IR 05000528/1992021
| ML17306A826 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 06/11/1992 |
| From: | Wong H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17306A823 | List: |
| References | |
| 50-528-92-21-MM, 50-529-92-21, 50-530-92-21, NUDOCS 9207090350 | |
| Download: ML17306A826 (44) | |
Text
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U. S.
NUCLEAR REGULATORY COMMISSION
REGION V
Report Nos.:
50-528/92-21, 50-529/92-21, and 50-530/92-21 Docket Nos.:
50-528, 50-529, and 50-530 License Nos.:
NPF-41, NPF-51, and NPF-74 Licensee:
Arizona Public Service Company P.
O.
Box 53999, Station 9012 Phoenix, Arizona 85072-3999 Facility Name:
Palo Verde Nuclear Generating Station Units 1, 2, and
Meeting Location:
Arizona Public Service Company (APS) Corporate Office Phoenix, Arizona Approved by:
~Summa r Meeting Conducted:
Hay 26, 199 ong, ie Reactor ProjectsSection II
<jii ~
ate igne A management meeting was held on May 26, 1992, at the APS corporate office to discuss the NRC Systematic Assessment of Licensee Performance (SALP) for the period between December 1,
1990, and February 29, 1992.
The NRC's initial SALP report was issued as Report Nos. 50-528/529/530/92-07.
Following the SALP meeting, the NRC held a management meeting with licensee personnel to discuss recent NRC observations and plant events.
9207090350 920616 PDR ADOCK 05000528
1. ~d
~TA~IS ri a
Pub ic Serv'ce Co PS 0. H. DeMichele, W. F.
Conway, J.
H. Levine, E.
C. Simpson, W.
E. Ide, R. K. Flood, R. J. Adney, G.
R. Overbeck, C. D. Hauldin, R. J.
Stevens, S.
C. Guthrie, P. J. Caudill, D. A. Johnson,
'nnac West President and Chief Executive Officer Executive Vice President, Nuclear Vice President, Nuclear Operations Vice President, Engineering and Construction Plant Manager, Unit
Plant Manager, Unit 2 Plant Manager, Unit 3 Director, Site Technical Support Director, Site Maintenance and Modifications Director, Licensing and Compliance Director, guality Assurance Director, Site Services Supervisor, Compliance R. Snell, Chief Executive Officer c
a Re ulato Commi si n
N J. Martin, T. quay, F. Menslawski, K. Perkins, L. Miller, H. Mong, D. Kirsch, C. Thompson, D. Coe, J. Sloan, Regional Administrator Director, Project Directorate V,
NRR Deputy Director, Division of Radiation Safety and Safeguards Deputy Director, Division of Reactor Safety and Projects Chief, Reactor Safety Branch Chief, Reactor ProjectsSection II Technical Assistant, Division of Reactor Safety and Projects Project Manager, NRR Senior Resident Inspector, Palo Verde Resident Inspector, Palo Verde Arizona Cor oration Commission J.
Brown, Electrical Engineer Additionally, approximately 100 other APS representatives, and representatives from participating utilities and the local media, were present for the meeting.
2.
S stematic Assessment of icense Performance SA P
Mr. Martin opened the SALP management meeting and indicated that a
management meeting would be held following the presentation of SALP results to discuss items of mutual interest.
Hr. Conway commented that the SALP was a generally fair assessment.
Hr. Hartin indicated that the
NRC would focus its presentation on the three areas of concern identified in the SALP report cover letter.
He noted that APS experienced significant performance problems toward the end of the SALP period, and that substantial action addressing these performance problems was warranted.
Mr. Conway indicated that although a written response to the SALP report is not required, APS intends to submit a written response indicating the status of its corrective actions for the recent plant events and escalated enforcement actions, and to identify some minor factual corrections to the SALP report.
Mr. Perkins presented the NRC SALP results in the areas of Plant Operations, Maintenance and Surveillance, Engineering and Technical Support, and Safety Assessment and guality Verification.
Mr. Wenslawski presented the NRC SALP results in the areas of Radiological Controls, Emergency Preparedness, and Security.. For each of the areas, APS management agreed with the NRC conclusions and highlighted actions being taken in the areas needing improvement.
Mr. Martin concluded the NRC's presentation of the SALP results by stating that further improvement is up to the licensee, as a Category
rating reflects satisfactory performance.
He noted that APS has significantly improved in the past several years and that now APS has a
solid and effective management team, good programs, and good tools.
