IR 05000327/1989007

Insp Repts 50-327/89-07 & 50-328/89-07 on 890205-0304. Violations Noted.Major Areas Inspected:Operational Safety Verification,Including Operations Performance,Sys Lineups, Radiation Protection,Safeguards & Housekeeping

ML20244D059
Person / Time
Site:	Sequoyah
Issue date:	04/13/1989
From:	Brady J, Jenison K NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20244D044	List: IR 05000327/1989007 ML20244D041 ML20244D048
References
50-327-89-07, 50-327-89-7, 50-328-89-07, 50-328-89-7, NUDOCS 8904210123
Download: ML20244D059 (19)

Text

---

__- - _

Mb UNITED STATES

"

, [. .. ' NUCLEAR REGULATORY COMMISSION l t3 .p

.,

-

g' ,' .

p

'

REGION 11 101 MARIETTA STREET, N.W,'

e ATLANTA, GEORGI A 30323 s s,,s*

,

Report Nos.: 50-327/89-07, 50-328/89-07 Licensee: Tennessee Valley Authority 6N 38A Lookout Place

~1101 Market Square Chattanooga, TN. 37402-2801 Docket Nos.: 50-327 and 50-328 License Nos.: DPR-77 and DPR-79 Facility Name: Sequoyah Units 1-and 2 '

Inspection Conducted: February 5,~1989 thru March 4, 1989 Inspectors: l/f /M Af w Mm ^4/[/JM9 y Jenisof 56nior' Resident Inspector Date Signed Inspectors: P. Harmon, Senior Resident Inspector P. Humphrey, Resident Inspector-D. Loveless, Resident Inspector ,

' Approved by: / /gM UM9 g Brady,.Act}fs Chief, Project Section 1 Date Signed-TVA Projects Division Summary Scope: This routine monthly inspection by the resident inspector ! was conducted in the area of operational safety verification including operations performance, system line ups, radiation protection, safeguards, and housekeeping. Other areas inspected . included maintenance observation-and review, surveillance testing observation and review, Unit 2 refueling activities, review of previous inspection findings, follow-up of events, review of licensee- i

~

identified items, and review of inspector follow-up item i Results: The licensee's performance in the areas of operational safety i verification, and maintenance and surveillance observations was generally adequate, except as noted below, and was fully capable of supporting current plant operations. The control room operators were observed to be professional and well managed. Management response to and support of plant activities and events was timely and effectiv Problems encountered with airborne radioactivity during the refueling outage were identified and successfully resolve An administrative weakness pertaining to NRC inspector of,

_k12 FJ; gfb

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

-,

' -

..

.

.

l

'

\

'

, 2

,

,

access to radiological controlled areas was identifie The licensee had, on six occasions described below, failed to establish and/or implement procedure Thi s resulted in a violation (50-327,328/89-07-01).

-

Failure to adequately implement refueling procedure associated with bending the fuel transfer cart during off-loading of j Unit 2 reactor' fuel bundles (paragraph 11.a). .

-

Failure to establish an adequate UHI venting procedure resulting in 100 gallons of contaminated water being sprayed into the containment yard area (paragraph 7).

-

Failure to adequately implement a temporary alteration control form (TACF) safety evaluation requirement regarding a Bailey j Meter Cabinet Seismic Restraint (paragraph 4.a).  !

-

Failure to establish an adequate resin bed installation procedure resulting in a power transient caused by an improperly borated mixed bed demineralized (paragraph 8).

-

Failure to adequately implement the requirements of an abnormal operating procedure as it relates to the Radiological Emergency Plan (paragraph 8).

-

Failure to establish adequate work request instruction for WR 328429 resulting in a reactor trip (paragraph 8).

_- _ _ .

- - _ _ _ _ _ _

'

..

.

,

.

. REPORT DETAILS Persons Contacted Licensee Employees J. Bynum, Vice President, Nuclear Power Production

• J. LaPoint, Site Director

• S. Smith, Plant Manager  !

T. Arney, Quality Assurance Manager

• R. Beecken, Maintenance Superintendent G. Boles, Maintenance PlanningLand Technical Supervisor L. Bryant, Program Support Manager

• M. Cooper, Compliance. Licensing Manager D. Craven, Plant Support Superintendent D. Elkins, Instrument Maintenance

'

• R. Fortenberry, Technical Support Supervisor M. Frye, Instrument Maintenance Manager J. Hamilton, Quality Engineering Manager J. Holland, Corrective Action Program Manager R. Miles, Modifications Manager

.J. Patrick, Operations Superintendent G. Putt, Work Control / Outage Superintendent R. Pierce, Mechanical Maintenance Supervisor -i A. Ritter, Engineer. Assurance Engineer

• R. Rogers, Plant Support Superintendent B. Schofield, Acting Regulatory Lic2nsing Manager J. Smith, Acting Supervisor Plant Report Section

• M. Sullivan, Radiological Controls Superintendent i S. Spencer, Licensing Engineer

• C. Whittemore, Licensing Engineer

• J. Walker, Operations Supervisor

• Attended exit interview Acronyms and initialisms used in this report are listed in the last paragrap . Operational Safety Verification (71707) Plant Tours r The inspectors observed control room operations and reviewed applicable logs including the shift logs, night order book, clearance hold order book, configuration log and TACF lo No issues were identified with these specific log '

L l

l-l i

. _ _ _ _ _ _ _ _ _ ____ _ _ ________ _

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

. ..

