
pump was in the required action range for high differential pressure.
The control room personnel discussed the issue with the IST coordinator
and decided to rerun the test with the fixed reference point in the
center of its 1 percent tolerance band. These test results indicated
the pump was performing acceptably. A DER was written to document an
operability determination for the pump.
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The inspectors noted that the basis for a permitting a tolerance band
around the fixed reference value was documented in NUREG-1482, Section
5.3, and was to allow licensees some flexibility in establishing
repeatable test conditions required by the Code. The NUREG required
that the tolerance band, and the method used to establish the band, be '
documented in the licensee's IST program. Although a basis was
documented in the program, the inspectors determined that the licensee
failed to adequately evaluate the range of the tolerance band for the
EESW pump prior to implementation to ensure that test results would not
inadvertently place the pump in the required action range. The licensee
was still reviewing the issue and their intended corrective actions at
the end of this inspection.
The inspectors determined that the IST program was being adequately
implemented. One inspection followup item was identified, as discussed
in Section M7.4, with the licensee's responses to an assessment team
issue. The inspectors concluded that the assessment team acceptably
reviewed this TI item.
E2 Engineering Support of Facilities and Equipment
E2.1 Safety Related Service Water Drain Line Pluaaina
a. Inspection Scope (37551)
On July 29, the inspectors identified that a one-inch drain line on the
Division I safety related service water return line to the "A"
Mechanical Draft Cooling Tower (MDCT) was partially plugged. As 1
documented in Inspection Report 96004, inspectors had previously !
identified a similar problem on March 31, 1996. During this inspection
period, inspectors interviewed licensee engineering and operations
personnel, and reviewed documents related to the issue. :
b. Observations and Findinas
On July 29, when inspectors identified that one of the drain lines was
partially plugged while the Division 1 RHRSW and Emergency Equipment i
Service Water (EESW) systems were in service. The inspectors noted that j
the drain line on the "C" MDCT return line had full flow, but the "A" l
line had very little flow, indicating that some plugging was occurring. l
The inspector notified the control room operators and the abnormal
condition was confirmed. DER 96-0844 was initiated to document event
occurrence. The licensee postulated that the cause for the clogging was
loose corrosion products.
The purpose of the one inch drain lines on the return lines to the MCDTs I
was to prevent freezing. As previously documented in Inspection Report ,
96004, under cold weather conditions, the potential existed for the _'
1
return lines to the MDCT's to partially freeze if the drain lines were
plugged. Due to the failure of the licensee to adequately test the one
inch drain lines to ensure that they could perform satisfactorily, a l
violation (96004-05) was issued on June 14, 1996.
As documented in the Detroit Edison Response to Notice of Violation
96004-05, dated July 15, 1996, corrective actions taken included: "As an
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[ interim measure, the drain lines have been included in the routine
i system engiserring walkdown checklist for periodic monitoring." Since
,
May 28, 19M , the system engineer only once actually verified proper
t operation of the drain lines for each division. The systems were run on
1 a weekly basis' for chemical treatment. Though the system engineer did
1
!
conduct biweekly walkdowns of the system, and a walkdown chocklist which .
included monitoring of drain lines was utilized, systems monitoring was '
. not planned to coincide with system operation. As a result, performance
.
of the drain lines was not adequately monitored.
} c. Conclusions
j
In response to the Notice of Violation 96004-05, the licensee committed
"
to have corrective actions to. prevent recurrence of the drain line
plugging. This included a planned system modification.- Recognizing
that no possibility of freezing existed during this inspection period,
the recurrence of the drain line clogging was of minor safety
consequences. However, the failure of the licensee to adequately
monitor system performance while it was running resulted in a missed ,
opportunity to gather data to ensure that planned corrective actions
would address the plugged problem.
