ML20135B685

Predecisonal Enforcement Conference Repts 50-295/96-11 & 50-304/96-11 on 961112.No Violations Noted.Areas Discussed: Apparent Violations Identified During 960722-0822 Insp Along W/Corrective Actions Taken or Planned by Licensee

ML20135B685
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	11/27/1996
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20135B679	List: ML20135B678 ML20135B685
References
50-295-96-11-EC, 50-304-96-11, NUDOCS 9612050098
Download: ML20135B685 (33)

See also: IR 05000295/1996011

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U. S. NUCLEAR REGULATORY COMMISSION

REGION lli

Docket Nos:

50-295:50-304

License Nos:

DPR-39; DPR-48

Licensee:

Commonwealth Edison Company

Facility:

Zion Generating Station

Dates:

November 12,1996

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Meeting Location:

Region Ill Office

801 Warrenville Road

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Lisle, IL 60532-4351

Type of Meeting:

Predecisional Enforcement Conference

inspection:

Zion Station

July 22 - August 22,1996

Inspectors:

Z. Falevits, Team Leader, Region lll

J. Guzman, Reactor inspector, Region 111

R. Winter, Reactor inspector, Region ll1

D. Rich, Reactor Engineer, Region til

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R. Stakenborghs, Contractor, Parameter, Inc.

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J. Heller, Contractor, Parameter, Inc.

Approved By:

Mark A. Ring, Chief

Lead Engineers Branch

Division of Reactor Safety

Meetina Summarv

Predecisional Enforcement Conference on November 12,1996

Areas Discussed: Apparent violations identified during the inspection were discussed,

along with the corrective actions taken or planned by the licensee. The apparent violations

involved: (1) an ineffective 10 CFR 50.59 Safety Evaluation process; (2) inadequate

modification closecut and post-modification testing; (3) failure to follow procedures and

inadequate procedures which contributed to lack of control of Technical Specification

Interpretations; (4) inadequate identification and resolution of recurring equipment

deficiencies; and (5) weak oversight of engineering activities.

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9612050098 961127

PDR

ADOCK 05000295

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PDR

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Report Details

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Persons Present at Conference

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Commonwealth Edison Comoany (Comed)

J. Mueller, Site Vice President, Zion

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J. Hosmer, Vice President, Engineering

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D. Sager, Vice President, Generation Support

H. Gavankar, Chief Engineer, Mechanical & Structural

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D. Farrar, Regulatory Assurance Manager, Zion

F. Gogliotti, Design Engineering Supervisor, Zion

B. Giffin, Engineering Manager, Zion

K. Housing, SOV Director, Zion

M. Burns, Primary Group Lead- System Engineering, Zion

L. Peterson, Modification Administration Supervisor, Zion

K. Moser, Assistant Superintendent of Operations, Zion

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W. Subalusky, Site Vice President, LaE me

L. Waldinger, Nuclear Oversight Manager

E. Connel Ill, Design Superintendent, Dresden

J. Hutchison, Site Engineering Manager

J. Meister, Site Engineering Manager, Braidwood

D. Wozniak, Site Engineering Manager, Byron

I. Johnson, Licensing Director

L. Holden, Nuclear Licensing Administrator, Zion

R. Ward, Director of Safety Review

M. Wiesneth, Licensing Engineer, Zion

J. Ashley, Mechanical Lead, Design Engineering, Zion

D. Galanis, Electrical Lead, Design Engineering, Zion

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A. Amoroso, Electrical Lead, System Engineering, Zion

F. Spangenberg, Regulatory Assurance Manager, Dresden

P. Gazda, Maintenance Engineering Supervisor, Zion

R. Niederer, Nuclear Lead, System Engineering

M. Zar, Project Manager, Sargent & Lundy

R. Lincoln, Lead Electrical Engineer, Maintenance Engineering, Zion

U. S. Nuclear Reoulatory Commission

A. B. Baach, Regional Administrator, Rlli

R. A. Capra, Director, Projects Division Ill, NRR

G. E. Grant, Director, Division of Reactor Safety (DRS), Rill

B. L. Burgess, Enforcement Officer, Rlli

M. A. Ring, Chief, Lead Engineers Branch, Rlli

M. L. Dapas, Chief, Reactor Projects Branch 4, Rlll

Z. Falevits, Reactor inspector, Rlli

J. G. Guzman, Reactor inspector, Rlll

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C. Y. Shiraki, Project Manager, Zion, NRR

