IR 05000456/1996023

Insp Repts 50-456/96-23 & 50-457/96-12 on 960727-0906. Violations Noted.Major Areas Inspected:Operations, Maintenance,Engineering & Plant Support

ML20129H247
Person / Time
Site:	Braidwood
Issue date:	10/23/1996
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20129H243	List: IR 05000456/1996023 ML20129H238 ML20129H244
References
50-456-96-12, 50-457-96-12, NUDOCS 9610310182
Download: ML20129H247 (20)

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l U.S. NUCLEAR REGULATORY COMISSION

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REGION III

Docket Nos: 50-456, 50-457

, License Nos: NPF-72, NPF-77

l Report No: 50-456/96012; 50-457/96012 a

Licensee: Commonwealth Edison (Comed)

Facility: Braidwood Nuclear Plant, Units 1 and 2 '

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Location: RR #1, Box 84 Braceville, IL 60407 I

Dates: July 27 through September 6, 1996 i

Inspectors: C. Phillips, Senior Resident Inspector ,

M. Kunowski, Resident Inspector d

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E. Cobey, Resident Inspector T. Esper, Illinois Department of Nuclear Safety Approved by: Lewis F. Miller, Jr., Chief Reactor Projects Branch 4

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i 9610310182 961023 j PENT ADDCK 05000456 O PDR ,

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l l EXECUTIVE SUMARY ,

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Braidwood Nuclear Plant, Units 1 & 2  :

j NRC Inspection Report 50-456/96012; 50-457/96012  !

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l This inspection included aspects of licensee operations, engineering, j maintenanco, and plant support. The report covers a 6-week period of resident ;

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Operations

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On August 14, operators failed to close ID0001D, the ID diesel generator i fuel oil storage tank inlet isolation valve, and failed to verify the 1 i valve closed on August 16. The failure to ensure the valve was closed resulted in an inadvertent transfer of about 2000 gallons of diesel fuel

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oil between outside storage tanks and the IB and ID diesel fuel oil

tanks on August 16 while operators were trying to fill the IB diesel-

driven auxiliary feedwater pump day tan On August 21, the inspectors identified that independent verification of i valve manipulations performed during the 2B DG operability monthly i surveillance was not conducted as required by the surveillance l

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procedure. Subsequent interviews by the inspectors of several operators j

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Braidwood Administrative Procedure BwAP 100-18, " Independent Verification."

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On August 25, valve IAB8478, the Unit 1 boric acid tank recirculation ;

. throttle valve, was found mispositioned open during the performance of !

l procedure Bw0P AB-6, " Transfer Of The Boric Acid Batching Tank To Unit 1 l

Boric Acid Tank." The licensee concluded the valve had been i mispositioned the previous day during an earlier performance of Bw0P AB-l The inspectors concluded that the failure to throttle and close

{ IAB8478 was due to a personnel error.

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Maintenance i

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On July 31, the inspectors identified the section of the surveillance

procedure used to perform the monthly operability run required the operator to start the diesel in accordance with Bw0P-11, "DG Startup."

. Bw0P-ll required the operator to manually cycle ISX169A, the essential l service water valve to diesel jacket water cooling valve, prior to the d

diesel generator start. The inspectors concluded that cycling ISX169A e prior to the start of the diesel was preconditioning the diesel l generator.

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The inspectors observed instrument maintenance (IM) personnel perform surveillance test BwIs 6.4.1-200, " Analog Operational Test / Surveillance Calibration of Containment Hydrogen Monitoring Analyzer Indicating Loop, for IPS48J, Train B Containment Hydrogen Monitor," and concluded that

, the IM personnel understood the task, utilized good work practices, and

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followed plant procedure j faaineerina i -

The inspectors identified that control room drawings that were marked as

" AUTHORIZED FOR USE" were not up to date and had no indication that a

revision was pending, and were being used in the control room for work j involving troubleshooting and preparing out-of-service boundaries. In addition, the licensee identified a backlog of 65 completed

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modifications involving over 2000 drawings which had not been update The inspectors concluded the backlog of out-of-date drawings was a

significant weaknes l Plant Support

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The inspectors observed during frequent routine tours that contaminated and high radiation areas were clearly marked, that general areas and

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emergency core cooling pump rooms were clean and free of debris, and that leakage of potentially contaminated liquid was minimal and properly contained.

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I Renort Details i Summary of Plant Status

i Unit 1 entered the period at or near 100 percent power and operated routinely

for nearly the entire period. The unit began a ramp down to full shutdown at i 8:00 p.m. on September 6 to repair steam leaks on the C and D steam

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Unit 2 entered the period at or near 100 percent power and operated routinely until July 29, at 1:00 p.m. At this time, the licensee reduced power to 42 percent due to a leaking safety injection system relief valve (paragraph 01.1). The relief valve was gagged and Unit 2 was returned to 100 percent power at 7:00 a.m. on July 30 and operated at or near 100 percent power for the remainder of the perio I. Operations 01 Conduct of Operations 01.1 Unit 2 Power Reduction Due To Safety Iniection (SI) Relief Valve Leakaae j Inspection Scone (71707)