10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Actions,"
required in part that measures be established to assure that conditions
adverse to quality, such as deficiencies, defective material and
equipment are promptly identified and corrected. Contrary to the above,
on July 29, 1996, inspectors identified partial plugging of the one inch
drain line on the Division 1 Residual Heat Removal Service Water Return
Line to the "A" Mechanical Draft Cooling Tower, a repeat occurrence (50-
341-96-06-05).
E2.2 Root Cause Investiaation of Reactor Water Cleanun (RWCU) Filter
Demineralizer Control Panel Fire
a. Inspection Scope (92902)
The inspectors reviewed the results of the investigation into an
electrical fire in the RWCU filter demineralizer control papel and
discussed the issues with the team leader and engineers.
b. Observations and Findinas
On July 7, operators identified a fire in the RWCU filter demineralizer
control panel in the reactor building. Prompt action to deenergize the
panel and put out the fire were taken. Damage from the fire, which was
limited to the local control panel, required that both filter
demineralizers be bypassed. Reactor water chemistry was maintained i
within TS limits while repairs were made.
I
At about the same time as the fire, the Sequence of Events Recorder '
(SOER) behaved erratically, then failed, and a solid ground was l
identified on the 130V balance of plant DC bus. I
'
A root cause evaluation team, headed by system engineering, promptly
investigated the event. The team determined that an AC relay (R13A)
i
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,
with DC monitoring power located in the RWCU panel failed and shorted !
120V AC onto the DC bus. The superimposed AC voltage caused the faulty
operation and failure of the SOER, and also caused the failure of a !
control room annunciator power supply. The annunciator power supply ,
failure resulted in the DC ground following the fire, but did not result !
in the loss of any annunciators. !
!
Failure of the relay was believed to be due to thermal aging. This j
condition was described in General Electric Service Information Letter :
(SIL) 229, Supplement 1, so no 10 CFR 21 investigation was performed by
the licensee. Licensee evaluation of the SIL will include this failure,
but did not previously identify that affected components existed in the i
RWCU system because this panel was treated as a vendor-supplied " black ;
box" and components were not listed in the site data base. '
Repairs were completed on July 12, and the system was restored to
service. Emineering continued to evaluate the failed relay for
reliability and other uses in the plant to determine if a replacement
part should be identified. DER 96-0755 was written to document the
event and track corrective actions.
c. Conclusions
The inspectors considered the licensee response to the fire, loss of
equipment, and repair efforts to be proper, conservative and deliberate.
The investigation was prompt and thorough, and included previous site
experience with a similar relay failure and fire. Reactor water
chemistry was maintained and closely monitored.
However, the inspectors were concerned by the failure to identify all ,
component locations in the plant affected by SIL 229, Supplement 1. The
licensee investigation to identify other " black box" components will be
tracked as an Inspection Followup Item (50-341-96-06-06).
E2.3 UFSAR Reauirement Review
A recent discovery of a licensee operating their facility in a manner
contrary to the Updated Final Safety Analysis Report (UFSAR) description
highlighted the need for a special focused review that compares plant
practices, procedures, and parameters to the UFSAR descriptions. While ,
performing the inspections discussed in this report, the inspectors
reviewed the applicable portions of the UFSAR that related to the areas
inspected. The inspectors verified that the UFSAR wording was
consistent with the observed plant practices, procedures, and
parameters.
E7 Quality Assurance in Engineering Activities
! E7.1 Review of Service Water System Self-Assessment Enaineerina Issues
!
, The assessment team raised 65 issues during its inspection effort, 35 of
- which were in the engineering area. The inspectors discussed the issues
1 and their proposed resolutions with the system engineering and plant
'
support engineering response team mer5ers. The inspectors also reviewed
DER closure packages, calculations, drawings, and procedure revisions to
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b
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ensure that appropriate corrective actions were being taken. ;
Additionally, the inspectors performed a walkdown of the mechanical i
l draft cooling tower motors to confirm the response to the assessment i
team's issue. ;
The inspectors determined that the licensee had taken appropriate
actions for those items where interim operability calls were made :
following the assessment team exit. Specifically, all the coolers were i
cleaned during the forced outage in March 1596 and the DGSW throttle !
valves. were reset to correspond to their des gn flow rate. Calculations !
were redone to account for industry accepted fouling factors and to use
the design value maximum service water temperature. The modification to
resolve the EECW makeup tank deficiency was reviewed in Inspection
Report 96004 and determined to be acceptable. The inspectors noted that
this modification was an interim solution until the EECW tanks could be !
relocated to a higher elevation.