B. A. Berson, Regional Counsel, Rlll

M. A. Satorius, Deputy Director, Office of Enforcement

A. Vegel, Senior Resident inspector, Fermi, Rlli

D. R. Calhoun, Resident inspector, Zion Station, Rill

E. W. Cobey, Resident inspector, Zion Station, Rll!

D. W. Rich, Resident inspector, Braidwood Station, Rlli

R. A. Burrows, Reactor inspector, Rlli

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R. A. Winter, Reactor Inspector, Rlli

Other

D. Dow, Indapendent Self-Assessment Team Member, Barrington Consulting

J. Yesinowski, Resident Engineer, Zion Station, IDNS

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11.

Predecisional Enforcement Conference

A Predecisional Enforcement Conference was held in the NRC Region til Office on

November 12,1996. This conference was conducted as a result of the findings of

an inspection conducted from July 22 through August, 22,1996,in which apparent

violations of NRC regulations were identified. inspection findings were documented

in Inspection Report No. 50-295/96011(DRS); 50-304/96011(DRS) transmitted to

the licensee by letter dated October 22,1996.

The purpose of this conference was to discuss the violations, root causes,

contributing factors, and the licensee's corrective actions. Also discussed were

circumstances that led to the apparent breakdown in the engineering processes

depicted in the apparent violations.

During the Predecisional Enforcement Conference, the licensee acknowledged the

violations. The licensee's presentation included a synopsis of the broader

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engineering issues identified in the inspection as well as the specific enforcement

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issues. The licensee also presented a synopsis of the causes, safety significance,

and corrective actions taken for each potential violation. A copy of the licensee's

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handout is attached to this report.

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Attachment: As stated

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ZION ENFORCEMENT CONFERENCE

NOVEMBER 12,1996

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AGENDA

INTRODUCTION

John Mueller

BROAD ISSUES

Bryant Giffin

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10.C.F.R. s 50.59

FrankGogliotti

CONFIGURATION MANAGEMENT / DESIGN CONTROL

Larry Peterson

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OPERABILITY ASSESSMENT PROCESS

Mike Burns

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PROCEDURE ADEQUACY AND ADHERENCE

Mike Burns

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CORRECTIVE ACTION PROGRAM

Bryant Giffin

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SQV

Ken Hansing

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SPECIFIC ENFORCEMENT ISSUES

Bryant Giffin

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10 C.F.R. 50.59

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CRITERION V - PROCEDURES

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CRITERION XI - TESTING (PROGRAM)

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CRITERION XIV - TESTING (PROCESS)/

CONFIGURATION CONTROL

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CRITERION XVI- CORRECTIVE ACTIONS

AGGREGATE ASSESSMENT

Bryant Giffin

REGULATORY ASSESSMENT

Denny Farrar

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CLOSING REMARKS

John Mueller

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BROAD ISSUES

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10 C.F.R. @ 50.59 PROGRAMS / PROCESSES

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ISSUE (S)

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Quality deficiencies

Incomplete determination of UFSAR impact _

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Procedural adherence

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Use of screen instead of safety evaluation

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Failure to identify technical specification changes

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Untimely off-site reviews

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CAUSE(S)

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Over focus on task management

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Inadequate management oversight / involvement

Failure to emphasize significance / impact of 50.59s

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Inadequate feedback and performance measures

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Unsuccessful implementation of previous corrective actions

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BROAD ACTIONS TAKEN/ PLANNED

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Reviewing 50.59s for quality / content

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Management is reordering priorities as necessary

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Management clarified expectations to workforce

Added additional " checks and balances"

Additional in-line reviews

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Department IIcad approvals

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Safety Evaluation Review Committee

Feedback mechanisms

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Revised 50.59 Procedure

Independent review team input

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Standardize NOD procedure

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Establish appropriate 50.59 performance measures and indicators

Have reassessed training requirements and will train in December 1996

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Feedback mechanism established to confirm satisfactory program implementation

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CONFIGURATION MANAGEMENT / DESIGN CONTROL

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ISSUE (S)

The process for controlling modifications and ensuring adequate post-modification testing package

closure was ineffective.