On July 29, during the performance of BwVS 5.2.f.2-1, "ASME Surveillance Requirements for the 2A SI Pump," the safety injection relief valve, 2SI8851, lifted which caused both trains of SI.to be potentially inoperable. The relief valve was on a common header for both SI train As a result, the licensee entered Technical Specification (TS) 3.0.3 and commenced reducing power in preparation for a plant shutdown to less than 350*F. The licensee subsequently made a one hour non-emergency !

report in accordance with 10 CFR 50.72(b)(1)(1)(A). The inspectors attended several planning meetings and observed several tests associated

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with the valve liftin , Observations and Findinas Prior to plant shutdown, the licensee determined that the relief valve, 2SI8851, could be gagged shut and both trains of SI declared operable, based on engineering judgement that the two remaining relief valves in the system were sufficient to provide over-pressure protection. This action was approved by the Plant Operations Review Committee and the plant shutdown was subsequently terminated. The licensee initiated a Level II Problem Identification Form (PIF) to investigate and determine the root cause of this even ' Conclusions The inspectors concluded the licensee's decisions regarding the Unit 2 power reduction, engineering evaluation, and return to power were appropriat '

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02 Operational Status of Facilities and Equipment 02.1 Essential Service Water (SX) System a. Inspection Scone (71707)

The inspectors reviewed the SX system, including' system lineups and drawings, and the design bases in the updated final safety analysis report. The inspectors also performed a walkdown of the system and .

safety-related components cooled by the system for proper configuratio '

In addition to SX system piping and components, safety-related components checked for proper configuration included diesel generator i coolers, component cooling water system heat exchangers, diesel and ,

motor driven auxiliary feedwater pump coolers, centrifugal charging pump '

coolers, SI pump coolers, residual heat removal pump coolers, spent fuel 4 pool cooling pump coolers, and primary containment refrigeration unit The inspectors also interviewed the SX system engineer and site engineering personne ;

b. Observations and Findinas The inspectors performed a walkdown of the SX pump rooms and noted the following items:

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The condition of the floors and walls was good and had improved since repairs for ground water leakage were complete Previously identified seal leaks on the pumps were repaired. The l walkdown revealed only one small water leak (packing leak on IA0V- )

SX178, the SX return from auxiliary feedwater pump IB heat exchangers isolation valve) which was contained and properly i routed to a floor drai Action requests (ARs) had been generated and AR identification tags were in place for items requiring repair or preventive maintenance (PM). There were about 20 AR tags found in the IB &

2B SX pump room and about 16 AR tags found in the 1A & 2A SX pump room. Conditions addressed on the AR tags included oil leaking from motor operated valve (MOV) operators, incorrectly set MOV limit switches, minor SX pump bearing oil leaks, missing / damaged insulation, and a valve replacement PM task require The IB SX pump suction strainer must be manually backwashed due to an auto timer malfunction, as indicated by caution tag 95-1-0626 l

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hung on October 3, 199 Tools, hoses, and equipment were stored in a back corner of the 1A and 2A SX pump room. The tools and equipment were not in use and no work was in progress in the area. This condition was reported to the operating shif l l

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All items on the system requiring ma'intenance were identified by

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were monitoring the system.

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. The SX system and associned components were aligned as required by Bw0P

SX-M1, " Unit 1 Operating Mechanical Alignment," and Bw0P SX-M2, " Unit 2

! Operating Mechanical Alignment."  !

i i Conclusions

i The inspectors concluded the following:

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The overall material condition of the SX system was satisfactory i

with an improving tren

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The housekeeping in the SX pump rooms was acceptable.

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The alignment of the SX system components was good.

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~0 Overfill of the IB and ID Diesel Generator (DG) Oil Storace Tanks

! Inspection Scone (71707)

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! On August 16, the IB and 10 DG fuel oil storage tanks were overfille !

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the inspectors estimated about 2000 gallons of fuel was inadvertently I t transferred from outside tanks to the inside 18 and ID tanks because of i

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a valve mispositioning. The inspectors reviewed the licensee's prompt :

! investigation report of the event; walked down the valve locations; _ l i reviewed Bw0P DO-13, " Filling the Unit 1 Diesel Auxiliary Feedwater Pump

Day Tank From The 125,000 or 50,000 Gallon Fuel Oil Tanks," and Bw0P D0- ;

3 7, " Filling a Unit 1 DG Storage Tank From The 50,000 or 125,000 Gallon j

! Fuel Oil Storage Tank"; interviewed one of the operators involved in the '

! event; and discussed the event with operations management.

