IR 05000346/1993026

Enforcement Conference Rept 50-346/93-26 on 931217. Areas Discussed:Review of Four Apparent Violations & Areas of Concern Identified During Insp 50-346/93-19

ML20059B211
Person / Time
Site:	Davis Besse
Issue date:	12/21/1993
From:	Lanksbury R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20059B198	List: IR 05000346/1993026 ML20059B197
References
50-346-93-26-EC, EA-93-297, NUDOCS 9401040034
Download: ML20059B211 (22)

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I U.S. NUCLEAR REGULATORY COMMISSION f

REGION III

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Report N /93026(DRP) EA 93-297  ;

Docket N ,

License No. NPF-3 -I Licensee: Toledo Edison Company Edison Plaza, 300 Madison Avenue  ;

Toledo, OH 43652 -i Facility Name: Davis-Besse Nuclear Power Station ].

Meeting Conducted: December 17, 1993

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Meeting At: Region III Office '

801 Warrenville R :l Lisle, IL 60532 '

i Type of Meeting: Enforcement Conference l

Inspection Conducted: Davis-Besse Nuclear Power Station l September 25 through November 22, 1993 l t

Inspectors: S. Stasek j J. M. Shine  !

S. D. Burgess i

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s Approved By: D - ILlL1l% -

Ri D. Lanksbury, Chi W - D'a t'e !

Reactor Projects Section 3B l

Meetino Summarv

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Enforcement Conference on December 17.1993 (Report No. 50-346/93026(DRP)) j Areas Discussed: A review of the four apparent violations .and areas: o ?

concern . identified during inspection 50-346/93019(DRP)), their safety-significance,- and corrective actions taken or planned by the licensee. The j

first apparent violation concerned:inoperability of the auxiliary feedwater 't system (AFC) for a period greater than allowed b.v: plant Technical i Specifications (TS). The three additional apparen: violations concerned- t procedure adherence. issues related to the implementation of configuration

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control requirements, TS valve position verification checks'not being ,

adequately performed, and inadequate corrective action to prevent recurrence t related to self-identified configuration control problem ,

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ETAILS - Persons Present at the Enforcement Conference  !

Centerior Service Company  ;

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D. Shelton, Senior Vice President-Nuclear  ;

L. Storz, Vice President-Nuclear

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Toledo Edison Company J. Wood, Plant Manager .

G. Gibbs, Director, Engineering T. Myers, Director, Nuclear' Assurance  ;

C. Hawley, Manager, Quality Control J. Moyers, Manager, Quality Assessments ,

R. Donnellon, Manager, Plant Engineering J. Holden, Manager, Design Engineering  :

S. Byrne, Manager, Plant Operations-W. O'Connor, Manager, Regulatory Affairs P. Smith, Supervisor, Compliance J. Galecki, Public Affairs l Members of the Public ,

T. Reeves, Analyst State of Ohio T. Henry, Environmental Writer, Toledo Blade  :

E. Hare, Senior Engineer, Licensing, Detroit Edison Company ;

U.S. Nuclear Reaulatory Commission. Reaion III J. Martin, Regional. Administrator, RI ,

G. Grant, Director, Division of Reactor Safety, RIII '

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J. Hannon, Director, Project Directorate III-3, Office of Nuclear Reactor Regulation (NRR)

T. Martin, Deputy Director, Division of Reactor Trojects, RIII R. Defayette, Director, Enforcement and Investigation Coordination ,

Staff, RIII _

L. Greger, Chief, Division of Reactor Trojects Branch 3, RIII '

R. Lanksbury, Chief, Division of Reactor Projects Section 3B, RIII S. Burgess, Inspection Team Leader, RIII J. Shine, Resident Inspecto", Davis-Besse Nuclear Power Station, RIII ;

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J. Hopkins, ' Project Manager, NRR R. Lickus, Chief, State and Governmental Affairs, RIII-J. Strasma,:Public Affairs, RIII J. Hansen, Operator Licensing Examiner, RIII

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. Enforcement Conference An enforcement conference was held in the NRC Region III Office on December 17, 1993. This conference was conducted as a result of the .

