Text

FOIA Request for Documents Re Current List of Plant Issues Matrix Related to Listed Facilities,Per 5 Usc 552(a)(3) & 10CFR9.23(b)
	ML20141C392
Person / Time
Site:	Dresden, Byron, Braidwood, Quad Cities, Zion, LaSalle
Issue date:	05/07/1997
From:	Johnson I; COMMONWEALTH EDISON CO.
To:	Racquel Powell; NRC OFFICE OF ADMINISTRATION (ADM)
Shared Package
ML20141C385	List: IA-97-171, Final Response to FOIA Request for Documents.Records in App a Encl & Available in Pdr.App B Records Withheld in Part (Ref FOIA Exemption 5); ML20141C379; ML20141C392;
References
	FOIA-97-171 NUDOCS 9706250155
	Download: ML20141C392 (153)
	v • d • e

,

k I)fl)dli)OM C.L!I!I h !i%*lll I IIUf IO%

i , ro, m< c w f7-/7/ _

n,u nu, onn t. u. (>ou m n gg ,g ,/5 <//

A000n0ft NA -

%fedCes%

May 7,1997 Mr. Russe.ll A. Powell Director, Freedom ofInformation Services i U.S. Nuclear Regulatory Commission Ofnce of Administration Mail Stop T-6 D4 Washington, D.C. 20555 Re: Freedom ofInformation Act Reauest

Dear Mr. Powell:

Pursuant to 5 U.S.C. Q 552(a)(3) and 10 C.F.R. 9 9.23(b), please provide copies of the current " Plant issues List" also known as the " Plant ' _;ues Matrix" related to each of the following facilities: Braidwood Nuclear Power Station Units 1 & 2 (Docket Nos. 50-237/249), Byron Nuclear Power Station Units 1 & 2 (Docket Nos 50-454/455), Dresden ;

i Nuclear Power Station Units 1,2 & 3 (Docket Nos. 50-237/249), LaSalle County Nuclear Power Station Units 1 & 2 (Docket Nos. 50-373/374), Quad Cities Nuclear Power Station Units 1 & 2 (Docket Nos. 50 254/265), and Zion Nuclear Power Station Units 1 & 2 (Docket Nos. 50-295/304). It is my understanding that the U.S. Nuclear Regulatory Commission (N.R.C.) Regional Division of Reactor Projects maintains these Plant issues Lists or Plant issues Matrices in database form to track violations, reportable events, key inspection 6ndings, program strengths and weaknesses and significant equipment problems for each N.R.C. licensed commercial nuclear power plant.

I would appreciate that any readily available materials be provided as soon as possible. In any case, I look forward to receiving your response to this request within the time prescribed by statute.

I agree in advance to pay any reasonable fees associated with this request. However,I request that you promptly notify me if you anticipate that the cost will exceed $500.00. I can be reached by telephone at (630) 663-2096.

Sincerely, VI I. M. Johnson Licensing Operations Director Nuclear Operating Division IMJ/jte ,

9706250155 PDR FOIA 970623 JOHNSON 97-171 PDR J

PLANT ISSUES MATRIX 28-^'"N7 <

Dresden y ;

! DATE p ID BY l SALP DESCRIPTION CAUSE 7j REF ;

f ;

4/10/1997 Self-Revealed * * * " * * * "

Unit 2 forced outage due to auxilary contact switch problems with 4 kV Equipment 97006 (draft) i

. breakers. Malfunction 3/29/1997 "*"""" "*""**" Unit 3 was shut down to commence planned refueling outage. '"***""* IR 97006 (draft) 3/3/1997 NRC Plant Support liigh radiation and high contamination area worker briefings were Teamwork / Skill 96016 thorough. Personnel working in the radiation protection area had a good Level understanding of radiation work permit requirements.

3/3/1997 NRC Engineering The review of several open operability evaluations for both units Other/NA 96016 indicated that the evaluations, equipment status, and schedule to restore t the systems or ompenents to fully operable status appeared reasonable.

2/26/1997 Licensee Operations Unit 3 unit supervisor left the confines of the control room for 6 minutes Personnel IR 97004 ,

while working on loop select logic problem. The Unit 2 unit supervisor Performance noted the absence and recalled the individual to the control room. Deficiency 2/13/1997 Licensee Engineering LPCI loop select logic was set nonconservative (900 vs. 940) due to inadequate IR 97004 .

procedural error. This item was identifed as part of the 11/21/96 CAL Procedure / Instr . ,

actions. uction ;

e 2/10/1997 Licensee Plant Support Actual tampering with security equipment. Security guard site access Personnel ENS 31759 authorization revoked. Performance !

Deficiency -

l 2/9/1997 Licensee Maintenance Transposed calibration data resulted in reversal oflow flow trip and reset Personnel IR 97004 setposts on the llPCI low flow switch. Performance Deficiency 2/8/1997 NRC Operations Following a mispositioned (one notch in vs. one notch out) control rod Conservative IR 97004 issue operations management did an assessment and concluded that th InforkfM lh thi'; record was dde!3d ,

control rod mispositioning, when viewed with other recent events, :

indicated a decSe in operations performance.. Management did not ja ::ccordance v/ith the_F.reedoa O! Ir, formation j

increase power (which was down for a condensate demineralizer service Act, exempuans ,

unit problem) until the corrective actions were started. F01A W - N [

t 2/5/1997 Licensee Maintenance Licensee determined that Unit 3 indicated total core flow was Personnel MR 3-97-0018 significantly below actual. Perfonnance I Deficiency

PLA NT ISSUES MATRIX 20-W97 Dresden DATE I ID IlY ;; SALP M. DESCRIPTION CAUSE h REF e [. -

1/30/1997 NRC Plant Support A violation involving a failure to properly limit personnel access inadequate IR 97002 authorization to a vital area was identified by the inspector. Oversight 1/30/1997 NRC Plant Support Security force members showed a good working knowledge of security Teamwork / Skill IR 97002 requirements and team work between different organizational levels Level within the security organization.

1/30/1997 Licensee Plant Support A non-cited violation involved a failure to terminate a security badge in a Teamwork / Skill IR 97002 timely manner was identified by the licensee This failure demonstrated Level weak coordinason between corporate and site security.

1/30!!997 NRC Plant Support Security intrusion equipment was observed to be working as designed. Teamwork / Skill IR 97002 A good working relationship existed between the security organization Level and mainte sance groups.

I/29/1997 NRC Operations Operators uese attendant to the panels, knowledgeable of the reasons for TeamworivSkill 97004 lit annunciators, and aware of activities in the plant. Level 1/29/1997 *""*""* """"*** **"***""

Unit 3 reactor critical after forced outage.

1/29/1997 NRC Operations ne startup of Unit 3 was performed safely with most communications Teamwork / Skill 97004 and command and control being good. Level I/27/1997 Licensee Engineering Several piping systems found outside code allowables per NRC GL 96- Engineering /De ENS 31670

06. sign Deliciency 1/24/1997 NRC Operations Operators were attendant to the panels, and knowledgeable of the Teamwork / Skill IR 96016 (draft) reasons for lit annunciators, and aware of plant activities. Level '

1/20/1997 NRC Engineering Knowledge of MOV site engineering team was good, as was corporate Teamwork / Skill 96015 interfaces. Level I/20/1997 NRC Engineering Self assessments in the MOV area provided good technical findings and Teamwork / Skill 96015 were beneficial in improving the MOV program. Ilowever, the tracking Level of corrective actions, was not formalized until aller the MOV self- .

assessment.

Page 2 of 38

PLANT ISSUES MATRIX 20-Aray-97 Dresden DATE 'i ID BY SALP i; DESCRIPTION il CAUSE Il REF n i; 1, I/17/1997 Licensee Maintenance I&C technician erroneously set the setpoint for the Unit 2 45% reactor Personnel ENS 31617 power bypass for the load reject / turbine trip scram signal Performance nonconservatively at a pressure corresponding to approximately 50% Deficiency power. Existed for approximately 4 days.

I/15/1997 NRC Engineering He inspector considered the implementation of the ASME code, Section Self-Critical IR 97003 XI, Class MC requirements, in containment coating inspection procedures, to be a positive step toward maintaining the torus and containment material condition.

1/15/1997 NRC Engineering The inspec' >r was unable to determine appropriate corrective actions for Other/NA IR 97003; URI torus pitting (pitting repairs and'or pitting characterization) had been performed as assumed in the bounding engineering calculations.

1/15/1997 NRC Engineering De inspector identified a pump installed in the Unit 2 torus basement Inadequate IR 97003; NOV that lacked installation documentation and for w hich an installation Oversight safety evaluation had not been performed.10 CFR 50.59 violation issued.

1/15/1997 NRC Maintenance Control room ventilation project personnel completed significant repairs Tean .vork/ Skill 96016 with good coordination between the ventilation group and other plant Level personnel.

1/9/1997 Licensee Engineering Primary containment electrical penetrations never subjected to type B Inadequate LER 23797001 local leak rate test due to breakdown of modification process. Both units Oversight affected.

12/20/1996 Licensee Engineering ECCS systems may be suseptible to NPSil problems due to suction Engineering /De ENS Call 31495 strainer design being based on an incorrect head loss value. Design was sign Deficiency based on I foot diop across strainers, new calcs show a 5.5 foot drop.

Licensee op eval was operable but degraded. Operators will throttle back flow if cavitation is observed; sufficient flow will be available.

Licensee to submit an emergency TS change to take credit for 2 psi containmert overpressure and limit torus and (CCSW) service water temp. to 75 F to ensure adequate NPSil. Long term a new analysis will be done and torus and service water restored to 95 F. LER 23796022 Page 3 of 33

PLANT ISSUES MATRIX NfaP97 :

Dresden -

f DATE i ID BY

{

SALP f DESCRIPTION f CAUSE REF j 12/19/1996 NRC Maintenance The licensee failed to do post-modification testing on the Unit 2/3 main inadequate 96014- ;

control room IIVAC system. Oversight !

12/13/1996 NRC Maintenance Repair of the reactor recirculation pump motor was completed Teamwork / Skill 96016 successfully in a well controlled manner. Level 12/13/1996 NRC Plant Support An assembly drill was successfully run. Teamwork / Skill IR 96016 (drafl)

Level 12/9/1996 Licensee Plant Support Failure to declare refuel floor radiation monitor inoperable and take Inadequate LER 23796021 technical specifications required action due to inadequate 10 CFR 50.59 Procedure / Instr safety evaluation. . A design issues worksheet was not used as intended ' uction !

because the proccJure failed to require it.

12/6/1996 NRC Engineering Inspector review of two temporary alterations identified some problems Personnel IR 96014 l with implementation and technical evaluations. This is an unresolved Performance l item. Deficiency 12/6/1996 NRC Maintenance . Significant repair work on the 3B reactor recirculation pump motor was involved IR 96014 l well executed and managed. Management l

t 12/6/1996 NRC Operations NRC identified houskeeping and problem identification weakness in Personnel IR 96014 {

Unit 3 LP heater bay. Performance ,

Deficiency 11/27/1996 Self-Revealed Maintenance Unit 2 IIPCI was declared inoperable due to water in the oil. Water Personnel IR 96014 i leaks were found in the tube oil cooler, and a rag was discovered in the Performance cooler water bcx which blocked significant portions of the cooler tube Deficiency openings. Licensee suspected the rag was present unce constuction.

Reference ENS 31390; LER 237%018 11/26/1996 Self-Revealed Plant Support Computer accounting system failed at the beginning of the plant Equipmect IR 96014 assembly drill causing confusion. A thorough drill critique identified Malfuncti >n i deficiencies and corrective actions.

I1/25/1996 NRC Engineering During review of the EDG test valve e_iection, the inspectors noted that Personnel IR 96014; VIO the system cngineer failed to incorporate all vendor data into the vendor Performance ,

equipment 'ech4cal information program. Deficiency ,

Page4 of 38

PLANT ISSUES MATRIX 20-Mar-97 Dresden l DATE ID BY SALP DESCRIPTION d CAUSE REF i h i 11/24/1996 Licensee Maintenance Stop work order was issued in response to the procurement and use of Personnel IR 96014 non-safety-related parts. The was partially in response to the 3 A CRD Performance pump isolation valve which had a pinhole leak. Deficiency 1I/21/1996 NRC Operations Operators used a conservative approach to evaluate a turbine control Conservative 96016 valve which was stuck closed. De plant operations review committee Decision performed a thorough review of the turbine control valve test plan.

I1/21/1996 Licensee Maintenance Stop w ork order issued due to contractors not adhereing to facility safe Persennel IR 96014 work practices. The stop work was of short duration. Performance Deficiency 11/15/1996 Self-Revealed Plant Support Unit 1 Diesell'civen Fine Pump failed sureseillance. The cause was a Equipment IR 96014 closing of the fuel supply solenoid valve that ocurred when a power lead Malfunction to the valve vibratec of'. The inspectors subsequently identified that the local diesel fuel storage tank lesel float was not working correctly. The inspectors also requested information about she level switches calibrations and the licensee determined that the switches were not in the calibration program.

I1/8/1996 NRC P! ant Support Deficiency 96201-05. The ISI identified that some licensee workers Personnel ISI were not aware of the radiological conditions in their work areas and that Performance these work areas were not restored to prework conditions after Deficiency completing the work.

I1/8/1996 NRC Maintena'Ke Deficiency 96201-20. He procedures used to test the control room Inadequate ISI IIVAC system and boundaries were not appropriate to circumstances, Procedure / Instr contrary to 10 CFR Part 50, Appendix B, Criterion V. uction I1/8/1996 NRC Engineering Deficiency 96201-28. Failure to implement commitments to GL 83-28 Inadequate ISI and GL 90-03. This issue has been cited. Oversight i1/8/1996 NRC Operations Con %I room oyrators properly controlled operational activities, such as Teamwork / Skill ISI surveillance tests, strictly followed procedures in most circumstances, Level and communicated effectively.

Page 5 of 38

PLANT ISSUES MATRIX 2 m ,97 Dresden DATE ID BY ,d

.g-- _

u CAUSE u

REF SALP

{ n h

.n _

DESCRIPTION ilh ;q f 11/8/1996 NRC Plant Support Deficiency %201-02. Failure to survey the work area (Unit 2 hotwell, Personnel ISI Unit 3 reactor building overhead) and assess the potential readiciug; cal Perfo mance hazards were contrary to the requirements of the radiation work permit Deficiency and 10 CFR 20.1501.

I1/8/1996 NRC Plant Support The 1996 exposure goal of 440 person-rem was the lowest exposure goal Teamwork / Skill ISI established at Dresden Station. As of November 7,1996, the station Level accrued 376 Rem.

I1/8/1996 NRC Engineering Deficiency 96201-21. The failure to perform a prompt operability Personnel ISI determination for CRlWAC within the time specified by DAP 07-31. Performance Subsequent differntial pressure measurements of the surrounding area Deficiency showed that 1/8 iwg was not maintained.

I1/8/1996 NRC Engineering ne team's .eview of the b30. FSAR, and ECCS calculations showed Engineerino,/De ISI that the ;&nsee did not have net positive suction head available sign Deficiency calculations that reflected the licensed plant configtntion. He team's review of the existing calculations, which provided some information about NPSil, showed a number of errors in the design control of assumptions and inputs.

I1/8/1996 NRC Plant Support From January 1,1996 through November i1,1996, the licensee reduced involved ISI the number of hot spots from 84 to 42 and planned to reduce this number Management to about 20 by the end of the Unit 31997 refueling outage.

I1/8/1996 Other Maintenance Testing weaknesses resulted in the failure to detect degraded systems and Inadequate ISI components. Longstanding programmatic problems with the in service Oversight test (IST) program were not comprehensively addressed from 1987 to 1996. Relief valve setpoints differed significantly, in some cases, from design pressures established for safety-related systems. Opportunities to address the IST program deficiencies, early in 1996, were not promptly recognized and evaluated. The licensee ar+d ISI tam identified additional testing concerns involving the 125 Vdc batteries, and the 250Vdc batteries, and ventilation systems.

Page 6 of 38

PLANT ISSUES MATRIX N 4-97 Dresden

, o DATE ID BY : SALP 1 DESCRIPTION CAUSE !! REF n

iI/8/1996 NRC Engineering De ISI team identified that the licensee was unable to maintain the Engineering /De ISI design basis of the containment cooling service water system under sign Deficiency cernin conditions, and identified significant weaknesses in the licensee's cor4 trol of design basis calculations, including a number of errors and nonconservative design assumptions. LER 23796020 11/8/1996 NRC Maintenance PIFs were not written when required aller the results of the oil sample Personnel ISI exceed the acceptance criteria; or when the Unit 3 ECCS keep till pump Performance discharge check valve failed open during post-maintenance testing. Deficiency

- - - - ISl; LER 23796019 iI/8/1996 NRC Engineering Deficiency $6201-19. Failure to test the Unit 2,125 Vdc battery at the specified amperage value is contrary to the requirements of procedure DES 8300-28. De failure to demonstrate perfonnance of an acceptable service test of the Unti 2,250 Vdc battery is contrary to the requirements of TS 4.9.A.3.

I1/8/1996 NRC Maintenance Two limit switches were not reworked and the PMTs were not Personnel ISI reperformed contrary to the work instructions, work to repair the Performance electrical cabinet for the 2/3 emergency diesel generator (EDG) fan was Deficiency not performed I AW the work instructions.

I1/8/1996 NRC Engineering Deficiency 96201-13. ISI identified numerous examples of the failure to Engineering /De ISI perform safety evaluations per 10CFR 50.59. Examples include sign Deficiency

1) potential USQ regarding CCSW flow and 20 psid during a LOCA,2) a 50.59 evaluetion was not performed to change the alignment of several HPCI valves positions. 3) Inadequate 50.59 for changing IIPCI isolation setpoints. 4) Failure to properly evaluate the llPCI steam trap replacement with an orifice.5) Failure to perform safety evaluations for installed temporary alterations.

I1/8/1996 NRC Plant Support Deficiency 96201-03. Failure to specify a maximum stay time on a Inadequate ISI radiation work permit and maintain locked high radiation area doors Oversight locked contrary to T3 6.12.2 and 10 CFR 20.1601 11/8/1996 NRC Operations Overall, operator performance was a noteworthy strength. Teamwork / Skill ISI Level Page 7 of 33

P 2 pap 97 PLANT ISSUES MATRIX Dresden DATE ID BY SALP DESCRIPTION CAUSE. REF j f

11/8!!996 NRC Engineering Deficiency %201-22. The ISI identified numerous examples of the Engineering /De . ISl; CAL.

failure to translate the design into drawings, specifications, and sign Deficiency procedures, contrary to the requirements of 10 CFR Part 50, Appendix B, Criterion III. CAL issued. Examples included omission ofelectrical

' loads in the 125 VDC battery sizine calculation, cable lengths and resistances incorrect. nonconservative 250 VDC battery sizing calculation (it did not accurately determine battery duty cycle loading).

I1/8/1996 NRC All/ Multiple Deficiency 96201-14. He ISI identified numerous examples of the . '"""*"* ISI failure to implement corrective actions contrary to the requirements of 10 CFR Part 50, Appendix B, Criterion XVI. Rese examples include the failure to address longstanding IST issues (SWSOPI valve deficiencies identified by NRC in 1993), CREV deficiencies, and SBLC VAT vulnerabilities closed with no action.

I1/8/1996 NRC Plant Support Deficiency 96201-06. Contaminated stanchion found in uncontrolled inadequate ISI area. Failure to maintain control of radioactive material contrary to the Oversight requirements of 10 CFR 20.1802 10!26/1996 Self-Revealed Maintenance A manual reactor trip was initiated in response to the loss of the 3B Equipment IR 96014 Reactor Recirculation Pump. Licensee took plant to cold shutdown Malfunction during troubleshooting. Cause was ground on "C" phase of pump motor stator due to insulation breakdown. Root cause appeared to be a wire labeling strap that was found in stator windings and damaged the insulation. Material probably entered motor in 1990-1991 when the endbell was removed for maintnence.

10G6/1996 Self-Revealed Operations ne plant response to the loss of a single reactor resirculation pump was Equipment IR 96014 in accordance with expectations and plant design. De control room Malfunction operators followed procedures and conducted an orderly shutdown.

10/18/1996 NRC Operations The facility was operated in a safe manner with gocd communication. Personnel IR 96013 Minor discrepancies continue to occur and attention to detail type issues Performance were observed. Deficiency Page 8 of 38

PLANT ISSUES MATRIX 2 M ar97 Dresden 1

DATE ID BY - ]p SALP DESCRIPTION CAUSE j REF I h

10/18/1996 Licensee Engineering from January 1995 through May 1995, Unit 3 primary containment Teamw ork/ Skill IR 96013; App Vio

. leakage was greater than 0.6 La due to leakage past the inboard and : Level outboard MSL drain primary containment isolation valves. He root cause was attributed to poor maintenance instructions for s alve assembly and lack oflicensee experience with Anchor Darling double disk gate valves. r(eference LER 24995007 10/18/1996 NRC Plant Support The contaminated material control program has improved since April Inadequate IR 96013 1995. Ilowever, corrective actions such as minimizing the number of Oversight "outside" RPAs and effectively controlling all outside RPAs have not been fully implemented. Continued improvement in the control of contaminated material was needed.

10/18/1996 NRC Engineering Design engineering response to isolation condenser support and Teamwork / Skill IR 96013 feedwater anchor issues was good. Level 10/17/1996 NRC Engineering 10 CFR Part 50, Appendix B, Criterion V, violation issued for Personnel IR 96012; NOV inadequate maintenance procedure for 4kV breakers. Inpsectors found Performance that a more thorough OPEX program review ofindustry initiatives may Denciency have identified the hardened grease issue before Dresden's 3A LPCI pump breaker failed.

10/17/1996 NRC Engineering 1) Lack of 125 VDC and 250 VDC breaker to breaker coordination for Engineering /De IR 96012; 2 URIs nonsafety related loads. 2) Dresden's actions to address cable ampacity sign Deficiency concerns have been slow in resolving this issue.

10/17/1996 NRC Engineering "flot Shorts" Apparent Violation. Inadequate IR 96012; APP VIO Oversight 10!!5/1996 Self-Revealed Plant Support Poorjob and OOS planning resulted in minor flooding and the extension Inadequate IR 96013 of the east fire main out-of-service boundary, ne planners did not take Procedure / Instr in to account the fact that slip joint piping was installed on the portion of- . uction the system that svas being worked on. After the OOS was hung and the intended section of piping removed, the slipjoint upstream of the isolation point gave way and resulted in the flooding.

Page 9 of 38

PLANT ISSUES MATRIX 2 Mar-97 Dresden DATE ID BY SALP DESCRIPTION CAUSE fl REF 4 10'15/1996 Self-Revealed Engineering U-2/3 EDG Ventilation Fan Power Supply Breaker Inoperable. Fire in a Equipment IR 96013 breaker control power transformer on the U-2 side of the alternate power Malfunction supply breaker for the " swing" EDG ventilaton fan. 7 day LCO. U-3 side of EDG not affected. Weak initial root cause evaluation resulted in additional troubleshooting. The event demonstrated the licensee's ditTiculity in identifying root causes of equipment failures. LER 24996016 10/8/1996 Licensee Engineering System Engineering found that the contcol riom could not be pressurized Engineering /De IR 96014; App Vio to the requireo pressure vith respect to Wjacent areas. Both units sign Deficiency entered a 14 Jay administrative LCO. System declared " operable but cegraded" on 10,21. Licensee continued to repair leaks. Inoperability of Control Room IIVAC being considered for escalated enforcement.

Additiona! rferences ENS 31109; LER 23796017; ISI 10.'8/1996 Licensee Engineering RWCU System for Both Units Outside Design Basis. Licensee Engineering /De ENS 31115 determined that if the pressure reducing valve (PRV) failed open, and sign Deficiency the high pressure isolation instrumentation both failed, the downstream low pressure piping would be overpressurized. If the PRV failed open,it would drop a maxinom of 900 psig (as designed). In order to avoid overpressurizing the downstream piping (with a concurrent instrument failure) the PRV would need about 950 psig drop. Licensee isolated RWCU on both units and installed a mechanical gag (temp alt.) on the PRV for each unit. RWCU was retumed to service.

The RWCU system did not satisfy the current licensing requirements for systems that had a direct interface with the reactor coolant system since a single pressure switch was used to initiate the isolation of both the inboard and outboard containment isolation valves.

Page 10 of 38

. . .. .- - . .. . _ . . . - - . . _ . . .- . - . . . . ~ . .. .. - - .-

t L

PLANT ISSUES MATRIX 2We97 Dresden i

DATE ID BY SALP DESCRIPTION j CAUSE REF } j h

10/2/1996 Licensee Maintenance U-3 IIPCI system declared inoperable due to a high area temperature Equipment ENS 31083; IR 96013 ' ;

reading during a surveillance and identification of a llPCI oil system Malfunction l problem. One of four instruments was reading above license e administrative limits (of 120 deg. F). i During U-3 IIPCI test, the Vdc aux oil pump found off. The "high oil pressure shut-off pressure switch had been reset to about 75 psig. in j 9/96 (was about 86 psig).' Pressure from shaft driven oil pump was about

75 psig, so aux pump tripped due to high pressure, as expected. LER ,

24996015 '

l l

During U-3 IIPCI test, the Vdc emergency oil pump would not start, [

Breaker problem. i 9/30/1996 Licensee Operations Material deficiencies included service water strainers backwash function inadequate 96013 ,

in manual instead of automatic mode (an operator work around), and an Procedurelinstr [

inadequate traveling screen wash nozzle spray pattern allowing for some uction .

fish carry-over into service water system. !

9/30!!996 " " * " " * * *""""" Special NRC Independent inspection Team begins first 2 week onsite ""***"" Special NRC !nspection .

inspection. Interim exit 10/1I/96. Back onsite 10/28 with interim exit ,

I1/8/96. Public Exit planned for 12/12/96 at the Dresden site.

e

.{

9/30/1996 NRC Maintenance The inspector noted that DOS 6600-01," Diesel Generator Surveillance inadequate 96013 Tests," verified that the compressors start at 220 psig, not 250 psig as Procedure / Instr !

indicated by the UFSAR. The licensee indicated that the UFSAR would uction I be revised to read that the receiver prassure was maintained greater than

or equal to 220 psig. ;

9/28/1996 Self-Revealed Operations U-2 & 3 Power Reduction Due to " Shad"(fish) Run. Licensee reduced Conservative IR 96013; OPEN power on both units due to high D/P on service water strainers. Strainers Decision l were fouled due to a fish run. Power was reduced to avoid equipment !

high temperatures. No temperature increases were identified. No problems with circulating water or main condenser vacumu. Last fish .

run on 10/2/96 [

l Page ll of 38

PLANT ISSUES MATRIX 20- 4 97 Dresden e .. . i DATE h ID BY !! SALP [, DESCRIPTION N CAUSE REF u d c ;

9/27,1996 NRC Maintenance The inspectors resiewed the past and current data tables for actior Other/NA 96013 requests (ARs) and work requests (WRs) both for outage and non-outage, planned and corrective backlogs. Each time this has been done the true backlog picture gets a little clearer. This latest recoding may establish a better standard for categorizing backlog items, and was to n atch the Comed sites better.

9/26/1996 Licensee Maintenance ne plant entered a 7 day LCO action statement when U-2 IIPCI was Equipment ENS Call (31061); OPEN declared inoperable due to the pump discharge temperature exceeding Malfunction 150F. The cause of the increase is being investigated. In the past, this has been due to discharge check valve leakage.

?

9/25/1996 Self-Revealed Maintenance The 3A CRD pump inboard seal exhibited leakage. The 3A CRD pump Personnel 96013 discharge valve (^-301-I A) would not pa<ide an isolation boundary and Performance a decision was made to replace the non-safety related valve. One week Deficiency after the repairs, a pin-hole leak appeared in the body of the replaced valve. The initial corrective actions was to establish a freeze-seal boundary to allow for valve replacement. This failed and the licensee decided to encapsulate the entire discharge valve. The encapsulation vessel allowed continued facility operation. Seven PIFs were written to document the breakdowns in engineering, maintenance, work control, procurement, and quality control for the original replacement.

9/20/1996 NRC Operations Unit 3 NRC drywell closecut found some minor debris, broken hanger, Personnel 96013 inappropriately covered condensing pots. The licensee resolved all Performance issues. Deficiency 9/10!!996 Self-Revealed Maintenance U-3 Group i Isuistion Due to Falling Object Bumpag Main Steam Line Personnel ENS Call (30989); IR Flow Instrument. While hoisting equipment through an open floor plug Performance 96013 OPEN in the reactor building (in one of the LPCl/ Core Spray corner rooms) a Deficiericy stanchion, that was support a safety barrier rope, fell through the opening. The stanchion struck the high steam flow instrument lines and a Group 1 Isolation occured. All valves operated as designed.

l' age 12 of 38

PLANT ISSUES MATRIX N'3P97 Dresden U

DATE ID BY SALP DESCRIPTION CAUSE REF

[ : [.

9/9/1996 Self-Revealed Maintenance U-2 Control Rod J-13 Fully Scramed During Surveillance Testing. U-2 Equipment ENS Call (30984) OPEN was at about 84 percent power during main steam line radiation monitor Malfunction 1/2 scram functional testing. While testing RPS channel A, control rod J-13 fully inserted into the core from position 48. Power dropped to about 81 percent. He licensee stated that no thermal limits were exceeded.

Scram solenoid pilot valves replaced and rod tested satisfactorily. Small amount (9 grams) of foreign material found in diaphram. Licensee considers this an isolated event.

9/7/1996 Self-Revealed Maintenance Time Delay Relays for U-3 Lo-Lo Level ATWS Signal Failed to Trip Equipment ENS Call (30978) OPEN within Required TS Tolerance. nree of four time delay relays failed the Malfunction surveillance. 7e relays were replaced. The licensee concluded that U-2 was not subject to the same failure. U-2 relays tested about 1 year ago. During the trouble shooting, after the time delay setpoint was adjusted, the relays would not consistently trip within the required tolerance. The root cause investigation was continuing.

9/1/1996 NRC Engineering U-3 EDG fuel oil transfer pump discharge guage over-ranged. Bird !nadequate IR 96013 time in previous 8 months. The guage does not have a safety related Oversight function. Further indication oflicense's problems in idnetifying and resolving root causes.

8/30/1996 NRC Operations A procedure " posted" in the plant was identified as not being the latest inadequate IR 96009/lFI revision. Continued inspector follow up of this condition is planned. Procedure / Instr uction 8/30/1996 NRC Operations A violation was issued for failing to meet Unit 3 emergency diesel Inadequate IR 96009/NOV generator operability requirements. Oversight 8/30/1996 NRC Maintenance A violation was issued for failure to follow procedural requirements in Personnel IR 96009/NOV calculating specific gnvity for the Unit 3,125 Vdc battery perfonnance Performance test. His was another ev. ample of calculation errors during a 125 Vdc Deficiency battery test.

8/30/1996 Licensee Maintenance All work was stopped for concems about w orker safety when a Conservative IR 96009 potentially lethal shock from a 4kV source was detected. He work Decision stoppage for personnel safety was a conservative response.

Page 13 of 38

PLANT ISSUES MATRIX 2 % 97 Dresden f DATE h ID BY N SALP - DESCRIPTION f CAUSE h- REF f o n .

8/30!!996 Licensee Maintenance A non-cited violation was identified for conducting surveillance test of inadequate IR 96009/NCV recondary containment leakage in greater than 5 mph wind. Procedure / Instr uction 8/30/1996 NRC Engineering Followup to AIT Inspection Report 50-249/96008 identified one Inadequate IR 96006/NCV example of failure to take effective corrective actions for past equipment Procedure / Instr failures and one non-cited violation for minor procedural deficiencies. uction 8/30/1996 Licensee Engineering A non-cited violation was identified for a non-conforming condition Engineering /De IR 96009/NCV regarding the reactor protective system scram pilot solenoid valve sign Deficiency indicating lights.

8/30/1996 NRC Operations A violation was identified for Electrical Bus 33-1 undervoltage special Inadequate IR 96009/NOV test proced ire which was not properly reviewed. Oversight S/30/1996 NRC Engineering Further evCuatan of ficensee's use of compression fittings from various Engineering /De IR 96009.'URI vendors is warranted after several examples of mixed compression sign Deficiency fittings were discovered in the facility.

8/30/1996 NRC Plant Support Continued problems were observed regarding Radiation Protection Personnel IR 96009/NOV.

Technician (RPT) performance. During m,vements of radioactive Performance waste, workers received unplanned intakes of radioactive material due in Deficiency par

to the poor performance of the RPT assigned to thejob. One vioi : ion was identified as a result of this evolution.

8/27/1996 Licensee ' Engineering U-3 Corner Room Support Steel Anchor Bolts Missing Since Original Other/NA RI Obseravtion; OPEN Construction, Anchor bolts not installed on main support beams in each of the rooms as designed. A bolt head was " tack welded" to the " corner !

angle." Purpose of bolts was to restrain lateral movement. Licensee '

repairing the connections. i 8/27/1996 ****"***** *"*""*" " * " " " *

U-2 STARTUP. - Minor problems during startup :nclu. led two cantrol IR 96009 roNectared inperable due to sticking (i.e. require i higit adve pcesure to move), llPCI pump discharge temperaturen ' bh due to cW'; valve leakage (repeat problem), and turbine trip during E tR' r. ' Mp test due to failed fuse.

Page 1-1 of 38

- - _ _ . . __ _- _ - , - - - . - - _ _ - . _ - - -- -- 1

PLANT ISSUES MATRIX 2Waw97 Dresden n

DATE l! ID BY ', SALP lj DESCRIPTION l CAUSE REF 8/23/1996 Self-Revealed Maintenance Unexpected Opening of Two LPCI Minimun Flow Valves While Filling inadequa e LER 50-249/96-01 I; ENS 3 A l{X . Root cause was failed check valve in ' eepfill system. Valves Procedureilnstr Call (30916) were reopened within 3 to 5 minutes. uction 802/1996 NRC Maintenance System engineers were not consistently providing early schedote inputs inadequate IR 96006 to the work planning process. This frequently resulted in schedule Oversight changes prior to begining work.