He stated that APS is at a critical juncture now, since problems still occur even though the people, programs, and tools are in place.
He stated that the key to improvement is to get the programs and people to work together effectively and consistently.
He noted that the NRC sees only a small portion of activities, but that the events observed are not characteristic of a top performing organization.
Improved personnel performance is required to keep such events from happening.
He also noted that Radiological Controls and Emergency Planning are good indicators for overall 'organizational performance, and this is a good sign at Palo Verde.
Mr. Conway responded that APS continues to strive for improvement and that APS management was not satisfied with the current level of achievement.
Mr. Conway noted APS'esire to be one of the nation's top performers by 1995.
Mr. Conway noted that the APS Business Plan clearly addresses the intent to excel and is matched with the overall APS corporate strategy.
ana ement Meetin Following the SALP meeting, the NRC conducted a brief management meeting to review recent events.
Mr. Levine opened by discussing some management perspectives.
He noted that management does not intend for there to be differences between the quality of work on safety systems and non-safety systems, though the maintenance program varies slightly for these categories.
In response to NRC questions, he described the substantial effort APS has recently made in observing performance, principally in the operations area, with the
- 2-
assistant plant managers, operations managers, and operations supervisors providing extensive coverage of operations activities on all shifts for the last three months.
A similar effort with supervisory personnel has been initiated in the maintenance area.
These efforts have improved consistency in performance and understanding of management expectations.
Nr. Mauldin continued with a discussion of control of work at Palo Verde.
He stated that three recent events were evaluated for common issues, then summarized how APS is addressing the issues.
He concluded that the principal problem lies in implementation of existing programs.
The progress of implementation of the Model Work Order (MWO) program was reported, noting that APS has increased its goal of the percentage of work orders using MWOs from 15X to 20X.
He also noted that the Trip Reduction Task Force has included trip hazard warnings in the MWOs.
Mr.
Mauldin stated that equipment failures attributed to human errors has steadily declined over the last five quarters from 110 to 16 failures per quarter.
He stated that APS had tailored an industrial safety program for specific use in maintenance observations, and that a Principles of Maintenance Practice booklet has been prepared and distributed.
A quarterly feedback letter has also recently been initiated to improve communications in the maintenance area.
He stated that a working group has been established to address the Maintenance Engineer program, with the intent to achieve more timely involvement of the Maintenance Engineer, particularly in work planning issues.
The use of probabilistic risk assessment in maintenance scheduling was briefly discussed.
Nr. Overbeck presented the results of the root cause of failure investigations for the reactor trip breaker problems.
In response to NRC inquiry, Nr. Overbeck stated that APS is considering the application of lessons learned to other breakers.
Nr. Overbeck then addressed engineering attention to emerging issues, discussing increased sensitivity to root cause of failure determination and quarantine guidelines.
Management expectations for the Shift Technical Advisor with respect to sensitivity and response to emerging issues was discussed.
The handling of vendor information and the response to industry operating experience was also reviewed.
Nr. Adney presented results of the evaluation of the Unit 3 loss of annunciator event.
Nr. Adney discussed the preliminary findings of the APS review which indicated weaknesses in management notification, work pre-briefings, and perceptions in differences between safety and non-safety work practices.
In response to NRC questions, he discussed why the work was prioritized as it was and why it was performed on night shift.
He also stated that the technician's actions to work beyond the scope of the work order were not consistent with management expectations, even though the work group supervisor and control room had been consulted beforehand by the technician.
Nr. Ide presented the recent problems with two high pressure safety injection check valves being found incorrectly installed.
He concluded that neither occurrence was safety significant, the first because other check valves effectively protected the piping outside containment, and
the other because the plant was in a mode where the valve and system were not required to be operable.
He stated that in addition to other corrective and preventative actions, all similar check valves in all three units have been determined to be properly installed.
Some of these valves were ultrasonically tested, some had evidence of previous reverse flow testing, and others were of a design not prone to the type of error made in the two occurrences.
Hr. Ide also presented the preliminary results of the investigation of one of the Unit I reactor trip to turbine trip circuits being found disabled since the previous refueling outage.
A redundant circuit was found to be connected properly and was confirmed to have operated successfully during a reactor trip in 1991.
Hr. Perkins commented that the messages from the SALP also apply to these recent events.
Mr. Martin noted that APS needs to prevent these types of events, which demonstrate the failure of several barriers, any of which could have prevented the events.