' Observations and Findinas The licensee's prompt investigation report stated the following:

. .the IB and 10 DG fuel oil storage tanks were filled on August 14;

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. the supply isolation valve (100001D) to the 10 DG fuel oil storage tank was left throttled open on August 14, when it should have been closed, per step F.22 of Bw0P D0-7, due to an incomplete turnover by operators and an incorrect valve position verification by an operator after filling the DG fuel oil storage tanks; 4

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licensee personnel were attempting to fill the IB auxiliary feedwater pump day tank on August 16 which shares a common fill line with the IB and 10 DG fuel oil storage tanks;

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1D0001D was required to have been verified closed by Bw0P D0-13 prior to the start of filling the IB auxiliary feedwater pump day tank and the operator incorrectly verified the valve closed on August 16 by visually observing the stem position instead of physically checking the valve shut;

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the operator that checked the valve shut on August 16 understood that a visual verification of valve position was acceptable; and

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the excess fuel oil was collected in the fire and oil sump which was later flushed to the waste water treatment syste The inspectors ir.terviewed the operator that checked the 1D0001D shut on August 16. He stated that he thought, at the time, it was acceptable to visually verify a valve position. However, operations management later stated to the inspectors that visual verification of valve position did not meet their expectation The licensee performed the following corrective actions:

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All crews of non-licensed operators were taken into the field and instructed on how to properly verify the position of a valv The operators involved with filling the IB and 10 diesel fuel oil tanks and the IB diesel-driven auxiliary feedwater pump day tank were counselle Operations training staff were instructed on valve positiot verificatio The inspectors reviewed diesel fuel oil tank readings from August 15 and concluded that licensee personnel inadvertently transferred about 2000 gallons of fuel oil from outside fuel oil tanks to inside fuel oil tanks on August 16 because 100001D was mispositione c. Conclusions The inspectors concluded that the failure to close 1D0001D on August 14 l and verify the valve was closed on August 16 was a violation of 10 CFR 50, Appendix B, Criterion V. This licensee identified and corrected violation is being treated as a Non-Cited Violation, consistent with Section VII.B.1 of the NRC Enforcement Policy (50-456/96012-01). i Valve mispositionings and configuration control weaknesses were discussed in Inspection Report 96005. Five violations were issued and a !

civil penalty was assessed. Unclear expectations regarding the !

manipulation and independent verification of valves was not identified j at the time as a root cause; therefore, no corrective actions were i propose !

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i The inspectors also concluded that the operations personnel interviewed

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were unaware of management expectations to physically check a valve in its proper position were not clearly communicated to operations personne '

04.2 Imoroner Indeoendent Verification of Valve Manioulations Durina DG Surveillance Testina Inspection Scone (61726)

The inspectors observed the monthly operability surveillance for the 28 DG on August 21, which was performed in accordance with 2Bw0S 8.1.1.2.a-

, 2, '2B DG Operability Monthly (Staggered) And Semi-annual (Staggered)

Surveillance," Bw0P-11, "DG Startup," and Bw0P-12, "DG Shutdown." Observations and Findinas During the performance of 2Bw05 8.1.1.2.a-2, the inspectors identified that independent verification of valve manipulations performed in steps F.9.7 through F 9.9 was not conducted. These steps required independent verification of the manipulation of the 2B DG day tank instrument leg

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drain valve (2002116B), the 2B DG starting air receiver drain valves

(2SA1478/D), and the 2B DG starting air separator drain valves (2SA1418/D).

Braidwood Administrative Procedure BwAP 100-18, " Independent l

! Verification," required independent verification of proper system alignment during the performance of safety-related surveillances. In addition, BwAP 100-18 required the type of independent verification to

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independently verify that the action to be taken was correct prior to taking the action and then verify that the correct action was take However, the operator performing the valve manipulations did not l independently verify the position of any of the valves upon completion l ef their operation. The independent verification performed consisted of

one operator watching the other perform the evolution without performing

any specific action which would have verified that the proper action had occurre Subsequent interviews of the two operators who performed the independent verification and two senior reactor operators (SR0s) from the same operating crew revealed the following:

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The operators stated they did not understand that they were j required to independently perform the same action The operators stated that if they knew what the valve was, checking the valve label was not required.

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The operators and at least one SR0 knew that there was guidance on how to perform independent verifications but did not know in what

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The operators could not remember the last time they were trained p on independent verificatio I

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i In response to the inspectors concerns, the licensee discussed independent verification with all the operations crews during shift

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turnovers. During this discussion, the procedural requirements of BwAP 100-18 were reviewed.

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The inspectors concluded that the failure to perform independent verification of valve manipulations as specified in the surveillance i procedure was a violation of 10 CFR 50, Appendix B, Criterion V (50-1 457/96012-02a). The inspectors also concluded that the operators did l not understand how to correctly perform independent verification in

, accordance with BwAP 100-18, " Independent Verification."

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! 04.3 Unit 1 Boric Acid Tank Recirculation Throttle Valve Miscositioned i

j Inspection Scone (71707)

On. August 25, valve IAB8478, the Unit I boric acid tank recirculation i throttle valve, was found opened instead of closed, by the' licensee, during the performance of procedure Bw0P AB-6,-" Transfer Of The Boric Acid Batching Tank To Unit 1 Boric Acid Tank." Licensee personnel performed a prompt investigation into the event. The inspectors reviewed the investigation report, Bw0P AB-6, BwAP 100-20, " Procedure Usage and Adherence," BwAP 100-18, " Independent Verification," and interviewed one of the operators involved in the even Observations and Findinas According to BwAP 100-20, the station had three procedure use categories

- " Continuous Use" procedures required that each step be read prior to the performance of the ste " Reference Use" procedures required that the procedure be reviewed prior to the performance of the task, the procedure be available at the location, and stated that the procedure should be referred to, as needed, by the workers to ensure the steps were being performed in the proper order, and procedural steps should be signed off as the appropriate steps were complete "Information Use" procedures should be reviewed prior to the performance of the task, the procedure should be available at the locations, and should be referred to, as needed, by the worker The licensee stated the following observations and findings in the prompt investigation report:

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Bw0P AB-6 required that 1AB8478 be opened, throttled to a boric acid transfer pump discharge pressure between 105 and 111 pounds

per square inch gauge (psig), and then closed after the boric acid l transfer. Bw0P AB-6 had last been performed on August 24, but ;

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valve 1AB8478 had not been throttled or closed at that time.