8/19/1996 Licensee Engineering Accident Analysis for RWCU llELB Outside Containment. The concern Engineering /De RI Observation; OPEN is that Pari 100 dose limits may be exceeded during worst case sign Deficiency conditions i e.1-131 dose equivalent at maximum TS limit). Dresden and Quad Cities do Not have automatic isolation of RWCU on room temperatures or flow, only low reactor vessel level and high drywell pressure. Licensee's compensatory actions included developing administrative prcredures to manually isolate RWCU iflocal area temperatures exce<ded 150 deg. F within 10 minutes.

8/9/1996 Self-Revealed Maintenance 120 Vac Electrical Shock During Maintenance on Bus 23. Maintenance Personnel RI Observation; OPEN personnel not wearing proper protective safety equipment. Cause vas Performance expectations not clearly understood to serify that terminals were de- Deficiency energized prior to cleaning and maintenance activities and to wear proper safety equipment. Tagout was correct.

8/8/1996 Licensee Engineering Through-Wall Leak on Inlet Nozzle of U-3 A-RWCU Loop, B-NRIIX. Equipment OPEN Leak identified during asbestos removal project of U-3 RWCU system. Malfunction Licensee later identified indications on U-3 B-RWCU Loop, B-NRilX, but no !cak. Problable cause is IGSCC. Licensee plans to perform weld overlay ASME Code repairs on leak.

8/8/1996 Licensee Maintenance Foreign Material Discovered in 2A SDC Loop. During inspection of 2A Equipment OPEN SDC pump discharge check valse, licensee determined that several Malfunction pieces of the valve were missing. Also identified debris in piping near the valve. Licensee performing a loose parts analysis for U ~. operation.

U-2 recirculation system is not in service. On 8G0, licene.e identified hinge pin and lock washer missing from 2B SDC purrp discharge check valve.

Page 15 0f 38

PLANT ISSUES MATRIX 2 pag 7 Dresden m ,

DATE ,d ID BY SALP DESCRIPTION . H CAUSE h. REF t i n

f e n 4 8/7/1996 NRC Operations - Inadequate Administrative Controls in Licensed Operator Inadequate - IR %009/NOV '

Requalification Program. Multiple examples (5) of SROs being Procedure / Instr removed from requaf.fication program and later reinstated without NRC uction notificatiorn Uceraec required to ammend individual license if person was remos-d from program. An example would be for a rotation to INPO. NRC identified one example and licensee reviewed records and identified remainder. All SROs had received appropriate refresher training and completed re-activation watches prior to performing licensed SRO duties.

8/6/1996 Self-Revealed Engineering Containment Cooling Service Water (CCSW) Flow 'ihrough 3 A LPCI Engineering /De ENS Call; OPEN lleat Exchange Not Achieve Required flow of 7000 g; c: with 2 CCSW sign Deficiency pumps. ( USFAF Section 6.2.1.3.2) Actual was 6900 gpm. Also, the 3A CCSW pump packing overheated during test. U-2 and U-3B LPCI IlXs all greater than 7000 GMP flow with 2 CCSW pumps. Licensee cleaned tubes and adjusted ilX outlet floiv control valve. Flow test 8/23 resulted in 6975 gpm. ENS call retracted 8/28. Licensee determined that since one train of LPCI was capable of 7000 gpm flow (3B llX) and was operable when 3A train failed, U-3 was within design basis. NRC reviewing the evaluation.

7/30/1996 Licensee Maintenance Electromatic Relief Valves 3-0203-3B and E pressure switches found out Other/NA LER 50-249/96-010 of tolerance due to setpoint drifL 7/25/1996 Self-Revealed Maintenance Electrical Shock During Maintenance on Bus 34 (a 4KV safety bus). Personnel IR 96009 During inspection of Bus 34, system engineering received minor Performance electrical shoc : due to not following electrical safety procedures and Deficiency using proper safety equipment, Tagout of bus was correct. Licensee stopped all onsite work due to concerns with personal safety.

7/23/1996 Self-Revealed Maintenance U-3 480 VAC Circuit Breaker Failed to Remotely Close on First Equipment IR 96006/URI Attempt. Cause appeared to be stiff grease on roller latch bearing. Malfunction Several of this type of breaker (GE model AK-75) had been overhauled by GE when the *RM-9 trip circuit" modification was performed. This breaker had not had the modification. Identified when licensee was re--

energizein ; Bu : 33-1 (after cubicle & breaker overhall). Last PM was -

1994. This issue is related to the 4kV breaker problems.

Page 16 of 38

20-Mav-97 PLANT ISSUES MATRIX Dresden REF DATE ID BY SALP DESCRIPTION CAUSE 7/23/1996 Licensee Engineering Potential Leak Path to Bypass Contianment (Post Accident) and Potential Engineering /De LER 50-237/95021-02 Increase in Part 100 Dose Rates. Licensee was re-evaluating IN 90-78 sign Deficiency and determined a potential backleakage path from reactor recirculation seals through CRD systern to llCUs. Preliminary evaluation indicated that the Control Room Dose Limits, Part 50, App. A, General Design Critera 19 may be exceeded. Licensee plans to modify the procedures to isolate this potential flow path by reducing the response from 4 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months to 1.5 hours5.787037e-5 days 0.00139 hours 8.267196e-6 weeks 1.9025e-6 months 7/23/1996 Self-Revealed Maintenance Electrical Maintenance Without Proper Work Package or Equipment Inadequate IR 96009 Results in Small Fire. Electrical maintenance personnel removing air Oversight conditioning vmpressor from service building roof using torch. Not have work package, compressor not depressurized, and no fire extinguisher. Small oil fire occured with monor injuries to personnel.

Work control process failed and poor personnel performance.

7/23/1996 Licensee Maintenance Degraded Security Barrier from U-2 ileater Bay (Protected Area) to Inadequate LER 50-237/SO3 Radwaste Tank Area (Vital Area). Maintenance removed the security Os ersight barrier to inspect the pipe tunnel between the two areas. Work package had step to inform Security prior to removing the barrier. Security was not informed when barrier was removed. Appropriate compensatory measures were taken.

7/20/1996 Licensee Operations U-2/3 EDG Given Manual Start Signal in Error During Special Test. Personnel LER 50-237/96-012 During a special test of U-2/3 EDG, operator inadvertantly moved the Performance control switch to the Start position vice the Auto position as required by Deficiency the procedure. The EDG had been running unloaded in the cooldown cycle when the ertor occured. The EDG remained unloaded and was suqsequently placed back in the coldown cycle. There was no apparent damage to the LDG or control circuit.

Page 17 of 38

PLANT ISSUES MATRIX 2 map 97 Dresden DATE ID BY SALP DESCRIPTION h CAUSE REF 9

7/15/1996 Licensee Operations U-3 and U-2/3 EDGs Out of Service at the Same Time. U-2/3 EDG was inadequate LER 50-249/96-009; IR inoperable to bus 33-1 during 4KV switchgear maintenance (begining on Oversighi 96009 6/23/96). The U-3 EDG was taken out of service for 4 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months to perform routine monthly operablilty surveillance while U-2/3 EDG was still inoperable. TS 3.9.D requires t hat one EDG remain operable with the plant in cold shutdown. Cause -s unanticipated increase on 4 KV breaker work scope.

7/12/1996 NRC Engineering SDC pump room electrical penetrations execeded the temperature limits Engineering /De IR 96006/URI specified in the UFSAR. sign Deficiency 7/12/1996 NRC Engineering Unit 2 and Unit 3 Reactor Building Ventilation does not meet the flow Engineering /De IR 96006/URI requiremer ts in the UFSAR. sign Deficiency 7/12/1996 NRC Plant Support Psycholog al evaluation of on-site contractor employees and site hired Persom el IR 96006/NCV licensee employees was not performed in accordance with procedure. Performance NCV for failure to follow procedure. Deficiency 7/12/1996 NRC Plant Support Licensee failed to take monthly tritium samples on Unit 1 Main Chimney Personnel IR 96006/NOV and the Units 2/3 Main Chimney and Reactor Building Vent Stack Performance between July 1995 and May 1996. NOV for violating TS 4.8.A.2 (Unit Deficiency

1) and TS 4.8.1 (Units 2 and 3).

7/12/1996 NRC Plant Support Weaknesses noted in llRSS surveillance procedure regarding acceptance inadequate IR 96006/IFI criteria and actions to be taken if a surveillance test fai!s. Procedurelinstr uction 7/12/1996 Licensee Operations Special Report Concerning inoperable Recombiners was issued. Other/NA IR 96006/lFI 7/8/1996 Self-Revealed Plant Support Internal Contamination of 2 Contract Personnel Working in Radwaste Inadequate IR 96009/NOV Stock Bay. Licensee was performing cleanup of material in radwaste Oversight stock bay. During a " slow time" the licensee decided to do some additional cleanup in the area. Personnel opened a couple of bags of material that were not covered by the originaljob RWP. Not sure if the bags were properly marked as contaminated material. Pe sonnel not use proper RP controls or monitoring when opening bags..

Page 18 of 33

T~

PLANT ISSUES MATRIX 2""P97 Dresden

! DATE ID BY SALP DESCRIPTION CAUSE REF 7/1/1996 Licensee Operations Possible Operator License Exam Compromise. Licensee found copies of Other/NA RI Observation NRC exam in training building copier. Exam was under securi agreement and should have been under lock and key. Eue 6/28/1996 Self-Revealed Engineering Loss of U-2 Annunicators for 8 minutes due to a fault on Line 1207. Equipment IR 96006/IFI When power restored, " loss of annunicator power" alarm for control Malfunction board 902-4 and 902-7 remained. Unit 2 was shutdown at the time.

6/21/1996 Self-Revealed Operations U-3 Isolat on Condenser Group V Isolation Valves Automaticly Closed Equipment IR 96006, LER 50-due to spurious signal. ' toot cause unkonwn. Isolation occured during Malfunction 249/96008 re-alignment of system dring normal U-3 shutdown.

6/21/1996 Licensee Operations Failure to Perform TS Surveillance on Nuclear Instruments During U-3 Personnel LER 50-249/96-007 Shutdown. During the power descension, the Unit Supervisor (US) Performance informed Instrument Maintenance department of shutdown. The US did Deficiency not direct the IM staff to preform the surveillances that were required during a plant shutdown. Recent SRM and IRM calibrations had been performned satisfactorily on 6/5/96.

6/20/1996 Licensee Engineering U-3 SHUT DOWN. 'Ihe unit was shut down due to licensee's concerns Conservative IR 96006 with retaibility of 4KV safety related breakers. Decision 6/12/1996 * " " " " * * " " " " * " U-3 Synchronized to the Grid. """"*** "*""""

6!11/1996 Self-Revealed Maintenance 3A LPCI Pump Breaker Not Open on First Anempt. Pump running for Inadequate IR 96006/URI torus cooling. Breaker not open on first two attempts from control Procedure / Instr room. Trip solenoid had been energized. Opened on third attempt. uction Cause for the specific breaker failure was the trip latch roller bearing was binding due to hardened grease. Generic cause was inadequate maintenance of 4kV breakers.

6/10/1996 *""""" """"*"

DRESDEN UNIT 3 STARTUP " " * * " * " """"*"

6/7/1996 Licensee Plant Support Licensee failed to take required service water grab sample while the Personnel IR 96006/NCV, LER 50-service water radiation monitor was inoperable. Performance 237/96008 Deficiency Page 19 of 38

PLANT ISSUES MATRIX 2 M e 97 Dresden t ,

jj 1- -

u 1 i DATE p. ID Bh f SALP ! DESCRIPTION l CAUSE h REF ;

, 5 ; , " .

6/1/1996 Licensee Operations Licensee delayed U-3 startup until the U-2 feedwater control system Conservative IR 96006 investigation had concluded that there were no concerns on U-3. Decision 5/31/1996 Self-Revealed Engineering U-2 Manual Scram During Feedwater Control System Testing. While Engineering /De IR 96006/NOV; LER 50-1 modifying the logic on the new " Bailey" Feedwter Control system (i.e. sign Deficiency 237/96009 to make a change to a gain calculation) the 2B FRV unexpectedly !

closed. Operators manually tripped reactor when vessel level dropped ,

below predetermined point. A violation for failure to follow procedures !

was issued .

5/28/1996 * * * " " " * * """""* U-2 STARTUP. '"*"*"" "***"****

5/25/1996 Self-Revealed Engineering U-2 SHU~i DOWN. De unit was shutdown to repair feedwater control Equipment IR 96006 system power supply. The failed power supply was identified during 3- Malfunction element level control testing.

5/25/1996 NRC Plant Support Inadequate RP Records. The licensee failed to keep adequate records Personnel IR 96004/NOV and information important to the safe and effective decommissicning of Performance the facility, particularly with regard to spills and the spread of Deficiency 'l contamination in and around the facility. NOV for failure to follow 10 ,

CFR 50.75(g).

5/25/1996 NRC Plant Support inadequate Radiological Surveys. Several items in the radioactive waste Personnel IR 96004/NOV tank rooms and infrequently accessed high radiation areas in the Performance radioactive waste building were not identified on the survey map for Deficiency entry; therefore, no survey information was available for them. NOV for failure to perform surveys to identify radiological hazards incident to i workers.

5/25/1996 NRC Plant Sepport A contractor employee was authorized unescorted access to the facility - Inadequate IR 96004/lFI based on previous access. The inspector concluded that a full Procedure / Instr j background check was required in accordance with the security plan. uction 5/25/1996 NRC Plant Support Security equipment maintenance backlog appears excessive. Inadequate IR 96004/!FI -

Oversight Page 20 of 33

PLANT ISSUES MATRIX 2 W ar-97 Dresden

! n : '

DATE ID BY ll SALP DESCRIPTION l! CAUSE REF

i 3 , 4:

5/21/1996 NRC Operations Loose Fibrous Material in U-3 Drywell. The inspectors identified loose Inadequate IR 96004/NOV fibrous insulation in the U-3 drywell which had been installed as a Oversight temporary heat shield as early as 1986. Station procedures required following Reg Guide 1.33, Revision 2, Appendix A which recommends the removal of all loose fibrous insulation from the drywell. The insulation was removed. NOV for failure to follow procedures.

5/20/1996 Self-Revealed Engineering U-3 Reactor Scram Signal While Shutdown Due to Trip of 3B Reactor Equipment LER 50-249.96006 Protection System MG. A thermal overload in the 3B RPS MG drive Malfunction motor had tripped resulting in the loss of RPS Bus A, a full scram, and the auto start of the A SBGT train with the associated reactor building isclation. Tht. cause was detrmined to be high ambient temperature and less than optimum design application of the thermal oserload relay and heater.

5/18/1996 Self-Revealed Maintenance Unit 3 Diesel Generator Auto-Start Due To Electrical Maintenance Personnel IR 96004/NCV; LER 50-Department Personnel Error. Electrical maintenance department contract Performance 249/96005 personnel took continuity readings on the wrong terminal points for Bus Deficiency 34 main feed breaker. These contacts are connected to the DG auto-start circuitry. The U-3 EDG ran successfully, and no equipment damage resulted. NCV for failure to follow procedure.

5/15/1996 Self-Revealed Engineering 3B Feedwater Regulating Valve Failure, Reactor Trip, and Emergency Equipment IR 96008; LER 50-Core Cooling System Actuation. Reactor vessel level transient due to Malfunction 249/96004 FRV valve stem separation. IIPCI injection and Group I (MSIVs) isolation. Two Gp. I valves automatically reopened due to failed relays when Gp. I signal was reset. Augmented Inspection Team was dispatched. NOV for inadequate corrective actions for failed relays and NCV for inadequate operating procedures in IR 96009.

5/6/1996 Self-Revealed Maintenance 2B SFP Pump Tripped Due to fligh D/P in Demin-filter. Cause was inlet Equipment RI Observation AOV not open ng when required. Concerns with SFP system were Malfunction previously identified in as URI 50-237;249/ 95014-01 and closed in IR 96002.

Page 21 of 38

o PLANT ISSUES MATRIX 2 M + 97 Dresden

~

DATE ID BY SALP DESCRIPTION CAUSE REF f'

5/1/1996 Licensee Operations U-3 System Checklists. Licensee began a detailed review and walkdown involved IR 96004/NOV of U-3 system checklists.10 person team. Part ofcorrective actions Management .

from NRC identified problems with U-2 checklists. NOV 50-237;249/ % 004-0I

~ 4/26/1996 Self-Revealed Maintenance U-2 IIPCI Inoperable. IIPCI was inoperable due to a leak in the main Inadequate LER 50-237/96-007-00

steam supply drain line. The drain line goes to the main c'.,ndenser. Oversight Cause ofleak was flow accelerated corrosion. ' liistory ofleaks in this line (U-3 also) since 1980s.

4/22/1996 Licensee Maintenance Failure to Follow Maintenance Work Procedures. A body-to-bonnet leak Personnel IR 96004/NOV was repaired as a minor work item on feedwater check valve 2-220-628.- Performe.nce Minor wo k is permitted only on components which do not compromise Deficiency

the AMSl or ISI pressure boundary and which have little potential for i

personnel .njury. This valve was under full reactor feed pressure. NOV 50-237;249/96004-03B was issued for failure to follow procedure.

4/20/1996 " * " " * " * ""**""* U-2 RESTART- neuanu un.u.n 4/18/1996 Self-Revealed Maintenance UNIT 2 SilUTDOWN. The unit was shutdown because ofinability to Equipment LER 50-237/96002 meet allowed LCO time for IIPCI system testing. Unit 2 IIPCI discharge Malfunction line would cool to less than 150 F as required by procedure due to leakage past the 2-2301-7 check valve.

4/17/1996 NRC Plant Support Chemical Agent Canisters (A Response Weapon) Inoperable. Sixty-six Equipment IR 96004/NOV percent of chemica! agent canisters issued to the station security force Malfunction were inoperable. The security plan requires that all canisters be operable. A violation (NOV 50-237;249/96004-10) was issued for failure to follow the security plan.

4/17/1996 Licensee Operations Improper Interpretation of TS Surveillance Interval. Licensee personnel Personnel IR 96004/NCV inappropriately applied a 25 percent " grace period" to a service water Performance Deficiency i grab sample frequency. The grab sample was required as part of a TS action statement for an inoperable service water radntion monitor; therefore, a NCV (50-237;249/96004-04) was issued for violating TS 3.2.F.3. i 4/15/1996 "*""***t * " " " " " U-2 RESTART FROM D2Rl4. """*"" "*"*""*

, t Page 22 of 38 l

PLANT ISSUES MATRIX 2 mar 97 Dresden u 1 y '- - - s i 1-DATE U ID BY SALP d DESCRIPTION j CAUSE 1 REF i

- d- l-h_ _

h i 4/10/1996 Self-Revealed Maintenance APRM Circuit Card Maintenance. Licensee canabilized resistors that inadequate - IR 96004 were thought to be spares to replace failed resisitors on the same APRM Procedurelinstr card. The resisters were in fact in use and the result was in a larger than uction expected APRM gain change. The root cause was determined to be a problem with the vendor drawing which had been incorporated into the surveillance procedure. This item .vas considered an additional example of electrical drawing deficiencies (U RI 50-237;249/95015-07).

4/10/1996 Self-Revealed Plant Support Low Leve' Intake During Maintenance. One radiation worker received a - Personnel IR %0N/NOV low level i itake of radioactive material during U-2 drywell basement Performance cleaning. The root cause was determined to be poor radiation protection Deficiency technician coverage. A violation (NOV 50-237;249/96004-08A) was issued for failure to perform surveys to determine the radiological hazards incident to workers.

4/4/1996 Licensee Operations U-2 Recirculation Loops Cross-Tie Valve. He 2 inch valve in the Inadequate IR 96004/NOV equalizing piping was found about 10*'. open during checklist review in Procedure / Instr response to NRC finding. License requires that valve is shut. Unit 2 was uction not in operation at the time; however, had the licensee not re-performed the system checklist, a license violation could have occurred. His was one of the findings that led to a NOV for Inadequate Conective Actions for deficiencies in system checklists.

(50-237;249/96004-01) 3/31/1996 Licensee Plant Support Radwaste Supervisor Tested Positive for Alcohol During "for-cause" Personnel ENS Call (3021I)

FFD testing. Individual was denied unescorted site access pending Performance review. Deficiency 3/29/1996 NRC Plant Support PVC usage in the plant was not well controlled. Specifically, no 10 CFR Inadequate IR 96002/URI 50.59 evaluation was done to address the increased PVC loading in the Procedure / Instr Fire llazards Analysis.' Resolution of this issue will be tracked under uction URI 50-237;249/96002-09.

3/29/1996 Self-Revealed Maintenance inadequate Corrective Action on 4kV Breakers. Numerous linkage Personnel IR 96002/NOV problems in 4kV breakers and poor root cause analyses have been Performance reponed dating back to 1989.. A NOV (50-237;24a/96002-06A) was Deficiency issued for failure to take prompt corrective actions.

Page23 of 38

_ - - - _ = _ _ _ _ - . _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ = _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ - _ _ _ _ _ _ - _ _ _ _ - _ _ - _ _ _

_ ~ --- _ .. . ~ - - . . _ ~ - - . .- _ - . - - . . . . . ..

t.

PLANT ISSUES MATRIX 2 mar 97 -

Dresdgn i .; F

DATE ID BY SALP I DESCRIPTION j CAUSE d REF i _. . .__ . o l 3/29/1996 Licensee Maintenance _ The revised peak loading of the duty cycle was not reflected in the Other/NA 96004 battery service tests performed during outages in 1995-1996 (Unit 2) and 1994 (Unit 3), and the testing was inconsistent with the design peak Ioading.

3/29/1996 NRC Plant Support Emergency Lighting. An inspector review of emergency light Personnel IR 96002/NOV and IFl suveillances performed since 1994 indicated that the licensee failed to Performance follow procedure when performing the 8-hour discharge test. There Deficiency .

were 26 examples in 1994 and 21 examples in 1995. A NOV (50-237;249/96002-05B) was issued for failure to follow procedure. .i Additional problems with the emergency lights were noted and will be i tracked under IF! 50-237;249-96002-10. j 3/29/1996 NRC Engineering UFSAR Deviations. Deviations were noted for locked closed Engineering /De IR 96002/URI !

conationment isolation valves, diesel fuel oil tank overflow, ACAD sign Deficiency ,

system, toxic gas analyzer, and IIPCI dedicated suction. The resolution of these deviations will be tracked under URI 50-237;249/96002-11.

3/29/1996 NRC Engineering Untimely Resoultion of Operability Evaluations. No engineering Engineering /De IR 96002/URI proposal has been submitted to date in order to resolve the lack of the . sign Deficiency ,

automatic purge mode for control room ventilation as described in the

UFSAR. URI 237;249/96002-07 was issued to track this deviation.

3/29/1996 Licensee Engineering Numerous licensee-identified UFSAR discrepancies remain to be Engineering /De IR 96002/URI resolved. These items were discovered through the licensee's 1993 sign Deficiency UFSAR rebaselining effort. URI 50-237;249/96002-08 will track these 'j issues.

3/29/1996 NRC Maintenance Skill of the craft weaknesses has resulted in numerous examples of Personnel IR 96002 ;

slowed work completion and potential for personnel injury. Assessment Performance of skill of the craft will be ongoing. Deficiency 3/27/1996 Self-Revealed Operations inadvertent Manual Scram While in Refuel Mode During Planned Personnel _ IR 96002; LER 50- .

Periodic Surveillance Testing Due to lluman Error, While performing a Performance 237/96006 planned instrument calibration on the drywell high pressure scram and Deficiency containment isolation switches, the operator reflexisely manually scrammeu the .. nit when an expected half-scram was received.

Page24 of 38

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

PLANT ISSUES MATRIX NIe97 Dresden a-DATE ID BY SALP DESCRIPTION CAUSE REF l; ll tl l

3/26/1996 SMM SCREENING MEETING Licensee ""*""" RI Observation 3/25/1996 Maintenance One EMD personnel received uptake during work on U-2 dryw ell sump pump motor. EMD personnel not wait for RPs to take air sample.

Self-Revealed " * * * " " " RI Observation 3/18/1996 Maintenance U-2/3 diesel fire pump inoperable due to engine coolant leak identified during w eakly maintenance run. (Operable 3/21) 3/15/1996 NRC Operations Discrepancies were identified in the Unit 2 Drywell during "close-out" Inadequate IR 96002/URI walkdown. Examples included missing screws form CQ electrical boxes, Oversight MOV covers not secured, and miscellaneous debris. His issue is unresolved pending review of the licensee's corrective actions. (URI 50-237/96002-0Ij.

3/15/1996 NRC Operations Improper control of feedwater heater controllers. The control room Personnel IR 96002 operators were staginging mechanical " jams" to keep the feedwater Performance heater switches in the pull-to-stop position if a loss of feedwater heaters Deficiency were to occur. The use of" jams" was not allowed by station procedures, and the " jams" were removed from the control room.

3!!5/1996 Self-Revealed Operations incorrect Operator Aid results in reactor level problem. Operators using inadequate IR 96002 an incorrect operator aid caused an unexpected three inch drop in reactor Procedure / Instr vessel water level due to instrument error not reflected on the aid. The uction aid has been corrected.

3/15/1996 NRC Maintenance Discrepancies were identified in the Unit 2 Drywell during "close-out" Inadequate IR 96002/URI walkdown. Examples included missing screws form EQ electrical boxes, Oversight MOV covers not secured, and miscellaneous debris. His issue is unresolved pending review of the licensee's corrective actions. (URI 50-237/96002-01).

3/12/1996 NRC Engineering Unit 2 refuel outage was extended again to implement structural steel Inadequate IR 95015\URI modifications o LPCI corner rooms. The licensee initially identified the Oversight failure to meet Code requirements in early 1994, but, did not plan on doing work until N RC questioned timeliness of corrective actions.

Page25 of 33

PLANT ISSUES MATRIX 20-uar97 :

Dresden g ,'

DATE ID BY SALP DESCRIPTION p CAUSE REF l f f f 3/7/1996 Self-Revealed Operations U-2/3 diesel fire pump inoperable due to cold weather. When low area Engineering /De ' RI Observation temperature alarm annunciates, temperature already below operable sign Deficiency setpoint. Modification earlier in year changed area temperature required for operability. Alarm setpoint not changed.

3/7/1996 Self-Revealed Engineering U-2/3 diesel fire pump inoperable due to cold weather. When low area Engineerit.g/De R1 Observation temperature alarm annunciates, temperature already below operable sign Deficiency setpoint. Modification earlier in year changed area temperature required '

for operability. Alarm setpoint not changed 3/5/1996 Licensee Maintenance U-3 IIPCI inoperable. Eng. determined that during IIPCI startup, the - Equipment , LER 50-249/96-002 main steam line drain valve leak had potential to become worse. Leak Malfunction '

was assoc: tied with 2/27/96 IIPCI leak. Restored next day.

3/4/1996 Self-Revealed Maintenance 2A CCS% pime packing leak. Equipm nt RI Observation Malfunction 3/4/1996 Licensee Maintenance Excessive oil found in U-2 EDG air box after planned maintenance. Inadequate RI Observation Also, SRI identified multiple minor material deficiencies after Procedure / Instr maintenance. uction 3/4/1996 Licensee Operations ACAD compressor inoperable. Identified at day 9 of a 7 day Personnel RI Observation administrative (DATR) LCO. Not TS or 10 CFR 50.44. Additional Performance ACAD issues are discussed in IR 96002 (IFI 50-237;249/96002-04). . Deficiency 3/3/1996 NRC Operations Discrepancies between UFSAR and locked valve program. (Discussed in Other/NA IR 96004/NOV IR 96002.) The licensee failed to adequately implement the station's locked valve program resulting in several plant configuration problems.

Numerous Corrective Action Requests, PIFs, and violations have -

previously been issued; therefore, a violation of 10 CFR Part 50, Appendix B, Criterion XVI was issued (NOV 50-237;249/96004-02).

The licensee has reviewed the locked valve issue along with the station

~ checklist issue in order to identify and correct deficiencies.

Page26 of 38

PLANT ISSUES MATRIX 2 W e 97 Dresden DATE ll ID BY g. SALP DESCRIPTION '

CAUSE REF 3/3/1996 NRC Operations Multiple problems found on " completed" U-2 startup checklists Other/NA IR 960M/NOV including some independently verified valves found out of position.

(Discussed in IR 96002.) The licensee's initial review and corrective actions were ineffective: therefore, a violation of 10 CFR Part 50, Appendix B, Criterion XVI was issued (NOV 50-237;249/960N-01).

The licensee's second re <iew had broader scope.

3/3/1996 Self-Revealed Operations 2C condensat" and booster pump 4kV breaker not close. Breaker not Personnel RI Observation properly " acked in." Additional 4kV breaker problems are being Performance tracked un Ier NOV 50-237;249/96006-06A. Deliciency 3/3/1996 Self-Revealed Maintenance Foreign material (rag) found in 2A CCSW pump. Foreign material in the Inadequate IR 96002/NOV system has been a recurring problem with CCSW dating back to late Oversight 1994; therefore, a violation of 10 CFR Part 50, Appendix B, Criterion XVI was issued (NOV 50-237;249/96002-06B). The rag in the CCSW system was due to poor FME control during maintenance on the 2/3 diesel fire pump which shares the same suction bay as all of the CCSW pumps.

3/3/1996 Self-Revealed Mainter.ance 2C condensate and booster pump 4kV breaker not close. Breaker not Personnel RI Observation properly " racked in." Additional 4kV breaker problems are being Performance tracked under NOV 50-237;249/96002-06A. Deficiency 3/3/1996 Licensee Operations Licensed operator signed a routine APRM surYeillance as complete and Personnel RI Observation satisfactory when 6 of 8 channels were above limits. Performance Deficiency 2/29/1996 Licensee Maintenance Both trains of control room ventilation degraded. A-train fan motor [] B- Equipment RI Observation train does not have backup cooling water supply. Malfunction 2/29/1996 Licensee Engineering Non-environmentally qualified connectors on U-2 post-accident Inadequate RI Observation radiation monitor in drywell. Checking U-3 & Quad Cities. Additional Procedure / Instr U-2 drywell concerns are being tracked under URI 50-237/96002-01. uction 2/29/1996 Licensee Operations Incorrect cation resin added to tank in radwaste system. Wrong resin Personnel RI Observation was delivered. Performance Deficiency Page 27 of 38

-. = - - _ -

f i

. PLANT ISSUES MATRIX 2""d7 Dresden g v DATE ID BY i

j [ SALP f DESCRIPTION f CAUSE g REF j

[

2/28/1996 Licensee Maintenance Problem with U-3 reactor recirculation MG set ventilation dampers. The Equipment . RI Observation resulting high temperature required about 35% rapid load drop. _ Malfunction 2/27/1996 Self-Revealed Engineering U-2 SDC system tripped. Apparently due to spurious high temperature Equipment RI Observation signal from a reactor recirculation loop thermo-couple (T/C). Malfunction 2/27/1996 Self-Revealed Maintenance U-2 RWCU system leak (about 100 gal /hr)into reactor building drain Equipment RI Observation i tank. Leak was past an isolation valve. Malfunction 2/27/1996 Licensee Maintenance Pin-hole size leak in U-3 IIPCI drain line to condenser. Found during Equipment RI Observation i rounds. ' Malfunction 2/27/1996 Licensee Operations New won :equest added to existing out-of-service tagout. Isolation inadequate RI Obsenation boundaries were inadequate for new work. Procedure / instr uction 2/26/1996 Licensee Plant Support Inadequate compensatory actions after security intrusion detection Personnel ENS Call \lR 96002iOpen

system became inoperable due to weather. Supervisor's error. Performance -

i Deficiency 2/25/1996 Licensee Operations Latch on fire door found taped over. Personnel RI Observation i

Performance l Deficiency 2/25/1996 Licensee Operations Configuration control problems (tagging) during integrated leak rate Personnel RI Obsenation testing (ILRT) Performance Deficiency

! 2/24/1996 Self-Revealed Engineering U-2 SDC systs.a tripped. Cause was apparently d e to spurious high Equipment RI Observation

temperature signal from a reactor recirculation loop thermo-couple Malfunction (T/C). Repeat problem.

2/24/1996 Licensee Operations' Multiple self-check enors found in performance of Unit 3 CRD Personnel RI Observation

accumulator OOS tagout. Performance i

Deficiency 2/23/1996 Self& Lic. Maintenance Unit 3 down power to fix material condition problems: 3A FRV re- Equipment RI Observation injection. IB r; actor recirculation pump low oil level, and replace 8 CRD Malfunction SSPVs.

l' age 28 of 38

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

Y r

PLANT ISSUES MATRIX 2""P97 Dresden n- - _

DATE y ID BY SALP DESCRIPTION CAUSE REF

{ j f [

2/23/1996 Self-Revealed Engineering 3D CCSW pump discharge check valve leaking back by resulting in Equipment IR 96002/NOV ,

, failure of keep fill system. Foreign material (wood) found in hinge of Malfunction valve. His was used as one of the examples of NOV for inadequate

[

corrective actions. (50-237;249/96002-06B) ~

2/19/1996 Licensee Engineering Control Room IIVAC and Operating Procedures Not Meet UFSAR .. Engineering /De IR %002; LER 50- l 1

Design. System was designed so upon toxic gas detection system sign Deficiency 237/96003 -;

actuation, the 8 train of Control Room IIVAC would shift to the !

recirculation mode and pressurize the control room ventilation envelope. I The concern was that during a LOOP and'or LOCA, power to the toxic ;

gas analyzer would be lost. The consequence would be that the i equipment nee led to pressurize the control room in the event of toxic gas would be unavailable. He licensee procedures to selign the systems within the required time frame were inadequate.