He also.stated that management needs to step back from the detail and look at the big picture, asking what these event tell about where APS really stands.
Hr. Conway stated that APS is continuing to look for the key to success, and Hr. Martin responded that the key may be continued attention to personnel performance.
Finally, Mr. Hartin commented that the NRC was still evaluating the significance of the reactor trip breaker event, loss of annunciator event, and check valve events, and the need for further NRC action.
Mr. Hartin thanked those in attendance and then concluded the meetin APS/NRC MANAGEMENTMEETING MAY26, 1992 AGENDA I.
OPENING REMARKS W. F. Conway J. B. Martin II.
1VDMAGEMENTPERSPECTIVES J. M. Levine III.
CONTROL OF WORK C. D. Mauldin IV.
REACTOR'RIP BREAKER INVESTIGATIONS G. R. Overbeck V.
UNIT3 LOSS OF ANNUNCIATORS INVESTIGATION R. J. Adney VI.
RECENT ISSUES
~ CHECK VALVESIMPROPERLY ASSEMBLED
~ TURBINE TRIP CIRCUITRY W. K Ide VII.
CLOSING REMARKS J. B. Martin W. F. Conway
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SENSITIVITYTO QUICKAt@) THOROUGH COMMUNICATIONOF F ROB IRMB
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SENSITIVITYTO TEM POTEN'HAL RISK OF PERFORNQNG WORK QUESTIONING AYI'ITUDEOF '%VHAT IF'ELF CHECKllNGHABITS
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A PERCEPTION THATTHERE ARE DVT'ERENCES BE'IWEEN SAFETY 326) NON-SAI'ETYRELATED WORK
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SENSITlM'IYTO PRESERVING ROOT CAUSE EVIDENCE
T E
ADDITIONALGUIDANCETO BE PUT OUT ESTABLISHA LIST OF SITVATIONSTIIATREQUIRE ENHANCED ENGINEERING INVOLVEMENT
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MANAGEMENTOBSERVATION PROGRAM FORMALIN OFERATIONS MOI MAINTE FEBRUARY 1992 NANCE SINCE BrIPROVE MANAGEMENTINVOLVEMENTAI'6)
AWARENESS OF FIELD A S
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MEMO ADDRESSING MORE 'IIMELYAND LOWER THRESHOLD OF REPORTING EVENTS THROUGH THE hRWAGEMENT CHAIN OBSERVE &6) CORRECT NANCE PRACTICES VS. EXPECTATIONS IN THE FIELD
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CONTINUE TO MAKESURE 'IIIATOUR FROCESSES MUI PROCEDUI&S DO NOT SUPPORT A DIFE'ERENCE INTel WAYWE DO WORK
P R P
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REINFORCE IN DISCUSSIONS WITH TECHNICIANS THAT AJW WORK BE DONE WITHTHE SAZN< HIGH STAM)&U)S FOR QUALjHYANI) COMPLETION
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DEVIX,OP GUIDELINES TO DETERS&< TEG< UWEL OF PRESERVATION OF INFORMATIONPRIOR TO TROUBLE SHOOTING
CONTROL OF WORK David Mauldin, Director Site Maintenance 4 Modifications
PVNGS CONTROL OF VVORK
~ RECENT EVENTS CONDENSATE PUMP TESTING (UNIT 2)
ICI WITTY)RAWAL(UNIT 1)
AI'VIUNCIATOREVENT (UNIT3)
PVNGS CONTROL OF %ORE COMMON ISSUES PROCEDURAL COMPLIANCE BARRIERS TO PREVENT INCIDENTS EMPLOYEE SENSITIVITYTO RISK/
QUESTIONING AYI'I'HJDE TEAM COMMUNICATION COMMUNICATIONOF EXPECTATIONS DIRECT IUGVlAGEMENT/SUPERVISOR INVOLVEMENT IN IMPLEMENTATION OF WORK
PVNGS CONTROL OF WORK
~ EFFECTIVE PROCESSES/PROCEDURES
~ MODELWORK ORDERS
~ TRTF/CRITICAL COMPONENTS IDENTIFIED
~ DECLININGHURST PERFORhh&lCE ERROR TRENDS
MODELWORK ORDER PROJECT STATUS 61 APPROVED MODELS AS OF JANUARY1, 1991
~ 332 APPROVED MODELS AS OF MAY1, 1992
~ 258 WORKING MODELS IN DEVELOPMENT 13.9% U'HLIZATION OF APPROVED MODELS ACROSS STATION
TRIP REDUCTION TASK FORCE
~ "CRITICALPLANT COMPONENT IDEKI.IFIER" WAIPIINGSINMODELWORK ORDERS LABELINGPROGEVQd
MANAGEMENTSENSITIVITYA2'G) INVOLVEMENT
~ hVQNTENANCE OBSERVATION PROGEVQVl
~ PRINCIPLES OF MAINTENANCEhhVIAGEMENT
~ "FEEDBACK"NEWSLETTER
~ 5/15/92 RISK ASSESSMENT/SENSITIVITY LEVELER
~ STANDDOWNMEETINGS/COMMUNICATION
~ QUALITYPERSPECTIVE - SAFETY/NON-SAFETY RELATED EQUIPMENT
~ REDEFINED MAINTENANCEENGINEERING ROLES & RESPONSIBII.ITIES
ACTOR TRIP BREAKER INVESTIGATIONSCOPE
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ROOT CAUSE OF FAILURE - GE BREAKER
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ROOT CAUSE OF FAILURE - WESTINGHOUSE BREAKER
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ATTENTIONTO EMERGING ISSUES
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VENDOR TECHNICAL INFORMATION EFFECTIVENESS OF INTERFACES BETWEEN ORGANIZATIONS INVOLVEDIN EQUIPMENTROOT CAUSE OF FAILUREANALYSIS