E8 Miscellaneous Engineering Issues (92902) ,
E8.1 (Closed) LER 50-341/96006: Missed American Society of Mechanical.
Engineers (ASME)Section XI required inspection of an EECW check valve
due to incorrect valve grouping. EECW check valve P440F1168, an eight- '
.
inch Powell swing check, was incorrectly grouped with three six inch ,
EECW check valves'that did not meet the grouping guidance of Position 2 r
of GL 89-04. As such, the valve was not inspected during the last
refueling outage as required.
The licensee disassembled and inspected the valve during the March 1996 !
forced outage, and verified the valve showed no significant signs of
degradation. The IST disassembly / inspection procedure was revised to
i place this valve in a separate group requiring disassembly and
inspection every refueling outage, while the remaining three EECW valves
would remain in the same sampling group. The licensee was updating the
IST program such that relief request VR-48 included the three 6-inch
j check valves and a separate relief request submitted the 8-inch valve.
! These actions were considered appropriate and this item is closed.
E8.2 (Closed) Insoection Followun Item 50-341/94007-05: Failures of motor
operated valves. This issue was thoroughly investigated and is
discussed in Inspection Report 95003. The failures were traced to use
of an unapproved solvent in the auxiliary contacts and contactors. Two
violations were issued for inadequate corrective actions and use of non-
l
conforming materials. This item is closed.
!
E8.3 (Closed) Insoection Followuo Item 50-341/94009-06: This item concerned
discovery of hardened grease in 480V and 4160V breakers. This issue was
thoroughly investigated and is discussed in Inspection Report 94012.
This item is closed.
! E8.4 (Closed) Insoection Follow-un Item 50-341/95002-01: This item concerned
! the testing of pumps for the IST program using reference curves without
a relief request. The licensee incorporated single reference point
'
testing for the majority of pumps included in the IST program. The
i licensee obtained NRC approval to use reference curves for the EECW and
core spray pumps. The inspectors reviewed the implementing prccedures
26
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___ __ _ ~ __
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1
and associated acceptance criteria and considered them acceptable. This ,
item is considered closed. l
l
E8.5 (Closed) Violation 50-341/95002-03: This item concerned the failure to !
provide adequate acceptance criteria to verify the full flow test for i
the core spray discharge check valves as required by ASME Section XI. i
The licensee implemented corrective actions to comply with Position 2 of
GL 89-04 to satisfy the full flow test requirement. The testing i
required by the IST program included disassembly / inspection on a i
refueling outage sampling basis and a partial stroke test on a quarterly l
basis. The inspectors reviewed the applicable implementing procedures I
and considered them acceptable. This item is considered closed.
E8.6 (Closed) Insoection Followuo Item 50-341/96004-07: The inspectors were
concerned that the installed EECW modification did not match the design
calculation assumptions. The installed configuration required running
of either a DGSW or RHRSW pump in addition to an EESW pump to provide
sufficient pressure so that flow from EESW to EECW would occur. The
inspectors reviewed the licensee's analysis and determined that the
calculation was performed assuming all service water pumps on a division
were running. Therefore the installed configuration matched the design
assumptions. This item is closed.