2/16/1996 NRC Operations While running two simultaneous Unit 3 diesel generator surveillances, Personnel IR 96002/NOV the inspector noted that ditTerent kW loading was required for each test. Performance !

The operators were unaware of the difTerent requirements for the Deficiency surveillances in progrm. An NOV (50-237;249-96002-05A) was issued for failure to foll)w procedure.

2/13/1996 NRC Plant Support Resin Spill in Radwaste Building that was Approximately I year Old inadequate IR 96004/NOV l Identified by Rif t ilP inspector. The Radwaste barrell storage area was a Oversight !

contaminated, locked high radiation area. Licensee had identified spill '

on survey map about 1 year earlier. Issue was initially documented as URI 50-237;249/95015-10. '

NOV for failure to perform adequate surveys (50-237;249-96004-08B) 2/13/1996 Self-Revealed Engineering U-2 SDC System Pumps Tripped. Apparent cause was spurious high , Equipment RI Observation

- temperature signal from a reactor recirculation loop thermo-couple. Malfunction

, 2/11/1996 Licensee Maintenance Mechanic used a hardened steel tenter punch to remove a gasket from Personnel RI Observation the U-2 reactor vessel flange. Gasket had already been removed. A one Performance inch gouge was put in flange. A licensee QC inspector was present when Deficiency the mechanic used the punch.

1 Page 29 of 38 -

--_ _ - _ _ _ _ _ _ _ _ _ - _ _ . _ _ _ = _ .

PLANT ISSUES MATRIX 2MW7 Dresden DATE ID BY !! SALP O DESCRIPTION CAUSE l REF 2/10/1996 Self-Revealed Operations Auxiliary operator inadvertently started U-3 EDG during routine local Personnel IR 95015; LER 50-control panel lamp check. Operator failed to utilize self-checking in the Performance 249/96001 performance of his duties. Deficiency 2/8/1996 Licensee Maintenance Safety bus fuse configuration OOS problems. Continuing examples of Personnel RI Observmion problems. No details. Performance Deficiency 2/6/1996 NRC Operations Work Authorized When Valve Was Not in Required Position. Personnel IR 95015/NOV Maintenance lod been authorized to begin for a LPCI valve even though Performance the actual valve positiuon did not match the position identified on the Deficiency OOS card on conrol room switch. Example of a Violation for failure to follow We-k Request procedure (50-237;249'95015-02C).

2/5/1996 Self-Revealed Operations Well water system freezing problems due to extreme cold weather. Plant Engineerieg/De RI Obsv.

operations were efTected due to inability to make more water combined sign Deficiency with low CST level.

2/2/1996 Self-Revealed Maintenance Loss of ventilation on U-3 recirculation motor generator (MG) sets w hen Equipment IR 95015 both operating fans tripped. Reactor power was rapidly reduced to about Malfunction 60 percent. Damper linkage contributed to the failure.

2/2/1996 Self-Revealed Operations U-2 EDG Tripped on Engine fligh Temperature due to Slow Response Personnel IR 95015 by Non-licensed Operator. Output breaker not close during test. EDG Performance running unloaded without cooling water. Operator not trip the EDG Deficiency prior to the high temperature trip. This was contrary to management's expectation.

2/2/1996 Self-Revealed Operations Proper Operator Respone to Loss of Ventilation on U-3 Recirculation Teamwork / Skill IR 95015 Motor Generator Sets. Reactor power was rapidly reduced to about 60 Level percent.

2/1/1996 Self-Revealed Engineering Uninteruptible power supply (UPS) battery low temperature due to low Engineering /De RI Observation Rx building ambient temperatures. Temperature control problems with sign Deficiency UPS room are longstanding.

Page 30 of 33

PLANT ISSUES MATRIX 2 par 97 Dresden

r. g , .

-)j

.' DATE ID BY j SALP DESCRIPTION j! CAUSE j REF i . i o . .

2/1/1996 Licensee Operations Non-licensed equipment attendant left the U-2 drywell access door Personnel IR 95015/NOV unlocked. Drywellis a locked high radiation area. Violation for failure . - Performance to lock a high radiation area (50-249/95015-09). Deficiency 1/30/1996 Self-Revealed Maintenance U-2 Groups II & Ill (RWCU & SDC) isolations and SBGT initiation Equipment IR 95015 during testing, not reportable. ABT failed to return power source due to Malfunction failed contact. Occured on 02/3/96 also.

1/30/1996 Self-Revealed . Operations Groups 11 and 111 Isolation and SGTS Initaition During Maintenance. Inadequate IR 95015 Contacts is instrument bus ABT shorted during maintenance. (Occured Oversight on 2/3/96 dso.) Concern was that even though the the potential for the loss of the instrument bus was high and this was idmtified during the pre-job breif, the licensee continued to conduct several other tasks (such as r

CRD timing & vessel cavity draining) in paralle during the ma atenance.

Non-conservatinve decision making.

1/27/1996 Licensee Operations Fuel Bundle Mis-oriented by 90 deg. During D2R14. The fuel was in . Personnel IR 95015/NCV the correct core location but mis-orientated. 'Ihe major concern was that Performance 3 people on the refueling bridge missed the error. Next crew identified Deficiency error. NCV for failure to follow procedures (50-237-249/95015-01).

1/24/1996 NRC Operations OOS " Test Cards" Not Placed on Control Switches of 2F and 2G Personnel IR 95015/NOV Drywell Coolers. Example of a Violatoin for failure to follow OOS Performance procedure (50-237;249/95015-02C) . Deficiency 1/18/1996 NRC Operations Multiple Examples of Problems with 4Kv Breaker Storage Breakers Personnel IR 95015/NOV -

racked out & not restrained, no FME covers, and non-EQ breaker put Performance .

into safety related cubicle. Licensee begins Level ll investigation. Deficiency. -

Example of a Violation for failure to follow procedures (50- i 237;249/95015-02E) 1/18/1996 NRC Maintenance U-2/3 EDG Air Lock Door (Secondary Containment) Found Ajar Equipment IR 95015 Multiple Times. Dwr would not fully shut after each use. Long- Malfunction standing n.aterial condition deficiency.

p Page 31 of 38

. ~ . - _ .- ~ _~ _ __ , _ . . - _ _ . . . _ . . _ _ _m.= _ _ _ _ _ . _ _ .____.____________.__.,___._.______.______m.

PLANT ISSUES MATRIX 2Mav-97 Dresden j

e j

o i

o l DATE ID BY i SALP DESCRIITION y CAUSE REF l I/18/1996 NRC Operations U-2/3 EDG Air-Lock Door (Secondary Containment) Ajar on Multiple Personnel IR 95015 Occasions. Door ajar on multiple occasions. RP personnel stationed at a Performance desk near door were aware that door was open. RP personnel had not Deficiency taken actions to close door. This occured twice within a 30 minute period. These were additonal examples of personnel living with poor .

material conditions.

1/18/1996 NRC Maintenance Several 4kV Breakers Found Unrestrained. Several breakers that had Personnel IR 95015/NOV been removed from cubilces were found unrestrained. Electrical Performance maintenance personel stated that the problem would be corrected. Two Deficiency days later, several of the breakers were found unrestrained again.

Example of a Violation for failure to follow procedures (50-237;249/95015-02E).

1/17/1996 NRC Engineering Unauthorized Modification in U-3 Torus Catwalk Area. Ventilation Inadequate IR 95015/NCV ducting was supported by temporay rigging (cable) which had been in Procedurelinstr place since 9/92. Work request had originally been to repair the uctior permanent supports for the ventilation ducting. The work request was closed in 12/92. Since work request was closed and rigging was not controlled under any plant procedures, this was considiered a modificaton to the plant. NCV for inadequate procedures (50-237;249/95015-04). This example demonstrated a continued weakness in licensee's ability to implemment system walkdowns.

1/16/1996 Licensee Maintenance Early Identification of Overheated U-3 Main Generator Exciter Brushes. Teamwork / Skill IR 95015 Electrical maintenance personnel identified heat related discoloration of Level brushes. The sly identification allowed for the 7 placement of the brushes on-line proir to a significant problem occuring.

1/16/1996 Self-Revealed . Maintenance U-2/3 Diesel Fire Pump Cracked Discharge Flange. This was ids ntified - Equipment - RI Observation during modification testing. Another example on poor material Malfunction condition.

Page32 of 38

PLANT ISSUES MATRIX 20-W-97 Dresden it i DATE ID BY l! SALP ji DESCRIPT!9N li CAUSE , REi' ~

1/16/1996 Self-Revealed Maintenance Loss of Pressure & Flow Indication of 2D CCSW Pump Durag Testing. Other/NA IR 96002/NOV Root cause never identified. This was used as one of the examples for a Violation of 10 CFR Part 50, App. B, Criteria XVI for failure to take adequate corrective actions for foreign material intrusion into the CCSW system. (50-237;249/96002-06B) 1/13/1996 Self-Revealed Operations inadequate OOS Boundary. Maintenance personnel determined that the Inadequate IR 95015/NOV section of the instrument air system piping being removed for repairs Procedure!!nstr was pressurized. Example of a Violation for failure to fo!!ow OOS uction procedure. (50-237;249/95015-02A) 1/13/1996 Self-Revealed Maintenance U-2 EDG Ou*put Breaker Failed to Close During Testing. Cause was inadequate IR 96002/NOV; LER 50-position indication interlock from a cross-tie breaker had failed due to Oversight 237/96001 damaged linkage. The U-2 EDG breaker would not have auto closed.

'llie licensee's continued failure to identify the root causes for 4kV breaker problems over several years (1989 to present) was an example of a Violation of 10 CFR Part 50, App. B, Criteria XVI. 50-237:249/96002-06A.

1/8/1996 Self-Revealed Maintenance Loose Relay Ccver Panel Falls OfTCausing a U-3 Italf Scram. Relay Personnel IR 95015 cover holddown clip broken, cover fell shorting contacts and caused a Performance half scram. Licensee found a second loose cover. Cause was poor Deficiency maintenance practice for restoring equipment.

1/7/1996 Self-Revealed Engineering Feeder breaker (27-4) to non-safety related MCC for spent fuel pool Engineering /De R1 Observation cooling demineralizers tripped due to bus overloading. sign Deficiency 1:7/1996 Self-Revealed Maintenance U-3 A feedwater regulator valve body to bonet steam leak. As of 2/27/96 Equipment / in IR 96008 RI Obsv. FiU multiple injections of sealant used to repair leak. On 4/27/96, the 3 A Malfunction FRV inlet isolation valve was shut to reduce leakage.

1/5/1996 Self-Revealed Mainenance 3A Service Water pump motor failed, cause age-related and lack of Equipment RI Obsv.

C:aning. Malfunction 12/27/1995 NRC Maintenance U-3 SBGT supply line to Rx building ventilation flan;;e (behind 3A MG Personnel R I Observation set) was missing 4 bolts. Performance Deficiency Page33 of 38

. . _ _. _- . - - . - - . - . - - . ~ . - - .. -

PLANT ISSUES MATRIX N'"M7 '

Dresden ,

DATE ID BY SALP l DESCRIPTION REF j f h. _ _ , __ _

h n CAUSE . f f. ;

12/26/1995 . Self-Revealed Maintenance U-2 Recirculation Pump Discharge Isolation MOVs (5A & B) Found . Equipment RI Obsv. l Overheated Nootherdetails. . Malfunction ,

12/22/1995 Licensee Maintenance U-2/3 diesel fire pump stuffing box not installed. Shortly thereafter Personnel RI Obsv..

wrong oil used in gearbox. Performance Deficiency NRC Personnel RI Observation ;

12/21/1995 Maintenance U-l SFP Poor liousekeeping. Electrical extension cord & tools approx.

I foot from edge of pool. . Performance [

Deficiency f 12.18/1995 Chairman Jackson, Hub Miller, and others visit Dresden station for plant tour and to discuss licensee performance. i r

12/17/1995 ~ Self-Revealed Engineering Unusual E ent declared due to hydrogen leak into Radwaste building. Fquipment IR 95014 !

112 from tank farm to U-2 main generator. Malfunction 12/15/1995 Self-Revealed Maintenance U-2 torus strainer plugging identified as part of post outage torus Eq@-.r.t RI Obsv. j cleaning process aller LPCI run. Malfunction i 12/15/1995 Licensee Maintenance Undersized bolts on both U-2 Core Spray recire. flow line flanges. Personnel RI Obsv.

Perfonnance Deficiency 12/14/1995 NRC Maintenance U-2 (2A & 28) SDC pump flanges missing bolts. Numerous other Equipment IR 95014 !

deficiencies identified on RWCU, SDC, & SFP systems. Malfunction i 12/14/1995 NRC Operations U-2 protected pathway incorrectly posted as 2A SDC vice correct 2B Personnel IR 95104

SDC. Performance .[

Deficiency 12/14/1995 NRC Maintenance U-2 FPC room - unauthorized temp. alt. (pipe supports). Personnel IR 95014 l Performance . t Deficiency 12/14/1995 NRC Maintenance Emergency lighting surveillance not done. Personnel IR 95104 Performance j Deficiency ;

Page 34 of 38

PLANT ISSUES MATRIX 20-Arag7 Dresden DATE ID BY SALP DESCRIPTION CAUSE REF l h ff f 12/11/1995 Self-Revealed Maintenance U-3 RWCU pressure control valve failed open when shifting control to Equipment IR 95014 manual. RWCU relief valve opened. 5 in. Rx vessel level decrease. Malfunction RWCU sys. auto isolated.

12/11/1995 Self-Revealed Plant Support 5 fire hydrants found frozen. Equipment RI Obsv.

Malfunction 11/29/1995 Self-Revealed Mais..ance Both U-3 SFP pumps tripped. Root cause was high pressure in demin- Equipment IR 95014\URI filter. Cause of high pressure was valve leakage from U-2 SFP cooling Malfunction system.

I1/27/1995 Licensee Maintenance Licensee identified MCC 38-3 breaker trip setting not properly set. Personnel IR 95014 Performance Deficiency 1I/27/1995 Self-Revealed Maintenance Both U-2 SFP pumps tripped. Root cause not determined. Poor initial Equipment IR 95014 investigation. Malfunction i1/17/1995 Licensee Engineering CRD Scram Discharge Volume gallery platforms did not meet UFSAR Engineering /De IR 95015 LER 95002 allowable stresses. sign Deficiency 1!/17/1995 Licensee Engineering CRD Scram Discharge Volume gallery platforms did not meet UFSAR Engineering /De . IR 95015\LER 95022 allowable stresses. sign Deficiency 11/12/1975 Sci-Revealed Maintenance While attempting to use the B train of OfTgas for the first time in 8 years, Inadequate IR 95014 112 fire ignited do to accumulation of resin fines upstream of recombiner. Oversight 11/10/1995 *"****"" """""* *"*"""* "*"***"*

U-2 refueling outage activities stopped by station management to refocus the outage management effort.

I1/9/1995 NRC Maintenance Pipe hangers for two 18 in. offgas lines in U-2 low pressure heater bay Personnel RI Obsv.

not made up. Performance

- Deficiency 1i/6/1995 "*"""" """"*" U-3 startup. unuun. ..uun...

I1/2/1995 Licensee Operations Diver authorized in U-2 cire water pit with no OOS tags hung. No entry Personnel RI Obsv.

made. Performance Deficiency Page 35 oj~ 38

PLANT ISSUES MATRIX - 2 M aP97

' ~

Dresden

. ,7 i ! DATE 'ID BY SALP 1 DESCRIPTION j ). CAUSE J REF

l. !l I

i1/1/1995 Licensee . Maintenance Wrong size impeller installed on 2A LPCI pump. Personnel RI Obsv.

Performance Deficiency 10/31/1995 Licensee Engineering Motor Control Center (MCC) feed breaker found with incorrect current Personnel . IR 95012\lR 95014\LER -

trip setpoint. Perfonnance 95020 URI & NCV ENS Deficiency call 10/29/1995 Self-Revealed Maintenance U-3 manual trip due to loss of circulating water (CW) system due to fish Equipment IR 9501LER 95019 clogging intake screens for one CW pump and one traveling screen Malfunction failure. At the time another CW pump was out of service and the plant was relying on the remaining two.

10/24/1995 NRC Maintenance liigh vibrations ca CRD system. Equipment . IR 95012 Malfunction 10/20!!995 Licensee Engineering U-2 scram discharge instrument volume found susceptible to single Engineering /De IR 95012\LER failure. Appeared to be the result of error made in modification change sign Deficiency 95019\NCV URI ENS call in mid 1980's. U-3 not afTected.

10/13/1995 Licensee Maintenance Non-like-for-like washer installed in 4kV breaker n61 documented in Personnel IR 95012 work package. Performance Deficiency 10/12/1995 Self-Resealed Maintenance U-3 IIPCI inoperable due to exhaust pot high level alarm. Caused by inadequate IR 95012iLER 95018 procedure not requiring draining of drain pot prior to slow start testing. Procedure / Instr uction 10/10!!995 Licensee Maintenance Poor communication resulted in CCSW suction bay level float being Personnel IR 95012 i

removed. - Performance Deficiency 10/10!!995 Licensee . Maintenance inadequate PMT on CRD D-5 resulted in non-cited violation. Neutral Personnel . IR 95012\NCV leads were swapped and not identified until next surveillance test. - Performance Deficiency

10/7/1995 Self-Revealed Maintenance Failure to perfbnn post-maintenance test (motor rotation check) on Personnel IR 95012\NOV shutdown coo'my MOV resulted in valve operator damage. Performance Deficiency Page 36 of 38

t

?

PLANT ISSUES MATRIX N'"P'7 Dresden n !

l DATE b; ' ID BY SALP DESCRIPTION b CAUSE pa REF j

. i. __ n 10/7/1995 ****"*"** *""""** """*"** *"*"*""

U-3 plant startup.

10/1/1995 Self-Revealed Maintenance U-3 generator exciter breaker secondary contacts damaged during Personnel 1R 95012 breaker installation. Cause was failure to follow maintenance procedures. Performance Deficiency 9/30!!995 * * * " " " " """"*" """""* """"***

Steve Perry, Comed VP-BWR, assumed duties 0 as Dresden Site VP.

Tom Joyce started a 6 month rotation with INPO.

9'28/1995 Self-Revealed Maintenance U-3 PLANT TRIP. Trip was due to loss of generator excitation. The Equipment IR 95010\LER 95017\ ENS .

cause was a failed resister in excitation circuit. Malfunction call 9/20/1995 Licensee Maintenance Wrong valve croked by VOTES test personnel at local control station. Personnel RI Obsv.

Failure to verify through self-check proper valve label prior to operation. Performance Deficiency 9/16/1995 **"*""" "*"""" """*"" ""*"""

U-3 STARTUP.

9/15/1995 Licensee Maintenance A sys. eng. opened a breaker for a U-2 transformer and protective Personnel RI Obsv.

relaying circuit without operations knowledge or approval. Performance Deficiency 9/12/1995 Self-Revealed Maintenance UNIT 3 SilUTDOWN. Operations initiated U-3 shutdown due to llPCI Equipment IR 95010 drain problems. Malfunction 9/11/1995 Self-Revealed Maintenance U-3 IIPCI inoperable. Exhaust drain pot failed to properly drain from Equipment IR 95010iLER 95016 previous surveillance. Cause identified as relayiswitch failure. Malfunction 9/9/1995 Self-Revealed Maintenance increasing temperature trend on 3D ERV tailpipe. Equipment IR 95010 Malfunction 9/7/1995 Self-Revealed Maintenance U-3 startup. 3A RWCU pump degraded -low pressure flow. Equipment IR 95010 Malfunction 9/5/1995 Self-Revealed Operations Group V isolation received while restoring a U-3 Isolation Condenser to Personnel IR 95010\LER 95015\NCV standby due to inadequately filling condenser. Performance Deficiency P.rge 37 of 38

PLANTISSUES MATRIX 2WaP97 Dresden If f DATE [ ^ ID BY SALP DESCRIPTION H n

CAUSE REF j-8/1/1995 Licensee Plant Support Shipped contaminated material (RWCU piping) offsite above DOT . Personnel IR 9501l\lR 95010 I

limits. Contaminated circuit breaker shipped offsite to non-licensed Performance facility. Deficiency i 5/28/1995 Self-Revealed Maintenance Inboard and outboard MSL drain primary containment isolation valves: Personnel 50-249/96013-01 VIO

- Failure to maintain primary containment leakage less than or equal 0.6 Performance

! La from at least January 1995 to May 28,1995, with the U-3 reactor Deficiency critical,is an Apparent Violation. The cause for the inboard valve leakage was low spots on the valve's seat du : to poor alignment (i.e., fit

, up) of the disk to seat. He root cause appeared to be poor maintenance 3 instructions for valve assembly and lack oflicensee experience with Anchor Darling double disk gate valves. The cause for the outboard i valve leak :ge was the valve disk's lower wedge was missing and the I

stem was 1 :nt. He licensee determined that the failure mechanism of

the outboard valve was excessive thrust applied during manual handwheel operation during Unit 3 refueling outage 13. The root cause

, was attributed to an inadequate design modification review in June 1994 that failed to identify that low torque values (about 33 fl-lbs) would l damage the valve during normal handwheel operation. A contributing j cause was informal controls for manual handuheel operation of motor operated valves.

u i

l Page 38 of 38 s.---------.:-----

m PLANT ISSUES MATRIX 204ry-97 i

Ouad Cities t

L ID BY

!' DATE SALP DESCRIPTION f CAUSE REF

3/29/1997 Unit I turbine generator retumed to service aner repair to several valves **"*"""

IR 97006 (draft) in the feedwater and EIO _ tem.

3/21/1997 ***"**"" """"*"

Unit I turbine geaerator taken ofiline to repair moisture seperator drain "***"""

IR 97002 (draft) tank level control valves. After the turbine was tripped, high flow in the turbine's EllC system resulted in a decision to shut down the reactor on March 22. ,

3/17/1997 NRC Operations improvements were noted to provide more stringent control room access, involved IR 97002 (draft) reduce incoming phone calls, and reduce the general noise level. Management 3/17/1997 NRC Maintenance De inspectors identifeid problems with implementation of the Personnel . IR 97002 (draft) maint'. nance rule. Specifically, the identification of MPFF events and Perfonnance the failure to promptly evaluate the Unit 2 CAM system status as (a)(1) Deficiency l under the .ule. Long standing issues regarding repetative regulator failures and water intrusion in the CAM had not been resolved. .

3/17/1997 """**"* **"*"""

Unit I tur. ine returned to service after replacement of the failed 108D **"""*** -

IR 97002 (draft) relay.

1 3/17/1997 NRC Plant Support Plant water chemistry was good, but problems with hydrogen gas supply, Equipment IR 97002 (drafl) condenser leaks, and reactor water cleanup system problems caused Malfunction chemistry transients.

3/17/1997 Other Plant Support i

A second event within 12 months of contaminated material generated inadequate IR 97002 (draft) onsite and found offsite was discovered by a scrap metal processing Oversight -

plant radiation detector.

3/17/1997 NRC Maintenance IC and iD RIIRSW pump overhaul activities were performed well. Teamwork / Skill IR 97002 (draft) ;

Level 3/17/1997 NRC Maintenance ne 2A control rod drive pump was rebuilt twice in 1996 and is still out Personnel IR 97002 i of service for high vibration and seal leakage. Performance Deficiency 3/17/1997 NRC Maintenance Numerous rotating equipment problems exist including including the 1 A Equipment IR 97002 rea dor feed pump which has been out of service for over 3 months, the l Malfunction IB reat tor feed pump which has a seal leak afterjust being overhauled, Information in this record was deleted :

the ! A ret -tor water cleanup pump and the 2A CRD pump-in accordance with the Freedom of information !

O Page 1 of 30 Act,"exem tions #

=

Ffil A-

/'I/ N

FLANT ISSUES MATRIX 2""P

Ouad Cities f DATE ID BY SALP 3 f{ l DESCRIPTION CAUSE REF 3/l!/1997 **"*""* " * " " * * "

Unit I was conservatively shut down after the 108D [ scram] relay failed ***""""

IR 97002 (draft) during testing.

3/7/1997 NRC Operations Operators failed to comply with TS action statement after the 108D RPS Personnel IR 97002(draft) VIO relay failed. TS required channel be placed in trip condition withir, I Peiformance hour; however, operators reset the trip for t-shooting I and 1/2 hot rs Deficiency after initial failure.

1 3/7/1997 NRC Operations The inspectors identified that additional exhaust fans were not started in Personnel IR 97002 (draft) VIO .

response to positive turbine building pressure as required by annunciator '

Performance procedures. F nce the fans were out of service, operators opened the Deficiency turbine building roll up door instead. '

2/28/1997 ***"****** ' *"'*******

Unit 2 was shut down about 8 hrs earlier than planned for a refueling ""*""" $

IR 97002 (draft) outage. The TS required shutdown was entered into after 4 of 5 ADS valves failed the required stroke times in the closed directions. Failed closure times were slightly above acceptable. The shutdown was in j

accordance with procedures and well executed.

2/28/1997 Self-Revealed Operations A Unit Two shutdown was required due to four of five power operated Equipment IR 97002 (draft) relicf valves failing to meet inservice testing closing time requirements Malfunction specified by plant procedures.

i 2/27/1997 Self-Revealed All/ Multiple An inadvenent ilPCI initiation occurred on Unit 2 during the inadequate IR 97002 (draft) performance of an IM surveillance. The surveillance was not intended to Procedure / Instr ,

be performed during power operations. Operator response to the uction unexpected IIPCI initiation was good.

2/27/1997 Self-Revealed Maintenance Unit Two llPCI inadvertently started, with possibility ofinjection, due to Inadequate IR 97002 (draft) a problem with automatic depressurization system surveillance tesiing. Procedure / Instr i uciton 2/14/1997 NRC Plant Support A routine security inspection identified two cited violations and two non- Personnel IR 97004 (draft); NOVs cited violadons. The cited violations included an inadequate vehicle - Performance search and and inadequate security barrier. The NCVs involved fitness Deficiency for duty procedures and an inattentive security officer. '

Page2 of 30 n . - a

PLANT ISSUES MATRIX 20 4 -97 Ouad Cities DATE ll ID BY ![ SALP ! DESCRIPTION !! CAUSE I REF I, n .. I 1t 2/5/1997 NRC Plant Support Several examples of a failure to followradiological procedures for Personnel IR 97003 (dratl) posting / control of contmiinated areas and radioactive material. Performance Deficiency 2/5/1997 NRC Plant Support Overall management oversight of the area radiation and continuous air inadequate IR 97003 (draft) monitors was weak. Oversight 1/27/1997 NRC Maintenance The inspectors observed some operator knowledge and procedural Inadequate IR 96020 weaknesses during the performance of the CREVS monthly surveillance Oversight test. The operations department did not promptly update the procedure and train operators on the current system status.

1/27/1997 NRC Engineering WEAKNESS: Problems identified with the licensee's operability inadequate IR 96020/El.l; IFl evaluation for the shared EDG start failure (evaluation did not arrive at Oversight 254/265-96020-04 root cause resolution or provide efTective followup action) and with methodology for determining EDG reliability data (poor component trending). An inspector followup item initiated to review licensee's root cause assessment, corrective actions and resolution of reliability testing.

1/27/1997 Licensee Operations IR 96020; NOV Some decline in control room operator performance was acted during Personnel the inspection period. Operators mispositioned a control rod during Performance control rod exercising and misaligned one train of the standby gas Deficiency treatment system.

1/27/1997 Self-Revealed Maintenance The shared emergency diesel generator experienced a failure to stop and Equipment IR 96020 a failure to start. The stop failure was attributed to a failed govemor Malfunction solenoid and the failure to start was an air start motor problem. Both failed components were repeat problems with the EDG system.

1/27/1997 NRC Plant Support The inspectors identified that the flow switch and pressure indicator for inadequate IR 96020 the service water effluent radiation monitor did not have a required Procedure / Instr ,

calibration frequency. uction 1/27/1997 Licensee Engineering ENS Call (31671): SEVERAL PIPING SECTIONS FOUND OUTSIDE Engineering /De UFSAR DESIGN ALLOWABLES per GL 96-06. sign Deficiency Page 3 of 30

i PLANT ISSUES MATRIX 2 p ay s t

Ouad Cities i

, . i DATE ID BY SALP DESCRIPTION REF f' f { { CAUSE l :

1 1/27/1997 NRC All/ Multiple Management oversight was not always adequate to ensure consistent Inadequate IR %020

- quality operability evaluations were being performed and validated for Oversight 'I key systems.

1/27/1997 NRC Maintenance The licensee failed to ensure that control room ventilatior, was inadequate IR 96020 ,

adequately testing using RilRSW. Procedure!!nstr uction i 12/23/1996 Licensee Engineering ENS Call (31503): ECCS SUCTION STRAINER NOT BUILT Engineering /De - IR 56020/E2.2; LER INACCORDANCE WITil DESIGN. UFSAR assumed the maximum sign Deficiency 96025;IFl 254/265-96020- i headloss across the ECCS suction strainer as 1-foot d'p at rated flow 06 (10,000 gpm). The installed strainer's analytical model used 5.8-foot d/p at rated flow. The 50.59 cvaluation used 5.5 and 3.4 psig containment !

over-pressure for short and long term calculations, respectively. System I declared operable, but degraded with no USQ. An amendment change was planned. An inspector followup item initiated to review the limits on over-pressure since specific values were not included in the UFSAR.

12/13/1996 NRC Maintenance Inadequate System Logic Functional Test for Control Room Ventilation inadequate IR 96020; NOV

, Isolation System. Based on resident inspector's questions, licensee Procedure / Instr reviewed logic tesi and determited that existing surveillance had not uction

adequately tested complete logic circuit. Licensee revised test and !

successfully completed surveillance. RIII DRS initial investigation !

determined that revised test appeared adequate. Additional references !

ENS 31452, LER 96-024 12/6/1996 N'IC Engineering VIO SL IV (Criterion XI " Test Control"): Failed to incorporate TS Inadequate IR 96017/E3.1 i requirements into applicable surveillance procedurn fer Control Room Procedure / Instr !

Emergency Filtration System Charcoal Adsorber, uction !

12/6/1996 NRC All/ Multiple Repeat problems with feedwater heater level control s alves and gland IR 96017 Equipment steam condenser level control _ valves necessitated increased operator Malfunction [

intervention, caused increased personnel radiation exposure, redirected 4 previously scheduled maintenance activities, and impacted unit operation.

12/6/1996 NRC Operations The U-l cirev.'ating water travelling screens maintenance was not well

[

Inadequate IR 96017 !

coordinated from a risk perspective. Oversignt Page 4 of 30 w

PLANT ISSUES MATRIX 2may-97 Ouad Cities

___._l DATE ID BY SALP DESCRIPTION CAUSE I -

REF l L '

12/6/1906 Licensee Maintenance During overhaul and modification of the 2D RHRSW pump, the licensee Inadequate IR 96017 identified and corrected a significant number of problems including Oversight deficiencies in vendor supplied parts. Mechanics initially installed the pump seal housing improperly. Final test results indicated that the overhaul effort was successful.

12/6/1996 NRC Operations Operations exhibited good control of switchyard work Involved IR 96017 Management 12/6/1996 NRC Operations Operations scheduling failed to ensure cold weather preparations were Inadequate IR 96014 completed before the onset of cold weather. Oversight 12/6/1996 NRC Operations Operations failed to ensure a surveillance test for HPCI operability was Inadequate IR 96014 performed in a timely manner. Oversight 12/2/1996 Self-Revealed Maintenance U-2 redused power to less than 15 percent due to problems with RWCU Equipment IR 96017 system isolation valve packing leak. Malfunction 11/26/1996 Self-Revealed Maintenance Shared staadby diesel generator inoperable to Unit 2 due to a relay Equipment IR 96017 problem. Malfunction i1/26/1996 NRC Engineering EA 96-530; Criterion III " Design Control" and 50.59): Two Inadequate IR 96019/El.l.b.iii & iv apparent violations regarding the safety-related function of the reactor Oversight f*WS*' #

building siding.

I1/24/1996 NRC Maintenance Design Control NOV for improper bolts used in two RHRSW pumps. Engineering /De IR 96017; NOV sign Deficiency 11/24/1996 Licensee Maintenance The control room emergency filtration system was declared inoperable Inadequate ENS Call 31377; LER because CREFs airflow was below the required minimum. Followup Procedure / Instr 96023 action included adjusted CREFs airflow and calibrating the permanent uction plant instrument loop. Previously the flow indication was not calibrated against an actual air flow measurement.

I1/12/1996 Self-Revealed Operations LPCI declared inoperable after pump discharge check valve failed to Equipment IR 96017 rescat, resulting in loss ofline fill pressure. Discharge piping Malfunction repressurized approx.1/2 hour later and LPCI was declared operable.

Additional references ENS 31320; LER 26596003 Page 5 of 30

PLANT ISSUES MATRIX 2""P

Ouad Cities DATE ID BY SALP DESCRIPTION CAUSE REF 10/28/1996 Licensee Engineering EA 96-53 I; TS, Criteria XI " Test Control" and 50.59) Inadequate IR 96017/E2.1; LER 96022 ENS Call (31227): INOPERABLE CONTROL ROOM EMERGENCY Oversight E2eranon f VENTILATION SYSTEM. Three apparent violations conceming the CREVS; 1) TS LCO exceeded,2) Post-modification and surveillance tests failed to ensure system met UFSAR requirements and 3) Inadequate safety review concerning a change to the UFSAR for control room HVAC calculations.

10/27/1996 Self-Revealed Maintenance U-2 main turbine taken off-line due to problems with moisture separator Equipment IR 96017 drain tank level control valves. Foreign material found on valves caused Malfunction two valves to : tack open.