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preliminary findings of the inspection conducted on September 25 through November 22, 1993, in which four apparent violations of NRC regulations and license requirements were identified. The inspection findings were-documented in Inspection Report No. 50-346/93019(DRP), transmitted to -

the licensee by letter dated December 9, 199 '

The purpose of this conference was to (1) discuss the apparent .

violations, causes, and the licensee's corrective actions; (2) discuss several areas of concern; (3) determine if there were any escalating or mitigating circumstances; and (4) obtain any information which would help determine the appropriate enforcement actio The licensee's representatives did not contest any of the apparent '

violationc end were in agreement with the NRC's understanding of the areas of cov er The licensee's representatives described the events which resulted in the apparent violations, including root causes and corrective actions 3 take In summary, the corrective actions concerning the AFW system *

included: issuance of standing orders.to prohibit the inoperable AFW !

configuration, review of other safety systems with cross-connect lines to assure no other similar problems existed, amendments to AFW system procedures to preclude applicable valve closure, and commitments to ,

revise, perform training, and enhance guidance regarding the AFW safety !

analysis and removal from service of TS required system Short term corrective actions concerning the configuration control issues included: performance of walkdowns on 17 systems to verify proper

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configuration, formation of a multi-disciplined management team to establish station configuration control policy, hsuance of memoranda to personnel communicating management expectations on the use of procedure exceptions, and introduction of Quality Control holdpoints into ongoing i modifications. Long term corrective actions included: containment ,

system walkdowns, evaluation of further system walkdowns, independent i

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assessment of the configuration control process, and resolution of the Management Corrective Action Reports issued on configuration control 1 problems and the corrective action progra At the conc'"' on of the meetino the licensee was informed that they !

would be notified in the near future of the final enforcement action.' . A copy of the licensee's and Nr ~ s presentations are attached to this repor Attachments: NRC Presentation Slides Licensee Presentation Slides

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D U.S. NRC REGION 111 .

DAVIS-BESSE ,

ENFORCEMENT CONFERENCE December 17,1993 9:30 A.M. (CST)

EA 93-297 REPORT NUMBER 50-346/93019 ;

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REGION lli OFFICE 801 WARRENVILLE ROAD LISLE, ILLINOIS

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DAVIS-BESSE ENFORCEMENT CONFERENCE Agenda INTRODUCTION AND OPENING REMARKS:

Thomas O. Martin, Deputy Director, Division of Reactor Projects ,

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NRC ENFORCEMENT POLICY Robert W. Defayette, Director, Enforcement and Investigation ,

Coordination Staff NRC OVERVIEW:

Thomas O. Martin, Deputy Director, Division of Reactor Projects SUMMARY OF APPARENT VIOLATIONS: '

John M. Shine, Resident inspector, Davis-Besse Sonia D. Burgess, Team Leader, Division of Reactor Safety LICENSEE PRESENTATION AND DISCUSSION:

Toledo Edison Company -

NRC FOLLOWUP QUESTIONS

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CLOSING REMARKS:  :

John B. Martin, Region lll Administrator *

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R l APPARENT VIOLATION i i

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Plant Technical Specification 3.0.3 states in part that when a Limiting Condition for Operation is not met, except as provided in the associated Action Statements, actions shall be initiated- ,

within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> to place the unit in a Mode in which the Specification does not apply by placing it, as applicable, in 1) :

At least Hot Standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />,2) At least Hot Shutdown within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, and 3) At least Cold ;

Shutdown within the subsequent 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> '

_ CONTRARY TO THE ABOVE  !

s On October 20,1993, with the unit at 100 percent power, both trains of the auxiliary feedwater system were  !

simultaneously made inoperable for approximately 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> '

without the unit being placed in at least Hot Standby during !

that tim ,

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The apparent violations-discussed in this enforcement conference are subject to further review and may be subject to change prior to any *

resulting enforcement actio f

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a APPARENT VIOLATION  !

10 CFR Part 50, Appendix B, Criterion V states that activities

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affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawing ;

CONTRARY TO THE ABOVE * The CCW/SW cross connect tell tale drain valves SW-235 and SW-237 were incorrectly listed as open in procedure DB-OP-06262, " Component Cooling Water System *

Operating Procedure," Revision 00 and procedure DB-OP-02523, " Component Cooling Water System Malfunctions," Revision 0 b. In April 1993, procedure DB-OP-00000, " Conduct of ,

Operations," Revision 00, step 6.8.8.a.2, was 1 inappropriately used to change the valve lineup listed in procedure DB-OP-06261, " Service Water System Operating Procedure," Revision 0 i Procedure DP-OP-06261, " Service Water Systern Operating ;

Procedure," Revision 00, limits and precautions step 2.2.1, )

incorrectly stated the containment air cooler (CAC) lineup -)

for the idle cooler. Step 2.2.1 was not changed to match !