E8.7 (Closed) Inspection Followuo Item 50-341/95011-02: Response to Generic
Letter 89-16 modification was designed for static loads only. Licensee l
performed calculations to confirm that the system would withstand
anticipated dynamic loadings. The inspector reviewed the licensee's
calculations and concluded that the hardened wetwell vent system would
,
withstand the anticipated dynamic load. This item is closed.
i
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E8.8 (Closed) Violation 50-341/95003-02A: Failure to take appropriate
corrective action to identify and resolve ITE contactor auxiliary
contact deficiencies. Contact sticking was attributed to an oil based
contact cleaner becoming sticky and impeding contact operation. The
inspector reviewed documentation indicating the licensee had cleaned or
replaced all auxiliary contacts in safety related contactors. Hon
safety related contactor were being cleaned or replaced and monitored by
an assigned tast force. Since Inspection Report 95003, the licensee
identified five contact failures. One contact contained a visual
residue from cleaner compound, all had cracked covers or bows that could
have interfered with contact operation. The licensee task force is l
continuing to monitor the performance and failure rate of ITE contactor !
auxiliary contacts. This issue is considered closed.
IV. Plant Support
,
R1 Radiological Protection and Chemistry Controls !
I
R1.1 Wrona Radioloaical Work Permit (RWP) Used
'
On July 9, the licensee identified instrumentation and controls (I&C)
-
workers had performed surveillances on the scram discharge volume (SDV)
i level detectors using the RWP for performing general I&C work (RWP
96-1011). However, the RWP stated "This RWP does not cover RB-1 North
27
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4
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and South SDV Functional Tests and Surveillances." The workers and one
radiation protection (RP) supervisor failed to realize that the work i
should have been performed under RWP 96-1025, which was issued i
specifically to track dose accumulated for work associated with the
SDVs.
DER 96-0761 was written to document the event and track corrective
actions. The involved individuals had their access to the
radiologically restricted area revoked pending upgrading, and training
for the I&C group was planned to cover specific RWPs used by that group.
Failure to follow the requirements of RWP 96-1011 is a violation of
,
'
technical specifications. However, this violation will not be cited
because the requirements of the Enforcement Policy,Section VII were met
(NCV 341/96006-07).
l
R2 Status of Radiation Protection and Chemistry Facilities
R2.1 Soent Fuel Pool Cleanout Activities
a. InsDection Scope (71750)
The inspectors reviewed plans for removal of irradiated equipment from
the spent fuel pool and packaging for shipment to a burial facility.
'
l
The inspectors also observed various aspects of the preparation and work
over this and the previous inspection period.
b. Observations and Findinas
l This project resulted in the removal from the spent fuel pool (SFP) and l
l shipment of 4 casks which contained crushed control rod blades, local l
power range monitors, shroud head bolts, jet pump beams, hoses, and a i
source pin rack. The project was intended to remove unnecessary
l equipment stored in the SFP while a burial facility was available prior
to planned reracking of the pool.
l The project was headed by a senior line manager, ensuring adequate i
- management support and attention. The group performing the work was a
l dedicated crew which included members of the RP staff, radwaste,
l engineering, and a licensed operator to coordinate efforts with the l
- control room.
!
l The work was concluded with about 20 percent of the planned work
l complete due to unexpected problems. The most time-consuming problem
'
was a shipping cask which was configured for the wrong type of liner by
the supplier, causing a 2 week delay. Reactor building access was also
restricted several times due to problems with the operation of the
railroad airlock doors. This and other minor problems were resolved in
a deliberate way.
.
c. Conclusions
!
, The inspectors concluded that work was performed in a deliberate manner.
When questions were raised, work was stopped until the questions were
- resolved. There was no observable schedule pressure, and management
28
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supported the decision to stop the partially completed project with
sufficient lead time to support preparations for the upcoming outage.
Coordination and cooperation with other organizations was smooth. This
was facilitated by having a multi-disciplined team, which frequently
updated other organizations with the status of work and required
assistance.
,
R5 Staff Training and Qualification in Radiation Protection and Chemistry
R5.1 RWP Como11ance Problems with New Workers
On June 14, a contract employee new to the site entered the control
room, a radiologically clean area, without performing the required whole
body frisk. After entering, RP questioned whether he had performed the
required frisking, which he realized he had not performed. RP then
surveyed the control room and found no contamination present. The
individual was upgraded on RP practices before having his access to the
Radiologically Restricted Area (RRA) restored.