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EFFECTIVENESS OF ACTIONS IMPLEMENTEDAS A RESULT OF INDUSTRY OPERATING EXPERIENCE
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ADEQUACYOF BREAKER RESPONSE TIMETECHNIQUES
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ADEQUACYOF RTSG MAINTENANCEPROGRAM
OOT CAUSE OF F ILURE - GE BREAKER Insufficient clearance between the under voltage trip paddle adjustment screw and trip shaft paddle clamp. (Root Cause)
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Combined with sudden jolt or kick created by closing forces of the breaker. (Causal Factor)
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Inadequate procedural guidance for adjustments.
(Causal Factor)
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Inadequate vendor information for adjustments.
(Causal Factor)
MMEDIATECORRECTIVE ACTION
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Revise PM procedure to adjust the clearance between the trip paddle and the armature with the UV device picked up to 0.030 inches.
Verified gap clearances on GE breakers installed in the Units.
CORRECTIVE ACTIONS TO PREVENT RECKH~NCE
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'btained GE endorsement for use of GE maintenance manual GEK-64459B.
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Obtained GE endorsement to adjust the IJV device dearance to 0.030 inches.
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Upgrade vendor technical manual,
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Revise PM procedure to incorporate upgraded vendor technical manual information,
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Train selected electricians on new requirement OOT CAUSE OF FAILURE -
STINGHOUSE BREAKER
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Accumulated effects of frictional forces due to misaligned and misadjusted components within the breaker trip mechanism.
(Root Cause)
Reset spring deformed.
Insulating block of "B" phase slightly rotated.
InsuHicient compression of main springs.
Excessive compression of arcing contact springs.
Less than optimum lubrication in various locations.
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Inadequate procedural guidance for adjustments.
(Causal Factor)
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Inadequate vendor bulletin review. (Causal Factor)
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Approximately 7% opening margin of DS-206 breaker.
IMMEDIATECORRECTIVE ACTION
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Developed CM work order to incorporate guidance of vendor technical bulletin and adjustments to increase opening margin to 13%.
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Performed CM work order on installed Westinghouse breakers.
CORRECTIVE ACTIONS TO PREVENT RECURRENCE o
Upgraded vendor technical manual
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Revised PM procedure to incorporate latest vendor guidance and results of the root cause of failure analysis.
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Train selected electricians on new requirements.
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Evaluate modification of DS-206 breaker to provide additional opening margi TTENTION TO EMERGING ISSUES
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Sensitivity of the front-line personnel and management to the significance of a RTSG breaker failing to open.
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STA involvement in root cause of failure determination.
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Effectiveness of the Equipment Root Cause of Failure Program.
CORRECTIVE ACTIONS TO PREVENT RECURIMNCE
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Established list of situations that require enhanced engineering involvement,
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Emphasized senior management expectation regarding timely communication of "need-to-know" information.
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Additional guidelines on situations that require timely interface and prompt action.
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Designated Root Cause of Failure Program Manager.