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Bw0P-AB-6 was an "Information Use" procedur BwAP 100-20 stated i that "Information Use" procedures should be reviewed before and i after the task.

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BwAP 100-18 required that alignments of safety-related valves be independently verified to be in the correct position. Several safety-related components were manipulated during Bw0P AB-6, but Bw0P AB-6 did not require an independent verification of valve position upon completion of the evolutio AB8477, the isolation valve for IAB8478, was closed as required ,

and the Unit I boric acid tank recirculation loop was isolated as '

required on August 2 One of the two operators involved in the evolution stated to the inspectors that he did not remember closing or checking closed 1AB8478 I on August 24. The operator also stated to the inspectors that 1AB8478 l was not throttled on August 24. The operator stated that the purpose of throttling the valve was to prevent pump runout should the control room ;

inject boric acid into the unit during performance of Bw0P AB-6. The i operator also stated that in his nine years of experience the control  !

room operators had never injected boric acid without first calling down j to ensure the proper lineup of the system. The operator stated that '

throttling the valve was unnecessary and slowed down the evolutio The licensee planned to take the following corrective actions: all I operating procedures were reviewed for the realignment of safety-related valves; operating procedures involving safety-related valve manipulations would be made " Reference Use" procedures by October 15, 1996; and where appropriate, an independent verification requirement would be added to operating procedures by March 30, 1997. The operators involved in the performance of Bw0P AB-6 on August 24, were counselled about their incorrect actions to not shut 1AB847 c. Conclusions The inspectors concluded that the failure to throttle and close 1AB8478 on August 24 was a violation of 10 CFR 50, Appendix B, Criterion This licensee identified and corrected violation is being treated as a  :

Non-Cited Violation, consistent with Section VII.B.1 of the NRC '

Enforcement Policy (50-456/96012-03). l l

The inspectors concluded that the failure to throttle and close 1AB8478  ;

was due to a combination of a personnel error, the operator's belief i that experience outweighed procedural requirements, and that Bw0P AB-6 Lid not require an independent verification of safety-related valve _- . - _- -.

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f 04.4 Conclusions on Ooerator Knowledae and Performance

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j The inspectors concluded that non-licensed operator performance

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indicated 3 lack of understanding of management expectations regarding

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valve position verification, independent verification requirements, and '

procedure adherence. The inspectors reviewed licensee prompt investigation documentation as discussed in paragraphs 04.1 and 0 Instructions on how to perform a prompt investigation were initiated after a previous investigation into an event (50-457/96009-02) was not initiated for several weeks afterwards. The inspectors concluded that in the case of the diesel oil tank overfill and the boric acid valve mispositioning the prompt investigation rapidly collected and documented good, accurate informatio Miscellaneous Operations Issues (92700)

0 (Closed) Insoection Followuo Item (IFI) 50-457/96009-02: No Valve Position Lights Lit For 2SI8801. The breaker for the motor operator for valve 2SI8801A, the charging pumps to cold leg injection isolation valve, was found not closed on May 14, 199 The licensee's root cause analysis was unable to determine a cause for the change in the breaker's positio The licensee identified the non-licensed operator who went to the breaker and returned it to service on May 14. The operator stated to the inspectors that in his opinion the breaker was in a tripped position, but he was not positive. The licensee performed an operability assessment of the breaker and discounted the operator's statement because no credible equipment failure mechanisms could be identified. Based on the assessment, the licensee concluded that the breaker was mispositioned, but no root cause for the mispositioning was .

identified. The licensoe's root cause an:1y::is stated that if the !

breaker were to be found in the tripped condition again it would be !

declared inoperable. The inspectors reviewed the root cause analysis ;

and operability assessment and had no further concern '

In Inspection Report 96009, the inspectors concluded that the progress of the licensee's investigation was slow based on a lack of any investigation into the event one month after it occurred. The licensee's corrective action was to issue guidance on what type of event would be included for prompt investigation, what information was to be gathered, and who was responsible for starting and conducting the investigation. The inspectors considered these corrective actions acceptable, and had no further concerns regarding the slowness of the investigatio . _ _ _ _ - _ . _ . . _ - _ _ _ . __. _ _._ _ __. _ _ . __

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II. Maintenance M1 Conduct of Maintenance M1.1 Preconditionina of a DG SX Valy_g Prior to DG Surveillance Testina Inspection Scone (61726)

l The inspectors observed the monthly operability surveillance for the 1A DG on July 31, which was performed in accordance with IBw0S 8.1.1.2.'a-1,

"lA DG Operability Monthly (Staggered) And Semi-annual (Staggered)