On August 1, a relatively new security guard was found to be drinking
water and chewing tobacco inside the RRA, contrary to RP procedure. The
individual's access to the RRA was restricted, and the individual was
subsequently terminated for other reasons. DER 96-0871 was written to
document the event.
These instances were additional examples of a failure to follow
Radiation Protection procedures which is a violation of technical
specifications; however, they will not be cited because the requirements
of the Enforcement Policy,Section VII were met (NCV 341/96006-08).
RP and training were evaluating the effectiveness of radiation worker
training as a result of these events. DER 96-0926 was written to track
corrective actions for this trend. The importance of these events was
heightened by the plans to bring in large numbers of contract workers
for the upcoming refueling outage.
P3 Emergency Preparedness Procedures and Documentation
P3.1 Review of Exercise Ob.iectives and Scenario (82302)
The inspectors reviewed the 1996 exercise objectives and scenario which
arrived in sufficient time before the exercise to permit NRC review.
The scenario provided an acceptable framework for the exercise and the
objectives were appropriately in the facilities evaluated by the
inspectors.
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P4 Staff Knowledge and Performance in Emergency Preparedness l
P4.1 1996 Evaluated Biennial Emeraency Exercise ,
'
a. Inspection Scone (82301)
'
. The inspectors evaluated licensee performance in the following emergency l
response facilities during the 1996 evaluated emergency exercise, which I
was run July 16:
. Control Room Simulator
. . Operations Support Center
] . Emergency Operations Facility
'
b. Observations and Findinas
.
b.1 The simulator control room crew was professional, and communications
i among the crew was efficient with repeat backs and acknowledgements
b'ing
e observed by the inspectors. The nuclear shift supervisor was
proactive in following plant conditions, review of emergency
classification procedures, and use of checklists.
' The Emergency Director (ED) rapidly recognized and declared the Unusual
Event, and then appropriately upgraded the classification to an Alert
due to the magnitude of the simulated seismic event. Command and
control in the control room was strong as indicated by the periodic
briefings and overall awareness of the emergency conditions. State and
local notifications were made within the required 15 minutes and the NRC
notification was made within the required hour.
b.2 TSC activation was coordinated and efficient. Support staffs for
communications, administrative, and status boards provided prompt l
continuous communications, organized and distributed information copies, !
and updated status boards continuously. The TSC staff overcame the
added challenge of the actual failure of the Emergency Response
Information System just prior to the drill. Plant conditions were
rapidly evaluated and the Site Area Emergency was appropriately
decl ared. Good teamwork was observed between the ED and his staff in ;
looking ahead for plant condition changes which could lead to emergency i
reclassification.
Informative public address announcements were made for onsite protective
actions. Continuous communications were maintained between the TSC,
control room, and the Operations Support Center (OSC). The ED exercised
good command and control by providing frequent briefings for facility i
personnel.
The inspectors noted that control room and TSC priorities did not always
coincide. The control room requested the TSC to assign a response team
to add water to the condensate storage tank using fire hoses. When the
response was slow, the control room dispatched one of their operators to
perform the job before the TSC and OSC were able to create, brief, and '
dispatch a response team.
30
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' The Health Physics Network (HPN) line was not staffed in the TSC after
several requests from the NRC. The HPN line from the TSC is important
i for communication of information regarding onsite and offsite
radiological conditions and related protective action decisions. The
,
failure to staff the HPN line at the NRC's request will be tracked as an
Inspection Followup Item (50-341/96006-09).
j b.3 The OSC staff was proactive in attempts to develop solutions to actual
'
and potential plant conditions. The OSC Assistant Coordinator and
Radiation Emergency Team Leader provided effective response team
- assignments. Radiological conditions and safety were emphasized to the
! teams. I
- OSC Coordinator status briefings were inferquent and informal; only four
briefings were observed. During these M iefings, staff attention was
- lacking, new relevant information was minimal, and no closure was
j observed for the briefings.
i
j' The Post Accident Sampling System (PASS) team was unable to obtain a
- reactor water sample because the sample panel did not function properly.