-

. . .

.

2 i

The inspectors also: conducted discussions with control room operato.rs, verified that proper control room staffing was maintained, observed shift turnovers, and confirmed operability of instruments-

. tion. The inspectors verified.the operability of selected' emergency ,

systems, and verified' compliance with Technical Specification (TS) '

limiting ~ condition for' operations (LCOs).

..

Tours of the diesel, generator, auxiliary, control, turbine and Unit 2 containment buildings, were conducted to observe plant equipment conditions, inclucing. potential fire hazards, fluid leaks, and excessive vibrations and plant housekeeping / cleanliness condition The plant was observed 'to be clean and in adequate condition._ The inspectors verified that. maintenance work orders had been submitted ,

as required and that followup activities and prioritization of work i was accomplished by the license The inspectors walked down accessible portions of the following safety-related systems on Unit 1 and Unit 2 to verify operability and proper valve alignment:

Containment Spray (Unit 1)

Residual Heat Removal (RHR) (Unit I and 2)

Safety Injection (Unit 1)

No deviations or violations were identifie ) Safeguards Inspection J In .the course of the monthly activities, the inspectors included a review of the licensee's physical security program. The performance of various shifts of the security force was observed in the . conduct of daily activities including: protected and vital area access controls; searching of personnel and packages; escorting of visitors; badge issuance and retrieval; and patrols and compensatory post .In addition, the inspectors observed protected area lighting, and protected and vital area barrier integrity. The inspectors verified interfaces between the security organization and both operations and maintenance. Specifically, the Resident Inspectors: 1 visited the central and secondary alarm station verified protection of Safeguards Information verified onsite/offsite communication capabilities The inspectors reviewed the licensee's ability to retrieve QA records in the safegaurds are Several current and past records were retrieved from the safegaurds cabinet Additionally, records were retrieved from storage tapes on the vital area access control system computer. No discrepancies were note No violations or deviations were identifie g _

_ _ _ _ _ . _ _ _ _ _ _

-

..

L .

.

{ <

'

. Radiation Protection-E - Th'e inspectors observed health physics. (HP) practices and verified the implementation of radiation protection controls. On a . regular

' basis, radiation work permits (RWPs) were reviewed and specific work i activities were monitored. to ensure that activities were being l conducted in accordance with the applicable RWP Selected radia-E tion protection instruments were verified operable and calibration frequencies were reviewe The following RWPs were reviewed in detail:

RWP.89 20288 00 00, Inspection of Unit 2 Lower Containment 3 RWP 89 20121 00 00, Unit 2 Ice Condenser, Upper and Lower .I During the. beginning of the Unit 2, ' cycle 3 refueling outage, .

multiple problems with airborne radiation were experienced in the d Unit 2 containment and auxiliary building. The licensee investigated'

and- determined the source to be the alignment of the ventilation system and the improper use of vacuum cleaners. Some vacuum cleaners were found to have no filters and some of those with filters were I found to have the' filters improperly installe Corrective actions were taken to modify the alignment of the ventilation system and to implement a more positive control over the vacuum cleaners. Radiological Control' Instruction, RCI-18, Control:

of Vacuum Cleaners, was written and implemented to maintain and .

control the use of vacuum cleaners used within the RC This  !

instruction requires the cleaners to be properly stored, maintained, and--tested to ensure operabilit In addition, procurement of a single vacuum system is being evaluated for- replacement of the smaller individual unit During the-inspection period the resident inspectors were detained at the entrance to Unit 2 lower containment. Recent upgrades in the RWP program required the health physics technicians to limit the groups and types of jobs allowed under one RWP. Therefore, the technician told the inspectors that no RWP existed that would allow the residents to enter containment. He stated that in the future, the resident inspectors would be required to submit an RWP request form .

I to 2 days in advance of the entr I The inspector discussed this issue with the radiological control superintendent. The inspector stated that this program was contrary to 10 CFR Part 50.70 which affords the resident inspector "immediate unfettered access". The superintendent stated that they had not j considered the NRC in the program and proceeded to fix the proble The inspectors entered the area approximately 45 minutes late The licensee is currently studying a program which would provide a standing RWP for uses by the resident inspectors for all areas that are currently accessible by operations. This program change should provide the access required in the futur ;

_- m_________.__- __ _

-

-

.

.

-'

.

.

.

>

.

.