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Evaluate quarantine guidelines for incorporation into a quarantine procedure.
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Improve sensitivity and knowledge level of operations and maintenance personnel on evidence preservation techniques.
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Revise STA's performance enhancement plans to clearly specify expectations with respect to root caus VENDOR TECHNICA NFORIHATION
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System Engineer did not recognize the significance of the Westinghouse technical bulletin.
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Maintenance Standards Advisor did not recognize the significance ofthe Westinghouse technical bulletin.
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Screening process for new vendor documents does not assure that safety
, significant information obtains timely and effective impact review.
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Vendor manual consolidation program did not appropriately prioritize the reactor trip switchgear vendor interface. As a result, RTSG breaker vendors had not yet been contacted.
CORRECTD7E ACTIONS TO PREVENT RECURRENCE
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Revised vendor document screening process to prioritize based on safety significance.
Use CRDR process to improve timeliness.
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Complete consolidation of RTSG vendor manual.
Review prioritization of vendor interfaces for the vendor manual consolidation program based on safety significance.
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Revise vendor interface periodic contact cycle for safety significant equipmen FFECTIVENESS OF INTERFACES TWEEN ORGANIZATIONS NVOLVEDIN E UIPMENT OOT CAUSE OF FAILUREANA YSIS
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No formal quarantine procedure.
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No list of situations requiring enhanced attention to root cause,
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Position of Root Cause of Failure Program Manager was vacant.
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. Confusion at engineering and maintenance interface between troubleshooting versus root cause process.
CORRECTIVE ACTIONS TO PREVENT RECURRENCE
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Designated Root Cause of Failure Program Manager.
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Issued letter identifying situations requiring engineering involvement in troubleshooting,
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Incorporate quarantine guidelines into a quarantine procedure.
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Revise MNCR procedure to allow STA to write root cause of failure CRDRs that meet ERCFA procedure guidelines.
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Improve sensitivity and knowledge level of operations and maintenance personnel on evidence preservation technique FFE IVENESS OF ACTIONS IMPLEMENTEDAS A RESULT OF NDUSTRY OPERATING EXPERIENCE
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31 of 31 commitments made as a result of Generic Letter 83-28 on the Salem ATWS event were reviewed and determined to be appropriate)y closed.
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Commitments made as a result of SOER 83-08 on the Salem ATWS event were reviewed and 1 of 12 was reopened.
CORRECTIVE ACTIONS TO PREVENT RECUIU&NCE
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Reopened SOER 83-08, Recommendation 10 on implementation of vendor technical data and incorporation of change DE UACY OF BREAKER RESPONSE TIMETECHNI UES
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Response Time Tester (RTT) utilizes an optical interface with plant protection system.
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Light intensity of PPS LEDs sometimes is not sufficient to actuate RTl'ircuitry.
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Failure to hold the relay hold push button until completion ofthe timing sequence may result in extended response times.
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Insufficient light intensity was identified as the cause of RTSG Breaker
"A" response time test failure. Optical pickup assembly was replaced, CORRECTIVE ACTIONS TO PREVENT RECOMMENCE
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Revise time response test procedure to place greater emphasis on the length of time required to hold the relay hold push button.
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Establish a minimum loop response time forincorporation into response time test procedur D UA OF RTSG MAINTEN NC TRAININGPROGRAM
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RTSG Breaker training is included in the low voltage circuit breaker course.
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Maintenance on GE AKR-30 and Westinghouse DS-206 Breakers, is a high difficulty,low frequency task.
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RTSG Breaker maintenance is not covered in electrical maintenance continuing training.
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Maintenance instructions were inadequate.
Some deficiencies were identified in the Westinghouse RTSG breakers.
Insulator block was found skewed.
Inspection of reset spring assembly found that it was slightly damaged and deformed.
Phase A and C main contactors were slightly under parallel which reduced the compressive force of its main opening springs.
Some deficiencies were identified in the GE RTSG breaker.
Different methods were used by Electrical Maintenance personnel to take measurements.
Different points were used for measurement of the same parameter.
CORRECTIVE ACTIONS TO PREVENT RECUI~NCE
~ Establish a RTSG breaker course separate from the low voltage circuit breaker course.