.
(See Section 04.1) The sample had to be simulated for drill purposes.
The inability to obtain an actual PASS sample will be tracked as an-
l[
t
Inspection Followup Item (50-341/96006-10).
b.4 Overall performance in the Emergency Operations Facility (EOF) was
effective. Facility staffing was rapid and efficient. Activities,
j including offsite monitoring kit checks, accountability, habitability,
i emergency ventilation lineup, and radiological control were performed
j effectively and promptly.
i The Emergency Officer (EO) was in frequent communication with the TSC.
i The E0 provided frequent and concise briefings to the EOF staff and the
NRC Site Team. The Nuclear Operations Advisor provided a detailed
} briefing to the arriving NRC site team. l
i
! Dose assessors provided the E0 with timely and accurate dose projections l
and performed numerous computer runs to anticipate potential changes in
'
!
i release rates, release paths, and plant conditions.
I The inspectors determined that E0F status boards were inadequate for
!
trending plant parameters. There were no provisions for posting the
i priorities established by the ED. The EOFs protective measures status ;
j boards contained no information from State officials. The plant i
- parameter trending, TSC priorities, and offsite protective action status ,
- information status board inadequacies will be tracked as an Inspection
- Followup Item (50-341/96006-11).
4
b.5 Facility critiques immediately following the exercise termination were
j self critical. Several instances where controllers inappropriately ;
'-
handled data occurred. On two occasions, misinformation was transmitted :
- offsite and had to be corrected. The impact of the misinformation
- transmitted to offsite authorities was minimal and did not impact the
j outcome of the exercise.
'
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c. Conclusions
,
j The exercise was successful in demonstrating that the onsite emergency :
- plans were acceptable, and that the licensee was capable of-implementing
i them. Overall exercise performance was very good. Emergency
4
classifications and associated notifications to the State, local
. government, and NRC were made in a timely manner. Post exercise !
! facility critiques involved exercise controllers and participants and
!
were very good. Three Inspection Followup Items were identified related
- to failure to staff the Health Physics Network in the Technical Support
- Center (TSC), problems with several status boards in the Emergency
l Operations facility, and the inability to actually obtain a post
j accident sample.
) V. Manacement Neetings i
'
X1 Exit Meeting Summiary
i
,
The inspectors presented the inspection results to members of licensee
- management at the conclusion of the inspection on August 9, 1996. The
!
.
licensee acknowledged the findings presented.
l The inspectors asked the licensee whether any materials examined during the
- inspection should be considered proprietary. No proprietary information was
i identified.
!