10/26/1996 NRC Maintenance Inspectors found unqualified workers supervised by vendor IR 96014;VIO Personnel representatives during reparis on the shared emergency diesel generator. Performance Deficiency 10/26/1996 NRC Maintenance Mechanical maintenance workers failed to follow procedures while Personnel IR 96014; VIO workin:3 on an emergency diesel generator air start motors. Rework was Performance required, an the supervisor was not informed. Deficiency 10/26/1996 NRC Maintenance The licensee showed some progress in the implementation of the work Teamwork /S. e. IR 96014 control process, as evidenced by some corrective maintenance backlog Level reduction and improed schedule adherence.

10/20/1996 NRC Maintenance Maintenance work on the 1C RHRSW pump and shared standby diesel Teamwork / Skill IR 96014 generator were well coordinated and executed according to schedule. Level 10/26/1996 NRC Maintenance he inspectors found poor supervisory oversight for work on the shared Inadequate IR 96014 emergency diesel generator. Oversight 10/26/1996 Licensee Maintenance Quad Cities put a hold on all parts received from the Comed Central Other/NA IR 96014 Receipt inspection and Test (CRIT) facility based on a number of problems with parts received.

10/26/1996 ""***"** ""*"""

SALP 13 ENDS (7/23/95 - 10/26/96) *""""" *"""""

Page 6of 30

I PLANT ISSUES MATRIX 20-W'-97 Ouad Cities

! DATE h ID BY l SALP DESCRIPTION h CAUSE j REF f 10'26/1996 Licensee Maintenance The licensee installed incorrect bolt material in the IC and 2C RilRSW Inadequate IR 96017; NOV pumps due to inadequate control of vendor processes. Other examples Oversight involving inadequate control of vendor processes and materials were identified. Violation of 10 CFR Part 50, App. B, Criteria 111, for use of incorrect bolt material.

10/23/1996 Licensee Operations The inspectors concluded that panel monitoring by control room Teamwork / Skill IR 96014 operators wac good in detecting the U-2 number 1 combine intermediate Level valve (CIV) not fully open, but monitoring could have been better in detecting generator swings produced during troubleshooting activities.

Operations' response to the CIV drifting closed was conservative.

10/11/1996 NRC Operations An NRC initial license examination was administered to eight Personnel IR 96302 individuals; three who had applied for Reactor Operator licenses and Performance lhe who had applied for Senior Reactor Operator Licenses. One Reactor Deficiency Operator applicant failed the written portion of his examination and was denied an operating license. All other applicants passed all portions of tneir examinations and were issued Reactor Operator or Senior Reactor Operator licenses.

10/11/1996 NRC Engineering STRENGTII: GOOD QUESTIONING ATTITUDE BY SYSTEM Other/NA IR 96014/El.l; LER 96021 ENGINEER led to the identification and subsequent repair of a design deficiency in the safety-related portion of the control room IIVAC system. Original design deficiency led to system inoperability.

10/11/1996 Licensee Engineering IR 96014/El.1; LER ENS Call (31142): INOPERABLE CONTROL ROOM (CR) IIVAC Engineering /De SYSTEM (Train B). The CR llVAC system is safety-reiated; however, sign Deficiency 96021; URI 254/265-the refrigeration condensing unit's (RCU) crankcase heater was powered 96014-04 from a nonsafety-related MCC 16-3. In this condition, it was not assured that the RCU would be able to perform its design function under all conditions. The crankcase heater was replaced with a safety-related heater, the power supply was rewired to safety-rehted MCC I 8-4, and the CR IIVAC system returned to operable status on 10/27/96. An unresolved item was initiated to followup CR flVAC system design discrepancies.

Page 7 of 30

. _ _ _ _ _ _ . _ _ _ _ _ _ _ _ . _ _ _ _ . _ - - - - - _ - _ _ - . _ _ - . _ ._ m

20 mar 97 PLANT ISSUES MATRIX Ouad Cities o m - .. .. 4 DATE S ID BY h SALP h DESCRIPTION CAUSE lj REF l

u >! il l 10/10/1996 NRC Plant Support A new EP Coordinator was hired and was providing good support to the involved IR 96011 program. Emergency Response Organization personnel appeared hianagement knowledgeable about their responsibilities, procedures, and emergency actions.

10/10/1996 NRC Plant Support The licensee successfully performed the 1996 biennial exercise, with Teamwork / Skill IR 9601I only minor problems related to (1) classification of the Unusual Event, Level (2) slow initial NRC notifications, and (3) simulator fidelity and exercise controller problems.

10/10!!996 NRC hiaintenance One of the primary causes for 4kV breaker failure was hardened grease Other/NA IR 96011;IR 96008 in the trip latch roller bearing. At Quad, the licensee had incorporated applicable vendor information into the maintenance procedure and were addressing 4kV breaker concerns in an acceptable manner.

10/10/1996 NRC Plant Support STRENGTil: Radiological environmental monitoring program (REh1P) Other/NA IR 9601I was good.

10/10/1996 NRC Plant Support Post outage task force identified several weaknesses in the work control Inadequate IR 96011 and planning processes, which were similar to past NRC observations. Oversight Specifically, previous station and industry experience was not effectively used to identify emergent work, and some known work was not appropriately identified. (Also see irs 96004 & 96006) 10/10/1996 NRC Plant Support A licensee radworker performance task force attributed the majority of Other/NA IR 96011 the events to poor rad vorker skills, a complicated work process, and inefTective past root cause evaluations. Long term corrective actions were being developed, but short term actions (increased training, tailgate sessions, etc.) have resulted in an improving trend.

10/9/1996 Licensee hiaintenance ENS CALL: UNIT 2 IIPCI DECLARED INOPERABLE. The licensee Equipment ENS Call 31122; IR could not determine if the system was filled and vented. Per TS 3.5.a 3, Nialfunction 96014; LER 265-96002 Unit 2 entered a 14 day LCO. A thorough root cause by engineering staff helped to resolve problems associated with improper venting of the system.

, , Page 8 of 30

PLANT ISSUES MATRIX 20 w 97 Ouad Cities

;; i. P DATE H ID BY jj SALP p!

! DESCRIPTION h CAUSE ij REF i

'i -.

u h it i 9/30!!996 NRC Plant Support The i A fire pump LCO took several days longer than planned due to inadequate RI Observation poor review and oversight. The IB pump LCO was planned poorly and Oversight never needed to be taken out of service for the work, performed. Fire protection LCOs are " administrative" and treated less aggressively than TS LCOs. (9/96) 9/27/1996 NRC Plant Support The NRC identified that the licensee failed to adequately implement all Personnel IR 96013; NOV vehicle access control requirements. Performance Deficiency 9/27/1996 NRC Plant Support Some material dcliveries into protected area were not adequately Personnel IR 96013; NOV controlled while unattended. This resulted in a NOV. Performance Deficiency 9/27/1996 NRC Plant Support EfTective management support activities was evident in equipment involved IR 96013 upgrades @and geometry, new security computer), maintaining Management sufficient resources (experienced and professional personnel), and continuing tactical training and drill activities.

9/23/1996 NRC Operctions Leaving the Safe Shutdown Makeup Pump in service during a Unit I Conservative IR 96012 startup in September 1996. Removal would have increased risk factor Decision for both Units.

9/23/1996 NRC Operations inspectors identify lack of sensitivity to potential seismic concerns. Personnel IR 96012 NCV NCV issued. Performance Deficiency 9/23/1996 Licensee Operations Unit I operators were noted to have knowledge deficiencies re RCIC Personnel IR 96012 condenser drain valve operation during Unit I startup. Performance Deficiency 9/23/1996 NRC Maintenance Inspectors note that several equipment problems uhich affected startup Personnel IR 96012 would have been identified earlier if more thorough post maintenance Performance testing had been performed. Deficiency 9/23/1996 Licensee Engineering A FW isolation valve experienced spring pack hydraulic lock. The Engineering /De IR 96012 inspectors and the licensee independently identify other important to sign Deficiency safety valves with similar spring pack features.

, , Page 9 of 30

PLANT ISSUES MATRIX 2 mar 97 Ouad Cities

! DATE -

ID HY SALP DESCRIPTION CAUSE REF f' l h 903/1996 Licensee Engineering A pressure switch associated with an SRV failed due to heat buildup. Inadequate IR 96012 -

Switch lagged because vendor manual warning was not communicated to Procedure / Instr laggers. uction 9/23/1996 NRC Maintenance During the feedwater regulating isolation valve spring pack repair work Teamwork / Skill IR 96012 -

in September 1996, the valve engineer was knowledgeable and provided Level assistance and oversight for the troubleshooting ard repair work.

9/23/1996 NRC Engineering Inspectors identify that the licensee LLRT program does not include Personnel IR 96012 NCV temperature compensation as required by applicable code to which the Performance licensee is committed. Deficiency 9/14/1996 Self-Revealed Plant Support Actions t .ker. y radiological protection in response to the spill were Teamwork / Skill IR 96012; URI good. The licensee had not yet determined how the spill occurred. His Level is an URI pending review of the licensee's corrective actions and root cause evaluation.

9/10/1996 Self-Revealed Maintenance Foreign material plugged a moisture separator drain level control valve. Personnel IR 96012 Unit I turbine taken offline to clean out the valve. Performance Deficiency 9/9/1996 Licensee Maintenance Workers failed to implement procedural controls and excavated 13.8 kV Personnel IR 96012 line. Performance Deficiency 9/8/1996 Self-Revealed Maintenance IC RilRSWP experienced 2 gpm seal leakage. ID RilRSWP decaired Personnel IR 96012 NOV inoperable due to hot bearing. VIO issued for RilRSWP worked without Performance quantitative acceptance criteria for seal dimensions. Deficiency 9n/1996 Self-Revealed Operations ENS call. Booster fans for the 'B' train of control room ventilation failed Other/NA IR 96012; URI to start. LER 96020 90/1996 Self-Revealed Maintenance Newly Installed U-2 FWRV controller experienced instability /siow Personnel OPEN response at low power. Vender modified software. Repeat of problem Performance with U-l modification. Deficiency 9/6/1996 Self-Revealed Operations liigh dose rate alarms were received on refueling floor. Crane operator Personnel OPEN snagged an LPRM in fuel pool due to inattention ta detail. LPRM was - Performance drawn near fuel pool surface by crane hook. Deficiency

, , Page 10 of 30

._- --_ - _ =

PLANT ISSUES MATRIX 2""P'7 ,

Ouad Cities !

i DATE ID BY SALP DESCRIPTION CAUSE REF f f _ f l 9/6/1996 Self-Revealed Operations Refuelir 4! 90or crane operator " snagged" an LPRM in the fuel pool due Personnel RI Observation ,

to inattention to detail. The LPRM was brought near the pool surface by Performance l the crane hook. Iligh dose rate alarms received on refueling floor. Deficiency 9/6/1996 ""*""" *"***"*** ........... ***********

Unit I =>3chronized to the grid following Q1Rl4 and extended i maintenance period.

9/4/1996 Licensee Maintenance Main Ster.m L.'ne Radiation Monitor functional test not performed within inadequate LER 96019 >

frequency established for Technicai :cification when in refueling Oversight i mode due to incomplete documentatic ; of a Technical specification ;

Interpretation 9/4/1996 Licensee Operations ENS call. Licensee entered and exited an NUE based on determination inadequate IR 96012 ' :

that a TS action statement for RPS surveillances hw not been met. Procedure / instr Licensee subsequently determined that action statement did not apply. uction !

Licensee mis-applied GL 87-09 upon initial identification of apparently missed surveillances. LER 50-254/96018 '

9/2/1996 Self-Revealed Maintenance New MSIV solenoids operate erratically. ASCO representative identifies Equipment iR 96012; NOV mismatching of plunger assembly. Mode change required for valve Malfunction repair. Part 217 VIO issued for lack ofquantitative acceptance criteria j for MSIV solenoid stem travel.

S/27/1996 Self-Revealed Maintenance Unit I remained at about 140 psig (TS grey area) for several days due to Personnel IR 96012 ,

inability to successfully complete RCIC and flPCI overspeed trip tests. Performance Several minor problems with turning gear auto-disengage and barometric Deficiency condensers complicated evolution. ,

8/27/1996 Self-Revealed Engineering Exhaust from swing EDG caused ventilation for SBO DG battery and Engineering /De RI Observation ;

day tank rooms to secure. NRC observed that control room operators sign Deficiency responded in a passive manner. Issue turned over to DRS for followup.

I t

t i

. . Page 1I of 30 .

PLANT ISSUES MATRIX 2 map 97 Ouad Cities

,, ,, r DATE ; ID BY j SALP DESCRIPTION CAUSE ll REF j fl ll 8/26/1996 Licensee Maintenance Licensee revised acceptance criteria for RCIC overspeed test. The test Inadequate IR 96012 required numerous attempts before meeting the success criteria. Factors Oversight contributing to the difficulty of passing the established criteria included use of a hand-held tachometer, first time evolution of overhauling the turbine since commercial operation of Unit 1, change in practices of using contract or vendor personnel, and the vendor manual instructions were not clear.

8/25/1996 Licensee Engineering Operators trip U-l during startup due to rise in indicated water level. Personnel IR 96012 Transient caused by BPVs coming open because of nonlinear calibration Performance of EllC at low pressure. LER Deficiency 8/25/1996 Self-Revealed Operations Unit 2 alternate 125 VDC battery drained due to operators leaving failed Personnel IR 96012 trickle charger attached. Performance Deficiency 8/23/1996 Licensee Engineering ENS call. Licensee retroactively declares secondary containment Engineering /De IR 96012; URI inoperable due to broken boits on blow-out panels. Engineering slow to sign Deficiency report problem. LER 96016 8/23/1996 Licensee Engineering Licensee's initial screening of degraded secondary containment blow-out Personnel IR 96012; URI panel bolts failed to identify all applicable UFSAR accident analysis Performance requirements. Deficiency 8/22/1996 NRC Plant Support The overall quality of the station and corporate self assessments, audits Involved IR 96008 and surveillance of the Emergency Preparedness program were excellent Management in scope and depth.

8/22/1996 Licensee EnFi neering Nine long-standing technical issues were identified and addressed by the inadequate IR 96008 licensee (e.g. degraded voltage, cable ampacity, hot shorts, IIPCI keep Oversight fill line support, and swing EDG rating) during the summer's forced outages. Five of these issues had not been corrected in a timely manner.

8/22/1996 "*"**""

Plant Support Overall perfoimance of 1996 EP exercise considered very good. "*"**"" IR 96011 8/22/1996 NRC Engineering Licensee is using an area radiation monitor in lieu of 10 CFR 70.24 Other/NA IR 9601 I; URI required criticality monitor. Licensee attempting to provide technical justification.

Page 12 of 30

PLANT ISSUES MATRIX 20-uap97 Ouad Cities o o o DATE H ID BY p SALP ll DESCRIPTION !! CAtISE N REF I

, ., ,1 11 i' I 8/22/1996 Licensee Engineering While reviewing the failure of the Unit 2 IIPCI discharge check valve to Engineering /De IR 96011; NCV open during testing, licensee detemined that installed test mechanisms sign Deficiency did not cycle valve flapper through its full movement (30 deg. instead of 75 deg.).

8/22/1996 Licensee Plant Support Licensee task force concluded that ALARA dose goals were exceeded inadequate IR 9601I (950 vs. 700 rem.) due to poor outage planning and work scope growth Oversight (not reasonably foreseen).

8/22/1996 Licensee Operations Two operators failed to position a condensate demineralizer drain valve Personnel IR 9601I in the required position. Feedwater flow to reactor not significantly Performance affected. Deficiency 8/22/1996 Licensee Engineering A high energy line break of 6' RWCU piping (Monticello identified Engineering /De IR 9601I; URI scenario) was found to be outside the bounding conditions of the sign Deficiency UFSAR. Licensee responding to NRR request for information and description of planned actions.

8'22/1996 Licensee Maintenance A maintenance mechanic staned to disassemble a lubricating oiler for the Personnel NOV 96011-04a Unit 2 SBDG cooling water pump by mistake. The work package Performance required workers to replace a lubricating oiler on the Unit 1/2 SBDG Deficiency cooling water pump. Example of NOV for failure to follow procedures. (Initia:ly identified as URI 96008-05) 8/22/1996 L::ensee Maintenance Severe plugging of vessel bottom head drain line results in innaccurate Inadequate IR 9601I bottom head temperature indication. Oversight 8/22/1996 Licersee Engineering Licensee identified that the rupture disk downstream of the 1D code Engineering /De IR 9601I safety relief valve had ruptured. No indication of relief valve lifling of sign Deficiency leak-by was found. Condition attributed to DWEDS piping arrangement.

8/16/1996 Licensee Engineering ENS call. Unit 2 ilPCI whip pipe restraint deermined to have been Engineering /De IR 96011; URI incapable of restricting applied design loadmg due to incorrectly sign Deficiency installed anchor bolts. Temporary Alteratio1 installed.

8/15/1996 """*"" """"*** n+nu*** **uneu Unit 2 synchronized to the grid.

, Page 13 of 30

PLANT ISSUES MATRIX 204for97 Ouad Cities i DATE ID BY SALP DESCRIPTION CAUSE REF 1 .t l f 8/l1/1996 Self-Revealed Maintenance . ENS call. Poor reassembly of11PCI discharge check valve led to Personnel IR 9601I excessive leakage (14 gpm) from mechanicaljoint. IIPCI declared Performance -

1 inoperable. Deficiency 8/9/1996 Licensee Engineering Both diesel driven fire water pumps were declared inoperable because of Engineering /De IR 96011; URI zebra mussel fouling of the inlet strainers. Biocide injection point was sign Deficiency downstream of fire water pump suction point in water bay. LER 96013 8/9/1996 Self-Revealed Maintenance i D RilR Service Water Pump experiences bearing failure (seat last Personnel IR 96011 4

worked in 9/93) due to mud in seal. Shaft also four..' to be incorrectly Performance sized. Deficiency 4 8/9/1996 Licensee Operations Operations management discontinued a U-2 startup pending the Conservative IR 96011 evaluatio.. of a breaker calibration test device. Electricans identified a Decision disparity between digital and analog readings on the device and were concerned that some safety related breaker's trip setpoints had been set non-conservatively.

7/29/1996 Licensee Maintenance Licensee identified and resolved problems with safety related battery Engineering /De R1 Observation mounting fixtures. Batteries being grounded by buildup of salt in sign Deficiency styrofoam padding. ,

7/29/1996 Licensee Maintenance Workers miswired power supply breaker for i A LPCI outboard isolation Personnel IR 9601I; NOV valve. QA inspectors signed that wiring was correct. Breaker smoked Performance during post maintenance testing. Deficiency 7/12/1996 Licensee Engineering Supports for nonsafety-related portions of reactor building ventilation inadequate IR 96008; URI supply ductwork were not installed. This condition placed safety-related Oversight portions ofdictwork outside UFSAR basis Condition identified in 1991; modifications made in 1996.

7/12/1996 NRC Engineering Licensee identified that a portion ofIIPCI keep fill line was not safety- Engineering /De IR 96008; URI related. Licensee's initial disposition of that condition was satisfactory. sign Deficiency inspectors questioned that conclusion.

7/12/1996 Licensee Operations Operator failed to open one of the suction valves for 2D RilR pump Personnel IR 96008; NCV while establishing shutdown cooling flow. Performance Deficiency

, Page 14 of 30

s PLANT ISSUES MATRIX 20-w-97 Ouad Cities

} DATE ID BY SALP DESCRIPTION CAUSE REF f f 7/12/1996 NRC Maintenance Miantenance activities of U-2 instrument air compressor involved poor Inadequate IR 96008 work practices and was poorly controlled. Oversight 7/12/1996 Licensee Engineering Licensee upgraded EDG fuel oil system to safety-related in 1991. The inadequate IR 96008; URI ,

safety-related portion of the system was supposed to be physically Oversight isolated from nonsafety-related fuel oil systems. Licensee failed to take action until 1996. LER 96012.

i

'7/10/1996 Licensee Maintenance Worker removed oiler from wrong EDG cooling water pump (no OOS Personnel IR 96011; NOV required). Performance Deficiency 7/8/1996 Licensee Engineering ENS call.107 valves required for Appendix R Safe Shutdown are Engineering /De IR 96008; URI susceptible to " hot shorts." An earlier opportunity to identify this issue sign Deficiency was missed during licensee assessment of IN 92-18.

7/5/1996 Licensee Operations Operator works radiological (non-safety related) entilation fans without Personnel IR 9601I an OOS. Performance Deficiency 7/3/1996 Licensee Operations Operators failed to identify a condition which rendered the shared Personnel IR 96008; NCV emergency diesel generator output breaker inoperable to Unit I for a Performance period of three shifts. Deficiency r 6/30/1996 NRC Maintenance NRC inspectors identify that plant procedures and trainir.g applicable to inadequate IR 96008; URI !

use of compression type fittings do not incorporate all vender Procedure / Instr recommended installation instructions, uction ;

i 6/11/1996 Licensee Engineering ENS call. Licensee determined that U-l EDG fuel oil transfer pump was Engineering /De OPEN !

inoperable due to degraded voltage issue. sign Deficiency ;

4 6/11/1996 Licensee Engine-ring Gallery steel platforms associated with safety-related equipment were Engineering /De IR 96008; URI l inadequate to withstand design basis seismic loading. Licensee - sign Deficiency originally identified condition in 1978 but never implemented necessary modification. LER 96010. I Modification completed in summer 1996.

l

. . Page 15 of 30 ;

PLANT ISSUES MATRIX 204/ar97 Ouad Cities DATE ID BY SALP DESCRIPTION CAUSE REF .l f' f 6/7/1996 . Self-Revealed Plant Support Over 200 rem resulted from emer~ gent engineering issues during the U-l Inadequate IR 96004 outage. Specifically: the installation of structural steel supports to the Oversight

, unit I and 2 residual heat removal (RilR) systems; increase in Inservice Inspection (ISI) scope due to signs ofIGSCC in reactor recirculation (RR) system piping; addition of weld overlays, on RR piping, based on indications of cracking; and additional valve work identified during local leak rate testing. (Unit I outage) 6/4/1996 ******"*" " " " * " " * * * * * " " " ""*"""

Senior Management Meeting 6/3/1996 Licensee Engineering OLD DESIGN DEFICIENCY DISCOVERED. In reviews for upcoming Engineering /De ENS Call mod to upgrade cables to safety related buses, the licensee found that sign Deficiency incorrect cable lengths were assumed for the Unit 2 cmergency diesel generator (EDG) fuel oil transfer pump. The licensee declared the Unit 2 EDG inoperable since 5/92.

5/29/1996 NRC Engineering AFTER NRC INTERVENTION, LICENSEE DISCOVERED Other/NA IR 96006 REACTOR BLDG OUTER WALL (DAMAGED BY HIGli WINDS 5-10-96) DOES NOT MEET UFSAR DESIGN REQUIREMENTS.

Licensee committed to replace siding prior to unit startup.

5/28/1996 Licensee Maintenance During post-maintenance testing of residual heat removal service water Personnel IR 9601I; NOV pump, licensee noted problems with the inboard bearing seal. Performance Maintenance personnel determined that the seal centernig clips were not Deficiency removed and the collar set screws were not tightened as required by the work package. Example of a violation for failure to follow procedure.

(Issue first identified as URI 96008-07) 5/24/1996 NRC Engineering ENS CALL. U2 operated in unanalyzed condition with IIPCI turbine Engineering /De IR 96008 discharge vacuum breakers isolated. sign Deficiency 5/23/1996 Licensee Engineering ENS CALL UI AND U2 LPCI INJECTION VALVLS INOPERABLE Engineering /De IR 96008; URI

. UNDER DECRADED VOLTAGE SCENARIOS. The licensee found sign Deficiency the condition while preparing mod for MCC 29-2 cable pull. Cable length informution in data base used for original voltage calculations was f non-conservative. LER 96009 l

. Page 16 of 30 _

l

PLANT ISSUES MATRIX 28-^'"M7 -

Ouad Cities

~

'l 1 i DATE j ID BY SALP

] DESCRIPTION CAUSE REF 5/17/1996 Self-Revealed Maintenance 2A CRD pump exhibits high vibration after only 40 hours4.62963e-4 days 0.0111 hours 6.613757e-5 weeks 1.522e-5 months of service Personnel IR 96012;IR 96008 following complete rebuild. Rotor found to contain incorrect material Performance and incorrect shims. Deficiency 5/17/1996 Licensee Maintenance ENS CALL B CR llVAC INOPERABLE. Controlling at 82 degress F Equipment IR 96006 vs. required band 70 to 80 degrees F. Malfanction 5/16/1996 NRC Engineering ENGINEERING TEST DIRECTOR INATTENTIVE DURING TEST Persennel IR 96006:IFl IN CONTROL ROOM. During full in activities inspector found Performance individual apparently asleep. Identified by IDNS inspector. Deficiency 5/12/1996 Licensee Maintenance 3 of 6 alternate rod insertion soleniod vent valves on U-2 failed to open Equipment IR 96006 during testing. Malfunction 5/12/1996 Licensee Maintenance 3 OF 6 ALTERNATIVE ROD INSERTION VENT VALVES FAILED Equ pment i

IR 96006 TO OPEN DURING TESTING ON UNIT 2. Vent valve solenoids Malfur.ction replaced. Licensee still performing root cause analysis.

5/10/1996 Self-Revealed Plant Support - ENS CAL L ALERT DECLARED DUE TO REACTOR BUILDING Other/NA IR 96006 DAMAGE AS A RESULT OF lilGli WINDS. 27 emergency sirens without power due to loss of power. Unit 2 shutdown due to degraded secondary continment but able to maintain required .25 inch d/p. ;

Conservative call by operations.

I 5/6/1996 Self-Revealed Operations CONTRACTOR ELECT RICIAN SilOCKED DUE TO FAILURE TO Personnel IR 96006 VERIFY DEAD LEADS AND OPERATOR NOT TAKING BREAKER Performance i OUT OF SERVICE PROPERLY. Deficiency i 5/6/1996 Licensee Maintenance UNIT 1 CONTROL ROD DRIVE IIEADER VALVE LEAKS DUE TO Equipment IR 96006 i SEAT DAMAGE. This valve hadjust been replaced during outage. Malfunction 5/6/1996 Self-Revealed Maintenance CONTRACTOR ELECTRICIAN SilOCKED DUE TO FAILURE TO Personnel IR 96006 !

VERIFY DEAD LEADS AND OPERATOR NOTTAKING BREAKER Performance ;

OUT OF SERVICE PROPERLY. Deficiency 5/1/1996 Self-Revealed Engineering 3 OF 5 RBCCW TCVs STUCK DUE TO SILT FOULING OF LOW Personnel IR 96006 ;

TOLERENCE VALVE INTERVALS. Valves previously replaced by Design engr due to poor performance. Deficic ncy l

. . l' age 17 of 30

PLANT ISSUES MATRIX 20w97 Ouad Cities DATE ID BY SALP DESCRIPTION CAUSE REF ff 5/1/1996 NRC Engineering PREDECISIONAL ENFORCEMENT CONFERENCE REGARDING Involved IR 96005;1R 96007; APP APPARENT FAILURE TO PROVIDE ADEQUATE DESIGN Management VIO CONTROLS TO MAINTAIN LPCI CORNER ROOMS

STRUCTURAL STEEL DESIGN MARGINS. The licensee initially identiGed the failure to meet design requirements in 1991.

5/1/1996 Self-Revealed Engineering LEAKING SSPVs CAUSED INABILITY TO RESET UNIT I SCRAM Equipment IR 96006 SIGNAL. SSPVs were not adequately tested for seating ability prior to Malfunction installation.

4/30/1996 Self-Revealed Maintenance FIRE IN IB PIIR ROOM DUE TO INADEQUATE PROTECTION Personnel IR 96006 FOR FL, MB *.BLE MATERIAL Willt E TORCll CUTTING. Performance Damage to electrical cables, but fire was put out quickly by fire watch. Deficiency 4/29/1996 Self-Revealed Maintenance MECilANIC WAS INJURED WillLE INSTALLING REACTOR Personnel IR 96006 IIEAD BOLTS DUE TO SAFETY DEVICE ON AIR "WRENCil" Performance BEING DISABLED AND WRENCil USED IMPROPERLY. Deficiency 4/29/1996 Licensee Maintenance REACTOR 11EAD SET AND PARTIALLY BOLTED ONE BOLT Personnel IR 96006; NCV IIOLE OUT OF ALIGNMENT. Technicians improperly aligned head to Performance wrong mark. Deficiency 4/25/1996 NRC Operations Operators incorrectly used a procedure change form to perform the Personnel IR 96006; NOV

" Control Rod Drive Scram Air lleader Test." Original test required no Performance fuel in vessel during test. A procedure change form was issued to allow Deficiency test with fuel in vessel. Violation for change ofintent of procedure without adequate review.

4/18/1996 Self-Revealed Operations One U-2 rod moved in wrong direction due to problem with notch Equipment IR 96006 override switch. Malfunction 4/17/1996 Licensee Plant Support UNAUTIIORIZED ACCESS INTO FACILITY BY INDIVIDUAL BY Personnel IR 96004 TAILGATING TilROUGil ACCESS. Intentional tailgating by . Performance contractor employee was caught immediatley by security. Deficiency 4/10/1996 Licensee Maintenance SBLC SQUIB VALVE DID NOT FIRE. FOUND LOOSE WIRE IN CR Equipment IR 96004 CABINET. Wire later improperly soldered - problem recurred. Malfunction

. Page 18 of 30

2 map 97 PLANT ISSUES MATRIX Ouad Cities DATE ID BY SALP DESCRIPTION O CAUSE h REF f hI 4/10/1996 Licensee Maintenance CONTRACTOR llORSEPLAY DURING CRD REBUILD AND Personnel IR 96004 INTENTIONAL BYPASS OF RAD MONITOR. RP tech identified, and Performance contractor sent offsite. Deficiency 3/24/1996 Licensee Operations POOR COMMUNICATIONS RESULTED IN AN EQUIPMENT Personnel IR 96004 OPERATOR REMOVING Tile BACKUP N2 TO U-l/2 EDG Performance DAMPERS IN LIEU OF Ti!E U-l BACKUP N2. Operator Deficiency -

acknowledgeo error and quickl corrected. No effect to equipment operability.

3/20/1996 Licensee Maintenance CONTRACTOR ems ASSEMBLED SWEDGELOK FITTINGS INTO Personnel IR 96004 ;

IIOKE FITTINGS ON IICUs. ems not trained on improper practice of Performance mixing matching fittings. Deficiency 3/19/1996 Licensee Maintenance U-2 flPCI declared inoperable due to apparent problems with auxiliary Equipment IR 96004 ;

oil pump. Actual problem was with control room annunication circuit. Malfunction 3/18/1996 Licensee Maintenance Tile MAIN FEED FROM BUS 19 TO BUS 18/19-5 (LPCI SWING Equipment IR 96004 BUS) CAUGilT FIRE. Found bad coil in contactor. Malfunction 3/15/1996 Licensee Operations ESF ACTUATION DURING OOS. Operator removed wrong fuses in Personnel IR 96004 RPS bus; resulted in ESF actuation, RB ventilation stopped, SBGT auto Performance started. All primary containment group Ill actuated components Deficiency i operated per design.

3/5/1996 Licensee ' Plant Support SCOTT CO. EMERGENCY SIRENS INOPERABLE DUE TO ERROR Equipment ENS Call; IR 96004 MADE BY PERSONNEL IN SCOTT COUNTY IOWA S!!ERIFPS Malfunction ;

OFFICE.

3/4/1996 Self-Revealed Maintenance U-2 CONDENSATE DEM!NERALIZER MASTER FLOW Equipment IR 96002; Open CONTROLLER OSCILLATIONS. Resulting pressure changes almost Malfunction !

reached low suction pressure trip of condensate booster pump.

3/4/1996 Self-Revealed Maintenance U-2 MAIN TURBINE CONTROL VALVE #2 OSCILLATING. Equipment IR 96002;IR 96004 Problem with servo-motor. Power rapidly reduced to < 45% Turbine Malfunction ,

offline next day for repairs.

. Page 19 of 30 _

_ - - - _ _ _ _ _ _ - ._ _ _ _ _ _ _ _ _ - _ _ _ _ - _ _ _ _ _ - _ _ - . _ _ _ - - - _ _ _ _ - _ _ _ - . = - _ _ _ - = _ _ - - - - - - . _ _ - . _ _ _ _

PLANT ISSUES MATRIX 20-Atarn Ouad Cities DATE ID BY SALP DESCRIPTION CAUSE REF

{ h 3/4/1996 Self-Revealed Maintenance SAFETY RELATED "B" CONTROL ROOM IIVAC TRAIN Equipment ENS Call; IR 96002 ,

REMOVED FROM SERVICE DUE TO SUPPLY AND EXIIAUST Malfunction !

DAMPERS l-AILED OPEN. Failed relay replaced.

3/3/1996 Licensee Operations Out of Service Error on Shared EDG. During planned maintenance of Personnel IR 96004; NOV j shared EDG with circuits associated with U-l EDG, license incorrectly Performance wrote and hung an OOS to remove fuses that would disable the shared Deficiency ,

EDG overcurrent protection during auto startup from the U-2 EDG !

circuits.

3/3/1996 Licensee Operations DURING PLANNED MAINTENANCE ON'U-l/2 SBDG CIRCUITS Personnel IR 96002; Open ASSOCIATED WITil Performance !

U-1, Tile OVERCURRENT PROTECTION RELAY FUSES FOR Tile Deficiency -

U-1/2 SBDG WERE REMOVED PER Tile OOS INSTRUCTIONS. ,

He OOS stated that removing the fuses would disable the U-l/2 I overcurrent protection during an auto startup from U-2 circuits. He U- ;

l/2 SBDG would not have auto started and loaded to Unit 2. l t

2/28/1996 Self-Revealed Maintenance U-l/2 SBDG INOPERABLE DUE TO FAILhiD BREAKER FOR OIL Equipment IR 96002; Open t CIRCULATING PUMP AND FAILED LUBE OIL llEATER. Malfunction j 2/25/1996 Licensee Maintenance B-TRAIN OF CONTROL ROOM VENTILATION SYSTEM Equipment ENS Call;IR 96002; LER INOPERABLE DUE TO LOW REFRIGERANT PRESSURE. Problem Malfunction 96011 ;

due to valve seat leaks inhibiting freon from collecting in condensor after [

operating service water system. Identified during operator rounds.