Attachment 1 when the CAC lineup was revised April 21, 199 d. During the May 1,1993, performance of DB-SP-03019,

" Service Water System Monthly Valve Verification (Train 1)," Revision 01, CAC outlet isolation valve SW-77, was left in the closed position vise the procedure's required open-positio The apparent violations discussed in this enforcement conference are subject to further review and may be subject to change prior to any l resulting enforcement actio l

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. SW operating procedure DB-OP-02011, " Heat Sink Alarm t Panel 11 Annunciators,"-Revision 01, stated the incorrec strainer discharge pressure for SW pump 2 and strainer differential pressures for SW pump-2 and The isolation valves for PDI SW-11210 and SW-11211 and fire connection valves SW-391, SW-392, and SW-393, were omitted from the operations checklist in procedure DB-OP-06261, " Service Water System Operating Procedure,"

Revision 0 g. Procedure DP-OP-06261, " Service Water System Operating !

Procedure," Revision 00, incorrectly identified SW-1389, SW-1390, and SW-1391 as relief valves instead of manual isolation valves upstream of the relief valve ,

h. Valve CC-209 was omitted in the valve lineup in procedure DB-OP-06262, " Component Cooling Water System Operating Procedure," Revision 0 . Procedures DB-PF-04731, "ECCS Room Cooler #1 Performance Test," Revision 1; DB-PF-04732, "ECCS Room Cooler #2 Performance Test," Revision 1; DB-PF-04734, l

"ECCS Room Cooler #4 Performance Test," Revision 4; '

DB-PF-04735, "ECCS Room Cooler #5 Performance Test," '

Revision 1; and DB-OP-06261, " Service Water Syste .!

Operating Procedure," Revision 00, contained no steps or incorrect steps to position instrument isolation valves SW-11104A/B, SW-11105A/B, SW-11106A/B, .

SW-11107A/B, SW-11108A/ '

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The apparent violations discussed in this enforcernent conference are subject to further review and may be subject to change prior to any resulting enforcement actio . :.

. APPARENT VIOLATION Technical Specification Surveillance Requirement 4.7.4. requires that each service water loop be operable at least once per 31 days by verifying that each valve (manual, power operated or automatic) servicing safety related equipment that is not locked, sealed or otherwise secured in position, is in its correct positio i CONTRARY TO THE ABOVE

Between February 1989 and October 15,1993, the containment air cooler inlet isolation valves SW-64, SW-65, SW-68, SW-69, SW-72, and SW-73 were not locked, sealed or otherwise secured in position and were not verified to be in the correct position every 31 days during power operatio ,

APPARENT VIOLATION 10 CFR Part 50, Appendix B, Criterion XVI states that i measures shall be established to assure that conditions adverse i to quality, such as failures, malfunctions, deficiencies, deviations, and nonconformances are promptly identified and .

corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetitio CONTRARY TO THE ABOVE Adequate corrective action was not taken to preclude repetitive configuration controlissues identified in QA audit reports AR-92-DESIN-01, AR-91-DESIN-01, and AR-91-DESIN-0 The apparent violations discussed in this enforcement conference are subject to further review and may be subject to change prior to any resulting enforcement actio :

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Davis-Besse Auxiliary Feedwater and  :

Motor Driven Feedwater Systems '

(Applicable Portions)  :

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Steam Steam Generator Generator el (2

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H AFCOS (CIV) M U AF599 (CIV)

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AF3870 M M M M AF3872 kJ l kll n ~-

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FW6398 FW5397 Motor Driven Feedpump O l r

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E CY DAVIS-DrSSE NUCLER POWER STADON

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DAVIS-BESSE NUCLEAR POWER STATION

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Enforcement Conference Presentation to the U. S. Nuclear Regulatory Commission

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December 17,1993

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CENTERIOR ENERGY DAVLS-DESSE NUCLMR POWER STADON AGENDA .