CAUSE(S)

Design / Configuration Control / Design Basis processes not viewed as being an essential

element of safe plant operations

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Failure to evaluate interim configuration of modifications which required changes

during installation / testing phases

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Failure to adequately document deviations from original design / testing intent

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Inadequate oversight of design changes which required deviation from original

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installation / testing intent

Failure to manage engineering tumover of design change assignments

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BROAD ACTIONS TAKEN/ PLANNED

Reviewed 50.59s for design changes that had been issued but had not been declared operable.

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No USQs identified

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Reviewed design changes that had completed installation but had not been closed out to

establish action plan for closure

Out-of-service process for design changes modified

Modification close-out area established to enhance modification package control

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OPERABILITY ASSESSMENTS

ISSUE (S)

Quality and use of operability assessments were inadequate

CAUSE(S)

Personnel preparing operability assessments are task oriented and do not appreciate the

significance of an operability assessment

Inadequate management oversight of operability assessment process

Failure to ensure that assessments are prepared by appropriate personnel

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Failure to ensure quality work

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Inadequate oversight of engineering judgements

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BROAD ACTIONS TAKEN/ PLANNED

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Clarified management expectations

Performing consistency review of operability assessments

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Reviewed open operability assessments

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Ongoing monthly review of operability assessment corrective action status

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Established Engineering Department 11ead approval / Engineering Manager review

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PROCEDURE ADHERENCE

ISSUE (S)

Recurring problems in administrative procedural adherence.

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CAUSE(S)

Inadequate management focus

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Failure to hold workforce accountable regarding adherence to administrative procedures /

processes

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BROAD ACTIONS TAKEN/ PLANNED

During training, clarified management expectations regarding procedure adherence

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Conducted stand downs / work stoppage

Developing / implementing management follow-up and expectation feedback mechanisms

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Initiated dual independent reviews of System Engineering tests performed during Z2R14

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(subsequent to the work stoppage)

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CORRECTIVE ACTIONS

ISSUE (S)

Corrective action efforts did not adequately identify causes of problems. Therefore, corrective

actions were too narrowly focused. In addition, effectiveness of corrective actions was not verified.

APPARENT CAUSES

Poor corrective action culture

Inadequate questioning attitude

Over focus on task management

Low priority for program implementation

Inadequate rigor regarding program implementation / verification

BROAD ACTIONS TAKEN/ PLANNED

Improved questioning attitude / corrective action culture

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Increased management involvement in corrective action process implementation

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Prompt assessment of component status is being addressed during daily event

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screening committee meetings

Department Ileads are ensuring corrective actions are effective

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SITE QUALITY VERIFICATION (SQV)

ISSUES

NRC-stated deficiencies should have been identified and pursued by SQV prior to NRC

inspection.

CAUSE(S)

Reactive Philosophy

Narrow view of performance issues and significance

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Failure to integrate off-site review issues into SQV assessments and actions

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Inadequate coverage of Engineering programs

Inadequate follow-through regarding corrective actions whe issues were identified

BROAD ACTIONS TAKEN/ PLANNED

Modified audits and surveillances will include broader assessments of performance to

properly characterize significance

Increased SQV coverage in Engineering programs (and other areas as necessary)

Clarifying and implementing expectations for corrective actions

Adding resources and expanding skills

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SPECIFIC ENFORCEMENT ISSUES

10 C.F.R. @ 50.59

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VIOLATION la

AUXILIARY FEEDWATER PUMP MODIFICATION

RESTATEMENT OF VIOLATION EXAMPLE

A modification changed the AFW pump steam supply steam traps. The modification was in service

even though testing was incomplete. Therefore, the modification was in a mode which was not

adequately analyzed (continuous bypass of orifices). No design change or 50.59 safety evaluation

was performed to address the new operating mode.