Identification and resolution of radiological. controls ~ issues ' appear to.be' improving. This reflects a positive attitude towards . issue resolutions and morel involvement of the first line HP management in plant activities. In addition, procedural compliance is becoming the rule,Las demonstrated by the misunderstanding discussed.abov No violations or deviations were identifie Positive trends were identified in the operational safety . verification area. General conditions in the plant were good.' Radiation protection and security are. adequate to support two unit operation . Survei'llance Observations and Review (61726)

Licensee activities were directly observed / reviewed to ascertain _ that surveillance of safety-related systems ar.d components were being conducted in accordance with TS requirement The- inspectors verified that: testing was performed in accordance with adequate procedures; test instrumentation was calibrated; : LCOs were' met; test .results met acceptance criteria requirements. and were reviewed by personnel other than the individual directing the test; deficiencies were identified, as appropriate, and any deficiencies identified during the testing were properly reviewed and resolved by management personnel; and system restoration was adequate. For completed tests, 'the inspector verified that -testing frequencies were met and tests were performed by quali fied 'i r.dividual s .

The following activities were observed / reviewed with no deficiencies )

'

identified except as noted:

SI-271, NI System Backup Calibration (Source Range) I SI-99, Functional Test of Source Range Neutron Flux Channels l SI-94.3, Periodic Calibration of Nuclear Instrumentation System I Backup Source Range Channel j IMI-92-IRM-FT, Reactor Protection System Intermediate Functional Test j SI-106.3, Ice Condenser - Ice Bed (Unit 2) l SI-260.3, SIS Cold Leg Injection Flow Balance  ;

No trends were identified in the area of surveillance performance during this inspection perio The area of surveillance scheduling and management was observed to be adequate. The completion of TS surveillance requirements was discussed at the highest levels of the TVA onsite Nuclear Power organization as a result of problems with schedule date performance slips. No TS surveillance requirements were identified that exceeded the required SR periodicit No violations or deviations were identifie . . _

u_ ___m_ _ _ _ _ _ _ _ _ _

- . _ _ .

_ _ _ _ _ - _ _ _ _ -

'

,

-

,

,

4. Monthly Maintenance Observations and Review (62703)

Station maintenance activities on safety-related systems and components were observed / reviewed to ascertain that they were conducted in accordance with approved procedures, regulatory guides, industry codes and standards, and in conformance with T The following items were considered during this review: LCOs were met while components or systems were removed from service; redundant components were operable; approvals were obtained prior to initiating the work; activities were accomplished using approved . procedures and were  ;

inspected as applicable; procedures used were adequate to control the activity; troubleshooting activities were controlled and the repair records accurately reflected the activities; functional testing and/or calibrations were performed prior to returning components or systems to service; QC records were maintained; activities were accomplished by qualified personnel; parts and materials used were properly certified; radiological controls were implemented; QC hold points were established where required and were observed; fire prevention controls were implemented; outside contractor force activities were controlled in accordance with the approved QA program; and housekeeping was actively pursue Temporary Alterations (TACFs)

The following TACFs were reviewed:

TACF 2-89-35-079 Fuel Cart Counter Interlock Bypassed TACF 2-89-37-090 Backup CR Source Range Instrumentation TACF 1-88-22-500 Bailey Meter Cabinet Seismic Restraint TACF 1-88-22-500 and a comparable one on unit 2 (2-88-2019-500) were reviewed in IR 327,328/88-56 and IR 327,328/89-02. As a result of that review it was determined that the TACF had been administered properly, but technical questions over the adequacy of the drawer restraint existed. The adequacy of the restraint and corresponding safety evaluation were reviewed during this inspection and found to be in erro In addition, the following documents were reviewed:

CAQR SQP 880601 Bailey Relay Racks LER 2-88-041 Bailey Relay Racks NRC GL 87-02 Seimic Adequacy of Mechanical and Electrical Equipment in Operating Reactor The safety evaluation associated with the above stated two TACFs indicated that the Bailey modules of concern were restrained in the vertical direction by a clip at the rear of the pan and that the only

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

_

_- .__ _ ..

.. ..

e r

.

.

'6

. .

degree of: freedom was. to. move forward toward the door. A cable was installed to prevent .this forward motion and maintain the module's contact with the-clip. When inspected ' by the NRC, several . drawers were identified on Unit 2, that had modules in which contact with the'

clip was not maintained and forward motion was not restrained by'the

~

cable installed .under the TACF. Therefore, the assumption; made in the TACF safety evaluation was invalid and not supported by the physical condition of the equipment in the fiel : CFR 50.59 states that the licensee shall maintain records of changes in the facility and of changes in. procedures madeLpursuant to this section to the extent that these changes constitute changes in the facility as described in the final safety analysis 1 report. It'

further states that these records must include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question. The licensee-implements its engineering safety evaluation through NEP 6.6,10 CFR 50.59 ' Safety Evaluatio This procedure addresses the licensee's program requirements and preparation of screening reviews and safety evaluations in support of proposed plant modifications (including temporary modifications) to operating plants. The safety' evaluation, which was completed in -accordance with NEP 6.6' and Administrative Instruct'on (AI) AI-9, Control of Temporary Alterations, to support the above TACFs, stated that the retaining wire was pulled snug tigh across the front face of the module and crimpe It .further stated that the purpo'se of this retaining wire was to prevent forward movement of the drawer sufficient to ensure contact with a rear drawer cli Step 22 of AI-9 requires that the alteration be installed exactly as describe Contrary to the above the retaining wires on several Unit 2 Bailey meter modules were not installed in accordance with the requirements of TACF 2-88-2019-500 in that the retaining wires were very loose and did not maintain the drawer in contact with the rear drawer cli This is' identified as Violation 327, 328/89-07-01, example b. Work Requests The following work requests were reviewed:

WR B283562 Reduce Packing leak - essential raw cooling water (ERCW)

pump M-B WR B132009 Replace Packing - ERCW pump M-B WR B209677 Adjust Packing Leak - ERCW pump M-B WR B295193 Adjust Packing - ERCW pump M-B No violations or deviations were identifie _ _ _ - _ _ - _ _ _ _ _ _ _ - _

..

.

.

.

' 7 Hold Orders (HO)

The inspectors reviewed portions of the following H0s~ to verify compliance with AI-3, revision 38, Clearance Procedure, and that the H0s contained adequate information to properly isolate the affected portions of the system being tagged. Additionally the inspectors verified that the required tags were installed on the affected equipmen ,

Hold Order Equipment 2-89-058 2A Auxiliary Feedwater Pump 1-89-132 6.9 KV Shutdown Board - the associated CAQR SQP 880473 was written to support this hold order 1-89-150 TDAFWP 1-FCV-1-16 No violatlons or deviations were identifie Preventive Maintenance Instructions The following preventive maintenance activities were reviewed:

PM 2806 Load Shed TDR - ERCW Pump M-B PM 1651 Routine Lubrication - Various pumps No violations or deviations were identified, Engineering Review of Safety Injection Pump Cooling Water At the request of the inspector, the licensee performed a safety evaluation for an alarmed condition in the control roo This alarmed condition corresponded to low seal water cooling flow for Unit I safety injection pump The existing flowrate indicated gallons per minute vice the alarm setpoint of 5.0 gpm. QIR report NE-MEB-SQP-PMO-89015 revision 0, RIMS B25 890211 200, addressed the flow issue and concluded that the pumps should be declared operable, and that normal seal life could be expected with the lower flow rate even during continuous pump operation. The report further concluded that the seal cooler flow rate should be re-established at 5 gpm and  ;

a review of possible seal degradation completed. Licensee closure of l this QIR will require resolution of the possible pump degradation issue. The licensee's corrective action appeared to be adequate and  !

the inspector had no further question . Management Activities in Support of Plant Operations TVA management activities were reviewed on a daily basis by the NRC inspector Resident inspectors observed that planning, scheduling, work control and other management meetings were effective in controlling plant

__ _____ __

. _

__-. - _ _ _ _ _ _

-

.

-

.

l

.

I

activitie First line supervisors appeared to be knowledgeable and involved in the day to day activities of the plant. First line supervisor involvement in the field has been observed. Management response to those plant activities and events that occurred during this inspection period appeared timely and effective. An example of this was management action taken by the operations supervisors to require automatic versus manual rod control and turbine control during steady state conditions. Operators are now required to document the rationale for placing either . system in manua . Site Quality Assurance Activities in Support of Operations During the inspection pericd, the site QA staff performed audits, inspections, and reviews. These issues were reviewed by the inspector and found to be adequately resolved by the license The following audits were reviewed by the inspector:

QSQ-M-89-220 RWP ALARA Refueling QSQ-M-89-121 Receipt Inspection QSQ-M-89-221 Surveillance Instruction (SI) Data Review QSQ-M-89-223 Turbine Building Sump Release QSQ-M-89-225 Boric Acid Sample QSQ-M-89-232 Configuration Control QSQ-M-89-235 Vendor Manuals - note: this review covered 17 vendor manual documentation changes and 10 vendor manuals. No deficiencies were identifie In addition CAQR SQP 88-06-12, Rod Insertion Limit, was reviewed. During the review of this CAQR, the inspector examined TS 3.1.3.6, FSAR section 7.7.1.3.2 and S01-55, Annunciator Response. There was an inconsistency between the immediate actions required under the S0I on each unit. There was also an inconsistency between the activities required in the FSAR and the actions required in the TS. The licensee reviewed this CAQR and determined that no operability issue existed. The inspector reviewed the licensee's activities and did not identify any system operability issue The inspector had no further question . NRC Inspector Follow-up Items, URIs, Violations (92701, 92702)

(Closed) URI 327, 328/89-02-01, UHI Depressurization and Emergency Diesel Generator (EDG) LCO Exit Event This Unresolved Item (URI) involved two separate parts. The exiting of the EDG LCO following performance of SI 26.2A on January 21, 1989 was reviewed by the inspector during the inspection period. The inspector determined that the LCO was properly exited, but that test deficiencies id2ntified during performance of the surveillance may have been improperly dispositioned. The operability of the EDG is not in question, but the process of test deficiency review and disposition for the specific event will be tracked by IFI 327, 328/89-07-0 _ _ _

- _ _ _ _ _ _--

..