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INTRODUCTION . . . . . . . . . . . . L. F. Storz, Vice President ISOLATION OF AFW . . . . . . . . . . J. K. Wood, Plant Manager CONFIGURATION CONTROL

- Service Water Valves Position Surveillance . . . . . . . J. K. Wood, Plant Manager

- Procedures / Drawings . . . . . . . G. A. Gibbs, Director - Engineering GOALS . . . . . . . . . . . . . . . . . L. F. Storz, Vice President T. J. Myers, Director - Nuclear Assurance

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CENTERIOR'

ENERGY oAvis-oessa nucuuut rowna srAnON

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ISOLATION OF AUXILIARY FEEDWATER TO STEAM GENERATOR 1-1  :

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E VIOLATION

• S/G 1-1 isolated from both AFW trains for approximately 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> making them inoperable

• Condition not recognized as invoking TS 3.0.3 resulting in TS violation e E CAUSE

= Misunderstanding of what constituted an operable train of auxiliary feedwater E SAFETY SIGNIFICANCE

• AFW system was incapable of mitigating without operator action, the full spectrum of postulated accidents for approximately 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> ,

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ISOLATION OF AUXILIARY FEEDWATER TO STEAM GENERATOR 1-1

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• Standing Order issued to prohibit valve closure l-

!- * - AF599/608 no longer stroked quarterly for IST i * Precaution on valve closure added to AFW Procedure L * Reviewed all other safety systems with cross-connects and found no similar -

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E LONG TERM CORRECTIVE ACTION '

• Revise.TS to reflect AFW safety analysis

• Training on LER and AFW safety analysis .

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M ' BROADER CONSIDERATIONS  !

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• Enhance-guidance regarding the performance of LCO maintenance activities

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DAVIS-DESSE NUCIEAR POWER STATION CONFIGURATION CONTROL ISSUES .

E VIOLATION

• Containment Air Cooler Service Water manual valves not locked open and position not periodically verified as required E CAUSE

• Misapplication of surveillance requirements for valves inside containment

• Surveillance test deficiency following removal of valves from the Locked Valve Program

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E SAFETY SIGNIFICANCE

• Valves are located inside containment and were verified in correct position

• No loss of safety function l

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EN GY DAVIS-BESSE NUCMAR MNT.R STATION CONFIGURATION CONTROL-ISSUES -(Continued)

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E3 IMMEDIATE CORRECTIVE ACTIONS

• Performed required surveillance

• Added SW valves to the Locked Valve Program

• Reviewed all other valve position verification surveillance requirements N LONG TERM CORRECTIVE ACTIONS

• Review of the Locked Valve Program E BROADER CONSIDERATIONS

• Configuration Control

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w OAvis.ncsse nucuwt rowsit sunow CONFIGURATION CONTROL ISSUES -(Continued)

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VIOLATION i

-* 10CFR50 Appendix B, Criteria V (Quality affecting activities conducted using

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-documented instructions, procedures or drawings) -

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Errors on P&lDs and Operational Schematics -

- Inadequate Operating Procedures

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Inappropriate procedure use by Operators

• 10CFR50 Appendix B, Criterion XVI (Measures shall assure that the causes of deficiencies are identified and corrective actions are taken to preclude recurrence) ,

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- Inadequate corrective action taken to preclude repetitive configuration control problems

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• No site wide policy that defined the philosophy and hierarchy for configuration a contro * Poorjudgment in providing and using the procedure exception processes

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• Inadequate management attention to follow-up of configuration controlissues

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CENTERIOR V ENERGY DAVIS-DESSE NUCUWL IMT.R STADON

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CONFIGURATION CONTROL ISSUES -(Continued)

E SAFETY SIGNIFICANCE

• Potential recognized for safety significant error -

• No operability issues identified E IMMEDIATE CORRECTIVE ACTIONS

• Walkdowns performed on 17 plant systems

• Documented discrepancies found on drawings and in procedures

• Multi-disciplined management team assigned to establish a configuration control policy

• OC Hold Points established for ongoing modification implementation

• Issued Standing Order following the ISE review of Safety Reviews for changes to

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Operating Procedures

• Communicated management expectations on the use of procedure exceptions

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__ _ _ _3 CONFIGURATION CONTROL ISSUES -(Continued) B E LONG TERM CORRECTIVE ACTIONS

• Walkdowns of plant systems inside containment -

• Evaluate scope of further systems walkdowns e independent assessment of configuration control / modification process

• Develop schedule and milestones

• MCARs on configuration control problems and corrective action program

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DAVIS-DESSE NUCtEAR POWER STADON GOALS  ;

t E Superior Corrective Action Process

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E Welcoming Attitude to Oversight E Willingness by All Employees to Document

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. Problems j E Effective Capture and Use of Corporate Experience-l

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