ADDITIONAL INFORMATION

A 50.59 evaluation and a modification addendum letter for the change was located

subsequent to the NRC inspection

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50.59 was inadequate

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CAUSF4S)

Inadequate rigor during 50.59 preparation

Inadequate management oversight

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SAFETY SIGNIFICANCE

No actual significance

Minimum potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Close modification before end of current outage

Will reperform 50.59

Complete broad corrective actions regarding 50.59

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VIOLATION lb

TEMPORARY HEAT TRACING AND INSULATION FOR SI RECIRCULATION PIPING

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RESTATEMENT OF VIOLATION EXAMPLE

Temporary Alteration 96-013 (March I8,1996) was inadequate regarding modification detail and

extent of equipment description. Zion failure to perform a 50.59 and document the results for a

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temporary modification that appeared necessary to prevent freezing was different from the UFSAR,

could potential impact another system, and could introduce new failure modes.

ADDITIONAL INFORM ATION

A 50.59 screen was performed; however, it incorrectly concluded that a full 50.59 safety

evaluation was not required

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CAUSE(S)

Inadequate rigor during 50.59 preparation

Inadequate management oversight

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SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Reperfonning 50.59 evaluation

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No USQ

Department IIcad approval of 50.59 screens

Complete broad corrective actions regarding 50.59

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VIOLATION Ic

SCAFFOLDING AROUND SI ACCUMULATORS

RESTATEMENT OF VIOLATION EXAMPLE

SE 50.59/0166/95, November 16,1996, (should have stated 1995) was performed to allow

scaffolding around the SI accumulators to remain in place inside containment during operation. Zion

placed the units in operation during a four month period that an off-site review was being performed,

with an incorrect SE to support installation, and little technical basis to support the USQ

determination. See Violation 2c.

CAUSE(S)

Inadequate rigor during 50.59 preparation

Inadequate management oversight

SAFETY SIGNIFICANCE

No actual significance

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Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Remove scaffolding as soon as practicable

Will reperform 50.59

Performed operability assessment

Complete broad corrective actions regarding 50.59

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VIOLATION 1d

CONTAINMENT PENETRATION SEAL

RESTATEMENT OF VIOLATION EXAMPLE

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Modification E22-1-95-218,"MOVs SI-8803A/B Bypass Line Addition" and the associated 50.59

SE credited a containment isolation valve seal water system function for the Volume Control System

that was not credited in the UFSAR. Zion identified two additional instances where a plant system

was not credited in the UFSAR but had been assumed to be a seal system in the containment

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isolation testing program. The safety evaluation was inadequate in that it failed to identify that

UFSAR Table 6.2.4 does not list a seal system for contaimnent penetration P-4 and thus the subject

modification was a change to the facility as described in the UFSAR.

CAUSE

Inadequate rigor during 50.59 preparation

Inadequate management oversight

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SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequence

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Regulatory significance

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CORRECTIVE ACTIONS

Will revise SE to identify that the UFSAR must be chenged

Will update the UFSAR

Complete broad corrective actions regarding 50.59

As a result of Zion's review of this system not being credited in the UFSAR, additional

similar examples have been identified - appropriate UFSAR updates will be made

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SPECIFIC ENFORCEMENT ISSUES

APPENDIX B. CRITERION V. " PROCEDURES"

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VIOLATION 2a

SR MODIFICATION CLOSEOUTS

RESTATEMENT OF VIOLATION EXAMPLE

Zion failed to ensure that SR modification closecut requirements were successfully accomplished

prior to declaring the modified SSCs as operable and placing them in use in accordance with

Modification, Installation and Testing Procedure ZAP 510-02, " Plant Modification Program,"

Sections G.6.d, " Quality Control," G.6.e, " System Engineer," G.7.c, " Modification Coordinator,"

G.7.d, " System Engineer Supervisor," and Appendix B, Section 3, " Mod Test Reuults Reviewed".

See Violation Examples 3a and 4.

CAUSE(S)

Inadequate management of turnover process

Failure to evaluate interim configuration of modification which required changes

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during installation / testing phases

Rationalization that procedural process completion was not a high priority if the

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component was capable of performing its intended safety function

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Inadequate management / oversight of backlog

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SAFETY SIGNIFICANCE

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No actual significance

No potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Nine safety-related design changes subsequently closed documenting completion of

modification testing requirements

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Testing documentation found for seven safety related changes - changes had to be

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re-reviewed, were deemed acceptable, and signed off

For one test - documentation had to be reviewed, test requirement was deleted, and

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document was signed off

One design change required completion of previously scheduled testing

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Future training to reeducate Engineering personnel on modification process

Established design change closecut schedule

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VIOLATION 2b

PIF PREPARATION

RESTATEMENT OF VIOLATION EXAMPLE

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Zion Procedure 7AP 700-08, " Problem Identification Process," Rev.1, Appendix A, item 16,

required the generation of PIFs for events or conditions identified by an assessment group. Although

the UFSAR conformance review was completed by the end of June 1996, only one discrepancy of

approximately 115 existing had a PIF generated as of the week ofJuly 22,1996, when the NRC team

arrived on site.