,

l s

. j

l' On January 21, 1989, operators attempted to depressurize the Unit 2 UHI l nitrogen accumulator from 1300 psig to atmospheric pressure in preparation for refu'eling. S01-87.1, UHI Accumulator, contains steps for reducing the accumulator's pressure through valve 2-FCV-87-13. A gas vent orifice-in-line with 2-FCV-87-13 has a 0.025-inch diameter hole and a design flow

. rate of 400 standard cubic feet per hour. Roughly 147,000 cubic feet of

nitrogen is contained _ in the accumulator at the ' operating pressure. At-the design flow rate, full depressurization would have required 15 day Consequently, the operators decided to use the. drain line off .the accumulator bottom. According. to AI-58, Maintaining Cognizance of Operating Status, Appendix E, handwritten instructions.may be prepared and used for performing evolutions not covered by approved procedures. The handwritten instruction, as written, provided for attaching a high pressure

' hose to valve 2-87-555 on the bottom of the accumulator. The hose was then run through the building door into the yard are When valve 2-87-555 was opened to start the depressurization, water began flowing from the hose at a high rate and the unsecured hose started whipping around the yard area. The ASOS stationed at the hose called for the operator at the valve to shut the valve. By the time the valve was shut and the incident stopped, approximately 100 gallons of water had been sprayed into the yard are Health Physics personnel were called to survey the area and determined that the water was contaminated. The area was secured and decontaminated. The source of the water in the j accumulator was determined to be from a failed or leaking diaphragm 4 between the nitrogen accumulator and the borated water accumulato j Although a pre-release sample had been taken at the vent valve, no sample was taken at the drain connection. In additiori, the possibility of water in the bottom of the accumulator was not considered, so the hose was not secured or routed to a container or sump. The handwritten procedure was inadequate in that it did not consider these conditions and resulted in an uncontrolled activity involving contaminated liqui This is identified as Violation 327, 328/89-07-01, example (Closed) URI 327,328/89-02-02 DNE USPD and TACF Review pertaining to Bailey Meter Instrument Module SEISMIC Qualificatio This item pertained to the installation of aircraft cable across the front face of Bailey Meter Company instrument modules. This review is contained in paragraph 4a of this report under TACF 1-88-22-500 and resulted in Violation 327, 328/89-07 example . Event Followup, LERs (93702)

On February 7, 1989, Unit 1 experienced an inadvertent boron dilution event while at 100% power when an improperly borated mixed bed demineralized was placed in service in the letdown stream. Records for the boration status for the IB mixed bed demineralized were not specific concerning the boration status of the demineralized bed. The resin status log sheet, SOI 62.4, Chemical and Volume Control System, Appendix A, showed the bed had been loaded on April 5,1986, but the lithiated and

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

__ - _ _ _ _ _ _ _

-

. .

.

.'

.

qh

borated procedural signoffs had been marked 'N/ Other personnel contacted thought they remembered that the bed .in questionhad been in

. service previously, and should therefore be properly borated. When the bed was placed in service at 7:58 p.m., the bed began removing boron from the letdown stream. This resulted in a dilution of the VCT and subsequently of the RCS. The operators were alerted to the dilution when the alarm for. Power Range Nuclear Instrument Channel- 4 alarmed at 10 percent power (Channel Deviation Alarm) at 8:22 p.m. The operators initially assumed that Automatic makeup to the VCT was causing the dilution, and began inserting control rods and borating to compensate for-the dilutio Forty gallons of 20,000 ppm boric acid was injected. At 8:28 p.m. the IB mixed bed was bypassed by the U0. ' The IB mixed bed was isolated at 8:38 p.m. An additional 40 gallons of boric acid was added-to the the RCS between 9:29 p.m. and 10:28 p.m. to return the control rods to their original position. The procedure used to verify that the mixed bed was properly borated prior to placing it in service, SOI-62.4 was -

inadequate, in that positive control over the boric acid content of the bed was not exercised and records associated with the boration status of the mixed beds are not included. This lack of control and documentation caused the power transient inciden This is identified as Violation 327, 328/89-07-01, example d, Failure to Develop and Implement Procedure During the ensuing investigation into this event by the P0RS staff, at 9:10 a.m. on February 9, it was determined that the Radiological Emergency Plan (REP) should have been implemented in accordance with A0I-3, Mal-function of Reactor Makeup Control, and that the NRC should have received a Notification of Unusual Event. At 9:37 a.m. this notification was made to the NRC Incident Response Center. Failure to enter the REP and declare-an Unusual Event as required by procedure A01-3, Malfunction of Reactor Makeup Control, Section B, Inadvertent Dilution, is identified as Violation 327, 328/89-07-01, example e, Failure to Establish and Implement Procedure This violation is similar to Violation 327, 328/88-34-0 The dilution event described above was complicated by the operational mode l~ in effect at the time the dilution began. The control rods were in Manual and therefore did not respond to the increasing Tave caused by the l reactivity additio In addition, turbine control was in the Imp-out mode, which held governor valve position fixe This combination allowed the ]