Surveillance," Bw0P-ll, "DG Startup," and Bw0P-12, "DG Shutdown." Observations and Findinas The inspectors identified a concern regarding the preconditioning of ISX169A, the DG SX cooling valv Surveillance procedure 1Bw0S 8.1.1.2.a-1, step F.2.5, required the DG to be started in accordance with Bw0P DG-11 "DG Startup." The inspectors identified that prior to the DG start, Bw0P DG-11, step F.1, required the verification of SX flow, which provided cooling to the DG jacket water system, by cycling 1SX169A, from the DG local control panel. This step was also utilized to verify the annunciator system was operable by verifying that the l annunciators "MCC Not Proper for Auto Operation" and "ESS Service Water I Flow Low" changed states when ISX169A was cycled. This cycling resulted in the valve being tested prior to the DG Stwt from the local control panel and during the DG start from the auw open circuit. The automatic opening of the ISX169A valve upon a D6 start was essential to the operability of the diesel generato ! Conclusions 1 The inspectors concluded that the cycling of ISX169A prior to the DG l constituted preconditioning of the diesel generator prior to performing a technical specification surveillance. 10 CFR 50, Appendix B, Criterion II, " Quality Assurance," requires in part that activities affecting quality shall be accomplished under suitably controlled conditions. Surveillance testing required by technical specifications to verify operability of equipment was an activity affecting qualit On numerous occasions, including July 31, ISX169A was cycled prior to the DG start. This is considered a violation of 10 CFR 50, Appendix B, ,

Criterion II, in that the technical specification surveillance testing

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was not accomplished under suitable conditions (50-456/96012-04). In addition, the inspectors noted that, similarly, the~ SX valves ISX1698, 2SX169A, and 2SX1698 for the IB, 2A, and 2B DGs were also cycled prior to monthly start .

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M1.2 Surveillance Test of 1PS48J. Train B Containment Hydroaen Monitor Inspection Scone (62707)

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The inspectors observed two Instrument Maintenance (IM) technicians

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performing surveillance procedure BwIS 6.4.1-200, Analog Operational Test / Surveillance Calibration of Containment Hydrogen Monitoring 4 Analyzer Indicating Loop, for IPS48J, Train B Containment Hydrogen

Monitor, for procedural and technical specification compliance.

. Observations and Findinas

The inspectors noted the following items

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Personnel were working to surveillance procedure and work package j -instructions.

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All instruments used were calibrated within the accuracy requirements of the test procedure and test report packag Instruments used in the test were of proper range and scale.

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The work area was well defined and all tools being used by IM

personnel were stored neatly within the work area.

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Proper personal safety equipment (hard hats, safety glasses, ear j plugs, gloves) was used by IM personnel.

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Control room personnel were notified before any step that would

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change control room indications or cause an alar '

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Technicians used self-checking and three-way communications l techniques to prevent error l

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Upon completion of the test, the technicians removed all equipment

and tools used for the test and restored the area to pre-test l condition c. Conclusions IM personnel performing surveillance test BwIS 6.4.1-200 on IPS48J, the i train B containment hydrogen monitor, understood the task being j performed, utilized good work practices, and followed plant procedures.

l M8 Miscellaneous Maintenance Issues (92902)

M (0 pen) Violation 50-456:457/95015-01: Failure to adequately implement j foreign material exclusion (FME) controls as required by Braidwood

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Administrative Procedure, BwAP 100-21, " Foreign Material Exclusion."

The licensee had completed immediate corrective actions to resolve the j specific deficiencies identifie However, the FME program was being i revised to address the adverse trend of FME events that the licensee had i experience i s

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p l The licensee had several procedures which provided varying guidance on

! FME. controls including BwAP 100-21, " Foreign Material Exclusion," and

. Standardized Maintenance Procedure, SMP-M-04, " Foreign Material .

l Exclusion." The latter was initially implemented in August 1995;

however, this guidance was not completely implemented since previously

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written work packages were not immediately updated with those requirements. - As new work packages were generated, the new requirements

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were incorporated into them.

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The licensee recognized that.all departments had not received training and were not required to follow the guidance contained in standardized maintenance procedures. As a result, the licensee was in the process of revising the guidance and incorporating all of the procedures governing FME into one Nuclear Station Work Procedure, NSWP-A-03, " Foreign Material Exclusion."- Additionally, approximately one-third of the maintenance personnel had not attended the required training on FM ,

The licensee indicated that this training would be completed prior to l the start of the next scheduled outage October 199 '

This item will remain open pending completion of the currently planned program revision III. Enaineerina E2 Engineering Support of Facilities and Equipment E2.1 Control Room Drawinas a. Insoection Scone (37551) .l Braidwood Administrative Procedure BwAP 1340-1, " Drawings Issued l Procedure," Revision 10, identified two types of design drawings: 1)

" AUTHORIZED FOR USE" drawings were verified current by the station's j Central File office before issuance and were for repairs, modifications, troubleshooting, procedure writing, or hanging out-of-service cards for safety-related, ASME (American Society of Mechanical Engineers) Code, or other regulatory-related equipment, and 2) "FOR REFERENCE" or "FOR INFORMATION ONLY" drawings were not verified current before issuance and were not for work on safety-related, ASME Code, or other regulatory-related equipmen ,

On August 8, the inspectors were in the main control room when an annunciator for the Unit 2 loop A Tave channel alarmed. The inspectors observed that the circuit card configuration for the Tave channel had been changed as part of the reactor coolant system resistance temperature detector bypass elimination modification (RTDBE) completed during the Unit 2 refueling outage which ended in May 1996. However, the control room drawings had not yet been revised. In that the drawing used was for " REFERENCE USE" only, the presence of out-of-date drawings was not unexpected by control room personnel; however, a problem identification form was written to document what had happene . -- .. .