2/24/1996 Licensee Engineering CRACK (6 - 8 inch) NEAR TilERMAL SLEEVE ON U-1 A CORE Equipment RI Observation j SPRAY PIPING BETWEEN Tile CORE SilROUD AND Tile Malfunction REACTOR VESSEL.

2/22/1996 Self. Revealed Maintenance U-l STANDBY DIESEL GENERATOR (SBDG) INADVERTANT Inadequate ENS Call;1R 96002; LER .,

STARTUP DURING OVERSPEED TESTING. After test, overspeed Procedure / Instr 50-254/96003 ;

- signal reset w ith local stadup switch was in " start" position. ~ uction I

i

. . Page 20 of 30

I PLANT ISSUES MATRIX 2M3P97 Ouad Cities l DATE h ID BY SALP f DESCRIPTION f CAUSE REF 2/21/19 % Licensee Engineering PROCEDURE DEFICIENT FOR SAFETY RELATED "B" CONTROL Engineering /De ENS Call;IR 96002 ROOM llVAC. If LOOP /LOCA occurred, no control room emergency sign Deficiency ventilation system booster fan to maintain positive pressure in control i

room. Procedures modified to remove relay to ensure booster fan starts. '

LER 96002 2/10/1996 Licensee . Operations MULTIPLE, INTENTIONAL BRIEF VIOLATIONS OF Inadequate IR %002; URl; NOV; CONTAINMENT INTEGRITY AND VOLUNTARY ENTRIES INTO Oversight Open TS 3.0.A FOR LEAK RATE TESTING TORUS ISOLATION VALVES. Indications ofweak operations mgmt oversight / sensitivity of primary containment function and weak knowledge of 3.0.A administrative requirements.

2/10!!996 ****""*" *"""""

STARTED U-l REFUEL OUTAGE QlR14 (SCilEDULED FOR 77 " * " * * * " * ***""*"*

DAYS) 2/7/1996 Scif-Revealed Maintenance U-l LOAD REDUCED DUE TO 3/4 INCil RELIEF VALVE LIFTING Equipment IR 96002; Open IN LOW "RESSURE FEEDWATER llEATER STRING. Valve gagged Malfunction shut lleater string bypassed. Condition corrected during QlR14.

2/6/1996 Self-Revealed Maintenance U-l filGli PR ESSURE COOLANT INJECTION (IIPCI) GLAND Equipment IR 96002; Open SEAL CONDENSER EXIIAUSTER TRIPPED DURING Malfunction SURVEILLANCE. Defective circuit breaker.

2/3/1996 Licensee Operations SAFETY RELATED "B"IIVAC SYSTEM INOPERABLE DUE TO Engineering /De ENS Call;IR 96002; Open EXTREME COLD TEMPERATURE (-28 DEG F). 14 day LCO exited sign Deficiency later in day. New technical specifications will eliminate exterior temperature requirement.

I/30/1996 Self-Revealed Maintenance U-l llPCI INOPERABLE DUE TO AUX. OIL PUMP CYCLING ON & Equipment ENS Call; IR 96002; Open OFF DURING SURVEILLANCE. Problems due to coordination of Malfunction pressure switch setpoint and relief valve setpoint.

1/29/1996 Licensee Engineering U-2 SBDG INOPERABLE DUE TO FUEL OIL TRANSFER Personnel IR 96002; Open DRIFTING Fi1 ESSURE SWITCil SYSTEM CilECK VALVE. Missing Performance personnel failing to adequately track surveillace tests. Deficiency Page 21 of 30

2 map 97 PLANT ISSUES MATRIX Ouad Cities j, 4 REF DATE ID BY SALP DESCRIPTION CAUSE ll j {

1/24/1996 Licensee Operations MIEMICAL RELEASE (SODIUM BISULFITE) INTO MISSISSIPPI Personnel ENS Call; IR 96002; Open RIVER DUE TO CllEMISTRY TECIINICIAN DISTRACTED FROM Performance CIIEMICAL INJECTION SECURING SEQUENCE / PROCEDURE. Deficiency I/23/1996 Self-Revealed Maintenance BOTil UNITS COMMENCED DOWNPOWER (0835) DUE TO Equipment ENS Call; IR 96002; Open INADEQUATE LEVEL IN CIRCULATING WATER FOREBAY. Inlet Malfunction trash rake clogged with debris from Mississippi river. Trash rake broken. Both diesci fire pumps inoperable due to inadequate forebay level (less than 568'6"). The RilRSW & SBDG cooling water pumps need 566'3" Downpower stopped at 1115 when debris removed from trash ract s.

1/22/1996 Licensee Maintenance TIIE "B" CONTROL ROOM llVAC SYSTEM CillLLER llEAD Personnel IR 96002; Open llEAT EXCilANGER (llX) IMPROPERLY INSTALLED YEARS Performance AGO. Identified by maintenance and corrected. Ileat exchanger Deficiency efficiency reduced but not inoperable.

1/15/1996 Licensee Engineering COMPUTER ROOM IN AUXILIARY BUILDING EXCEEDED Engineering /De ENS Call;1R 95010; URI MAXIMUM DESIGN BASIS FOR FIRE LOADING DUE TO SLICE sign Deficiency ELECTRICAL DATA BASE IMPROPERLY Cil ARACTRIZING CABLE LENGTil AND CABLES UNDER FLOOR NOT ACCOUNTED FOR.

1/10!!996 Licensee Maintenance CUT ON BOTTOM GASKET OF ELEMENT IN Tile 2G Personnel IR 95010 CONDENSATE DEMINERALIZER. Result was high d!p on post Performance strainer and removal from service. This is a continuing problem for Deficiency operators.

1/4/1996 Self-Revealed Maintenance SilARED "A" DIESEL FIRE PUMP TRIPPED ON OVERSPEED DUE Equipment IR 95010 TO OILY RESIDUE ON MAGNETIC PICKUP IN CONTROLLER. Malfunction 1/3/1996 Self-Revealed Maintenance LEAK OF 2A MOISTURE SEPARATOR DRAIN TANK LEVEL Equipment IR 95010 INSTRUMENT PIPING DUE TO CORROSION OF DEGRADATION Malfunction OF FLEXIBLE PIPE. Reduced power to 25% replace flex pipe.

. Page22 of 30

PLANT ISSUES MATRIX 2 Mar 97 Ouad Cities ;

l DATE ID BY SALP I f

DESCRIPTION l b

CAUSE

)l REF f ,

1/1/1996- Self-Revealed Maintenance U-l MAIN GENERATOR TRANSFORMER COOLING FAN . Equipment IR 95010 TRIPPED. Forced load reduction to troubleshoot and repair. If I fan . Malfunction - !

trips. entire group of 6 fans trip Breaker tripping coordination problem.

Occurred summer 1995 too. Problem not yet resolved - need mod to i replace molded case circuit breakers. ,

I/1/1996 NRC ' Engineering U-2 RCIC TRIP TilROTTLE VALVE CORRECTIVE ACTIONS Inadequate IR 95010 WERE NOT. ERFORMED AS PLANNED BY OPERATIONS FOR A Oversight PREVIOUS EVENT. f 12/31/1995 Self-Revealed Maintenance Loss of control room annunciator audible alarms due to a computer Equipment IR 95010; RI Observation failure (a condition repeated several times in 1995). Malfunction -

12/28/1995 Self-Revealed Maintenance U-2 stator water cooling temperature control vah e failed. Controlling Equipment IR 95010 - ;

manually. Malfunction ,

12/23/1995 Licensee Maintenance U-l power reduced to repair an air leak to IC2 feedwater heater level Equipment IR 95010 control valve. Malfunction '

12/22/1995 Licensee Operations inadvertant start of residual heat removal (RilR) pump. PIF written that Personnel IR 96002;IR 96012; NCV described unexplained RilR system alarms when RilR service water Performance ;

(SW) pump started during surveillance. Investigation determined RilR Deficiency pump was actually started. ;

12/20/1995 Licensee Operations U-2 RilRSW to safety related control room chillers isolated for about 1.5 Inadequate IR 95010 years. Check valves did not pass enough flow, so licensee isolated Oversight RilRSW. Additionally, no controls or restrictions put on U-l RilRSW i to insure a supply to chillers. '

12/19/1995 NRC Engineering U-l llPCI solenoid valve on air operated valve (AOV) drain valve (l- Personnel IR 95010;NOV; LER i 2301-28) for steam line inlet drain pot not oriented correctly. Seismic Performance 95009 qualification questionable in that orientation. Deficiency 12/12/1995 Licensee Operations Operator opened the IC RilRSW pump discharge valve past limits in Personnel IR 95010 i operating procedure. The valve seat guide was broken. Performance Deficiency !

. . Page 23 of 30

PLANT ISSUES MATRIX 2may-97 Ouad Cities DATE h, ID BY SALP f DESCRIPTION CAUSE REF

! i i 12/7/1995 Licensee Maintenance Mechanics damaged pump impeller to IC Rif RSW pump during Personnel IR 95009 maintenance. Performance Deficiency 12/6/1995 Self-Revealed Maintenance U-l llPCI steam inlet supply valve failed inservice testing (IST) during Equipment IR 95009; LER 95008 routine surveillance. Opened too slow. Malfunction 12/5/1995 Self-Revealed Maintenance Loss of ENS phones. Equipment ENS Call;IR 95009 Malfunction l1/30/1995 Self-Revealed Maintenance U-2 IIPCI failed during surveillance. Discharge flow & pressure Equipment ENS Call;IR 95009 oscillations. Malfunction iI/29/1995 Self-Revealed Maintenance U-2 shut down due to electro-hydraulic control (EHC) leak on supply Equipment ENS Call;IR 95009 line to #1 turbine control valve (TCV). Leak repaired & U-2 restarted. Malfunction 11/23/1995 **"**"*" " " " " * " " " " " * " ***"**"**

U-2 STARTUP AND MAIN GENERATOR SYNCilRON17ED TO GRID 1I/22/1995 Self-Revealed Operations U-2 startup activities problems: Personnel IR 95009 Performance i) reactor operator (RO) mispositioned a switch on nuclear instruments Deficiency -

(IRM); result was a half-scram signal. Self-check error.

ii) Operators improperly marked required steps as N/A and entered procedure at wrong step. Result was the generator trip during startup.

I1/19/1995 Self-Revealed Maintenance U-2 SBDG inoperable due to slow startup during surveillance (11/19 & Equipment IR 95009 11/20/95). Malfunction i1/16/1995 Licensee Maintenance Steam leaks in U-l heater bay. Leaks on 1Cl & IC2 heater vent piping. Equipment IR 95009 Flow Accelerated Corrosion (FAC) engineers not informed. Malfunction i1/14/1995 Licensee Engineering Nuclear engineers developed wrong rod pull sheets. Poor review of new Personnel IR 95009 software implementation. Rod worth minimizer (RWM) prevented rod Performance movement. Deficiency 11/13/1995 ""*"*"* ""***"" U-l STARTlip AND GENERATOR SYNCIIRONIZED TO GRID ***"****** ****""*"

f

(

, . Page 24 of 30

_-. . . - . - . - - . -- . _ - _ _ - - - - - _ _ = _ _ - - - _ _ - _ _ - _ _ . _ _ _ - - --_

. PLANT ISSUES MATRIX 2 map 97 Ouad Cities :

DATE ID BY SALP DESCRIPTION CAUSE REF f l i f ;

< 11/13/1995 NRC Maintenance Steam leaA in U-l heater bay on 2 inch line. Two inch or less had been inadequate IR 95009 identified by FAC program as susceptible to corrosion in 9/95. Unit i Oversight l refueling outage 14 (QI R14) had not included plans to inspect any of the .l pipeing 2 inches or smaller that were susceptible and not modelled. j Also, offgas loop seals blown again. The drain from iB moisture ;

separator not working. Charcoal beds got wet, but operable. t i1/9/1995 Self-Revealed Maintenance U-l start .p. Main steam line drain valve (220-1) packing leak identified Equipment IR 95009 ;

during startup. U-l shut down next day. atalfunction ;

11/4/1995 Self-Revealed Maintenance U-1/2 SBDG failed to start on surveillance. Time delay relay in Equipment IR 95009; IFI j protection circuit failed. Malfunction '

i1/3/1995 Self-Revealed Maintenance U-2 SBDG operable. Air starting motors were identified as the root Other/NA IR 95009; URI cause of the U-2 SBDG starting problems from 8/95 to 10/95. I i

i I/3/1995 Self-Revealed Maintenance U-l C & D inboard main steam isolation valves (MSIV) failed to close Equipment IR 95009 on spring press alone during " fait safe" testing. Replaced valve stem Malfunction packing; valves passed.

11/l!!995 Licensee Maintenance Shared instrument air compressor placed on limited service due to Equipment IR 95009 increased vibration and temperature indications. Malfunction II/1/1995 NRC Maintenance Boron deposits on U-2 standby liquid contro!(SBLC) relief valves. Heat Personnel IR 95009

, trace elements for U-2 SBLC not set at the eppropriate temperatures. Performance j Deficiency i I1/l/1995 Licensee Maintenance U-l "IE" drywell cooler power supply cable experienced a high current Equipment IR 95009 {

condition. Cable replaced. Malfunction j i

4 l

r i

Page 25 of 30 l

PLANT ISSUES MATRIX - 2 M aP97 Ouad Cities -

n , .. .

f DATE ID BY SALP CAUSE REF y 1 l } DESCRIPTION f l 11/1/1995 NRC Maintenance Numerous examples of scram valve limit switches not properly aligned. Personnel _

IR 95009 ,

Many previously iderttified and not corrected; some were recently Performance identified. The limit switches provided scram valve position indication Deficiency ;

to control room operators. Did not affect of the operability of the scram !'

valves.

ilydraulic control unit (IICU) directional control valve solenoids l interfered with scram inlet valve stroking.

I1/1/1995 NRC Maintenance Water leaking on to a 13.8 kV transformer and on top of the U-l SBDG Equipment IR 95009 .

outputjunctio, box in the turbine building after a heavy rain. Similar Malfunction j leaks fou :d ir ! e turbine building previcusly. The licensee corrected the immediate issue when informed, but not the overall problem.

i1/1/1995 Self-Revealed Engineering U-2 SBDG ventilation fan tripped due to undersized thermal overloads. Engineering /De IR 95009

Overloads replaced with higher rated overloads. sign Deficiency [

t 11/1/1995 Self-Revealed Maintenance Clogged drain on U-l offgas moisture separator resulted in moisture Equipment IR 95009 :

carryover into the absorber beds. Malfunction !

10/31/1995 NRC Operatiors Interim administrative control to prevent overloading safety bus feeder Inadequate IR 95009 I breakers not implemented Procedure / Instr !

uction 10/26/1995 Self-Revealed Maintenance Smoke from motor control center (MCC) 28-2 feeder breaker to Equipment RI Observation j hydrogen seal oil current transformer. Malfunction !

10/25/1995 Self-Revealed Maintenance U-2 "2G" drywell cooler fan blade failure. Destroyed ventilaton Equipment IR 95009 ;

ductwork and cooling water (RBCCW) piping. SRI tour in drywell Malfunction ;

noted cooler was still leaking even after isolated. liigh nitrites in torus from leak. j

?

10/24/1995 Self-Revealed Maintenance U-2 SBDG failed to start on monthly routine surveillance test. Root Equipment IR 95009 f cause attributed to air start motor degradation. Root cause evaulation Malfunction was better. but had not identified performance criteria for air start motors.

Page26 of 30

PLANT ISSUES MATRIX _ 20-uar97 Ouad Cities

i' t f DATE ij ID BY- hI SALP ! DESCRIPTION CAUSE f REF l

. a _ .< - _. <

10/23/1995 Self-Revealed Plant Support Rock Island sirens inoperable due to lightning damage. Same cause as Other/NA-- ENS Call;IR 95009 Whiteside City in 9/95. Emergency planning was not aware if corrective actions were being taken to fix root cause.

10/23/1995 Licensee Maintenance Licensee stopped all but essential maintenance activities to re-evaluate Other/NA IR 95009 ;

the work control process. ,

10/22/1995 Licensee Engineering . U-l & 2 susegrible to a single failure in the scram logic for the scram Engineering /De IR 95009;NCV; LER [

discharge instrument volume. BOTil UNITS were SilUT DOWN since sign Deficiency ~ _95007 l the identified condition was outside the plant's design basis. Problem !

first identified at Dresden U-2. .

i 10/21/1995 Self-Revealed _ Maintenance U-2 EllC leak on #1 TCV and the turbine was taken off-line for repair. Equipment IR 95009 During the recent refuel outage, new fittings frorr. GE were installed as Malfunction ;

part of a modification. j 10/20!!995 Licensee Maintenance Maintenance personnel identify oil leak into sevice water side of U-l Equipment IR 95009

~

reactor recirculation motor generator (MG) set IlX. Malfunction i

10!!8!!995 Self-Revealed Maintenance U-2 IIPCI failure during surveillance due to oscillations with pressure, Equipment IR 95009;IFI; LER 95008 !

turbine speed, and flow. Minor flow oscillations had been occurring Malfunction .'

since the last refueling outage. j ADDITIONALLY, inlet drain pot high level alarm stayed in after start.

Drain valve AOV 2-2301-28 did not open. ;

i 10/17/1995 Licensee Maintenance Licensee identified brittle wires to U-l SBDG time delay relays. Equipment RI Observation l Malfunction i

10!!6/1995 Self-Re- ealed Maintenance Unit 2 primary containment isolation AOVs (2-220-44 and -45) failed to Equipment IR 95009; IFI; LER 95008 [

close and failed the local leak rate test. Malfunction !

10/12/1995 Self-Revealed Maintenance ' U-2 "C" condensate booster pump outboard bearing running hot due to Personnel RI Observation j improper installation of seal. Performance .[

Deficiency 10/5/1995 Licensee Maintenance U-2 power reduced to repair TCV and turbine bypass valve (TBV) Equipment IR 95007 l components. Malfunction ;

i

. . l' age 27 of 30 t

PLANT ISSUES MATRIX 2ntay-97 ;

i Ouad Cities jp l DATE h, ID BY SALP DESCRIPTION CAUSE REF j f l 10/4/1995 Self-Revealed Engineering 480 Vac U-2 MCC (29-2) tripped on overload during routine operations. Engineering /De . IR 93007; NOV 111; LER -

Normal loads exceeded 300 amp rating. Emergency loads also exceeded sign Deficiency 95006 breaker ratings on some of the other safety MCCs. Similar event at Dresden in 1994. Quad only addressed one MCC (28-2). Quad had data :

to indicate problem on MCC 29-2. ,

10/4/1995 Self-Revealed Maintenance U-2 HPCI inoperable due to not going on turning gear. No root cause Equipment IR 95007 :

identified. Malfunction - l 10/1/1995 Self-Revealed Maintenance U-2 TCV #2 continued to oscillate. Equipment IR 95007 Malfunction 10!!/1995 Licensce Engineering Fcur U-l motor operated valves (MOV) susceptible to cracked motor- Equipment IR 95007 (

rotors due to IGSCC. Motors replaced. One of the four indicated Malfunction l potential cracked rotor during diagnostic testing. ;

10/I/1995 Licensee Maintenance U-2 CRD cart elevator malfunctioned during replacement of CRD K-7. Equipment IR 95009 Result was workers receiving extra dose (Oct/Nov 1995). Malfunction 9/29/1995 Self-Revealed Maintewnce U-2 TCV #2 began oscillating. Equipment IR 95007 ;

Malfunction i 9/29/1995 Licensee Maintenarce Craft performing acid etching in the SBO building used too high a Personnel IR 95007;IFl concentration of muriatic acid and damaged exposed copper conductors. Performance U-l SBO battery charger trip. Damage to both units. Deficiency 9/26/1995 Self-Revealed Maintenance U-2 SBDG failed to start during routine surveillance. Licensee attributed Equipment IR 95007; URI cause to fuel oil priming pump. Poor root cause evaluation. Malfunction l 9/18/1995 Self-Revealed Maintenance U-2 reactor core isolation cooling (RCIC) inoperable following routine Equipment IR 95007

{

surveillance mn due to over pressure in suction piping. Leaking Malfunction ,

isolation valves. I 9/12/1995 Self-Revealed Plant Support Sirens in Whiteside City inoperable due to lightning damage to radio Other/NA ENS Call;1R 95007 i control unit.

f 9/4/1995 Self-Revealed Engineering U-l HPCI inoperable due to slow stroke times on three AOVs. Equipment IR 95007 Engineering avaluated the stroke increase as acceptable. Malfunction i

. . Page 28 of 30 t I

PLANT ISSUES MATRIX 2 mar 97 Ouad Cities DATE ID BY SALP DESCRIPTION CAUSE REF f h l 9/2/1995 "*"""" """""* """*"" """"*"

U-2 STARTUP 8/28/1995 Licensee Operations U-2 SBDG started slower than " usual." Identified by operators. Equipment IR 95009 Licensee review ofissue was shallow. Malfunction 8/25/1995 Self-Revealed Maintenanc: U-2 trip from 60% power while testing pressure regulator in EllC Engineering /De IR 95006;IFI; LER 95005 system. Identified oft-set problem in modification implemented per GE sign Deficiency service information letter (SIL).

8/18/1995 Self-Revealed Maintenance U-l reactor recirculation pump speed increased unexpectedly resulting in Equipment ENS Call;IR 95006 a momentary power level above 102.5 %. Malfunction ,

8/17/1995 "**"*"" """"*" ****""*** " * * * " ' "

U-2 STARTUP 8/16/1995 Licensee Plant Support Installation of hand geometry and protected area land vehicle protective Other/NA IR 95009 systeras.

8/12/1995 Licensee Maintenance Control room chiller compressor failed due to freon leak. Iloie at a sil- Equipment ENS Call;IR 95006 brazedjolt. Malfunction 8/12/1995 Self-Revealed Mainteoance U-2 turbine taken offline and reactor shutdown to repair a leak in the Equipment IR 95006 LilC system and repair relief valve seat leakage. Malfunction 8/6/1995 Self-Revealed C,.mtior.s liigh reactor water level transient during feedwater regulating valve Personnel IR 95006 testing. Operaters failed to scram U-2 when a previously discussed Performance !

parameter exceeded the trip criteria. Deficiency 8/5/1995 " * * " * " " """""' U-2 GENERATOR SYNCllRONIZED TO GRID """*"" """"***

8/2/1995 ***"""" *"*"""* "*"""" """*""

U-2 STARTUP 7/31/1995 Self-Revealed Maintenance L1-2 shutdown during startup due to TBV oscillations. The GE SIL was Personnel IR 95006 installed during maintenance without a proper review prior to its Performance incorporation into the plant. Deficiency 7/29/1995 Self-Revealed Maintenance U-2 shut down due to TBV oscillations. Equipment IR 95006 Malfunction 7/27/1995 **"**"*" ""**""* ""***"" *"""""

U-2 STARTUP AFTER VACUUM PRESSURE SW:TCll AND TBV REPAIRf i

. . 1%ge 29 of 30

PLANT ISSUES MATRIX : 2 Mar 97 Ouad Cities l

DATE ID BY SALP DESCRIPTION CAUSE REF l

7/26/1995. Licensee Maintenance' All four U-2 condenser vacuum pressure switches were out of TS Personnel ENS Call; IR 95006 tolerance Pressure switches replaced during outage due to problems Performance .!

i with drift New switches also prone to drift. Licensee changed setpoint Deficiency and increased calibration Tre : my.

7/26/1995 Self-Revealed Maintenance U-2 shutdown due to TBV oscillations. Equipment IR 95006 Malfunction ;

t l 7/24/1995- Self-Revealed Maintenance U-2 reactor recirculation pump speed increase due to test equipment Equipment . IR 95006 i problems. Power increased about 5 %. Malfunction 7/22/1995 *""""" *""""" '"*"""* """""*

SALP 12 EN!it'D (12/26/93 - 7/22/95).

7/20/1995 "*"""" "*"""" U-2 STAP, TUP AFTER Q2R13 COMPLETED. """**"* "*******"

f a

Page 30 of 30 a o

^

PLANT ISSUES MATRIX LASALLE :

DATE -ID BY SALP DESCRIPTION CAUSE l REF l t'4/23/97 Licensee OPS- Licensee announced delay in planned ------ -----

restart until Spring 1998. -Delay attributed to not receiving requested budget allocation. As a result, the licensee layed-off a significant number of contractors. The licensee also de-unitized the organizational structure to free up additional resources.

04/14/97 NRC OPS CAL supplement issued to include specific ------ ----- '

commitments by the licensee to address i human performance problems in operations, material condition issues affecting startup, and deficiencies in engineering support to operations that have been identified by the NRC and licensee.

03/21/97 NRC OPS The licensee failed on May 23, 1996, to programmatic. IR97003 notify the NRC of the permanent reassignment of a licensed individual to a position which did not require a license.

The inspectors also identified that the status of licenses could not be readily x verified by the shift manager. informal communications were used to inform site personnel c5 changes in license status.

and lists used to cbntrol licenses were ,

inaccurate. No instances were identified '

s' where an operator inappropriately assumed a licensed position.

03/21/97 NRC MAINT Work instructions for inspecting the steam procedure IR97003 tunnel check dampers did not contain-appropriate qualitative or quantitative acceptance criteria.

c

E PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE .REF 03/21/97 NRC PS Inspectors observed poor housekee)ing due human IR97003 to work activities in several hig1 performance radiation and high contamination areas-including reactor water cleanup heat l exchanger and filter /demineralizer rooms, radwaste tunnels, and radioactive waste storage areas.

03/21/97 Licensee ENGR Failure to perform IST testing of RHR procedure IR 97003 containment spray isolation valves in correct direction (safety function) required by ASME code during two surveillance intervals. Incorrect revision to procedure following earlier recognition that safety function of valves s was in opposite direction.

03/21/97 NRC MAINT EDG testing in accordance with a procedure IR97003 maintenance procedure was delayed when operators identified that the procedure had not been revised to reflect changes in an operating surveillance procedure and because of equipment nomenclature ,

deficiencies. '

03/13/97 Licensee OPS Due to significant weaknesses in command human PNs and control, communications, and control performance panel awareness demonstrated during licensee simulator e.aluations, licensee s management suspended several licensed R0s and SR0s from licensed duties pending remediation training.

03/05/97 ----

Licensee implemented unitized .

organizational structure.

03/03/97 NRC OPS During testing of the 2A EDG. the nuclear human .IR97003 station operator failed to follow performance procedure by recording the time that the EDG reached rated load instead of the time that the EDG output breaker was closed.

PLANT ISSUES MATRIX LASALLE DATE ID BY , SALP DESCRIPTION CAUSE REF 03/01/97 NRC OPS A surveillance procedure contained procedure IR97003 incorrect acceptance criteria (contrary to statements in the UFSAR) for lake level.

An Unusual Event was declared after the licensee identified that lake level had been allowed to rise above the level of flood protection barriers in the plant.

03/01/97 NRC OPS Poor material condition of the lake make- material IR97003 up and blowdown system contributed to an condition Unusual Event. Operators had been reluctant to secure the cooling lake makeup pumps knowing the difficulty involved in restarting the pumps, thus allowing lake level to rise. After identifying lake level above plant flood barrier design limits. draining the lake ,

i was delayed due to a blowdown valve that had been broken for some time and had a ,

history of frequent repairs. '

02/28/97 NRC PS Chemistry housekeeping was generally good + IR97005 and technicians used good sampling techniques and raditaion protection practices.

02/28/97 NRC PS Reactor water chemistry was effectively .+ IR97005 controlled and the analytical capability of the laboratory was good, with sampling and analytical equipment well maintained. ,

02/28/97 NRC PS Although chemistry department self- human IR97005 assessments were causing the licensee to performance address problems in procedural adherence -

and interdepartmental communications, site quality verfication reviews and audits did not identify similar problems.

t e a

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE l REF i

02/28/97 NRC PS Effluent activity released and associated + IR97005 dose were appropriately calculated and the effluent monitoring instrumentation, with the possible exception of the wide range gas monitor, was well maintained.

Inspectors found no problems with calculated releases. Gaseous and liquid effluent monitors were in good operating condition, within calibration. and had appropriate setpoints. A number of recent minor problems w th wide range gas monitors resulted in a lack of confidence in the reliability of the monitors.

02/28/97 NRC OPS The licensee failured to perform required human IR97003 testing of the 1A residual heat removal performance (RHR) pump shutdown cooling suction valve.

1E12-F006A. within the required test interval. Operations personnel lacked attention to detail when reviewing the surveillance procedures.

02/27/97 NRC OPS The "0" EDG was tested at rated load for human IR97003 56 minutes, four minutes less than the 60 performance minutes operating time required by the

~

procedure.

02/26/97 NRC MAINT Two equipment deficiencies were identified human IR97003 by the inspectors and the licensee during performance the EDG 1A testing. Rework of the jacket water cooling heat exchanger. service water flange gasket which had been replaced while the diesel generator was out-of-service, resulted from inadequate maintenance practices. In addition the licensee identified that inappropriately '

sized fuses had been installed in the EDG ventilation exhaust damner control circuitry.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 02/25/97 Licensee MAINT Required surveillance testing of the Unit human IR97003 1 RHR pump 1A discharge high/ low 3ressure performance switch was not performed within t1e required time interval because a work control scheduler failed to follow the scheduling procedure.

02/23/97 NRC PS A radiation protection technician did not human IR97005 ensure reasonable efforts were made to performance prevent the spread of contamination from the contaminated areas in the Unit 1 "A" and "B" heater drain pump rooms prior to releasing them for use. No controls were in place to prevent ground water from flowing from the posted contaminated areas to adjacent clean areas.

02/23/97 NRC PS Hoses and ropes in the radioactive waste human IR97005 building and Unit 1 "A" heater drain pump performance room breached a contaminated area boundary without being taped or tied securely where they exited the area.

02/23/97 NRC PS The boundaries of two sample sinks in the human IR97005 chemistry laboratory that were posted as performance Jotentially contaminated areas did not lave the contaminated area boundaries delineated by rope or tape.

02/23/97 NRC PS Inspectors observed poor housekeeping due human IR97005 to work activities in several high performance radiation and high contamination areas including reactor water cleanup heat exchanger and filter /demineralizer rooms, radwaste tunnels, and radioactive waste storage areas.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 02/23/97 Licensee PS Several material condition problems material IR97005 involving liquid radwaste processing condition equipment including leaking bottles of sulfuric acid, significant corrosion of an acid day tank, and a number of radwaste control panel deficiencies. Tha licensee was developing a plan to address radwaste material condition problems.

02/21/97 Licensee ENGR The licensee did not test the start of the human LER control room and auxiliary electric performance 97006 equipment room ventilation system fans during diesel generator LOCA load sequence testing due to a mis-interpretation of the term " auto-connected loads" in TS.

02/20/97 Licensee ENGR Operating procedures did not ensure that a procedure LER drywell floor bypass path was not created 97005 or that over-pressurization of the standby gas treatment system would not occur during a LOCA with containment venting in progress.

02/20/97 NRC MAINT Due to a non-conservative test procedure LER methodology, calibration procedures for 97008 the rod block ronito; did not ensure that the monitor would be enabled before reaching 30 percent power. -

02/14/97 Licensee ENGR Testing involving air flow measurements procedure LER for the main control room (CR) and 97004 auxiliary electric equipment room (AEER) ventilation system was not conducted in accordance with the methodology prescribed in the TS.

02/12/97 Licensee ENGR A lake blowdown flow instrument (used for programmatic IR97003 liquid radwaste discharges) had been replaced in 1994 with inadequate design controls.

PLANT ISSUES MAlRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 02/11/97 NRC OPS The inspectors observed an operator human IR97003 removing a breaker from service without performance having the required procedure available at the work location. This was an additional example of the violation issued in NRC Inspection Report 96018 for failing to follow procedures (50-373/97018-02:

50-374/97018-02). The inspection also revealed that operators did not know the expectation regarding the use of

" reference use" procecures.

02/08/97 Licensee MAINT Licensee management stopped work programmatic IR97003 associated with the General Electric SBM (s;;itchboard, miniature) switch replacement project. Noted problems included inconsistent work methods, testing procedure problems, and receipt inspection deficiencies. Although this was considered an appropriate action the deficiencies that resulted in the stop work order indicated that previously identified weaknesses within the licensee's maintenance processes continued to exist.

02/06/97 NRC OPS A control room operator and unit human IR96020 supervisor were unware of actions performance implemented during an RHR suveillance and did not expect resulting alarm that was received. A control room operator was also not aware of the RHR configuration and its basis when questioned by an inspector.

02/06/97 NRC OPS Performance of a non-licensed operator did human IR96020 not meet licensee management expectations performance during a shift briefing. The operator was unable to communicate work priorities.

equipment status, or problems to be resovled.

. . ~ . . ..

1m PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 02/06/97 NRC MAINT Over-pressurization of waterleg pump material IR96020 discharge piping on HPCS narrowly averted condition by operator action when equipment failed during a surveillance.

02/06/97 NRC MAINT RHR pump inservice test surveillance procedure IR96020 procedure did not ensure repeatable reference flow rate was used as required by the ASME code.

02/04/97 Licensee ALL Corrective actions to address work control programmatic IR96020 process deficiencies and specific equipment problems continue to be weak.

The Site Quality verification organization has had a Corrective Action Request open on the ineffective corrective action program since late 1993 and the licensee has not demonstrated the ability to fix the problem.

02/04/97 NRC PS Site quality verification personnel were programmatic IR96020 effective in actively pursuing the occurrence of an improperly disabled fire door, successfully using this event to demonstrate continued programmatic deficiencies with the work control process, and ensuring broader licensee corrective actions.