increasing Tave to raise steam pressure, which in turn allowed the turbine )

to accept more load, which, through reactivity feedback effects resulted I in a reactor power increase. The actual power increase was calculated to have peaked at 100.8% and Tave peaked at 580 F from the steady state l_ values of 100% and 578.6 F, respectively. The licensee determined through analysis and simulator event recreation that the power transient would not have occurred if the control rods had been in. automatic and turbine control had been in Imp-in mode of control. After discussions with the resident staff, operations supervisors stated that automatic rod control and Imp-in turbine control would be used in the future unless control problems or instabilities forced use of the alternative mode In ,

addition, the licensee agreed to document the rationale for disregarding l steps in their GOI's in the future. At present, steps in the G01's may be i disregarded at the discretion of the SOS by marking the step N/A per AI-6, Mwn-----_.___-__ .-_-__ - _ _ - - __.a _

- _ _ _ _ . _

.

.

.

Log Entries and Review. GOI-5, Normal Power Operation, requires' the rod

. control system to be in automatic when above 30% power, and the turbine control to be in the Imp-in mode above 25%. Instabilities had been observed in the Imp-in mode in the past, and the operators felt n. ore comfortable with manual rod control, so they routinely operated with Imp-out and Manual contro On February 10,1989, Unit 1 tripped from 100% power at 8:36 The reactor trip initiation signal was a steam flow / feed flow mismatch coincident with low steam generator leve Just prior te the event, instrument maintenance personnel were replacing a flow rate recorder for the condensate dump-back to the condensate storage tank. The recorder had I been removed for maintenance by WR 328429. During the replacement of the recorder, while relanding leads, the instrument technician inadvertently grounded the two leads together. This caused the power supply breaker #39 on the 120 volt vital instrument bus to tri This breaker supplies, among other loads, the controllers for the feed regulating control valves for steam generators #1, #3 and #4. Loss of power to these controllers resulted in closing the feed regulating valves to those steam generator The result of the feed loss was feed flow less than steam flow and a low SG level of 25% within seconds. The plant responded in a normal manner to the trip, and the operator took manual control of auxiliary feedwater flow rate to reduce the ccoldown. Tave decreased to a low of 539 F., and the operators responded by Emergency Borating at 80 gpm for approximately 9 minutes, at which time a shutdown margin calculation was completed, allowing the termination of the boratio The licensee determined that this event could have been prevented by unplugging the power supply to the chart recorder prior to workingRon the assembly. Instrument technicians routinely work on energized low voltage equipment, often necessitated by troubleshooting. Work planning practices require disconnecting power when the voltage is sufficient to cause personnel injury. Working on energized equipment when not specifically required was discussed with the Maintenance Superintendent shortly after the trip. The Maintenance Superintendent stated that this practice would be reviewed by his staff. Operators in the turbine building thought that a steam leak was occurring after the trip due to a simmering MSR relief, and notified the control room. As a result of this information, the plant declared an Unusual Event and notified the NRC response center. The NOUE was cancelled when it was verified that a steam leak did not exis SQM 2, Maintenance Management System, contains requirements for planning i of maintenance activities. Guidance and requirements for ensuring work activities are conducted in a safe and conservative manner were not adequate in the preparation of WR 328429. This was demonstrated by the reactor trip and NOUE that were generated when the WR was used in the chart recorder maintenance. Failure to establish an adequate work control procedure is identified as Violation 327, 328/89-07-01, example _ _ __ _ _ _ _ _

..

.

.

o ,C j ll .

?

y UNIT 1-(0 pen) LER 327/88-043, . Inadequate Fire Watch Patrol Resulted In a Noncompliance with TS 3.7.1 The -inspector reviewed the LER and determined _that the licensee was < implementing the corrective actions stated in the LER. During the review