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, The inspectors subsequently reviewed sets of piping and

instrumentation diagrams (P& ids) and electrical bus schematics (" key diagrams") used in the control room for day-to-day

operations and occasional out-of-service'(005) preparation. These drawings were stamped " AUTHORIZED FOR USE."

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. engineering group who'were responsible for marking-up drawings to

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show changes that were part of planned or ongoing modification After a modification was completed and the affected components or systems were returned'to service, this group was responsible for drafting final revisions of the drawings and sending them to the I offsite, corporate Central Drawing Facility, where final drawings 1 were made and converted to microfil l Finally, the inspectors interviewed personnel from the station's

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Central File office, in which a copy of marked-up drawings for

! modifications was maintained, and from which " AUTHORIZED FOR USE" i drawings were distributed to maintenance personnel and others in i

need of current drawings and " REFERENCE USE" drawings'were l s distributed to workers who did not necessarily need current

revisions. Central File personnel also updated the " AUTHORIZED FOR USE" drawings used by control room personnel.

L b. Observations and Findinas The response of the control room crew to the alarm was good.

There were good communications among operators and supervisors and

' a good review of control room indications to ensure a plant transient was not occurring. Likewise, the initial ,

i troubleshooting by the operators involving a review of compu:er I i points and electrical drawings was done with enthusiasm and a i sense of challenge.

!- However, the inspectors observed during a review of the i " AUTHORIZED FOR USE" control room drawings, that sheet 2 of M-60, the Unit I reactor coolant system, and sheet 4 of M-135, the

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. Unit 2 reactor coolant syster, had not been marked up to show the <

, equipment affected by the RiDBE or marked to indicate a revision i to the drawing was pending. The RTDBE had been complete on Unit I

! in the fall of 1995 and on Unit 2 in the spring of 199 ;

i In addition, the inspectors noted that several key diagrams were i not the current revisions or marked up to show revisions were ,

pending:

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I - diagrams 20E-1-4007A and D, 480V ESF Substation Busses ,

131X (IAP10E) and 132X (IAP12E), revisions L (current I revisions were M),

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diagrams 20E-1-4012A-D, 120 VAC Instrument Bus 111-

114, revisi

ns P, N, L, and S (current revisions were

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- diagram 20F 1-4008E, 480V Aux Bld ESF MCC 131X2

, (IAP25E) tnd 131X2A (IAP25E-A), was not marked up to i

show revisions pending for modifications P20-1-92-601

(October 30,1995) and E20-1-96-254 (July 2,1996).

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. Braidwood Administrative Procedure, SWAP 1340-1, " Drawings Issued

! Procedure," Revision 10, stated, in part, that P& ids or key

! diagrams which were issued and maintained current through Central

File were marked as " AUTHORIZED FOR USE," would have open design i

changes listed on the drawing, and could be used for

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j troubleshooting, writing temporary procedures, or preparing an i

, out-of-service. Procedure BwAP 330-1, " Conduct Of Operations," '

Revision 18, required, in part, that only controlled, approved a

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documents, such as P& ids and key diagrams, were to be used by shift operating personnel to conduct operations, and that these l i documents were to be maintained current. Contrary to these two

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procedures, as of August 8, P& ids and key diagrams that were l marked " AUTHORIZED FOR USE" and used by shift operating personnel l in the control room were not maintained curren J As part of corrective actions, the licensee removed all identified drawings marked as " AUTHORIZED FOR USE" from use and replaced them with !

"INFORMATION USE ONLY" drawings. The licensee has ensured that all

" AUTHORIZED FOR USE" drawings must be obtained from a Central File clerk. Administrative clerks were auditing all drawings and stamping them " revision pending" where appropriat Finally, the site engineering group apprised the inspectors that there was a large backlog of incorporating drawing changes (over 2000) from the two RTDBEs into approved design drawings, such as P& ids and electrical drawings. The backlog was attributed to available staffing levels and the need to convert the original manually marked-up drawings to the computer drafting format. The inspectors also asked about the status of drawing revisions for other modifications that had been completed. Site engineering personnel were unable to. provide the status on the 65 modifications that were currently completed. At the exit meeting on September 5, the licensee stated to the inspectors that additional designers had been assigned to work on the backlog and that many of the RTDBE drawings had since been revised and sent offsite for conversion to microfilm. A schedule had been established for further reducing the backlog. All RTDBE drawings were scheduled to be revised by December 1 In addition, a monthly report on the status of drawing revisions for completed modifications had been initiated, based on corporate engineering guideline . _ _ _ _ . _ _ ______. _ _ _ . . .