02/03/97 NPsC ENG Station minor modifications performed on programmatic IR96019 components and system using Nuclear Design Information Transmittal forms rather than the process defined in adminstrative procedures. Some did not have written-safety evaluation screenings required by the adminstrative procedures. Examples included EDG flange bolts, shutdown panel brackets. and control room sealing.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 02/03/97 NRC ENG Site appendix for nuclear design procedure IR96019 information transmittal procedure did not receive onsite review in accordance with adminstrative procedures.

02/02/97 Licensee ENGR Potential unanalyzed. condition due to design LER opening doors to filter housings to control 97002 CR/AEER refrigeration unit condensing coils to melt snow accumulation.

02/01/97 Sel f- OPS A non-licensed operator failed to follow a human IR96020 disclosing fire protection surveillance procedure, performance resulting in a deluge of an unit auxiliary transformer.

01/31/97

~

Licensee OPS An uncontrolled waste sludge tank level human IR96020 increase was caused by an poor operator performance self-checking when he missed a page in the procedure.

01/27/97 NRC All LaSalle placed on NRC watch list and ------ -------

letter issued to Comed pursuant to 10 CFR 50.54(f).

01/22/97 NRC OPS During interviews some operators stated programmatic IR96020 that they did not have confidence in hte ability of the licensee *s formal problem identification and resolution process to fix identified problems. As a result.

these operators did not use the process.

01/21/97 NRC OPS Operator failed to install and tighten human IR96020 bolts that helped secure cubicle doors to performance Division 3 switchgear frames, contrary to procedure.

_e--m- - - - - - - --

_ - - - - - - _ _ e

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF l

-01/17/97 NRC PS Conduct'of security activities was + IR97002 professional with marked improvements in:

communications among all levels of the security organization. definition of roles and responsibilities of staff members.

reduction of administrative and other duties that distracted supervisors. and

procedure development. Senior site security management involvement was good.

However. Epirit of teamwork continued to be lacking.

01/17/97 NRC PS Mon-cited violation issued involving an human IR97002 unescorted visitor in the protected area performance for approximately one hour.

01/17/97 NRC PS Security staff identified an increase in + IR97002 the number of security doors left unsecured after use and responded promptly and effectively in conducting a root cause analysis of these events.

01/17/97 NRC PS Audit requirements of the security plan + IR97002 were met. Audits performed in September ciid November 1996 were effective .in addressing and evaluating the security program.

. 01/17/97 NRC PS Security staffing was adecuate. Key + IR97002 personnel changes were mace in top management positions since the previous security inspection.

01/15/97 Licensee ENGR Crack indications identified on two Unit 2 material RIs jet pump risers. condition 01/13/97 Licensee ENGR Control room radiation monitor logic design IR96020 doesn't meet single failure criteria due control to inadequate evaluation during 7/93 modification to prevent spurious actuations.

_ _ _ _ _ . _ _ _ _ _ _ _ _.a_ _ . _ _ _.__._________m_____m --

__ u ..___ _.- _ . _ _ _ _ _ - _ _ . _ _ _ _ _ _ _ _ _ _ _ _

.. _ . _ . _ . . _ _ . _ _ _ . . _ . _ _ _ _ _ . . . _ . _ _ _ . _ _ . - _ . _ . _ . . . - - . _ , _ . _ __m 4

PLANT ISSUES MATRIX LASALLE ,

DATE ID BY SALP DESCRIPTION CAUSE REF ,

t 01/08/97 Licensee ENGR Loose parts monitoring system has been design LER inoperable since 1985 when the automatic control 97001 recorder was removed, contrary to the SER, after it failed 12/30/96 Sel f- MAINT 25 gallon oil spill near screen house due material ENS Call disclosing to poor material condition of rented air condition j compressors being used to sparge air into plant intake to prevent ice buildup on racks. ,

12/27/96 NRC OPS A control room operator was not using the human IR96320 most current revision of a procedure performance :

attachment to record surveillance test and .

data. programmatic 5

12/27/96 NRC OPS Operator removed the wrong breaker from human IR96020 service while isolating a battery charger performance for maintenance. Operator failed to i question a discrepancy between the 00S and ,

the plant labeling. ,

t 12/17/96 Licensee ENGR Division 2 RHRSW outside design basis. design LER i

, Failure of nonsafety related dike could control 96020 i

lower lake level enough-to cause ,

waterhammer and failure of RHRSW. i 12/13/96 Licensee ALL Completion of licensee *s independent self Long term -------

assessment (ISA) and announcement of performance !

extended shutdowns on both units problems 12/13/96 Licensee ENGR Thermal overload bypass circuit design for design LER 16 RHR valves did not meet UFSAR control 96022 !

requirements. Thermal overloads are not ,

bypassed when the operators are required ;

to remote manually operate the valves l under accident conditions. [

12/10/96 Licensee ENGR During audit licensee identified use of procurement ENS Call !

bolts on safety systems that were included {

as fradulent on DOE notification. Testing showed some outside hardness and carbon i content. i

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 12/05/96 Licensee ALL Licensee announcement of unitization of Long term Morning orga7ization to better focus on performance Report performance problems problems 11/28/96 NRC MAINT No acceptance criteria in monthly EDG slow procedure IR96018 start surveillance for evaluating potentially degraded air start motor.

Operations was not congnizant of the reason for recording the data.

Potentially degraded air start motor and EDG if test data not timely reviewed.

11/27/96 Licensee MAINT Diesel fire pumps declared inoperable due procedure ENS Call to surveillances not performed at required frequency.

11/26/96 NRC OPS Operator did not have procedure at work human IR96018 site during testing of EDG auxiliaries. performance 11/15/96 Licensee ENGR Licensee failed to take a]propriate action corrective IR96018 to address SBM switch pro)lems following action 1979 GE notification and other reviews in 1990 and 1995.

11/06/96 Licensee ENGR Potential hot shorts due to control room design LER fire could result in mechanical damage to control 96016 several MOVs required to achieve and maintain hot shutdown. (Affects 10 RCIC and and 5 RHR valve on each unit.)

Inadequate respcnse to IN 92-18. ,

11/06/96 Licensee MAINT Main control room possibly outside design design IR96018 basis due to inadequate surveillance control procedure that did not measure dP across all applicable spaces next to control room. ;

11/04/96 Licensee ENGR RHR pump seal coolers do not meet design design LER pressure requirements because requirements control 96018 were not included in original purchase specifications.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 10/30/96 Licensee MAINT 480 V switchgear feedbreakers to Unit 1. procedure. IR96018 Division II MCC 136X1 and 136X2 degraded condition (mechanical trip interlocks primed to trip in seismic event) due to failure to take timely corrective action for similiar event in July 1995. EM procedure not revised to check mechanical interlock disengages (required air gap) when a breaker is fully racked to connect in its cubicle until 2/96. after these breakers were installed. MCCs supplied Div II EDG support equipment. SGTS loads.

essential lighting main steamline valve logic. control room and aux electrical room HVAC.

10/25/96 NRC MAINT Several plant housekeeping conditions human IR96013 existed that had the potential to performance adversely impact plant operations, s:.-" w the use of duct tape where it could interfere with valve operation. Thest.

conditions were also indicative of poor worker practices.

10/25/96 NRC PS Several examples of the failure to adhere Human IR96013 to required radworker practices. The performance inspectors were concerned that actions taken by the licensee to address problems with radworker practices and radiological housekeeping conditions, were not sufficient to ensure long-term and consistently good performance in these areas.

10/25/96 NRC ENGR Informal process for review, approval. and programmatic IR96013 prioritization of engineering requests was ineffective in ensuring the timely completion of engineering work. Many old ERs not resolved and in review status.

Several actions from 1994 RCIC rupture

, disk event had not been taken.

. PLANT ISSUES MATRIX - 1 LASALLE .

DATE ID BY SALP DESCRIPTION CAUSE REF l 10/23/96 Licencee MAINT GE performed liquid penetrant examination Procedure IR96017 on incorrect HPCS safe end to reactor nozzle weld: due to lack. of specifying weld location in work package and poor lighting. Licensee-conducted 24 hour2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months ISI standdown. j 10/18/96 NRC .PS Continuing weaknesses with contractor Programmitic IR96014 oversight, work control and planning, and and human !

self checking with respect to radiological performance- i controls. Examples from L2R07 included.a :

station RPT failing to post the-RWCU room as a high radiation area, unnecessary dose expended on installation of recirculation i piping plugs (improperly sized and had to i replace. and periodic re-entries to '

reinflate plugs due to air leakage) and a failure to document in a PIF two !

contractors receiving facial contamination while traversing an areas outside their 3 work area. l 10/18/96 NRC PS Station dose for 1996 was 953 rem as of Programmatic IR96014 i 10/96, significantly above the 78 rem i goal. The increase was attribur's to emergent / unplanned work and material -;

4 condition improvement efforts. .

I

~

PLANT ISSUES MATRIX .

LASALLE :

DATE- ID BY SALP DESCRIPTION CAUSE REF l 10/18/96 NRC PS Good ALARA controls for exposure control Program,natic IR96014 (teledosimetry, remote monitoring via camera, hydrolazing), but several weaknesses in work control process :

regarding review and implementation of >

ALARA plans and RWP which may result in j additional worker exposure. RWP radiological holdpoints sometimes less conservative than that in ALARA plan. !

information on ALARA plans and RWPs often !

unclear or not applicable. a single RWP used to control several activities on some ;

jobs when multiple RWPs would be more consistent with ALARA principles. ;

10/16/96 Licensee MAINT EDG fuel oil not analyzed in accordance Procedure LER with TS due to procedure deficiencies. 96013 i Verification of kinematic viscosity for :

new fuel not done and analysis of old fuel not always done at correct frequency. ;

10/16/96 Licensee MAINT Substantial foreign material identified in Programmatic IR96013/

silt layer of Unit 2 suppression pool with IR96018 i potential to clog ECCS strainers. !

Inadequate correction action to Bulletin i 95-02. i 10/15/96 Self OPS Inadecuate cold weather preparations Progammatic -------

causec freezing and the resultant rupture and human ,

of several station heat supply coils on performance i reactor building ventilation, turbine :

building ventilation, and radwaste l building ventilation. The ability to maintain heat to the buildings was a challenge throughout the winter months ^

while replacement equipment was procured and installed. i

. 6

._:____m_ _._m_._.._m_ . , .. __-

.m_- -

___m-- , - - . _ __ _.m _ _ _ _

_--__=m_.,._

PLANT ISSUES MATRIX LASALLE l DATE .ID BY SALP DESCRIPTION CAUSE REF l 10/13/96 NRC OPS Licensed operator lesson plans did not Programmatic IR96018 address SER commitment to operate-CR and AEER charcoal filters in the event of high radiation at the air intake.

10/12/96 sel f- OPS Equipment operators did not follow out-of- Human -IR96013 disclosing service instructions resulting in the Performance wrong battery charger being de-energized.

10/10/96 Licensee ENGR Auxiliary Electric Equipment Room found to Programmatic IR96013/

not meet GDC 19 habitability requirements IR96018 due to failure to understand the design and licensing basis. 1995 removal of MSIV leakage control system did not analyze AEER dose and in fact hadn't been implemented since plant startup. Also could not maintain FSAR required dP.for AEER.

10/10/96 NRC MAINT Inadecuate freeze seal maintenance Procedure / IR96013

~ procec ure. Workers establishing a freeze human seal on an emergency diesel generator performance (EDG) cooling water line demonstrated a good questioning attitude in identifying

, that the subject procedure did not contain the required information. However.'a maintenance. department first line supervisor attempted to resolve the problem by enlaining the intent of the procedure ratler than seeking a formal' work package clarification or' procedure revision.

10/10/96 NRC PS Maintenance worker was not weartap Human IR96013 required protective clothing while in a peformance contaminated area. The worker was wearing rubber gloves and rubber shoe covers but did have on cloth gloves or cloth shoe covers.

-&+ s___- _u_ -

____._____________m__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ . _ _ _ _ . _ _ _ _ ,

___m_. _ , _ _ . . . . _ . _ - _ _ _ . . . . . _ _ _ _ _ _ _ _ _ _ _ . -

. .. . . . - .. - ~. . . . . - . - . - . . - - - - - .. - - ..- -- -_ . ..- - - -- ~ -

PLANT ISSUES MATRIX --

.LASALLE l DATE ID BY' SALP DESCRIPTION CAUSE REF l 10/09/96 Licensee MAINT Failure to follow work request Human IR96013 i' instructions which resulted in Performance

, installation of jet pump plugs in the wrong reactor recirculation loop. A fuel i

handling supervisor demonstrated poor ,

procedural-adherence practices by '

continuing with jet pump plug installation even though he was aware that a required drawing was missing from the work package. ;

10/08/96 NRC ENGR Potential weakness in the licensee's Inadec uate IR96016 !

implementation of NRC guidance (GL 91-18) Procec ure/ :

on TS-required equipment operability. Instruction -

Licensee's program overly reliant on TS ,

surveillance test results for operability ;

~ determinations.

10/07/96 NRC PS Inspectors identified that various hoses Human IR96013 !

crossing a contaminated area boundary in performance :

the 2D heater drain-(HD) pump room were '

not secured. The licensee corrected the 1 condition, however, on October 11. the '

inspectors again identified hoses breaching a contaminated area boundary in ,

-the 2A HD pump room that were not taped or r secured. ;

10/02/96 NRC MAINT Failure of maintenance workers to follow a Human IR96013 procedure during reassembly of the O EDG Performance i service water strainer which resulted in excessive leakage of a strainer backwash valve. necessitating rework.

Documentation in the. rework package was not thorough. representing an impediment to good root cause analysis.

09/29/96 NRC MAINT Failure to follow work practices required human IR96013 by fire protection procedures for ensuring performance a safe welding environment. Combustibles ,

in area of welding.

. - - . .... ~

PLANT ISSUES MATRIX i LASALLE DATE 'l ID BY SALP DESCRIPTION- l CAUSE- l REF l :

i

09/29/96 licensee OPS Four channels of the IRM trip function human IR96016 1 were inadvertently removed from service performance !

under an 00S for the APRM trip function !

.(trip functions shared a common RPS contact which was jumpered out of ;

service). Compliance with the RPS technical specification was achieved fortuitously (scram inserted for unrelated work).

09/28/96 Licensee OPS Inadequate review of 00S checklist results human LER in TS violation. EDG taken 00S and performance 96008 '[

primary containment vent and purge .

downsteream isolaation dampers to purge -

air filters deactivated to comply with TS.

00S cleared for maintenance and dampers also inadvertently cleared although EDG

]. inoperalble.

09/28/96 licensee OPS Irradiated fuel movement was conducted human IR96016 t outside the applicable TS requirements performance !

(while Containment Purge and Ventilation system valves were in a condition where one valve functional but inop., the other i valve closed but energized). When the !

condition was identified, the on-duty operators misinterpreted the TS time !

clock, and thought that they were in an 8-hour LCO rather then non-compliance.

09/28/96 licensee ENGR Some WKM 70-13 A0Vs would not close under human IR96016 their design basis dynamic -loads. The performance inspectors determined that the problem had i not been formally documented by a PIF and :

, had not received a formal operability i assessment in March or April.1996 as !

required by plant procedures.

_ _ ~ _ . __ --_ _ _ ____,_._____..__..____m_

_ . _ _ , _ _ _ _ _ _ ._ - - - -_ _ _ _ . _ . _ _ _ _ _ _ _ _ . . . _ _ _ _ _ _ _ _ _ _ _ . _ = _ _ _ _ _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ _ _ .

l PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 09/28/96 licensee ENGR A proactive and thorough preventive Sel f- IR96016 maintenance initiative led to Critical identification of a potentially generic concern with the effective diaphragm area and spring preload (spring to close) of WKM Model 70-13 ADV actuators. These A0V actuators were used in the RCIC (steam drains) and PCIS systems at LaSalle.

Problem initially identified in March / April 1996.

09/24/96 NRC ENGR The size of the pump impeller for the "A" design IR96011 RHR Service Water Pump was increased using control a maintenance work request and by-passing the change control process. This resulted in increased pump pressure and flow which involved work-arounds and finally improper in service testing of the RHR service water pumps.

09/24/96 NRC ENGR Licensee did not understand design basis design IR96011 for service water system based on number control of calculations using different assumptions, the existence of calculations for non-installed equipment, and using out-dated information in calculations.

09/24/96 NRC ENGR Licensee did not understand basis for TS design IR96011 surveillance recuirements in lake screen control house. When seciment levels above those allowed by TS were discovered. licensee first leveled silt so that level was under TS requirement and then removed without governing procedure or instruction. Also.

surveillance arocedure required only portion of lace screen house be tested.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 09/24/96 NRC ENGR The pump casing material on the service design IR96011 water spent fuel pool makeup pumps was control changed from carbon steel to stainless steel using a maintenance work request without using or involving the design control process.

09/24/96 NRC ENGR Calculations VY-004, ATD-0375 and 3C7-089- design IR96011 001 did not include heat piaing heat loads control even though a modification lad changed the system to take suction from only the suppression pool which is a hot water source.

09/24/96 NRC ENGR Licensee did not recognize adverse trend Programmatic IR96011 on 2B RHR heat exchanger )erformance, had not balanced flows throug1 the heat exchangers, and had no service water corrosion detection program for the system.

09/24/96 NRC ENGR UFSAR not updated for license amendment to Programmatic IR96011 increase allowable suppression pool temperature in July 1989. Several other incorrect statements noted in UFSAR.

09/24/96 NRC OPS Licensee performed a thorough review of Procedures IR96010/

technical specification clarifications, IR96011 deleted several, and identified a few cases where amendments were necessary.

09/15/96 NRC ENGR Engineering personnel did not identify a design IR96011 potential water hammer problem with the control RHR heat exchangers. After questions were raised by the NRC. the licensee initiated an engineering evaluation. the results-of which indicated that a water hammer problem existed in the RHR service water system. Both Units 1 and 2 remain shutdown until a ' keep-fill" system modification is installed to correct this problem

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 09/22/96 sel f- MAINT U1 S/D due to turbine control valve material IR96010 disclosing problems. condition 09/20/96 ------- -------

Unit 2 shutdown for Refueling Outage ----- ----

IR96013 09/19/96 NRC OPS Failure to follow the general procedure human IR96013 for shutdown and to initiate a procedure peformance change reflecting the actual shutdown process used. Shifted recirculation pumps to slow speed using instrument surveillance procedure versus operating procedure.

09/17/96 sel f- ENGR Spurious Unit 2 RWCU isolation on high human IR96013 disclosing differential flow. Long term recurring performance problem that had not been resolved.

09/07/96 sel f- MAINT Reactor building ventilation control material IR96010 disclosing system malfunction causing difficulty in condition maintaining required reactor building differential pressure.

09/06/96 self- MAINT Failed backwash valve for EDG "0" was material IR96010 disclosing challenge to operators, condition 08/20/96 self- PS Administrative overexposure when rawaste personnel IR96014 disclosing operator failed to note alarming performance electronic dosimeter due to high noise and poor levels. (Previous overexposure in 1993 corrective due to same reason.) Need or operator in action vacinity of tank draining had not been communicated to radiation protection department.

08/19/96 NRC ENGR Corrective actions to address a licensee personnel IR96010 identified problem with weak root cause performance analysis and troubleshooting techniques were being slowly implemented and appeared to have limited effect. This issue was identified in a corrective action record more than two years ago and has also been discussed in several NRC inspection reports.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 08/19/96 sel f- ENGR Failure of the RCIC rupture disc. programmatic IR96010/

disclosing / Inadequate corrective actions from similar IR96013 NRC 1994 event. (Apparent Violation) Failure to install drain line tap and procedurally check for water. Following second failure, root cause team recommendations to PORC were weak and included preconditioning of the RCIC system. and corrective actions continued to be slow and lacked management involvement.

08/18/96 self- MAINT #2 turbine control valve closed material IR96010 disclosing unexpectantly and immediately reopened. condition Challenge to operators.

08/14/96 sel f- ENGR Weak root cause analysis of 0 DG failure. weaknesses in IR96010 disclosing / Root cause team was narrowly focused on root cause NRC one component as causing the failure and analysis recommended non-conservative actions to PORC.

08/14/96 NRC MAINT Inadequate documentation of safety related personnel IR96009 work performed on the essential service performance water strainers during the service water event.

08/08/96 licensee PS Unescorted visitor in protected area due personnel IR96002 to inadequate transfer of escort performance responsiblities.

08/08/96 self- MAINT Break identified in iake makeup line. material IR96010 disclosing Challenge to operators. engineering and condition maintenance organizations.

08/02/96 licensee OPS Failure to conduct TS surveillance on procedure IR96007 eight manual primary containment isolation deficiency valves. They had not been checked monthly. but were controlled administratively and checked every 18 months.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 07/31/96 NRC MAINT Corrective actions taken as a result of personnel IR96009 the service water event did not prevent performance unauthorized work on equipment such as the strainer flow measurement and excavation of the cooling lake dike.

07/31/96 licensee PS 'ssed Firewatch due to poor 00S: the human IR96007 initiator and reviewer of the fire performance impairment did not properly identify the fire protection equipment that was to be taken 00S.

07/24/96 licensee PS A deliberate violation of the security human IR96004 plan was identified involving the removal performance of a security badge from the protected area and subsequent effort to surreptitiously return the badge to inside the protected area.

I 07/22/96 self- OPS Unplanned entry into TS 3.0.3 due to loss materiel IR96007 disclosing of containment air particulate and noble condition /

gas monitors due to materiel condition work control problems and work control weaknesses.

07/22/96 licensee OPS /MAINT Several 00S errors occurred in a short human IR96007 period of time and the operations manager performance initiated an 005 standdown. Individually.

the 00S errors were insignificant but together represent a negative trend.

07/14/96 NRC MAINT Inadequate Maintenance procedure for procedural IR96009 reassembly of the Unit 2 RHR service water deficiency strainer .

07/--/96 NRC ENGR The size of the non-essential service design IR96009 water strainer screens were larger than control the size specified in the UFSAR.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION l CAUSE REF 07/--/96 NRC/ ENGR For years, the EDG service water strainer design IR96009 licensee backwash flow was set considerably below control the minimum of 250 gpm as required by Section 9.2.1.2 of the UFSAR. Under these conditions. there was no assurance that the strainer backwash would have functioned as designed.

07/02/96 licensee RP Inadequate evaluation of radiological Programmatic IR96014 controls for drywell at power entry to inspect IRMs. Higher than expected dose rates on May 22 entry not assessed prior to July 1-2 entry. Also didn't consider Information Notice 88-63 on effects of incore irradiation of IRMs.

06/--/96 NRC MAINT Inadequate control or work allowed a foam work control IR96009 sealant to be injected in the service water tunnel 06/29/96 ------

OPS Both Units were shutdown due to foam --------

IR96007 sealant in service water tunnel 06/26/96 sel f- OPS! MAINT Unit 1 Reactor scram and MSIV isolation IM work IR96007 disclosing during IM surveillance of MSIV hi flow dp practice switches (SOR switch). Violation issued deficiency for failure to take corrective actions. and procedure one previous evcnt and PIF without weakness corrective action.

06/24/96 NRC ENGR Failure to initiate prompt actions to personnel IR96008 remove the sealant material from the performance service water tunnel and system after the service water clogging events resulted in extended risk of significant reactor cooling problems.

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 06/24/96 NRC ENGR Inadequate problem documentation by system personnel IR96009 engineers contributed to the mis- performance classification of lake screen house crack sealant work. This work activity affected operability of the essential service water and the ultimate heat sink for both units.

06/24/96 NRC ENGR Operability evaluation for second service personnel IR96008 water event was weak. Testing of the foam performance sealant did not simulate water tunnel weakness in condition. Licensee did not challenge root cause vendor information. No thorough tunnel inspection.

06/24/96 sel f- all Second power decrease due to service water work control IR96007 disclosing problem due to low service water header weakness IR96008 pressure. Power reduced to 77%. IR96009 C6/22/96 NRC PS Maintenance of the Post Accident Sampling programmatic IR96005 System and line organization self-assessments of the chemistry and REMP programs had improved.

06/20/96 NRC ENGR Operability Evaluation for essential personnel IR96008 service water was weak: problems with performance service water pressure were initially in conducting thought to be due to " corn cob" root cause sandblasting material. Op Eval was narrowly focused and not thorough.

06/19/96 NRC OPS Inadequate procedures for the backwash of procedures IR96009 non-essential service water strainers hampered operators when responding to the strainer clogging events. Additionally.

no instructions for manual backwash of the essential service water strainers were included in other operating procedures 06/19/96 NRC OPS STRENGTH: Control room operator response Teamwork / IR96009 during the service water clogging events Skill Level was good.

- - - - - _ . - - _ _ . _ _ . _ - - _ . - = - ---_-----.2=---- , . - - - _ - - -- - - - - = . _ - _ - - - - .--__

PLANT' ISSUES MATRIX LASALLE _

DATE ID BY SALP DESCRIPTION CAUSE REF 06/19/96 NRC OPS Licensee did not make a prompt operability personnel IR96009 determination when there were indications performance that the foam sealant material might not float as assumed in the original operability evaluation. Even after foam material was discovered on the bottom of the service water tunnel, plant management did not immediately declare the associated safety systems inoperable.

06/19/96 NRC OPS Regional NRC management had to influence personnel IR96009 the decision to expand the scope of the performance licensee's service water system investigation to include inspecting-at least one essential service water system strainer. After finding relatively large pieces of sealant material in the inspected strainer the NRC again had to become involved in the decision to verify the strainer backflush capability and to place both units in cold shutdown.

06/19/96 self- all First power decrease due to service water work control IR96007 disclosing problem due to foam sealant injection in weakness IR96008 the lake screen house. Service water IR96009 header pressure dropped requiring power reduction on both units to 77%.

06/15/ % sel f- OPS /PS Failure of the radwaste evaporator causes materiel IR96006 disclosing spill of highly contaminated water and condition sludge and creates a high radiation area. i 06/13/96 NRC OPS / ENGR The drywell post-accident H2/02 management IR96006 (hydrogen / oxygen) monitors were riot being deficiency j operated consistent with the UFSAR. and the 50.59 had not been performed. The operators were given directions per " night orders" to operation the monitors in this ,

configuration.

PLANT ISSUES MATRIX ,

i LASALLE .

DATE ID BY SALP DESCRIPTION

_m .

CAUSE REF l 06/11/96 NRC PS Contrary to RP requirements, hign pressure personnel IR96006 water inses running from inside the performance :

reactor building under the trackway doors !

to an outside high pressure spray system. t were left unattended. The hoses were used ;

during source term reduction activities !

, and were a potential unmonitcred reletse l pathway. t 06/05/96 licensee PS Six individuals were granted protected personnel IR96005 area unescorted access authorization performance without the full backgrcund investigation ,

being conducted within 180 days in -

viclation of 10 CFR 73.56.

05/31/96 NRC ENGR Multiple differences between plant management IR96011/

equioment configurations and the deficiency IR96009 i associated system descriptions in the j Updated Final Safety-Analysis Report i

, (UFSAR) were not identified and corrected.

05/28/96 licensee CPS- Control Rod Mispositioned by an operator personnel IR96006 3 due to the failure to self-check. ONE performance i immediately identified and corrected the deficiency error.

05/28/96 sel f- MAINT Unit 2 EHC Instrument Line Leak caused by equipment IR96006 ;

revealing fatigue failure initiatM a fire alarm and mal function required swapping EHC triin.

05/24/96 NRC PS Numerous deficiencies with implementation programmatic IR96006 !

of the REMP program were identified. The ,

licensee also did not describe corrective actions for deviations from the REMP sampling requirements in the 1995 annual ;

report. as required by the ODCM.

I t

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

_ _ _ _ - - - . * . s .v- - . & _

f PLANT ISSUES MATRIX LASALLE DATE ID BY SALP I DESCRIPTION CAUSE l REF -l 05/24/96 NRC PS- Plant water chemistry control was' good programmatic IR96006 with improvements noted in reactor water sulfate levels, however, feedwater iron levels remained above average and material condition problems continued to impact chemistry 05/24/96 licensee PS- Missed Firewatch: an auxiliary building personnel IR96005 firewatch was missed for 7 hours8.101852e-5 days 0.00194 hours 1.157407e-5 weeks 2.6635e-6 months . The performance watchperson thought that the watch was no deficiency longer required w'len a fire impairment was removed. He was anaware that there was another fire impairment which required the watch.

05/20/96 sel f- OPS Unit 2 Forced Outage Due to #3 Turbine equipment IR96005 revealing Control Valve (TCV) and #1 Bypass Valve mal function (BPV): On 04/24 during routine cycling of-TCVs. the #3 TCV stuck shut due to mechanical binding in the shutoff valve.

The unit was run at reduced power due to this condition. A maintenance outage was planned, however, the spurious opening of BPV #1 caused the unit to be shut down on 5/21. The cause of the #1 BPV problems were a failed card (max combined flow limiter). the pre-amp, and the servo- i

-valve.

05/16/96 self- OPS Operator out-of-service error almost personnel IR96005 revealing necessitated Unit 2 scram: when tagging performance !

out a condensate transfer pump the deficiency i operator mistakenly closed the common r suction valve to the CRD pumps.

05/13/96 licensee OPS Operating Department Individual Cntered personnel IR96005 Radwaste Truckbay without Dosimetry: the performance individual did not perform a self-check. deficiency Dose received was minimal.

PLANT ISSUES MATRIX LASALLE l DATE ID BY SALP DESCRIPTIO CAUSE REF 05/12/96 self- OPS Unit 1 manual scram due to high vibration equipment IR96005 revealing on the turbine bearing #11 and 12: the malfunction cause of the high vibration was improper clearances on the stationary oil deflectors on both bearings. These were supplied by GE as part of the Turbine Supervisory Instrumentation Modification.

Unit 1 was restarted on 5/16 and synched to the grid on 5/17.

05/06/96 self- OPS Unit 1 Synch to the Grid following L1R07: ***** IR96005 revealing problems with EHC calibration and reactor chemistry slowed startup significantly.

04/27/96 NRC PS Personnel Failure to Report Aberrant personnel IR96005 Behavior: tra jnspectors determined that a performance security indivicual had exhibited aberrant deficiency behavior (chiseling a hole in a cinder block wall with a pocket knife, and making statements tc another watchmen about being destructive when he is bored) and it was not problem report to management as a potential FFD concern.

04/22/96 sel f PS Second resin intrusion event: This one material IR 96005 disclosing due to Unit 2 condensate polisher. condition 04/22/96 NRC OPS Degraded RCIC Su3 port Not Evaluated in a personnel IR96005 Timely Hanner: t1e inspectors identified performance that a degraded RCIC rupport was not deficiency evaluated 9roperly. An operator identified the condition on 4/6: however.

engineering was not informed until 4/22 when they performed an evaluation which concluded RCIC was operable.

04/21/96 licensee MAINT Failure to Perform a Tech Spec personnel IR96005 Surveillance: operations failed to perform performance weekly surveillance of the manual scram deficiency pushbuttons (LOS-RP-Wl).

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE l REF l C4/21/96 licensee OPS - Improper Hanging of an Out-Of Service: the personnel IR96005 2A condensate transfer pum) was performance inadvertently isolated ratler than the 2A deficiency condensate makeup pump. Before the error was recognized the reactor operator ,

attemated to start the condensate transfer pump aut quickly identified the pump was not perferming correctly and shut it down. ,

No damage to the pump was sustained.

04/21/96 sel f- MAINT Unit 1 Chemistry Excursion during Startup: skill of the IR96005 i revealing the unit _was started up on 4/21 and later craft and

that day a chemistry excursion occurred post due to a resin intrusion. The internals maintenance of a check valve in the RWCU system was test replaced during the outage. A machining i defect on the valve casing caused the ;

valve disk is stick open during startup.

This problem should have been identified while working on the valve. i 04/17/96 licensee MAINT- High vibration on 2A CRD Pump following- personnel IR96005 maintenance Delayed Maintenance on 28 CRD performance i pump: while disassembling the 2A CRD pump, deficiency -

the mechanics did not question that a ;

coupling bolt was missing and subsequently reassembled the pump and coupling as they .

found it.

04/17/96 sel f- MAINT Unit 1 Shutdown after attempting startup inadec uate IR96005 revealing following LIR07: Unit 1 was started u) on procecures - -

4/13. however. due to calibration pro)1 ems rework with the EHC turbine speed control system the turbine could not achieve 1800 rpm. i The unit was shut down on 4/17.

e s

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 04/16/96 NRC PS Response facilities were in an excellent material IR96004 state of operational readiness. Material condition conditions had improved significantly.

Emergency equipment inventories and maintenance were good, with timely corrective actions taken when deficiencies were identified.

04/16/96 NRC PS The material condition of the Operations material IR96004 Support Center had significantly improved. condition 04/16/96 NRC PS Emergency communications capability was programmatic IR96004 very good.

04/16/96 NRC PS A violation of 10 CFR 50.59 was identified personnel IR96004 pertaining to the failure to evaluate the performance emergency response effect of new site structures on the accuracy of the meteorological monitoring system. This represents a long standing discrepancy with the UFSAR.

04/16/96 NRC PS The '.995 cumulative dose of 520 rem was management IR96004 the lowest in recent history. and both non-outage station dose and individual worker exposures continued to decline.

04/16/96 NRC PS Improvement in ALARA planning was noted personnel IR96004 with the use of cameras and shielding and performance the incorporation of Limerick Station

" lessons learned" in radwaste modification work.

04/16/96 NRC PS Unit 1 drywell dose rates (20-100 mrem /hr) management IR96004 remained constant due to Zinc injection.

04/16/96 NRC PS Problems with schedule adherence, work personnel IR96004 scope control, and rework resulted in performance additional dose during the Unit I refueling outage (11 rem was accrued from r work activities alone)

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

PLANT ISSUES MATRIX LASALLE r

DATE ID BY SALP DESCRIPTION CAUSE REF 04/16/96 NRC PS Problems with interdepartmental personnel IR96004 communication, shielding installation, and performance tool availability delayed several maintenance activities and impacted RP coverage.