CAUSE(S)

Perception by FSAR Conformance Review Team Leader that PIF generation after self-

assessment completion was acceptable practice

SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

PIFs initiated and screened for significance in accordance with ZAP 700-08

Letter from Site Vice-President to all employees emphasizing management expectation for

initiation of PIFs

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VIOLATION 2c

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SCAFFOLDING REMOVAL

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RESTATEMENT OF VIOLATION EXAMPLE

Procedure ZAP 920 -01, "Use Of Scaffolding and Ladders," requires that scaffolding be removed

following work completion. However, scaffolds were left inside the containment when both units

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were operating - essentially being used as a permanent change. In addition, contrary to ZAP 920-

01, the scaffolding had not been inspected every month since installation and the scaffolding was

in direct contact with safety related equipment. See Violation Ic.

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CAUSE(S)

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Tendency to default to easy way to accomplish task without adequate consideration of all

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administrative requirements

Failure by management to hold personnel accountable for adherence to procedure

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Inadequate knowledge of administrative requirements

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SAFETY SIGNIFICANCE

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No actual significance

Minimal potential consequences

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Regulatory significance

CORRECTIVE ACTIONS

Walkdown requirements reemphasized to involved personnel

Performed walkdown of plant scaffolding

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30 day walkdowns perfonned since issue identified

Surveillance tracking database modified to prompt 30 day walkdowns

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Will remove scaffolding as soon as practicable

Management initiatives reinforcing requirement to follow all procedures

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VIOLATION 2d

MATERIAL MONITORING INFORMATION UPDATES

RESTATEMENT OF VIOLATION EXAMPLE

Procedure ZAP-500-13A, " Performance Monitoring, Evaluating and Goal Setting Within the

Maintenance Rule Program" requires a monthly update of trending window data. In June 1996, at

least eight system engineers failed to update the material condition monitoring information used for

trending of component and system performance on thirteen systems.

CAUSF(S)

Failure to appreciate importance of following administrative procedures

Inappropriate priority regarding Maintenance Rule information updates

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Failure by management to hold personnel accountable for administrative procedure

noncompliance

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SAFETY SIGNIFICANCE

No actual significance

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Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Clarified management expectations regarding priority of Maintenance Rule activities

Assigned Engineering Manager's administrative assistant to focus on Maintenance Rule

Action Plans

Management initiatives reinforcing requirement to follow procedures

Engineering Manager monitoring update status

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VIOLATION 2e

DEGRADED VOLTAGE IELAY DIAGRAMS

RESTATEMENT OF VIOI,ATION EXAMPLE

ZAP 510-02, " Plant Modification Program," requires that all affected controlled design documents

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be listed in the design package to ensure appropriate revisions. During the review of degraded

voltage relay set point changes, the NRC identified that six safety related Key Diagrams (22E-1-

400011,22E-1-4000J,22E-2-4000ll,22E-2-4000J,22E-1-4000C and 22E-2-4000C had not been

revised to show the addition of the safety related degraded voltage relays.

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CAUSE(S)

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Inadequate attention to detail

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Inadequate management oversight

SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Management expectations for attention to detail emphasized

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DCR issued fbr subject key diagrams

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VIOLATION 2f

EMERGENCY PROCEDURE ES 1.3," TRANSFER TO COLD LEG RECIRCULATION"

RESTATEMENT OF VIOLATION EXAMPLE

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The NRC identified that Emergency Procedure ES 1.3, " Transfer to Cold Leg Recirculation," Rev.

18 did not include guidance and instructions for the volume control system which was used as a

penetration seal water system. This could have resulted in system operation being terminated and

loss of the penetration seal.