~ Select a few electricians to be trained RYSG i t
~ Complete training of selected electricians on new requiremen IYI N
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MAY4, 1992, UNIT3 IN MODE 1 AT 100 PERCENT POWER
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WORK IN PROGRESS TO IDEXI'IFYPOTE%I IAL CONFIGURATIONPROBLEM VGTH BELLALA%MSWITCHES
'I o
ELECTRICIANS INSPECTING Aj&RMSWITCH IN ENERGIZED PANEL
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REMOVED.SCRNV ON 24V CONNECTOR
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AT 0436 MST, MAY4, L&Q)DROPPED ACROSS 480V BUS
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CAUSING LOSS OF NON-CLASS PLANTANAKJNCIATORS AND PC COLSS
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AT 0708 MST, MAY4, CMC COLSS LOST, POUTER REDUCED INACCORDANCE WITHTECKMICALSPECIFICATIONS
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AT 0819 MST, MAY4) PLANT COMPUTER INOPEKLSLE, ALf<RT DECLARED IN ACCORDANCE %H'H EPIP-02
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AT APPROXIIVj'ATKLY1450 MST, MAY4, CMC &6) PC COLSS OPERABLE, PLANT COMPVIER RETUIPKD TO SERVICE.
tuD,CTOR POWER MAIN'I'AI:NEDAT 70 PERCENT
E N
F EVENT
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MAY6, 1992, 2320 MST, PLAZA'&PAJNCIATORRETURNED
. TO SERVICE
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AT 2321 MST, MAY6, ALERT TERlVHNATED
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AT 2340 MST, MAY6, MtIT3 COIVQHENCED CONTROLIMD SHVH)OWN FOR ADDITIONALPLANTANNUNCIATOR TESTING AZG) VERI%CATION
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MANAGEMENTISSUES NOTIFICATIONMETHODS AND EXPECTATIONS FRONT-LINE SENSITIVITYAZG) ASSESSMENT OF EQUIPMENT&6) PERSONAL RISK CULTURE OF SAE'ETY VERSUS NON-SAFETYWORK PLAINER/ENGINEERINGP;HERFACE
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WORK PRACTICE ISSUES USE OF INSULTINGBLANM<T USE OP CAFI1IRE
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O'IHER ISSUES EXISTING GROUM) PATH RESULTING FROM MISSING SCREW LEAD ROVI'INGAND TERlVHNATION
"COXIENTION"BE'IWEEN THE PC A5tD CMC
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VICE PRESIDENT - NUCLEARPRODUCTION ISSUED LETIER G EXPECTATIONS
.EVALUATEMETHODS &6) TfUINPERSONIWL ON HOW TO PROPERLY ASSESS RISK OF WORK TASKS CONTINUE TO REINFORCE MANAGEMENTAlIU FROGRANI REQXHREMENTS TERAT THE QUALITYOF SAFETY A2'6)
NON-SAFETY RELATED WORK BE THE SWEE STRENGTHEN MAINTENANCE/ENGINEEIUNGINIERFACE EVALUATECURRENT PRACTICES OF RES L&uS
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EVALUATECAUSE OF MISSING SCREW G LIFIED
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CONDUCT AN EVALUATIONOF AS-BUILTWIRING SPECIFICATION Al'6) INSTA12 ATIONPRACTICES FOR PROPER IMPLEMENTATION
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COMPLETE UPG&uE OF PERSONI'WL AND EQUIPMENT SALTYPROGRAM TO BE MORE APPLICABLEFOR POWER PLANTENVIRONMENT
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COMPLETE MODIFICATIONTO PLANT COMPUTER TO EL%AGNATE"CON'IXNTION"BE'DVEEN PC AND CMC COLSS
{INSTALINDIN UNITS 1 AM)2)
CHECK VALVES 2 CHECK VALVESINSTALLEDINCORI&CTLY.
SIR - V133 INSIDE CONTAB'tMENTISOLATION CHECK VALVE FOR HPSI LOOP 1A IMPROPERLY ASSEMBLED IN AUGUST 1989.
SIA - V404 HPSI "A"DISCKILRGE CHECK VALVE IMPROPERLY ASSEMBLED IN IR3.
MARTY IGNIFICANCE:
SIE - V133 NO ADVERSE SAFETY SIGNIFICANCE.
VALVEWAS CAPABLEOF PASSING REQUlRED HPSI INSECIXONFLOWASDEMONSTfUTEDBYTESTING.
REDUI%3ANT CHECK VALVES DID PREVENT REVERSE FLOW FROM RCS.
SIA - 404 IDENTH<~D DURING DYNAMICMOVTESTING.