04/16/96 licensee OPS Reactor Operator Removed Key from Mode personnel IR96004 Switch: this placed the unit into a Tech performance Spec action statement. Operator was not deficiency

" thinking" and did not understand the consequences of his actions. He was terminated based or. past performance problems.

NRC OPS A temporary alteration (TA) of the 2B Personnel IR96005 diesel generator caused a local alarm Performance which operators identified and ignored. Deficiency ihe TA defeated the motor driven fuel pump function of a backup to the engine driven pump for approximately five years and no action was taken by operators to correct the annunciator response procedures.

04/16/96 licensee OPS Operators created a workaround to automate materiel IR96004 generating the weekly list of switchyard condition / .

deficiencies to counter the slow Personnel resolution of the deficiencies. Performance Deficiency i 04/16/96 NRC OPS Inadequate temporary procedure changes of Inadec uate IR96004 controlled LaSalle Operating Procedures Procec ure/

(LOP) located in the relay house were used Instruction twice without proper review or approval.

The procedures were for testing relays in the switchyard and improper performance of the procedure could result in tripping one of four 345 kV offsite power O @

PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 04/16/96 NRC OPS Operators took the "0" diesel generator Personnel IR96004 (DG) out of service during testing on Unit Performance 1 to prevent an automatic DG start. Deficiency However. should the DG be required to operate during a potential accident on Unit 2. the DG would have needed to be manually started by operators. The operators. although not in violation of Technical Specifications. " worked around" a degraded condition to complete the testing.

04/16/96 NRC OPS STRENGTH: Heightened level of awareness Teamwork /

IR96004 briefings were generally thorough. Skill Level Operators maintained good control of control room activities.

04/16/96 Sel f- MAINT Weak procedures led to the inadvertent de- Inadec uate IR96004 Revealed energizing of the security uninteruptible Procec ure/

power supply during performance of Instruction preventive maintenance.

04/15/96 licensee PS Six Managers and Three INP0 Personnel human IR 96004 Violate RWP: these people accessed the perform.

refuel floor, a posted high radiation area. The RWP they were on did not allow access to high radiation areas.

04/12/96 licensee OPS Amertap Pumps Found Deadheaded: during a human IR 96005 walkdown by the system ongineer, he perform. and identified that the operators had not materiel properly restored the equipment following condition a weekly surveillance. As a result, the pumps were deadheaded for 24 hours2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months and a seal leak on the A pump had degraded.

k PLANT ISSUES MATRIX LASALLE DATE ID BY SALP DESCRIPTION CAUSE REF 04/12/96 self- MAINT Painter Inadvertently Tripped an RPS Bus: human IR 96004 disclosing the )ainter accidently bumped the EPMA perform.

breacer. This caused the trip of the RPS bus. containment isolation. and a half scram. When the painter recognized what he did, he inappropriately reset the breaker.

04/09/96 sel f- MAINT ESF Actuation While Valving in RVLIS: unknown. IR 96004 disclosing a Division III actuation occurred due to a licensee has pressure spike while IMs were valving in not ,

RVLIS. The 1B DG started and HPCS pump determined started and injected into the vessel for 14 seconds. Reactor level went from 44 to 58 inches. Violation for failure to take adequate corrective actions to prevent recurrence. A previous identical event occurred on Unit 2 on May 3 1995. (Not ceportable because the test considered the possibility of the actuation and pre- -

planned for it.) '

04/04/96 NRC MAINT/PS Violation for Failure to Comply with human IR 96004 Procedures: the inspectors observed hot perform.

work (cutting, grinding. welding) not being conducted per procedure. There were combustibles in the area and not properly covered.

04/03/96 self- MAINT dSF Actuation during Ex;ess Flow Check procedures. IR 96004 disclosing Valve Testing: a instrument rack spike possibly caused a Unit Division II initiation (1A other root DG. and B and C RHR pumps started). causes Initial cause appears to be procedure problem. (Not reportable because the test considered the possibility of the actuation and pre-planned for it.)

_ . . . _ _ _ . _ _ _ _ _ _ _ _ - _ _ - ___.________m _ . _ __ -

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

PLANT' ISSUES' MATRIX LASALLE :

DATE. l ID BY l SALP 'l' DESCRIPTION l CAUSE l REF l 04/02/96 .self- MAINT FME. Plug in Stator Water Cooling System: human IR-96004 disclosing after returning the system to service. perform.

following work during the outage. it did not operate properly. The cause was a FME plug left in the system piping.

04/01/96 licensee MAINT Failure to Complete Tech' Spec Surveillance human . IR 96004- i within Required Time: all aspects of the perform and Tech Spec required response time test work control ;

surveillance for Unit 1 Division 2 could i

not be completed during the originally ,

scheduled time (03/13) due to safety .

concerns. Poor communications led to the t

failure to complete all aspects of this j test before it was past 1.25 date (04/03). ,

I

[

i I

i

' l i

i l

t I

I i

, a e

s PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 04/22/97 NRC Ops AIT (inspection completed on 3/7/97) Human 97007 determined that, during 2/21/97 reactivity performance mani3ulation event, there was a total breacdown in command and control by operations supervision resulting from (1) inadequate communications between operators, operations supervision, operations management. and nuclear engineering department personnel, and (2) the failure of operations supervision.

operations management. and plant management to provide clear directin to the operating crew regarding the planned shutdown. The licensee also took inadequate corrective actions to precursor events and after this event did not implement adequate immediate corrective actions.

04/14/97 NRC Ops CAL supplement issued to include specific ------ ------

ccmmitments by the licensee to address human performance problems in operations, material condition issues affecting startup, and deficiencies in engineering support to operations that have been identified by the NRC and licensee.

03/26/97 NRC Plant Tygon tubing associated with yellow Human 97009 Support containment (leak collectors) did not have performance radiation tape or radioactive material markings at various locations in the auxiliary building.

03/25/97 NRC Plant Individual removing protective clothing Human 97009 Support containers from the fuel building did not performance use a survey instrument to survey each bag of contaminated clothing.

., # , "+" indicates a positive attribute / occurrence.

e 2

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 03/25/97 NRC Plant Inadequate control of contaminated Human 97009 Support boundaries (cords and hoses not properly performance secured) in auxiliary building and turbine buildings. Improper postings.

03/21/97 NRC Plant Overall effectiveness of licensee's + 97008 Support emergency preparedness facilities, equipment, training, and organization was good. Licensee personnel performed conservatively during actual activations of the Emergency Plan.

03/21/97 NRC Plant Quality assurance oversite of the Programmatic 97008 Support emergency preparedness program was good.

However, contrary to 10 CFR 50.54(t) annual reviews of the emergency preparedness )rogrtam did not address the adequacy of t1e offsite interface with the State of Illinois.

03/17/97 Licensee Ops Significant voiding in Unit 2 reactor Human 97002 vessel had been occurring since 2/18/97 performance which was approaching level that could challenge NPSH for shutdown cooling.

Licensee had unnecessarily taken vessel level instrumentation out-of-service.

Problem occurred despite several previous generic communications and a similar (but less significant) event on Unit 1 in 9/96.

03/11/97 Self Maint Unusual event declared for Unit I loss of Material 97008 offsite power due to a system auxiliary condition transformer trip upon the. failure of a pressure sensor.

02/28/97 Self Maint During reassembly of the diesel driven Procedure 97005 fire pump, the discharge flange was cracked as a result of overtorquing the bolts.

, , "+" indicates a positive attribute /occmrrence.

PLANT ISSUES MATRIX i

ZION DATE ID BY l SALP DESCRIPTION CAUSE REF l ,

02/28/97 Self Ops Unusual event declared when a U.S. ------

97008 i National Weather Service weather balloon instrumentation package landed across the !

Unit 2 Switchyard System Auxiliary Transformer. '

02/25/97 NRC Ops NRC AIT arrived on site to investigate Human 97006/ ;

2/21/97 event involving inadequate control performance 97007 of reactivity manipulations. CAL issued i which requires, prior to s'tartup of either i unit, that the licensee discuss :

investigation results. performance issues. I and corrective actions with the NRC and

.ioplement a remediation plan. ,

02/25/97 NRC Maint 2B EDG work instructions contained Procedures 97002 incorrect torque value.

02/25/97 NRC Ops Licensee staff failed to recognize the Human 97007 potential significance of a hydraulic performance transient that occurred while performing .

RHR valve testing. i 02/24/97 Licensee ~0ps Unusual Event declared due to plant not Human 97002/ :

being brought to cold shutdown condition performance 97007 !

as required by TS for inoperable reactor coolant flow transmitters. ;

Instrumentation had been taken 00S on :

2/22/97 without operators realizing TS ramifications. causing them to not enter cold shutdown when required by TS. (Plant was already in hot shutdown.) Exited UE ;

when cold shutdown reached on 2/25/97. :'

This event demonstrated similar weak operating practices, which included poor command and control. and training deficiencies. that contributed to tha i occurrence of the February 21 reactivity i management event. .

1

. , "+" indicates a positive attribute / occurrence. '

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 02/21/97- Self Ops During plant shutdown, reactor operator Human 97002 withdrew control rods without proper performance /

oversight. Breakdown of teamwork and program l command and control of evolution. t 02/21/97 Self Maint Unit 1 shutdown commenced due to failure Human 97002 i of diesel-driven containment spray to performance start within design time during surveillance. (Circuit failure.) '

02/21/97 NRC Ops Licensee failed to test both starting Human 97002 ;

trains of "C" contaminated spray pump. performance 02/21/97 NRC Ops Licensee failed to implement changes to Human 97002 t testing procedures for "C" containment performance spray pump in response to 1993 violation.

02/16/97 Self Maint Electrician received an electric shock due Human 97002 to poor work practices. performance 02/13/97 Self Maint A fuel oil leak occured during post- Procedure 97005 <

maintenance testing of the 2A EDG due to t maintenance personnel failing to tighten a fitting. '

02/13/97 NRC Ops Abnormal operations procedure for loss of Procedure and 97005 service water did not address confirmed material ;

emergency diesel generator heat exchanger condition fouling due to fire system debris.

02/13/97 NRC Eng Additional discrepancies' identified with Program 97002 recirculation sump configuration with i respect to drawirgs. ;

02/13/97 Self Maint Licensee determined that 2A EDG failed to Design 96020/

start due to starting air. control valve control 95005 not opening was caused by improper installation of a shipping plug.

, , "+" indicate.s a positive attribute / occurrence. ,

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 02/13/97 Licensee Eng Unit 1 and 2 4KV and 480V buses declared Program 97002 inoperable due to seismic concerns of.

disconnected breakers.

02/11/97 Self Maint Maintenance personnel overterqued EDG 2A Procedure 97005 cooler outlet flange which resulted in a service water leak through a crack. ,

Overtorquing has been a recurrent problem.

02/10/97 Licensee Plant Inaccurate boron concentration results for Program / 97002 Support the refueling water storage tank resulted procedure in the licensee starting to shutdown Unit 1 in accordance with an LC0 action statement. Following a dilution.

procedure inadequacies resulted in a lack of mixing and recirculation of the tank.

02/07/97 NRC Plant The conduct of security operations was + 97004 Support good, with continued improvements in the organization's professionalism and communications. Security contract staff shortages in the nuclear security officer and access control inspector positions were eliminated. resulting in a reduction in the use of overtime and an increase in tactical response drills conducted.

Generally. contract security force performance was good. Personnel errors '

were few and moderate in significance.

02/07/97 NRC Plant A review of security related problem Human 97004 i Support identification forms (PIF) indicated a performance ;

continuing need to 3romote worker personal !

accountability in t1e areas of badge .

control and vital area door control. A security drill to evaluate performance in ,

the conduct of warehouse package searches showed a lack of worker understanding of '

tasic expectations.

. . "+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 02/06/97 Licensee Ops Due to inadequate pre-evolution briefing Human 97002 the pressurizer surge line was cooled down performance at an unexpected high rate during a RCP swap.

02/05/97 Licensee Maint SQV identified programmatic breakdown of Program 97002 I&C department control of the classification of periodic calibration of plant instrumentation program.

02/05/97 NRC Maint Licensee failed to take adequate Human 96020 corrective actions to resolve cause of performance water in auxilliary feedwater pump bearing.

02/05/97 NRC Maint Licensee failed to adequately address Human 96020 impact of incorrect oil being added to the performance 2B containment spray pump.

02/01/97 NRC Ops Two examples of weaknesses in the Eagle 21 Procedure 96020 failure abnormal operating procedure which would make recovery from a steam generator level transient at low power more difficult.

01/27/97 NRC All Zion placed on NRC watch list and letter -------- ------

issued to Comed pursuant to 10 CFR 50.54(f).

01/27/97 Self Maint 2A EDG experiences loss of lube oil . Material 96020/ ,

Cylinder liner crack and piston failure condition 95005 identified.

01/27/97 Self Maint 2A EDG surveillance aborted due to trip Human 96020/

chart recorder not hooked up properly, performance 95005 (Repeat occurence.)

01/24/97 Licensee Eng Generic Letter 96-06 applicable for Zion: Design ENS pipe stresses outside design limits but control operable for SW supply to RCFCs and expansion of water in isolated piping.

"+" indicates a positive attribute /occt.crence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 01/22/97 NRC . Plant Since April 1996, two of seven persons Human 96021 Support authorized to approve / release contaminated performance /

material shipments had not successfully program completed the annual training as required by the administrative procedure.

01/22/97 NRC Plant Radiation protection procedures concerning Human 96021 Support radioactive material shipping were not performance /

updated to be consistent with the program April 1, 1996 revisions to the NRC and DOT requirements.

01/22/97 NRC Plant Since January 1996, the licensee had not Human 96021 Support followed procedures which ensured that the performance /

a tivity of radioactive wastes were program accurately determined in accordance with 10 CFR 61.55(a)8. Although the licensee had an annual requirement to analyze resins to determine radionuclide scaling factors. the steam generator blowdown and primary resin scaling factors had not been determined in over two years.

01/22/97 Licensee Plant The licensee suspended all shipping of Human 96021 Support radioactive material and radioactive performance /

waste. Based on NRC findings, senior program plant management were not confident in the radiation protection department's ability to ship materials in accordance with procedures and the regulatipns.

01/22/97 NRC Ops Instances of non-conservative licensee Human RIs actions with respect to EDG and motherhood performance LCOs due to licensee interpretations.

01/22/97 Self Eng 2B EDG abnormally high lube oil Material 96020/

temmratures caused by fouled heat condition 95005

, exc1 angers. (Repeat occurence.)

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 01/22/97 NRC Plant The April 1996 SOV audit of the Program 96021 Support radioactive material program was not thorough and failed to identify fundamental weaknesses in the program.

01/21/97 Licensee Eng Plant not analyzed for design stresses and Design ENS loads for PORV lift transient. (Possible control conflict with previous licensee correspondence.)

01/21/97 NRC Ops 0;arator did not follow abnormal operating Human 96020 procedure in response to Eagle 21 failure performance event.

01/20/97 ----- ---

Unitization of plant organization --- - -----

implemented.

01/19/97 Self Maint 2B EDG tripped on high turbocharger Material 96020/

lubricating oil ratio due to excessively condition 95005 cold EDG room temperature.

01/18/97 Self Maint Multiple problems with Eagle 21 digital Material RIs control system: Several occasions had condition problems with bistables including channel trips. One failure resulted in reactor pressure transient.

01/18/97 Self Maint 1A EDG surveillance aborted due to strip Human 96020/ ,

chart recorder not hooked up properly. performance 95005 ___

01/18/97 Sel f Maint 1A EDG manually tripped due to freezing of Material 96020/

jacket water level sensing line. condition 95005 01/17/97 Licensee Maint EDG discharge check valves not tested as Programmatic 96020 required by IST program.

. . "+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION ,

t DATE ID BY SALP DESCRIPTION CAUSE REF 01/17/97 Licensee Ops Failure to perform EDG hot restart Procedure RIs surveillance within load range specified by TS since initial plant operation. In addition, the EDG starting air discharge check valves had not been tested as required by the IST program.

01/14/97 Self Maint Poor work practices and acceptance of Human 96020 '

unexpected plant conditions resulted in a performance delay in recognizing a personnel safety ,

hazard during containment spray system maintenance. A control room operator failed to communicate the abnormal position of two containment spray system !

valves, which delayed investigation of the condition.

01/14/97 Self Ops Failure of operators to follow 00S Human 96020 procedure resulted in inadequate performance protection of Unit 1 containment spray ,

system maintenance activities.

01/11/97 Self Ops Corrective maintenance on volume control Material 96020 ;

system valves delayed Unit 2 downpower to condition investigate recirculation sump cover.

01/10/97 NRC Eng Engineering slow to recognize and Human 96020 appro)riately evaluate impact of lack of performance vent 1 oles in containment sump covers.

01/08/97 ------- ---

Unit 2 outage extended to address numerous ------- 96020 issues including containment coating.

material deficiencies, and program -

reviews.

i

. . "+" indicates a positive attribute / occurrence.

. . - . . . . - ~ . .- ~ - - - -. - . - . . _ . . - . - . . - . ... . . . .

PLANT ISSUES MATRIX I ZION DATE ID BY SALP DESCRIPTION CAUSE REF l ;

01/08/97 NRC Plant Poor planning and coordination in the Human 96021 '

_ Support preparation of a shipment of radioactive performance /

waste resulted in the halt of the Program evolution. A current analysis had not ,

been performed for ine waste stream, 1 Licensee personnel also inadequately .

directed the carrier's vehicle near a !

contamination boundary, which resulted in !

the carrier's vehicle striking and moving 1 the boundary and brushing against a i container of resin within the contaminated -

area. :

01/08/97 NRC Plant Operations personnel failed to follow Human 96021 Suport radiation protection contamination control performance .

procedures. The individual removed an item from a contaminated area without either containing the item or having a i qualified person survey the item. Plant i management indicated that this was a i routine operations practice. i 01/02/97 NRC Ops Licensee failed to perform safety Program 96020 evaluation of open omrability assessments ,

(15) prior to mode c1ange. !

12/31/96 Licensee Eng Numerous deficiencies identified with Material 96020 !

cable tray configuration (previous Safety Condition / :

System Outage Modification Inspection Program ,

findings). .

12/26/96 Licensee Eng Licensee identified that several valves Program 96020 were not tested as required by IST program. j I

i.

I i

"+" indicates a positive attribute /occtcrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 12/24/96 NRC Plant Access to safety related equipment Material 96021 Support continued to be significantly encumbered condition /

by high source radiological source term Program and contamination. A large number of contamir.ated areas within the Auxiliary Building. i.e. residual heat removal pump and heat exchanger rooms. centrifugal charging pump rooms. and radioactive waste tank and pump rooms impeded operator and plant staff access.

12/24/96 NRC Ops Containment coatings (paint) not in Material 96020 conformance with UFSAR and potential ECCS contition/

si reen fouling. Program 12/16/96 NRC Ops Inspectors identified numerous equipment Material 96020 deficiencies in Unit 2 containment (e.g. Condition pipe supports damaged. missing fasteners.

frayed cables. cracked weld on RCP oil collection device. etc.)

12/12/96 Licensee Eng RCS loop vent and drain valves (8 valves) Program 96020 had never been tested under the IST program.

12/09/96 -----

P1 ant The licensee shipped radioactive material Human 96021 Support to the Byron site with contact radiation performance /

levels which exceeded regulatory limits. Program The licensee's survey indicated contact dose rates of 0.7 mrem /hr: however, the shipping papers indicated contact dose rates were less than 2 mrem /hr. As a limited quantity shipment. dose rates are required to be no greater than 0.5 mrem /hr.

12/05/96 ----

Licensee announces planned unitization of ---------- ------

organizational management structure.

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION l DATE ID BY SALP DESCRIPTION CAUSE REF 12/04/96 NRC Plant Good aerformance was observed during the Human 96021 Support Decemaer 4.1996 medical drill, with the performance /

exception of some minor problems in Program contamination control. Communications and coordination with offsite response personnel ensured that the simulated casualty was well understood.

Contamination control practices were good; however. a potentially conta ninated security officer was not well controlled.

12/04/96 NRC Plant Radiological housekeeping and contaminated Human 96021 support area boundaries were not well controlled. performance Several areas within the Auxiliary Building were identified having protective clothing strewn about the area unsecured hoses crossing contaminated area boundaries. hoses containing fluids (within contaminated areas) not leading to collection devices. and pump leakage in the horizontal pipe chases.

11/28/96 Self Maint Inadequate maintenance procedure reculted Procedures / 96017 in damage to the 1A AFW pump turbine Human inboard bearing. performance 11/27/96 NRC Maint Inspector identified untorqued connection Program 96017 on containment air hydrogen loop isolation valve.

11/24/96 Licensee Eng Discrepancy between UFSAR and actual Program 96017/

clearances for water level above and below 96020 fuel assemblies during fuel transfers.

11/22/96 -------- -----

Licensee completed onsite Independent ------- ------

Safety Assessment.

11/22/96 Licensee Eng Spring tension on Unit 2 PORV's changed Human 96020 without using appropriate design process. performance

"+" indicates a Dositive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 11/20/96 Self Eng During RPS and ESF response time testing, Human LER system engineer inadvertently shorted a performance 96010 contact resulting in actuation of several Unit 2 containment isolation valves.

Engineer needed longer leads and opted to use some already connected (a shortcut).

Disconnected from test box instead of relay panel first.

11/14/96 Licensee Ops Recurring overtime policy violations Procedures / 96017 (previous DET item) Program 11/11/96 NRC Maint Licensee failed to address operability for Human 96017 j TS battery surveillance tests with performance parameters outside test acceptance ,

criteria: Occurred on 11/11. 11/4. 10/7 and 4/1/96 11/07/96 NRC Eng Inspectors identified that licensee failed Human 96017 to assess the operability of safety- performance /

related pipe suppo.'ts in a timely manner. Material Condition 11/07/96 NRC Maint Failure to implement prompt corrective Human 96013 actions for steam gene.ator tubes: with performance weld zone indications before returning the generators to service following the 1995 refueling outeges. The licensee's safety focus in managing steam generator tube degradation has improved when compared to the 1995 refueling outage. However, the inspectors had concerns with four tubes in SG C with ET indication lengths greater than existing calculations allowed for tube structural integrity and the causes of the potential SG tube leakage identified for ten tubes during the secondary side SG pressure testing.

e

'+" indicates a positive attribute / occurrence.

_ ___ _ . __ . . m. _ . _

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 2

11/07/96 Licensee Eng- Fuel movements took place during Z2R14 and Design 96017/ .

all previous refuel outages without pipe control 96020 !

tunnel exhaust ventilation path routed through the charcoal filters. Caused by removal of a block wall between fuel handling building and containment to facilitate moving equipment.

11/06/96 NRC Maint Inspector identified gas cylinder Program 96017 improperly securred to seismic scaffolds.

11/06/96 NRC Ops Licensee identified that operating Procedure LER procedure for unisolating and filling a 96025 i reactor coolant loop from the refueling cavity violated TS surveillance requirement to account for residual water ;

in the drained loop, sample the refill !

water for boron, and sample the loop for boron prior to opening the loo) stop valves. Violation occured eac1 tim evolution performed since 1983. i 11/04/96 NRC Maint Inspector identified examples of thread Human 96017 i engagement criteria not met for conduit performance support for feedwater isolation valves. ;

11/03/97 Self Ops Operation of out-of-service valve resulted Human 96017 in spill of 400 gallons of RW5T water: Performan'a/

. Inappropriate operator response to Materia' .

material condition problem on valve reach Condition !

rod indication. ,

. . "+" indicates a positive attribute /occe rence.

PLANT ISSUES MATRIX ZION n= -

DATE ID BY SALP~ DESCRIPTION CAUSE REF l 11/01/96 NRC Plant The conduct of security operations was +. 96018 Support professional: with marked improvements in the clarity and thoroughness of shift turnovers and staff communications in general. NRC observed functional tests of the perimeter alarm system and protected area ingress search equipment demonstrated the operability of the equipment. X-ray operators responded promptly and effectively to the discovery of actual contraband during ingress search. A tour of plant security areas showed good worker security awareness.

11/01/96 NRC Plant Sk urity contract staff shortages: in the Program 96018 Support contract security organization continued to result in the use of overtime and adversely impacted the ability of the training organization to conduct response team exercises.

10/31/96 Self Maint Poor work practices and inadequate Procedures / 96017 maintenance procedures resulted in five Human protective trips of the 2A EDG during post performance maintenance testing 10/28/97 Licensee Maint Maintenance personnel added the incorrect Human 96020 oil to-the 2B containment spray pump performance 10/28/96 Licensee Ops Missed TS surveillance caused by failure Procedure 96017 to recognize inoperable "0" emergency diesel generator. Unit 2 control switch placed in PTL per operating procedure for bus outage but not readily apparent that would affect operability for Unit-1.

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE- .ID BY SALP DESCRIPTION CAUSE REF 10/28/96 Self Eng LLRT failure indicated that Unit 2 ' Human LER Appendix J Type B leakage exceeded TS Performance 96009 requirements during previous operating ,

cycle due to inadequate review of 2A safety injection pump discharge relief valve closed piping functional capability.

When penetration was added to Appendix J program in 1995. licensee failed to note there was an already identified active ,

lfak. Subsequently recieved NOED to not -

test until next refuel outage.

10/26/96 NRC Plant Poor operability of radiation monitors: Material 96016 Support chronic operability problems. inaccurate Condition /

control room indications. lack of station Program commitment in implementing $ction plans.

10/24/96 NRC Plant The radiological condition of the plant Material 96016 Support was poor.: Access to many areas Condition /

containing safety related equipment was Program impeded by high radiation levels and/or i high contamination levels. No clear plan for addressing these conditions was identified by the inspector. i i

i I i l

P I

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 10/24/96 NRC Plant During the Unit 2 refueling outage. Program 96016 Support radiation worker contamination control practices and the control of radiological aostings and boundaries were good; lowever, the licensee continued to identify radiation worker ALARA issues.

Although pre-job ALARA briefings were very detailed. problems were identified concerning the content of some ALARA plans and radiation work permits. Examples included entrance to the inside missile barrier (IMB) area was very congested on several occasions and licensee's initial ALARA plan and RWP for the C cold leg LSIV repair contained several typographical errors that affected the radiological hold points and contained certain unclear instructions to workers.

10/24/96 NRC Plant The licensee did not use the appropriate Procedure 96016 Support environmental lower limit of detection (LLD): for liquids when analyzing liquid samples for licensed radioactivity prior to unconditional release. Licensee documentation did not indicate that licensed material was unconditionally released from the restricted area.

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ! ID BY SALP DESCRIPTION CAUSE REF !

10/24/96 NRC Plant- Problems were identified concerning the Material 96016 Support licensee *s calibrations of the radiation Condition /

monitoring system. The reliability of the Human Control Room radiation monitoring display Performance system and the licensee's control of the '

system's configuration was poor. Several large differences between as found and as left calibration data. radiation monitor display system used an incorrect internal conversion constant. calibration data for the containment purge monitor indicated a failure to meet acceptance criteria but the individual performing the calibration incorrectly noted that the conditions were within the acceptance criteria. resulting '

in corrective actions not being accomplished.

10/24/96 NRC Plant The licensee provided effective control Human 96016 Support and documentation of effluent releases.: Performance Offsite dose calculations for radioactive releases were performed in accordance with the licensee's Offsite Dose Calculation Manual.

10/24/96 NRC Plant The Control Room and Fuel Building / + 96016 Support Auxiliary Building ventilation testing -

program was well implemented by the engineering staff. The material condition was good as evidenced by satisfactory i testing results and high operability. The inspectors identified a single occurrence of incorrect information in the licensee's Electronic Work Control System concerning a Technical Specificat ion surveillance.

~

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY l SALP DESCRIPTION CAUSE REF 10/23/96 NRC Ops Operation of reactor at greater than 100 Procedure 96017 percent power (3250 MW thermal): due to incorrect licensee interpretation of license condition.

10/15/96 NRC Ops Inspectors identified leaking service Material 96017 water motor cooler resulted in pump being Contidion declared inoperable.

10/15/96 NRC Ops Licensee failed to implement corrective Program 96017 actions for an inoperable battery exhaust ventilation system.

10/08/96 Self Maint Contractor cross connected service air Human 96014 wi h demineralized water: allowing water Performance into service air system. Bypassed work controls.

10/07/96 NRC Plant Personnel deployment strategy devised by Program 96018 Support security for protecting against an external adversary with the characteristics of the NRC design basis threat was not adequate.

10/07/96 NRC Plant Generally command and control of the Human 96018 Support response force during the security drills Performance was poor indicating a need for additional tactical training or shift drilling.

10/07/96 Self Ops Equipment attendants (EA) isolated the Human 96014 backup air supply to RHR valves 2HCV-RH606 Performance and 2HCV-RH618 instead of the main air supply during out-of-service: due to incompete knowledge of intended configuration.

"+" indicates a positive attribute / occurrence.

_, - ~ _ _

m...

PLANI ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE f REF 10/06/96 Licensee Ops During shutdown of the 1A DG the operator Human 96014 incorrectly reduced generator power: from Performance 4 MW to 0 MW instead of required 1 MW and failed to hold generator power at 1 MW for 15 minutes due to inattention to detail.

Similar error on 9/9/96.

10/05/96 Self Maint >or material condition of check valves: Material 96014 resulted in two radioactive gas releases Condition it, the auxiliary building and the Unit I containment.

10/05/96 NRC Eng Temporary fan was attached by duct tape on Design 96014 the Unit 2 manipulator crane: over the Control refueling cavity while fuel assemblies were being moved.

10/05/96 Licensee Ops Unit 1 inadvertently entered a TS LCO: for Procedure 96014 the penetrativ;, pressurizatior 'em when a technician lifted a Unit 2 let icated at the "0" pp air compressor. L recognized immediately until pointed out by SOV personnel in the control room.

(Good finding by SQV) 09/26/96 Self Eng 500 gallons of water was inadvertently Procedure 96014 drained: from the Unit 2 RWST to the transfer canal during testing performed by system engineering.

09/25/96 Self Maint Instrument air lost to the Unit 2 Procedure 96014 containment: as a result of a poorly planned maintenance activity to install valve blocks on the instrument air containment isciation valves.

"+" indicates a positive attribute / occurrence.

.m -

PLANT ISSUES MATRIX-ZION __

ID BY CAUSE REF DATE f SALP DESCRIPTION 09/24/96 Self Plant Technical specification violation when an Human 96016 Supoort/ RPT incorrectly positioned filter paper Performance Or, causing a SPING to enter low-flow fail mode.: Core alterations and containment atmosphere purge continued with the failure going unnoticed by operators despite alarm. Licensee did not have an operable radiation monitor capable of automatic isolation of the containment purge / vents.

09/23/96 Self Eng System engineer signed off the step in Human 96014 TSGP 97 without performing the associated Performance action that ensured energization of undervoltMy relay 4?7TD1 before de-energizinc relay SDR/27-2. Caused actuation of 2A service water pump breaker.

09/22/96 Self Ops 3,000 gallons of demineralized water were Procedure 96014 sprayed inside containment: due to failure to verify that valves off the demineralizer water header were closed ,

prior to opening the demineralit d water containment isolation valves.

09/2E/96 Licensee Plant. Supt Licensee failed to perform compensatory Material 96016 sampling: when ODCM radiation monitor Condition /

(2RT-PR26) was out of service. Human Performance 09/19/96 -------- ---

Unit 2 shut down for refuel outage. ------ -----

"+" indicates a positive attribute / occurrence.

. PLANT ISSUES MATRIX-ZION DATE ID BY DESCRIPTION CAUSE l REF -l-

_S_ ALP _ .

09/18/96 Licensee ~ Ops. . Inadvertent Unit 1 entry into TS'LCO: for Human 96014 l containment isolation valves during stroke Performance /

testing of the 2A steam generator Procedure atmospheric relief valve. Acceptability i of valve stroke time was not evaluated by ;

the personnel performing the test. The operators and the unit supervisor did not .

recognize that exceeding'the valve data !

, required the valve to be considered :

inoperable. ;

09/17/97 NRC Ops Exceeded TS LCO required action time Human 96014 interval: of eight hours between Performance verifications of offsite power 1 availability during 2B DG outage. Four additional examples identified for earlier '

DG outages. Caused by incorrect l understanding of Technical Specifications. .

09/16/96 NRC Ops Operator continued to pull control rods Human 96014 l even though control board rod demand and Performance-rod position. indication deviated greater ;

than 12 steps: on several occasions during ,

withdrawal of shutdown banks. Did not ;

enter A0P or investigate rod Josition ,

indication problems. Caused ]y deficiencies in communication of i

expectations for conduct of startu). in ,

command and control during rod wit 1drawal.

and in operator sensitivity to possible i rod misallignment due to known position !'

indication problems.

t l

5

"+' indicates a positive attribute /cccuirence. l

i PLANT ISSUES MATRIX ZION 1

DATE ID BY SALP DESCRIPTION CAUSE REF l 09/15/96 Self Ops Uplanned LCO entry when Equipment Human 96014 Attendant partially disassembled the 2B Performance safety injection (SI) pump component ccoling water flow transmitter: in an effort to reset the SI pump cooling water low flow annunciator. Caused by inadequate equipment attendant communications and understanding of '

duties.

09/10/96 NRC Maint Quality control (QC) inspection for the Human 96014 torquing of the 2B emergency diesel Performance generator jacket water cooler end cover w: not independent since the QC inspector set the torque wrench for each torque increment.

09/09/96 Self Maint EDG 2A declared inoperable due to fouling Procedure 96014 of HXs: Attributed to 8/14/96 backflush of fire protection header. Previous >

5/59/96 fouling of EDG 2A HXs attributed normal accumulation between cleanings.

09/05/96 NRC Maint Procedure VT-3/4-1, revision 2 "VT-3/4 Procedure 96013 Visual Inspection Performed for Section XI." was used for an inspection and did not specify acceptance criteria for clearances between the building structure and the pipe su) port baseplate.