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PARTIAL LIST OF PERSONS CONTACTED
Licensee
<
S. Booker, Assistant Supervisor, Maintenance
C. Cassise, General Supervisor, Maintenance
W. Colonnello, Director, Safety Engineering
R. Delong, Superintendent, System Engineering
T. Dong, NSSS, Technical Engineering
'
P. Fessler, Plant Manager, Operations
L. Goodman, Director, Nuclear Licensing
J. Kauffman, ERS,,RERP
E. Kokosky, Superintendent, RP and Chemistry
J. Korte, Director, Nuclear Security
-
R. Laubenstein, NSS, Operations
R. McKeon, Assistant Vice President / Manager, Operations
W. Miller, Technical Support '
J. Nolloth, Superintendent, Maintenance
D. Ockerman, Supervisor, Operations
J. Plona, Technical Director
W. Romberg, Assistant Vice President and Manager, Technical
33
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'*
1 *
l
INSPECTION PROCEDURES USED
IP 37551: Onsite Engineering
l
'
IP 40500: Effectiveness of Licensee Controls in Identifying,
Resolving, and Preventing Problems
IP 40501: Licensee Self-Assessments Related to Team Inspections
IP 61726: Surveillance Observations
IP 62703: Maintenance Observation
! IP 71707: Plant Operations
- IP 71750
- Plant Support Activities
l IP 82301: Evaluation of Exercises for Power Reactors
IP 82302: Review of Exercise Objectives and Scenarios for Power
i
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Reactors
IP 92902: Followup - Engineering
IP 92903: Followup - Maintenance
TI 2515/118: Service Water System Operational Performance Inspection
ITEMS OPENED AND CLOSED
Opened
50-341/96006-01 VIO Inadequate procedure in that all RHRSW valves were not
included in S0P
50-341/96006-02 NCV Failure to follow procedures for vendor control and
safety tagging
50-341/96006-03 VIO Temporary plant space request not initiated for staged
equipment
l
50-341/96006-04 IFI No provision to stroke time test valve in Inservice
Testing Program
l
'
50-341/96006-05 VIO Partial plugging of one inch drain line on Division 1
50-341/96006-06 IFI Failure to identify all aging thermal components as
described in SIL 229
50-341/96006-07 NCV Wrong radiological permit used on surveillance for
scram discharge volume level detectors
50-341/96006-08 NCV Three instances of failure to follow RP procedures
50-341/96006-09 IFI Failure to staff HPN line at NRCs request
50-341/96006-10 IFI Inability to obtain a PASS sample
50-341/96006-11 IFI Plant parameter trending, TSC priorities, and offsite
protective action status information status board
inadequacies
Closed
50-341/96006 LER Missed ASME Section XI required inspection of an EECW
check valve due to incorrect valve grouping
50-341/94007-05 IFI Failures of motor operated valves
50-341/94009-06 IFI Hardened grease in 480V and 4160B breakers
50-341/95002-01 IFI Testing of pumps for IST program using reference
curves without a relief request
50-341/95002-03 VIO Failure to provide adequate acceptance criteria to
- verify full flow test for core spray discharge valves
l 50-341/95003-02A VIO Failure to resolve ITE contactor auxiliary contact
I
deficiencies
.
50-341/95011-01 IFI Frequent control room indicator lamp failure
l 50-341/95011-02 IFI GL 89-16, modification designed for static loads only
i
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50-341/96004-07 IFI Installed EECW modification did not match the design '
calculation assumptions
- LIST OF ACRONYMS USED i
,
ALARA As low As Reasonably Achievable
ASME American Society of Mechanical Engineers '
, CCHVAC Control Center Heating Ventilation Air Conditioning
I
CFR Code of Federal Regulations
CITA Comprehensive Integrated Technical Assessment
CST Condensate Storage Tank
Deco Detroit Edison Company
DER Deviation Event Report
DFP Diesel Fire Pump
DGSW Diesel Generator Service Water
ED Emergency Director
EDG Emergency Diesel Generator
EECW Emergency Equipment Cooling Water
, EESW Emergency Equipment Service Water
E0 Emergency Officer
EOF Emergency Operations Facility
ESF Engineered Safety Feature
GL Generic Letter
- GSW General Service Water
HPCI High Pressure Coolant Injection
IFI Inspection Followup Item
IR Inspection Report
LER Licensee Event Report
MDCT Mechanical Draft Cooling Tower
NASS Nuclear Assistant Shift Supervisor
NCV Non-Cited Violation
NRC Nuclear Regulatory Commission l
NSS Nuclear Shift Supervisor
OSC Operations Support Center
PASS Post Accident Sampling System
PRA- Probable Risk Assessment
RCIC Reactor Coolant Injection System
RHRSW Residual Heat Removal Service Water
RP Radiation Protection .
Radiologically Restricted Area
'
RRA
RWCU Reactor Water Clean-Up
RWP Radiological Work Permit
SFP Spent Fuel Pool
SIL Service Information Letter
SOER Sequence of Events Recorder '
S0P System Operating Procedure
TS Technical Specification
VIO Violation
l
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