SYSTEM NOT REQUIRED FOR PLANTCONDITIONS.
NO ADVERSE SAFETY SIGMFICANC OUTSIDE COKTAIHMEHT IHSIDE COHTAIHMEHT SIS~NVCOS SID NVSSI NOT LCC LOOf 5 a4 NY455 SIC WCIC 5IT ac~xoIA ma tuuf 5 515 tOS LtSl tuuf 5 alstol SIC ~NVSO)
514~llVCIS 515 WCIT 514 WCSC SIC~WCll SIT IE xol5 COLO LEO LOOf SA sls-wccT u u
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UVCCC 50 uvcss a5 Uv45T SIC~W454 COLD LEO LDOf 5 ~
SIA~WCCO
Jll~WCCS 515 UVCSS u
aA~WCCC
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I CIAiHYSOC SIA~UV455 514 W454 aA UVCST 515iWCCC v(SS 5lr ac xolo Sll~llV454 SIT SIC~XOID COI.O LEO LOOf IA Lt51 tuuf I SIA~tOI SIA WCCS SIA WCCT SIA~UVCC<
COLO LTC LOOf 15 Nt51 tuuf I al tos QJ NVCCC I
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coxFAI~ucEl7 a4-werc CIC UVCTS SAFETY IHJECTIOH SYSTEM Figure C-3 C-8
INADEQUATEMATCHMA; NG DIRECTIONS.
PERSONNEL ERROR.
MU>>:
VALVESWERE REWORSND.
REVIEWED ALLBORG WAIWERBONNET HUNG CHECK VALVES.
UT INSPECTED ALLCHECK VALVESWHICHWERE NOT:
BOLTEDBONNET REVERSE FLOW TESTED 10 VALVES PER UNITUT INSPECTED AND NO DEFICIENCIES IDENTIFIED.
PROCEDURE CHANGE ON MATCHMARKING%ILL BE PROCESSED.
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REACTOR TRIP TO TURBINE TRIP CIRCUIT EXPLANATION:
AS FOU1'6) CONDITION:
4 FIELD LEADS DISCONNECTED IN CEDMCS.
FOUND DURING ENGINEERING WALKDOWN OF ANOTHER DESIGN CHANGE.
INVESTIGATION:
SAFETY SIGNDQCANCE REDUNDANT-TRIP SYSTEM BY DESIGN.
REDUNDANTTRIP WORKED CORRECTLYDURINGPLUS IN 1991.
CORRECTI'VE ACTION:
FIELD LKQ)S RE-TERIViHNATEDIN UNIT 1 FIELD LZM)S VERDURED IN UNIT2 4 3 FUNCTIONALTEST OF TRIP CIRCUIT PERFOM4ED.
WEI 5/22/92
CEDMCS ROO COILS STATION 125 VDC UNDER-VOLTAGE DETECTORS [4)
PYCS ANNUNC CUST. TRIP EHC CUST. TRIP FROM STATION 125 VDC
INVESTIGATION LF<~S DISCONNECTED FOR DCP RETEST IN1VIARCH-APRIL 1990 A PROBLEM WAS ENCOUNTERED IN RETEST AND 'IXiE TESTING WAS REPEATED BYA SECOND TECHNICIAN.
A GENERIC STATEMENT "RESTORE" WAS USED IN WORK PACKAGE TO RE-TERIViHNATELEADS.
WORK ORDER DOCURKNTATIONINDICATESLEADS LIFTED BUT NOT RE-LANDED.
YVORKORDER REVDKWBY:
I & C TECHNICIAN WORK GROUP SUPERVISOR WORK CONTROL PLAI'PKR DID NOT IDENTIFY
%EI 5/22/92
SIMS IIORX ORDER ATTACHMENT
'%IS DOCUMENT IS PART OF A HORX CONTROL PACKAGE AND IS NOT TO BE SEPARATED FROM IT IBOg 00347083 HRg 336399 IIORX CENTER.IOITC.
ATTACHMENT OF HORX DESC IMPLEMENT SITE MOD 1-SM-SF-001.
REHIRE CEDMCS UV RELY,Y CONTACTS.
EQ 1JSFNC01A ZQ DESC CEDMCS CABINET (Cl)
INSTRU LOC 05MAK09SA08120 IIORK TYPE CM 4 0 RETEST/FUNCTIONAL CHECK:
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~4's I F~ 4.1 FE!rORN A FUNCTIONAL TEST BY SINUIATINS AN UNUERVULTAUE CONDITION AT RELAY K4802 AND VERIFYING THAT THE NC CONTACTS CHANGE STATES AS PER DESIGN.