Consequently. t1e visual examinations performed were inadequate in that they failed to identify several cases of clearances between the building structure and the support baseplate that were not within established criteria specified in procedure NWSP-S-05.

"+" indicates a positive attribute / occurrence.

_ _______ _ . _ _ . . . _ _ . _ . .. . _ _ _ - - . .- ~ _ _ _ _ _ ~

~

' PLANT ISSUES MATRIX l

ZION DATE ID BY l SALP DESCRIPTION CAUSE REF 08/26/96 Self Maint Unit 1 shutdown due to failure to install Human 96014 the hypoid gear locating key for two PORV Performance \

block valve drive sleeves: during the 1995 Procedur0 Unit I refueling outage. This resulted in a PORV block valve tripping on thermal overloads.

08/25/96 NRC Eng Single failure of blackout detection Design LER control circuit would prevent automatic control 96022 scquencing of 4 KV and 480 volt safe shutdown loads during LOOP.

08/22/96 NRC Eng Over 100 discrepancies between UFSAR and Procedure 96011 as-built and operated plant, which were identified during licensee's UFSAR conformance review, were not formally

. documented: for resolution due to -

inadequate procedures and failures to follow procedure.

08/22/96 NRC Eng Breakdown in modification package closure Program / 96011 process: Nine safety related and 19 non- Human safety related modifications installed and Performance ;

placed in service although not authorized by operations and not received appropriate .

post modification testing. ,

08/22/96 NRC Eng Ineffective 10 CFR 50.59 safety evaluation Program / 96011 -

process: Multiple failures to perform Human safety evaluations. and inadequate safety Performance '

evaluations.

08/22/96 NRC Eng Weak and inadequate operability Program / 96011 assessments: Three of 12 reviewed were Human deficient. such as not ' evaluating .

Performance operability at design flow conditions for charging pump degradation noted during ECCS testing.

"+" indicates a positive attribute /occurrerce. i

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 08/22/96 NRC Eng Trending of equipment problems and Program / 96011 resolution of recurring equipment problems Human +

was weak: Repeated failures of Performance containment spray sodium hydroxide spray additive tank level indication. radiation monitors and the reserve feed breaker for Unit 2 ESF busses without adequate followup and action. Trending by system engineers such as lube oil analysis was inconsistent.

08/22/96 NRC Eng Numerous inappropriate technical Program / 96011 specification interpretations (TSIs): Four Human examples of using TSIs versus required TS Performance amendments with several others changing the intent of the TS.

08/22/96 NRC Eng Management expectations were not clearly Human 96011 defined, nor understood by engineering performance staff: For example, management expected system engineers to evaluate lube oil analysis sample results. even though engineers had not been trained or qualified.

08/21/96 NRC Ops Significant number of rod position Material 96010 indication system problems during Unit 1 Condition startup: Resulted in weak command and control when numerous personnel clustered around process computer.

08/18/96 Sel f Maint Unit 1 reactor trip when MSIV closed Program 96010 greater than 10% due to failure of limit switch: causing shrink in the 1D steam generator and a low low trip signal. Poor preventive maintenance on limit switch.

. . "+" indicates a positive attribute /cccurrence.

PLANT ISSUES MATRIX ZION DATE ID B_Y ! SALP DESCRIPTION l CAUSE REF 08/16/96 Sel f Ops Operator inadvertantly overflowed lake Human 96010 discharge tank: caused by failing to Performance fully close LDT iniet isolation valve valve causing backup of 7000 gallons onto floor of auxiliary building. (Repeat of January 20. 1996 event.)

08/16/96 NRC Maint Maintenance personnel failed to adequately Human 96010 document missing part: during 1B Performance centrifugal charging pump shaft driven oil pump inspection.

08/15/96 Self Ops Licensed operators failed to include valve Human 96010 in partial clearing of 005: on aux steam Performance system which resulted in cross-tying aux steam with service air system.

08/07/96 Licensee Eng Engineering personnel failed to include Human 96010 necessary supporting information in Performance operability assessment: to justify conclusion that 1B charging pump was operable with degraded shaft-driven oil pump.

08/05/96 NRC Maint Scaffold around 1B containment spray pump: Human 96010 obstructed operation of pumps discharge Performance valve. Corrective actions inadequate from June 17. 1996 event 07/31/96 NRC Ops Fallen radiological postings and obscured Human 96010 radioactive material posting. Performance 07/30/95 Licensee Ops Fuel handling personnel inadvertently Programs 96010 dropped two new fuel assemblies: during Procedures receipt inspection due to an inadequate rigging step in procedure.

. "+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE ID BY SALP lf DESCRIPTION CAUSE REF 07/26/96 Licensee Ops Non-licensed operator misaligned 28 diesel + 96010 generator air regulation isolation valve:

while performing a valve 1ineup verification. Good finding by maintenance engineer walking down diesel.

07/26/96 Licensee Plant Supt Licensee failed to perform compensatory Material 96016 sampling: when ODCM radiation monitor Condition /

(1RE-0015) Was out of service. See also Human 7/5/96 event. Performance 07/26/96 Licensee Plant Supt Procedure failured to specify actions to Procedures 96010 meet technical specification action stitement: when containment high radiation mcoitor was inoperable during mainte.wnce TS not violated since other monitor was operable.

07/15/96 Sel f Ops Unit 2. excessive load placed on the 2G Human 96008 EDG during performance of the monthly TS Performance surveillance: caused by NSO manipulation of controls. This is a repeat of the May 19 event.

07/12/96 Licensee Ops Failure to perform post-maintenance Human testing: on a Unit 2 containment Performance isolation valve following repairs to the valve's open limit switch.

07/09/96 NRC Plant Supt Longstanding plant practice of impro3erly Program 96008 transporting chemistry samples: witlout surveying the materials for surface contamination.

07/05/96 Licensee Plant Supt Failure to obtain and analyze sample: Material 96016 when TS radiation monitor (OR-PR07) was Condit. ion /

out of service. Human Performance

"+" indicates a positive attribute / occurrence.

. PLANT ISSUES MATRIX t ZION DATE ID BY SALP DESCRIPTION CAUSE REF- ,

07/01/96 NRC Plant Supt Replacement of the'1A DG C02 discharge Procedures 96008 timer rendered the automatic function of .

the CO2 system inoperable: status was not !

recognized by fire protection. operations, and electrical maintenance personnel.

06/24/96 Licensec OPS Both Unit I reactor coolant drain tank Human 96008 ,

(RCDT) pumps were deadheaded: due to the performance i failure to realign RCOT flow path !

following a placement of an 005 for the i holdup tank (HUT) maintenance activity. !

06/23/96 NRC Eng System engineer slow in initiating a PIF: Human 96008 .

for holes in ductwork in the fuel transfer performance ;

canal area and any bypass flow around the i charcoal bed.

06/21/96 NRC Ops Good communications and coordination

96008 among: fuel handling. radiation protection, and decontamination personnel during the filtration unit retrieval .

. evolution. I 06/18/96 Lic Engrg System engineer identified that + 96008 scaffolding: could potentially affect the operation of two governor control valves in the Unit I high pressure. turbine area.

06/13/96 NRC Ops One of two Unit Supervisor's command and Training 96008 control. during the dynamic simulator examinations was a weakness.: .

Additionally, the lack of attention to ,

detail. lack of self checking and failure ,

to use Annunciator Repsonse procedures contributed to several JPM failures.

06/12/96 Lic Ops Returned containment isolation valve to Human 96014 service without recognizing and performing performance appropriate post-maintenance testing

"+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX ZION DATE l ID BY SALP DESCRIPTION CAUSE REF 06/12/96 Self Ops Portable filtration unit fell seven feet Human 96008 onto the transfer canal island: due to a performance radiation protection technician's (RPT) improper rigging of the-unit.

06/10/96 Lic Plant An individual, who was not a qualified Human 96016 Support radiation protection technician, alarmed a performance radiation detection device, failed to notify radiation protection personnel, and removed the contamination.

06/10/96 Lic Plant Radiation worker performance and adherence Human 96008 ,

Support to radiation work permits and procedures performance were weaknesses during the fuel canal decontamination.

06/10/96 NRC Plant Water chemistry program was consistent Program 96008 Support with industry guidelines, and chemistry Human staff provided good reviews and analysis performance of primary and secondary chemistry data.

05/21/96 NRC Ops Operator Work Around List was not Program 96008 routinely reviewed by licensed operators:

to ensure awareness of all plant conditions.

05/21/96 NRC Ops The operations staff received insufficient Training 96008 training on the newly implemented computer systems for administrative control of work activities: (Electronic Work Control System (EWCS)). and the PT-14 system for tracking 00S equipment and the workaround list.

"+" indicates a positive attribute / occurrence. i

PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF l 05/19/96 Self Maint Operators were challenged when several Material 96007 i components did not-perform as expected Condition during Unit 2 shutdown for inoperable EDGs: Specifically. low power reactor -

trip block. P-7. did not actuate requiring operators to trip reactor, moisture seperator reheater control system could not be placed in manual operation requiring local operator action to close valves. 2C main feedwater pump could not be placed on turning gear.

05/19/96 Self Ops Unit 2, 2A Emergency Diesel Generator Human 95007 Output Breaker Reverse Power Trip: caused Performance by NSO manipulation of controls. .

05/19/96 Self Ops Unit 2. 2B Emergency Diesel Generator Material 96007 ,

Failure: due to zebra mussel fouling in Condition the lube oil heat exchanger and intake air ,

heat exchangers.

05/15/96 Self Mixed bed demineralizer temperature Material ;

excursion: the letdown demin inlet divert Condition valve, and the CCW letdown heat exchanger temperature control valve. responded sluggishly while establishing Unit 1 :

letdown flow. The temperature of the resin reached 148 F for several minutes.

~

05/08/96 Lic Plant supt Security contractor falsified employee Human LER 96-background checks. performance 501 04/25/96 Lic Plant supt U2 Inoperable containment air lock ~ door Human 96007 exceeded 24 hour2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months LC0: RP technicians performance making containment entries experienced problems with the air lock door over a period of days. No PIF. no AR written. & ,

Ops / Engineering not notified until 4/25

"+" indicates a positive attribute /occui rence. '

PLANT ISSUES MATRIX ZION DATE D BY SALP DESCRIPTION CAUSE REF 04/21/96 Self IC low pressure turbine reheat stop and Material 96007 intercept valves failed to remain closed: Condition following turbine trip testing during Unit 1 startup.

04/20/96 Self Maint Two EHC oil spills occurred due to Human 96007 maintenance mechanics: installing bolts of performance an incorrect length for the moisture seperator reheat intercept and stop valves ori fices .

04/1S/96 Self Unit I reactor trip: low flow sensed on Material 96007 two of three RCS loop flow transmitters. Condition Root cause of trip was entrapped gases in the loop flow sensing lines. which have never been routinely vented post outage.

04/10/96 NRC/Lic All six containment spray additive (CS) Material 96006 eductor throttle valve positions different Condition from the positions specified in System Operating Instructions: Licensee was not aware of discrepancy until NRC pointed it out: subsequent licensee analysis determined system was operable.

04/08/96 Li' Isolation valve seal water system check Personnel 96006 valves had not been tested: for their Performance closing function in accordance with the IST program since the Unit I refueling outage in Fall 1995. Identified by licensee IST engineer during data review for Unit 2 outage.

"+" indicates a positive attribute / occurrence.

e PLANT ISSUES MATRIX ZION DATE ID BY SALP DESCRIPTION CAUSE REF 04/02/96 NRC Maint Four loose bolts on the 'O' DG after Personnel maintenance and modification work: had Performance been comoleted on the DG. This deficient condition' did not render the DG inoperable as the post-maintenance test (PMT) had not been performed yet on the DG.

+" indicates a positive attribute / occurrence.

PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 3/10/97 ************* ************** ***********

Branch 3 PPR Meeting 2/7/97 NRC Plant Support Certain chemistry QC procedures v.. Inadequate 97003 PASS surveillance procedures were Procedure inadequate: (1) they did not contain acceptance criteria to determine the acceptability of surveillance results and (2) they did not ensure the validity of high purity germanium detector calibrations (as recommended by RegGuide 1.33. Appendix A).

2/7/97 NRC Plant Support Weaknesses in the analytical Inadec uate 97003 chemistry interlaboratory program Procec ure were identified: (1) analytical results were not compared and reported in a timely manner and (2) the licensee did not always resolve analysis results which were not in agreement with program acceptance criteria.

n

PLANT ISSUES MATRIX 4

BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 2/7/97 NRC Plant Support Excellent primary and secondary Program 97003 systems water chemistry program.

During 1996. the concentrations of chloride and fluoride in the primary systems were maintained between 3-5 parts per billion.

Effective control of chemical intrusions and secondary system additives reduced the potential for system corrosion and decreased radiological source term. The licensee experienced some circulating water intrusinns in July 1996 (unit 1) and February 1996 (unit 2). which corresponded to minor, short term increases in the concentrations of sodium and chloride in the steam generators.

2/5/97 NRC Plant Support PASS maintenance items were not Program 97003 resolved in a timely manner. In June 1995. the licensee identified Equipment a problem with the containment air Malfunction sampling panel (CASP) circuitry which had sometimes resulted in the disablement of a radiation monitor.

When the gas partitioner module was connected to the AC outlet within the CASP (as directed by procedure) or the light within the CASP panel was activated, radiation monitor IPR 11J (containment atmosphere) was disabled.

PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF

/5/97 NRC Plant Support Chemistry PASS training was very Training 97003 interactive and the discussions were thorough. The trainer emphasized the potential radiological conditions of a PASS sample and the sample system.

2/4/97 NRC Plant Support Chemistry technicians demonstrated Persor.nel 97003 good analytical techniques and Performance knowledge of procedure requirements and references.

2/4/97 NRC Plant Sup; crt Chemistry technicians were Program 97003 verifying QC performance tests for laboratory instruments with an uncontrolled aid. The licensee did not perform a periodic review to ensure that the aid was consistent with the data base as required in BwAP 550-25.

2/4/97 NRC Plant Support Statistical biases in fourth Program / 97003 quarter 1996 and first quarter 1997 Personnel chemistry instrument QC data were Performance not resolved in a timely manner.

These biases potentially indicate minor problenis concerning the instrument calibration or the calibration standard or an instrument operability problem.

2/3/97 NRC Plant Support Two aluminum (Al) standards were Personnel 97003 improperly labeled with respect to Performance the procedure required shelf-life.

l

PLANT ISSUES MATRIX

, BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 1/2/97 NRC Maintenance Inspectors identified that the work Perscnnel/ 96021 package was not present at the work Procedure site for the 1C heater drain pump. Adhereance Also the foreman could not explain the purpose of the procedure steps.

12/31/96 NRC Maintenance The inspectors observed that the Personnel / 96021 surveillance on the 2B RHR pump was Procedure performed in a competent and well Adequacy controlled manner. However the licensee failed to enxure that a required change to the surveillance procedure was made prior to use.

12/23/96 NRC Engineerin[ Lack of complete understanding of Personnel 96021 regulatory requirements: Performance Understanding of the ASME code and Deficiency the applicable generic letter guidance was poor when a through wall flaw was identified in the 1A essential service water system in that the train had not been removed from service nor had any corrective .

action been taken.

12/19/96 NRC Operations Inspectors observed operators add Personnel 96021 lubricating oil to the 2B Emergency Performance Diesel Generator in violation of a i procedure. Operators were unaware of the procedures existance.

12/9/96 NRC Maintenance Inspectors identified several carts Procedure 96021 secured to safety-related Adhereance equipment. This was also and identified by the inspectors on Corrective 11/4/96. l Actions

PLANT ISSUES MATRIX BRAIDWOOD e DATE ID BY SALP DISCRIPTION CAUSE ~l REF 12/5/96 Licensee Plant Support The alarm setpoints for the fuel Personnel LER.

handling incident radiation Performance 97003 monitors were not in accordance with Technical Specification Table 3.3-6 (i.e. 10 mrem /hr). The as found setpoints were 100 mrem /hr (alert) and 2000 mrem /hr (high

.. alarm). (97003) 12/1/96 Licensee Maintenance Two spent fuel assemblies were Procedure 96021 mispositioned in the spent fuel Adhereance pool. '

11/18/96 NRC Operations During turbine valve exercise. Personnel 96019 control room operators demonstrated Performance poor performance in the following Deficiency areas:

Reactivity control and management.

. Alarming annunciator response. and

. Teamwork between NSO and shift engineer.

11/18/96 NRC Maintenance Failure to follow procedure: while Personnel 96019 installing manways and diaphragm Performance plate for Unit 1 1C Steam Deficiency Generator.

11/14/96 Licensee Engineering Questioning attitude: A system Team work / 96019 engineer demonstrated a knowledge Skill level of expected system performance and a questioning attitude to detect electronic noise effecting vibration readings on a diesel oil transfer pump since the vibration measurements initially obtained met ,

the acceptance criteria.

PLANT ISSUES MATRIX BRAIDWOOD -

DATE ID BY SALP DESCRIPTION CAUSE REF 11/11/96 Licensee Engineering Through self assessment system Personnel 96019 engineer identified problems with Performance '

drawings from construction phase. Deficiency control and instrumentation drawings depicted power leads to the control room dampers hydromotors inaccurately.

11/6/96 ************* *********"**** ***********

Branch 3 PPR meeting.

10/25/96 Licensee Engineering The licensee's efforts to evaluate Teamwork / 96017 steam generator tube integrity by Skill level ;

assessing growth rates for this '

type of cracks by historical eddy current data reviews / comparisons and in-situ pressure testing was indicative of an aggressive 4 program. ,

10/19/96 NRC Operations Several indicators of poor Personnel 96019 communication and operation Performance l practices were evident during Deficiency drain-down evolutiort for mid-loop operation and nozzle dam installation.

Blockage of the pressurizer manway vent pathway

Creation of a loop seal on the reactor head vent pathway

Exclusion of ar. additional drainage verification method from the drain down procedure.

10/12/96 Licensee Operations Power-operated relief valve Inadequate 96018 inadvertently lifted: when Procedure operators overfilled pressurizer Instruction during cooldown and depressurization of Unit 1.

PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 10/12/96 Licensee Maintenance Performance of maintenance without Inadequate 96019 necessary documentation: Licensee Procedure personnel landed 125 VDC lead in Instruction reverse polarity on an instantaneous prepositioning board for IB Diesel Generator. 1 10/04/96 Licensee Maintenance Two safety injection vent and drain Inadequate 96014 valves and two LLRT connectors were Procedure not included in primary containment Instruction integrity verification surveillance procedure. ,

10/3/96 Licensee Engineering Questioning attitude by operators: Inadequate 96019 The licensee observed cooler than Procedure /

normal temperatures in the Unit 1 Instruction essential switchgear room. An inadequate PMT failed to reveal that control relay contacts were configured incorrectly.

09/30/96 NRC Engineering High numbr (14) of temporary Engineered 96014 alterae- installed in the plant Design for g. ' u Ji than 18 months: Deficiency however. good progress toward reduction of the total number of temporary alterations was made.

09/23/96 Licensee Maintenance Severe lube oil leakage from 1A Equipment 96014 motor-driven feedwater pump when Malfunction placed in operation following a lengthy idle period: identi fied when the licensee was performing repairs to the IC turbine driven feedwater pump.

09/23/96 NRC Operations Prompt action by the Unit 1 reactor Other/NA 96014 ;

operator prevented a significant plant transient: after a failure of l the master feedwater pump

, , controller.

L

I PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 09/11/96 Licensee Operations Diesel Generator Fuel Oil Tank room Personnel 96014 sprayed with water: non-licensed Performance operators mispositioned valve while Deficiency performing surveiliance.

09/11/96 Licensee Operations Fuci pool cooling pump found turned Personnel off for E hours. Fuel pool temp Performance went up 7 degrees (below alarm Deficiency setpoint) 09/10/96 NRC Operations Failure to use updated procedure: Inadequate 96014 while performing monthly Procedure operability surveillance for Unit 1 Instruction diesel generator.

09/06/96 NRC Engineering Lack of complete understanding of Personnel 96019 regulatory requirements: A lack of Performance complete understanding of the 10 Deficiency CFR 50.59 requirements when returning the unit to service with the Unit 1 cold leg reactor coolant stop valve degraded without documenting a 10 CFR 50.59 safety evaluation.

09/06/96 NRC Operations Unit 2 pre-surveillance essential Personnel 96012 service water to diesel jacket Performance water cooling valve manipulation: Deficiency performed prior to the start of the diesel generator morahly surveillance.

08/30/96 Sel f- Operations IC condensate booster pump Personnel Revealing destroyed: when operator Performance inadvertently shut the suction Deficiency valve instead of the discharge valve.

08/25/96 Licensee Operation- Mispositioned boric acid tank Personnel 96012 recirculation throttle valve: Performance found open while transferring boric Deficiency acid between tanks.

i PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 08/21/96 NRC Operaticns Failure to perform independent Personnel 96012 verification: by operators Performance performing valve manipulations Deficiency '

during the 28 DG monthly surveillance. t 07/31/96 NRC Operations Unit 1 undocumented testing: of Personnel 96012 the essential service water valve Performance to diesel jacket water cooling Deficiency valve prior to diesel generatcr start.

07/03/96 Licensee Engineering Several roll-up fire doors for Engineered 96014 rooms containing safety-related Design equipment failed to close: when Deficiency outside air ventilation was supplied during surveillance testing.

06/17/96 Licensee Operations Spent fuel improperly repositioned: Personnel in the spent fuel pool into a Performance configuration that was not bounded Deficiency by the existing criticality analysis. but was subsequently analyzed to be acceptable. however ~

was later moved.

06/07/96 Licensee Operations Missed diesel fuel oil sample: Personnel required'by Technical Specification Performance due to sample schedaling. Deficiency 06/04/96 Licensee Operations Fire Protection Appendix R Design Personnel i Discrepancies: due to erroneous Performance evaluation during preparation of Deficiency '

original analysis regarding the operation of the of the VC dampers during a fire.

06/03/96 Licensee Operations Failure to maintain differential Personnel pressure between the Aux Building Performance and atmosphere: due to an Deficiency inadequate controls process.

PLANT ISSUES MATRIX BRAIDWOOD DATE ID BY SALP DESCRIPTION CAUSE REF 05/23/96 Licensee Operations Failure to Enter Tech S xc 3.0.3: Personnel due to he failure of t1e Unit Performance Supervisor and the Unit NSO to Deficiency recognize that bot the containment floor drain leak detection system flow transmitter and containment atmosphere radiation monitor skid were simultaneously inoperable 05/06/96 Self .

Operations 2A Auxiliary Feedwater Pump Personnel Revealing Inadvertent Start: after being Performance placed in Local an the remote Deficiency shutdown panel due to the 2B steam generator level being below the Lo-2 setpoint. The 2A AFW pump had been placed in pull-to-lock on the main control panel.

4/3/96 Licensee Engineering Poor engineering practice: The Personnel 96014 acceptance criteria change to the Performance 1A RHR pump surveillance procedure Deficiency was not incorporated into all of the procedures that were affected by the change.

03/96 Licensee Maintenance Maintenance on Flow Orifice With Personnel 96005 Incorrect Work Authorization: Performance partially disabling the only Deficiency operable Unit 2 safety injection pump. The other safety injection pump was also out of service for planned maintenance, with the unit at full power.

PLANT ISSUES MATRIX BYRON DATE ID BY SALP DESCRIPTION CAUSE REF 3/10/97 ************* ************* *************

Branch 3 PPR meeting 3/7/97 NRC Plant Support Inspectors found that training on the Personnel 97003 Jost accident sample system had not Performance 3een conducted as regtdred on 6mo.

intervals. Had been conducted annually.

3/5&6/97 NRC Plant Support Inspectors had to prompt chem. techs. Personnel 97003 to prevent errors while sampling Performance reactor coolant.

3/5/97 NRC Plant Support Inspectors found chem. techs. not Personnel 97003 following procedures by not Performance evacuating a vial for a gas sample.

3/97 License Plant Support The chemistry staff was found to be N/A 97003 tracking the findings and taking appropriate actions to 1995 and 1996 SQV. corporate. and vendors audit findings.

3/97 Licensee Plant Support In 1996. the chemistry line N/A 97003 organization began a surveillance program to identify weaknesses in the chemistry program.

3/1/97 Sel f Maintenance FME-Foreign Material Intrusion Personnell 97002 Revealing requires rework of two pumps. lA CS Performance pump had 3/8x1/4" particle in the shaft seal causing leakage during refil . 1B CS pump post maint. test run had high temp. on the thrust bearing and dirty oil resulting from a large chi) (1"x3") of paint between the thrust ] earing and the housing.

Both pumps had to be reworked to eliminate the FM resulting in a delay

!in plant startup.

s o .

, - - - _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ((/

PLANT ISSUES MATRIX BYRON l DATE ID BY DESCRIPTION CAUSE REF

} ALP 2/17/97 Sel f Plant A radioactive waste operator Personnel 97002 Revealing Support / Ops. transferred water from one of the Performance and release tanks to the regen waste tank 97003 and over-filled the regen waste tank.

The operator did not monitor tank level during the transfer. and the high level alarm had been disabled by the recieot of the low level alarm.

Consequently, the over-pressurization and deformation of the tank resulted in a spill of radioactive liquids to

g the floor drain system and in significant damage to the tank.

01/09/97 NRC Plant Support Maintaining water tight doors shut. Corrective 96012 Previous corrective actions to Actions preclude unattended open water tight doors were ineffective in keeping the doors closed.

01/97 NRC Operations SOV audits and assessments were Personnel 96012 positive contributors to oversight of Performance station operations.

12/96 NRC Plant Supporc The security plan did not accurately Other 96010 describe the location or correct description of tiie Vehicle Barrier System in all instances.

12/96 NRC Plant Support The Access Authorization Program was effectively implemented.

12/31/96 Self Maintenance An operator demonstrated a good Correctiv 96012 revealing questioning attitude in the Actions identification of low flow in the 1B essential service water pump room cooler. However. the failure to properly use matchmarks to reassemble the cooler components could have been prevented by reasonable corrective

, o . action from other events.

PLANT ISSUES MATRIX BYRON DATE ID BY SALP DESCRIPTION CAUSE REF 12/30496 NRC Engineering Modification w/out 10CFR50.59 Personnel 96012 evaluation. The inspectors Performance identified that a surveillance procedure for the Containment Floor Drain Leak Detection System (IRF008) was implemented to compensate for the loss of alarm function without declaring the system inoperable or performing a safety evaluation.

12/29/96 NRC Engineering Operators failed to identify the Personnel 96012 degraded condition of the containment Performace floor drain leak detection system when the alarm was locked-in due to a secondary side steam leak.

12/17/96 L; ensee Engineering The licensee identified and Other/NA 96009 agressively purusued the motor control center spacer issue with Westinghouse. The operability -

assessment and corrective actions to install the spacers were timely and trorough.

11/12/96 NRC Engineering Spent Fuel Pool (SFP) Boraflex. The Personnel 96009 inspectors concluded that the Performance licensees submittal. regarding SFP Boraflex degradation and the decisicn to " checker board" the SFP were not pursured in a timely manner until after discussions with the NRC.

[ ,

PLANT ISSUES MATRIX :

BYRON l DATE ID BY SALP DESCRIPTION CAUSE REF 10/21/96 Licensee Plant Support On four separate occasions in October Personnel 97003 1996, the licensee identified Performance inadequate radiological postings:

either the high radiation area posting or the contaminated area .

i posting for the unit 1 volume control tank room was found to be on the t valve aisle door. The licensee ,

conducted a thorough investigation !

which reported that a contract '

individual admi u ed to " finding" and i replacing postings which had fallen !

and " moving" postings which he .

believed were incorrect.

11/90 NRC Operations l The requalification training feedback Other/NA 96011 system was good.

11/96 NRC Operations The station auxiliary transformer Team Work 96009 i switching and restoration operations Skill Level were carefully planned and professionally executed.

11/6/96 ************* ************* Branch 3 PPR meeting *************

1 10/7/96 NRC Plant Support A violation was issued due to a fire Personnel 96009 door being impaired without a Performance Barrier / Fire Protection Systems Deficiency Impairment Permit.

8/95 - NRC Operations A lack of formal controls to limit Other/NA 96011 10/96 examination material overlap was a ,

weakness.

10/15/96 NRC Engineering System engineering failed to Personnel 96009 appreciate or understand the Performance importance of the surveillance test Deficiency with respect to SX system operability.

i

PLANT ISSUES MATRIX ;

BYRON ,

DATE ID BY SALP DESCRIPTION CAUSE REF 10/15/96 NRC Engineering Inadequate corrective action to Other/MA 96009 repair the trash racks since 1993 demonstrated a lack of knowledge of .

SX system design by the licensee and a willingness to operate with a :

degraded safety system. l 10/15/96 Licensee Engineering The licensee identified errors in the Other/NA 96009 ;

ultimate heat sink cooling tower !

basin makeup calculation. (It did not ,

raflect the SX system design features l since initial plant operation.) The l 1991-1992 design basis reconstitution failed to identify this error.

i 10/15/96 Licensee Engineering The licensee identified that silt Other/NA 96009 levels in the SX cooling tower basin did not meet the surveillance ;

acceptance criteria. Based on the excessive silt found on 10/15/96. the licensee determined that the SX '

system was inoperable when the plant '

relied on the deep well pumps for i makeup capability. !

7/93 to Self Operations Operations failed to recognize the Corrective 96009 10/97 Revealing significance of the reduced Actions and operability of the SX system due to Personnel the degraded trash screens in the SX Performance r cooling tower basins. This was even with the evidence of the damaged SX i strainers caused by transported i cooling tower fill material. '

10/15/96 NRC Maintenance Surveillance test OBVS SX-5 contained Other/NA 96009 inadequate acceptance criteria to determine SX system operability. '

i

PLANT ISS'JES MATRIX BYRON DATE ID BY SALP DESCRIPTION CAUSE REF 10/96 NRC Operations Licensee. validation of examination Personnel 96301 material lacked comprehensive review Performance as evident by errors detected during Deficiency examination administration.

10/96 Sel f-Revealed Operations The applicants' effective use of Team Work 96301 communications during dynamic Skill Level scenarios enhanced good teamwork.

10/96 NRC Plant Support The Access Authorization Program and Team Work 96010 the Vehicle Barrier System were Skill Level effectively implemented.

09/05/96 NRC 10 CFR 20.1902(a) violation: A Inadequate 96008 Plant Support l storage area in the Aux. building had Procedure rad levels in excess of 5 mrem /hr at Instruction greater than 30cm that was not posted.

09/96 Sel f-Revealed Plant Support Licensee's control of Unit 2 outage Team Work 96008 dose was a strength. Skill Level 09/96 NRC Operations Teamwork between rad protection. Team Work 96008 Plant Support chemistry. and operations staff was Skill Level effective in reducing source term in Unit 2.

08/96 NRC Operations Unit 1 auxiliary feedwater trains (2) Personnel 96006 inoperable: "A" train was inop due Performance to a surveillance when the "B" train Deficiency was made inop due to the attachment of a strip chart recorder ,

07/96 Licensee Operations A loss of examination material Other/NA 96301 control required the generation of replacement examination and resulted in a substantial delay in examination administration.

l

PLANT ISSUES MATRIX '

BYRON DATE ID BY SALP DESCRIPTION CAUSE REF 07/02/96 Sel f-Revealed Maintenance Unit 1 manually tripped: in response Equipnent 96005 to a loss of feedwater to the B steam Mal function generator. The startup feedwater supply valve ftiled closed due to a faulty solder connection on the instrument air line to the valve control.

06/30/96 Self-Revealed Maintenance Unit 1 main turbine trip: due to Equipment 96005 failure of the teflon oil seal Mal function between the generator and the !

exciter The reactor did not trip because pcNer was below the 30 ;

percent interlock. i 06/12/96 Self-Revealed Operations Unit I reactor coolant system Personnel 96005 i excessive dilution: after a Performance i refueling outage with reactor Deficiency i partially drained: and with the j reactor isolated from the steam generators.

05/96 Licensee Engineering Unit 1 steam generators each Equipment 96004 ;

categorized as C-3: eddy current Malfunction t inspections found more than one i percent of the tubes in each i generator to be defective.

j 05/23/96 Sel f-Revealed Operations Surge tank overflowed 7000 gallons Engineered 96005 i into the floor drains: due to loss Design of station air. the makeup water Deficiency '

supply valve to the component cooling water system surge tank failed open I as designed. ,

05/23/96 Sel f-Revealed Operations Operators manually trip Unit 2: due Engineered 96005 to loss of offsite power to Unit 1. Design :

Plant configuration had all non- Deficiency essential cooling service water pumps ,

and station air compressors powered

. .. from Unit 1. ,

PLANT ISSUES MATRIX BYRON DATE ID BY SALP DESCRIPTION CAUSE REF 05/23/96 Sel f-Revealed Maintenance Complete loss of offsite power to Equipment 96005 Unit 1: because of moisture Malfunction intrusion into one of the bus ducts which caused a ground fault.

04/96 Licensee Operations Inoperable safety injection Engineered 96004 accumulators: when occasionally Design cross-connected during periodic fill Deficiency or pressurization operations.

03/22/96 Licensee Engineering Containment spray chemical addition Other/NA 96003 system: set to provide sodium hydroxide at a rate greater than allowed by TS.

03/13/96 Self-Revealed Operations 2A diesel generator tripped: when an Personnel 96003 operator inadvertently opened the DG Performance output breaker instead of the Ceficiency governor adjust switch during the routine monthly surveillance.

03/13/96 Self-Revealed Operations NSO inadvertently adds boric acid to Personnel 96003 the reactor coolant system: during Performance filling of the spent fuel pool Deficiency transfer canal from the Unit 1 boric acid blender. resulting in a 2 ppm increase and a corresponding 0.7 degree F decrease in reactor temperature.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ML20141C392

Text

Dear Mr. Powell:

Navigation menu

Search