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! c. Conclusions {

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The inspectors concluded that the failure to provide current i revisions of " AUTHORIZED FOR USE" drawings to control room personnel was an example of a violation of 10 CFR 50, Appendix B, Criterion V (50-456/96012-02b). The inspectors also concluded that the untimely revision of RTDBE design drawings and the lack ;

of a current status of drawing revisions for completed modifications was a significant weaknes l E8 Miscellaneous Engineering Issues (92903)

E (Onen) Licensee Event Reoort (LER) 50-456/96009: Violation of Technical Specifications Due to Safety Injection Valves Lifting J and Failing to Reseat. As discussed in 01.1, on July 29, during an extended run of the 2A SI pump, the licensee identified that valve 2SI8851, the common cold leg injection line relief valve, lifted and failed to reseat. The pump run was terminated and the valve was subsequently gagged closed while the licensee investigated why the valve lifted. On August 2, as part of.the investigation, the licensee ran the 1A SI pump to determine if the associated relief valves lifted. Valve ISI8853A, the 1A SI pump hot leg injection line relief valve, lifted and was subsequently gagged close It was replaced on August 15. The licensee bench tested the valve after its replacement and determined that it was set to lift at 1680 psig vice the 1750 psig setpoint. The valve was subsequently sent offsite to a contracted laboratory for further evaluation. . The replacement of valve 2SI8851, which requires both trains of SI to be out-of-service, was scheduled for the spring 1997 Unit 2 refueling outag In addition to the vendor evaluation of ISI8853A and the replacement of 2S18851, other corrective actions included adding the SI relief valves to the station's inservice testing (IST)

program, an evaluation of other relief valves for periodic testing, verifying the lift setpoint of the SI relief valves at the next unit refuel outage, and conducting an effectiveness review of all corrective actions for this problem. As discussed in Inspection Report 93011, the licensee was not required by the current governing 1983 version of ASME Section XI, to include the relief valves in the IST progra l i

The inspectors monitored the licensee's investigation and !

subsequent testing. The lack of a pre-job walkdown of the work l area by radiation protection and maintenance personnel caused a '

delay in replacing the ISI8853A valve on August 15, but overall, i the investigation and testing were well conducted. This LER will J remain open pending inspector review of the vendor's evaluation of the ISI8853A valve and completion of the corrective action ;

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IV. PLANT SUPPORT R1 Radiological Protection and Chemistry Controls RI.1 General Comments (71750)

Using Inspection Procedure 71750, the inspectors conducted frequent tours of the radiologically protected area and found that high radiation areas and contaminated areas were clearly marked. General areas and emergency core cooling system pump rooms were clean and leakage was minimal and contained. The amount of contaminated area was small and provided only a minimal barrier to normal operation R8 Miscellaneous Radiological Protection and Chemistry Controls Issues R (closed) Violation 50-456:457/96002-02: Inadequate procedure for operating sample heat trace control equipment while taking a containment air sample. The inspectors verified through discussion with personnel and a review of documents- that the corrective actions stated in the licensee's response, dated April 10, 1996, to the Notice of Violation had been taken. The actions appeared adequat F2 Status of Fire Protectior, Facilities and Equipment F2.1 Repair of Carbon Qic tide System Valves (71750)

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a. Inspection Scone On August 14, the inspectors observed equipment operators place an 00S to repair 0C0036, the master selector valve for the auxiliary building carbon dioxide system, to repair a flange lea A week earlier, the valve had been replaced when it and IC0030A, ,

the local release valve for area IEE1 of the Unit I upper cable ,

spreading room, were found by licensee personnel to be leaking by ,

their seats during a routine surveillance. The inspectors also '

verified that firewatch personnel had been stationed in the seven rooms affected by the 00 ,

b. Observations and Findinas The maintenance work on 0C0036 was rielayed about five hours while a fourth valve was added to the original three valves in the 00S. From discussions with licensee personnel, the inspectors determined that poor communications in the operations department caused the delay. A reactor operator (RO) in the 005 group did not approve the original three-valve 00S request, but wanted the fourth valve added. The disapproval, which occurred at the end of the R0's shift (day shift), was relayed to the fire marshall, who wrote the 00S request, but the explanation for the disapproval was not. Because of a perceived urgency to start the work, the fire marshall had an SRO on afternoon shift approve the 00S. The

, next day, when the RO returned to work, the need to add the fourth valve

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to the 005 was conveyed to the fire marshall, who subsequently halted work until that was don The inspectors also reviewed the licensee's investigation of the failure of- the original 0C0036 valve. The licensee found that six internal screws were missing from the valve disc retainer plat One screw was found in the seat of the IC0030A valve, causing i to leak, but the other five were not found and were believed by licensee personnel to be somewhere in the carbon dioxide syste The licensee's initial evaluation indicated that the remaining five screws would not prevent any of the 36 area valves in the system from opening, because of the valve design, but that a screw could lodge in the seat arid prevent valve closure. The licensee was not able to determine if.the screws were missing because of a maintenance error, manufacturing error, or design proble :

Procedure BwHS 4002-025, " Upper Cable Spreading Room Zone 1S-50 Low Pressure CO, System Actuation Surveillance," was revised to !

improve controls over access to tested areas in case one or more j of the remaining five screws lodged in a local release valve after ;

the valve was opened for a test and to require a visual check of the valve after the test to look for any screws. The licensee !

also planned to either inspect the currently in place 0C0036 valve for improperly tightened screws or to verify the valve to be new or rebuilt by the vendo !