THE NC CONTACTS SHOULD BE CLOSED ISEN THE RELAY IS DEEHERGIZED AND OPEN MKN RELAY IS ENERGIZED.
THE FOLLOWING CABLES MILL IIAVE TO BE ISOLATED TO VERIFY CONTACT CONTINUITY.
CABLE NUMBER iEMA13NClRC2
~MA13NC1R12 lEMA13NC1R02
~EMA13HCIR82 LOCATION 1JSFNC01A-02 T12401, T12402 lJSFNCOlA-04 T14401, T14402 1JSFHC01C-04 T34401 ~ T34402 1JSFNC01C-02 T32401> T32402 4 ~ 1 1 AT CABINET 1JSFNC01B B
PRESS TIE UV1 PUSHBUTTOH AND ENSURE THAT COHTACTS 5/6 6s 9/10 OF UV1 K4802 IN 1JSFNCOlA ARE CLOSED BY VERIFYING CONTACT CONTINUITY THRU TERMINALS TB4811-12/13 TO TB4811-16/17.
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~w Z3]w 4.1;2 4.1.5 4.1.6 4.1.7 RELEASE THE UV1 PUSHBUTTON AND VERIFY THAT THE CONTACTS IN STEP S.l.l OPER.
PRESS TIE UV2 PUSHBUTTON AND ENSURE THAT CONTACTS 5/6 6I 9/10 OF UV2 K4802.1JSFNC01A ARE CLOSED BY VERIFYING CONTACT COHTINUITY THRU TERMINALS TB4821 12/13 TO TB4821 16/17.
RELEASE THE UV2 PUSHBUTTON AND VERIFY TIIAT TilE CONTACTS IH STEP+.1.3 OPEH.
't m~ S/l/g1 PRESS THE UV3 PUSHBUTTON AND ENSURE THAT CONTACTS 5/6 6I 9/10 OF UV3 K4802 IJSFNC01C ARE CLOSED BY VERIFYIHG CONTACT CONTINUITY THRU TERMINALS TB4831 12/13 TO TB4831-16/17 ~
RELEASE THE UV3 PUSHBUITON AND VERIFY THAT THE CONTACTS IN STEP P.l.5 OPEN.
et~ 5/!/If PRESS THE UV4 PUSHBUTTON AND EHSURE THAT CONTACTS 5/6 6I 9/10 OF UV2 K4802 1JSFNCOlC ARE CLOSED BY VERIFYING CONTACT CONTINUITY THRU TERMINALS TB4841" 12/13 TO TB4841 16/17 ~
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AND HOUNTING HARDWARE ARE REINSTALLED.
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VERIFY THAT 'OlE "HAIHTENANCE REQUIRED" TAG, (IF USED) llAS BEEN REMOVED THE EQUIPMEHT. RETURN THE "HAIHTEHAHCE REQUIRED TAG IH THE HORK PACKAGE.
~ S.s NOTIFY TlK HAIN CONTROL BOARD OPERATOR UPON COMPLETION OF MORK.
4.1.8 RELEASE THE UV4 PUSHSUTTON AND VERIFY BlAT TlK CONTACTS IN STEP/. 1-7 OPEH
" mr Sjg/ff P 4.2 ADDITIONALRETEST INSTRUCTIONS MAY BE ADDED.
IF A HORE APPROPRIATE RETEST HAS BEEN DETERHINED, OR ANY CHANGES TO THE llORK IHSTRUCTIOHS ARE MADE THAT AFFECT THE RETEST REQUIREMENTS.
4.2.1 IF ADDITIONALRETEST REQUIREHEHTS ARE REQUIRED, BASED ON THE llORK PERFORMED'
RETEST AMEHDHENT MAY BE PREPARED BY THE HCD PLANNER, OR THE RELEASING ORGANIZATION MAY APPROVE RETEST CHAHGES BY SIGNING AS THE RETEST DESIGNATOR ON A NEV "RETEST EVALUATION FORM". THE LATEST
"RETEST EVALUATION FORM" SllALL BE RETAINED IN THE MORK PACKAGE.
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OF UHSATISFACTORY RETESTING SHALL BE DOCUMENTED OH A
"CWORK PERPORHED CONTIHUATION" SHEET.
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