the inspector noted several discrepancies. These were discussed in a memo (Loveless / Watson) and will be reviewed by the NRC in the futur This item' remains ope . (Closed) TI'(2515/100) Proper Receipt, Storage. and Handling of Emergency Diesel Generator Fuel 011 The inspector responded to the questionnaire survey as requested by NRC Region II, Division of Reactor Safety. No safety issues were identifie This issue.will be evaluated for generic considerations by the Division of Reactor Safet . (Closed) TI 2515/93, Inspection for Verification of Quality Assurance Request Regarding Diesel Generator Fuel Oil Multi-Plant Action Item A-1 The inspector. reviewed the licensee's program for the procurement of diesel fuel oil and determined that the diesel fuel purchased for the emergency diesel generators is included in the QA program as required by SQA159, rev. 7, Standards and Guides for Quality Assurance Level III Items. In addition, a review.of Receiving Report #58-00826 was performed with special - emphasis on chemical analysis that included acceptable chemical limits and the results of those measured. No deficiencies were note This item is close . Refueling Activities (60710) The inspector reviewed the incident associated with bending the fuel transfer cart during the off-loading of Unit 2; reactor fuel bundles which occurred on February 11, 198 This event resulted from attempting to raise the upender without first having the fuel transfer cart fully inserted and therefore causing damage to the cart track and cart baske The licensee was aware that at the time the fuel handling operation began, the equipment was not functioning properly. The counter, whose purpose was to track the position of the fuel cart and provide an interlock permissive on the fuel pit side of the fuel canal for the upender, was electrically by passed. This by pass was implemented via TACF, 2-89-35-079. As a result, FHI-7, rev.25, Refueling Operation, was revised by ICF 89-0149 to require operator L verification that the cart was fully inserted before upending the fuel assembl !

,

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

__ _ _-_ - _ _

l

'

,.

.,

'

.. ,

.

!

13 -]

1 Prior to the incident, it was reported that the fuel transfer car j was experiencing problems with the torque switch causing the cart.to {

stop on over-torqu On February 10, 1989, a second TACF, 2-89-33-079, was-issued to install a spring loaded bypass switch tha allowed the torque switch.to be momentarily bypassed after a trip on high torque. An ICF, 89-0187, was implemented to address the use of this switc In addition, the licensee experienced problems with the load cell on i the reactor side upender. The position of- the reactor side upender !

was in error, indicating " frame up" when the frame was in the " frame -

down" position. This problem required the operator to pull up on the upender cable to reduce- the load on the upender load cell in order to traverse the car The fuel-transfer cart bending event is similar to the incident that occurred during the last Unit 2 refueling outage which resulted in damage to 2 RCA units. That incident -was attributed to an unwarranted challenge of the fuel transfer conveyor interlock and inadequate visual verification as required by FHI-7 and resulted in a Violation, 50-328/84-36-01, being issue However, the cause of the event that occurred on February 11, 1989 was . attributed to a failure to follow procedure, FHI-7, which-requires visual verification that the cart be fully inserted. prior to raising the upender. This failure to follow the refueling procedure

~will be identified as Violation 50-327, 328/89-07-01, example Damage to a 'used fuel module has the potential for serious impact on personnel safety and exposur The licensee's corrective. actions include the revision and implementation of FHI-7 to require for double verification that the fuel bundle is fully inserted into the upender prior to upending the bundl During the beginning of the Unit 2, cycle 3 outage, continuous problems with airborne radiation were experienced in the Unit 2 containment and auxiliary building. The ~ licensee . investigated and determined the source to be the alignment of the ventilation system and the use of vacuum cleaners with no filters and those with filters which were improperly installe Corrective actions were taken to modify the alignment of the ventilation system and to implement a more positive control over the vacuum cleaners. Radiological Control Instruction, RCI-18, Control of Vacuum Cleaners, has been' written and implemented to maintain and control the use of vacuum cleaners used within the RC This j instruction requires the cleaners be properly stored, maintained, and 1 tested to insure operability. In addition, procurement of a single vacuum system is being evaluated for replacement of the smaller individual unit _ - _ - _ _ _ _ _ _ _ _

-

-.

. *

'

e Radiological controls appear to be improving which reflects the attitude and efforts of the managemen . Exit Interview (30703)

The inspection scope and findings were summarized on March 3,1989, with those persons indicated in paragraph.1. The Senior Resident Inspector described the areas inspected and discussed in detail the inspection findings listed below. The licensee acknowledged the inspection findings and did not identify as proprietary any of the material . reviewed by the inspectors during the inspectio Inspection Findings:

Results: One violation and one Inspector Followup Item were identified:

VIO 327, '328/89-07-01, Failure to Establish and Implement Procedures, with six examples:

Example a, Failure to adequately implement Unit 2 refueling procedure associated with the fuel transfer cart during off-loading of reactor fuel bundles (paragraph 11.a)

Example b, Failure to establish an adequate UHI venting procedure resulting in 100 gallons of contaminated water being sprayed into the containment yard area (paragraph 7)

Example c, Failure to adequately implement a TACF safety evaluation requirement regarding a Bailey meter cabinet seismic restraint (paragraph 4.a)

Example d, Failure to establish an adequate resin bed installation procedure resulting in a power transient caused by an improperly borated mixed bed demineralized (paragraph 8)

Example e, Failure to adequately implement the requirements of an abnormal operating procedure as it relates to the Radiological Emergency Plan (paragraph 8)

Example f, Failure to establish adequate work instruction for WR 328429 (paragraph 8)

i IFI 327, 328/89-07-02, Test Deficiency Review and Disposition J for EDG SI-26.2A No deviations or unresolved items were identifie g _ . _ _

_ _ _ _ _ ,

, .