F2.2 Fire Drill Insnection Scone j On August 31, the inspectors observed a weekend fire drill, which included the town of Braidwood volunteer fire departmen !

! Observations and Findinas l l

The inspectors determined that overall, the fire drill went well. The inspectors observed good communications between personnel from the town l of Braidwood fire department and station fire protection personnel. An i unlabelled inoperable fire hydrant was discovered by the licensee during the drill and a PIF was written. The licensee's follow-up review determined that the need to label the hydrant as 00S was not printed out ;

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on the list used by the group that implemented fire protection compensatory measures because the entire list was not electronically transferred from the fire marshall. The licensee no longer electronically transmits the data. The licensee planned to hand deliver the list of compensatory measures to the fuel handling departmen F2.3 Conclusions on Status of Fire Protection Facilities and Eauipment The inspectors concluded that the delayed 00S on the carbon dioxide system valves and the unlabelled hydrant indicated that support of some fire protection activities needed improvemen .

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The reason for the failure of 0C0036 is an Inspection Followup  !

Item 50-456/96012-05. The inspectors concluded the performance of '

the station fire brigade and the coordination with the Braidwood fire department during the drill was good. The inspectors )

concluded that the safety consequence of the outside fire hydrant .

being unlabeled was small because it was not a fire suppression -

system required by 10 CFR 50, Appendix j V. Management Meetings X1 Exit Meeting Summary  ;

The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on September 5,199 The licensee acknowledged the findings presente The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie :

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i PARTIAL LIST OF PERSONS CONTACTED

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Licensee s *H. G. Stanley, Site Vice President

• T. Tulon, Station Manager

*H. Pontious, Nuclear Licensing Administrator l' *M. Pavey, Regulatory Performance Administrator

• J. Nalewajka, Integrated Analysis Administrator i K. Bartes, Executive Assistant W. McCue, Support Services Director

.' R. Flessner, Site Quality Verification Director

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• R. Byers, Maintenance Superintendent

] *D. Miller, Work Control Superintendent T. Simpkin, Regulatory Assurance Supervisor i

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• H. Cybul, System Engineering Supervisor

• A. Haeger, Health Physics / Chemistry Supervisor

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• Dupuis, Maintenance Staff Supervisor

{ *J. Meister, Engineering Manager

! D. Cooper, Operations Manager

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M. Turbak, Independent Safety Engineering Group Supervisor

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• B. Claveau, Operations j *M. Cassidy, Regulatory Assurance - NRC Coordinator

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} L. Miller, Chief, Reactor Projects Branch 4

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• C. Phillips, Senior Resident Inspector

* Kunowski, Resident Inspector j *E. Cobey, Resident Inspector IDEi T. Esper

• Present at the exit meeting l

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i INSPECTION PROCEDURES USED

IP 37551: Onsite Engineering i IP 61726: Surveillance Observations IP 62707: Maintenance Observation

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IP 71707: Plant Operations l IP 71750: Plant Support Activities IP 92700: Onsite Followup of Written Reports of Nonroutine Events at Power

Reactor Facilities

IP 92902

Followup - Maintenance j IP 92903: Followup - Engineering

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[ ITEMS OPENED, CLOSED, AND DISCUSSED i

Ooened

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50-456/96012-01 NCV diesel fuel oil valve mispositioned j 50-456/96012-02 VIO failure to follow procedures

50-456/96012-03 NCV boric acid valve mispositioned j 50-456/96012-04 VIO failure to ensure suitable conditions for testing

50-456/96012-05 IFI reason for valve failure Closed 50-456/96002-02; 50-457/96002-02 VIO inadequate procedure for operating i sample heat trace control equipment

{ 50-457/96009-02 IFI no valve position lights lit for

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2S18801

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50-456/96012-01 NCV diesel fuel oil valve mispositioned j 50-456/95012-03 NCV boric acid valve mispositioned Discussed l 50-456/96009 LER violation of TS due to SI valves lifting and failing to reseat l 50-456/95015-01; 50-457/95015-01 VIO failure to adequately implement FME i Controls i

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LIST OF ACRONYMS USED AR Action Request

! ASME American Society of Mechanical Engineers l CFR Code of Federal Regulations l DG Diesel Generator l ESF Emergency Safety Feature ,

FME Foreign Material Exclusion ,

IFI Inspection Followup Item  ;

i IM Instrument Maintenance l IST Inservice Testing LER Licensee Event Report MOV Motor Operated Valve NCV Non-Cited Violation l NRC Nuclear Regulatory Commission l 00S Out of Service l PIF Problem Identification Form l P&ID Piping and Instrumentation Diagrams

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PDR Public Document Room PM Preventive Maintenance psig Pounds Per Square Inch Gauge R0 Reactor Operator RTDBE Resistance Temperature Detector Bypass Elimination Modification SI Safety Injection i

SRO Senior Reactor Operator

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SX Essential Service Water System TS Technical Specification VIO Violation i

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