. . .

%

? ,

. i 15 .

i During the reporting period, frequent discussions were held with the Site Director, Plant Manager and other managers concerning inspection finding . List of Acronyms and Initialisms ABGTS- Auxiliary Building Gas Treatment System ABI - Auxiliary Building Isolation ABSCE- Auxiliary Building Secondary Containment Enclosure AFW - Auxiliary Feedwater AI -

Administrative Instruction A01 - Abnormal Operating Instruction AVO -

Auxiliary Unit Operator ASOS - Assistant Shift Operating Supervisor ASTM - American Society of Testing and Materials BIT -

Boron Injection Tank C&A -

Control and Auxiliary Buildings CAQR - Conditions Adverse to Quality Report CCS -

Component Cooling Water System CCP -

Centrifugal Charging Pump CCTS - Corporate Commitment Tracking System CFR -

Code of Federal Regulations COPS - Cold Overpressure Protection System CS -

Containment Spray CSSC - Critical Structures, Systems and Components CVCS - Chemical and Volume Control System CVI -

Containment Ventilation Isolation DC -

Direct Current DCN -

Design Change Notice DG -

Diesel Generator DNE -

Division of Nuclear Engineering ECN -

Engineering Change Notice ECCS - Emergency Core Cooling System EDG - Emergency Diesel Generator EI -

Emergency Instructions ENS -

Emergency Notification System E0P -

Emergency Operating Procedure EO -

Emergency Operating Instruction ERCW - Essential Raw Cooling Water ESF -

Engineered Safety Feature FCV -

Flow Control Valve FSAR - Final Safety Analysis Report GDC -

General Design Criteria

, G01 -

General Operating Instruction l GL -

Generic Letter HVAC - Heating Ventilation and Air Conditioning HIC - Hand-operated Indicating Controller HD -

Hold Order HP -

Health Physics ICF -

Instruction Change Form j

,

I

_ _._-_-_m___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ - _ - _ _ . _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ _ - - - _ . _ . _ _ _ _ _ _ _ _ . _ _ _ _

_ - _ -_-_ . - _

.

..

.,c ..

,, a

.

1-

l IDI -

Independent Design Inspection-IN -

NRC Information Notice IFI -

Inspector Followup ite IM -

Instrument Maintenance IMI '- Instrument Maintenance Instruction

,

,IR -

Inspection Report

[ KVA -

Kilovolt-Amp KW -

Kilowatt KV -

Kilovolt LER -

Licensee Event Report LCO -

Limiting Condition for Operation

,

'

LIV -

Licensee Identified Violation LOCA - Loss"of Coolant Accident MCR -

Main Control Room MI- -

Maintenance Instruction MR -

Maintenance Report MSIV - Main Steam Isolation Valve NB -

NRC Bulletin NOV -

Notice of Violation NQAM - Nuclear Quality Assurance Manual NRC - Nuclear Regulatory Commission OSLA - Operations Section Letter - Administrative OSLT - .0perations Section Letter - Training OSP --

Office of Special Projects PLS Precautions, Limitations, and Setpoints PM -

Preventive Maintenance PPM -

Parts Per Millionn PMT -

Post Modification Test PORC - Plant Operations Review Committee PORS - Plant Operation Review Staff PRO -

Potentially Reportable Occurrence QA

-

Quality Assurance QC

-

Quality Control RCDT - Reactor Coolant Drain Tank RCP -

Reactor Coolant Pump RCS -

Reactor Coolant System RG -

Regulatory Guide RHR -

Residual Heat Removal RM -

Radiation Monitor RO -

Reactor Operator RPI - Reactor Protection Instrumentation RPM -

Revolution Per Minute RTD -

Resistance Temperature Detector j RWP -

Radiation Work Permit l RWST - Refueling Water Storage Tank J SER -

Safety Evaluation Report SG -

Steam Generator SI -

Surveillance Instruction SMI -

Special Maintenance Instruction

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

j

e ,,

f - '- ' ,

i i

,

f.:

501 - . System Operating Instructions SOST - Shift Operating Supervisor SQM

-

Sequoyah Standard' Practice Maintenance SQRT - Seismic Qualification Review Team SR- -

Surveillance. Requirements SRO -

Senior Reactor Operator STA' -

Shift Technical Advisor STI -

Special' Test Instruction

TACF - Temporary Alteration Control Form TAVE - Average Reactor Coolant Temperature TDAFW- Turbine Driven Auxiliary Feedwater TI -

Technical Instruction TREF - Reference Temperature TROI - Tracking Open Items TS -

Technical Specifications TVA -- Tennessee Valley Authority UHI -

' Upper Head Injection UO ' . - Unit Operator URI -

Unreso)ved Item USQD - .Unreviewed Safety Question Determination

VDC -

Volts Direct Current VAC -

Volts Alternating Current WCGJ- Work Control-Group Work Plan

'

-

?WP WR -

Work Request i

%

'

.