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CAUSE(S)

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Seal system function not addressed in the Westinghouse Emergency Response Guidelines

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Failure to recognize this when preparing Zion ERGS

SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Obtained input from other Comed PWRs on post-accident control of ECCS systems as a seal

system

Ongoing review by Licensing of basis for acceptance of current methodology

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VIOLATION 2g

TECIINICAL SPECIFICATION INTERPRETATIONS

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RESTATEMENT OF VIOLATION EXAMPLE

Issues documented in Sections 1(d),2(a),3(a), (b) and (c) modified the Technical Specification

requirement or intent and therefore, procedure ZAP 130-02, " Technical Specification Interpretations"

was not followed.

CAUSE(S)

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Inadequate procedural guidance (pre 1995)

Inadequate onsite reviews (pre 1995)

Inadequate management oversight of TSI process

SAFETY SIGNIFICANCE

No actual significance

No potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Generated procedural guidance (1995)

Performed line by line review of TSIs

Dispositioned TSis with identified deficiencies

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License amendments submitted

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Deletions / revisions of deficient TSis

Performed 50.59s on remaining TSis

Trained licensed operators regarding revised / deleted TSIs

Modified administrative tracking controls on TSis

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Enhanced procedure goveming TSIs

Reinforced expectations for procedure compliance

incorporated existing TSis into TSIP submittal

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SP. ECIFIC ENFORCEMEM ISSUES

CRITERION XI. TESTING

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VIOLATION 3a

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PLANT OPERATION WITH INCOMPLETELY TESTED PLANT MODIFICATIONS

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RESTATEMENT OF VIOLATION EXAMPLE

Operation of the plant with installed safety related modifications that have not been completely

tested to demonstrate that modified SSCs will perform satisfactorily on demand. See Violation

Examples 2a and 4.

CAUSE(S)

Inadequate management of turnover process'

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Failure to evaluate interim configuration of modification which required changes

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during installation / testing phas'es

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Rationalization that procedural process completion was not a high priority if the

component was capable of performing its intended safety function

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Inadequate management / oversight of backlog

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SAFETY SIGNIFICANCE

No actual significance

No potential consequences

Regulatory significance

_ CORRECTIVE ACTIONS

Confirmed that management control of the modification installation process has improved

Nine safety-related design changes subsequently closed documenting completion of

modification testing requirements

Testing documentation fbund for seven safety related changes - changes had to be

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re-reviewed, were deemed acceptable, and signed off

For one test - documentation had to be reviewed, test requirement was deleted, and

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document was signed off

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One design change required completion of previously scheduled testing

Future training to reeducate Engineering personnel on modification process

Established design change closure schedule

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VIOLATION 3b

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CHARGING PUMP DEGRADATION

RESTATEMENT OF VIOLATION EXAMPLE

Inadequate operability assessment on the 1B Charging Pump degradation and inadequate full flow

test.

CAUSE(S)

Failure to recognize the need to evaluate pump test results with respect to all accident

scenarios

Inadequate test acceptance criteria (full flow test)

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SAFETY SIGNIFICANCE

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No actual significance

No potential consequences

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Regulatory significance

CORRECTIVE ACTIONS

Re-performed operability assessment for 1B Charging Pump and confirmed operability

Full flow test procedure for Charging and Safety Injection Pumps has been revised to require

evaluation of pump performance data

Incorporated testing into ZlR15 to confirm iB Charging Pump curve

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SPECIFIC ENFORCEMENT ISSUES

CRITERION XIV. " TESTING TRACKING"

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VIOLATION 4

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TESTING MARKING / TRACKING SYSTEMS

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RESTATEMENT OF VIOLATION EXAMPLE

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Failure to indicate by use of suitable marking or tracking systems the operability status of safety

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related SSCs modified by plant modifications that had been installed as early as 1986, placed in use,

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but not declared operable or signed or completed. This issue is similar to Violation Examples 2a and

3a.

CAUSE(S)

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Inadequate management of turnover process

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Failure to evaluate interim configuration of modification which required changes

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during installation / testing phases

Rationalization that procedural process completion was not a high priority if the

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component was capable of performing its intended safety function

Inadequate management / oversight of backlog

SAFETY SIGNIFICANCE

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No actual significance

No potential consequences

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Regulatory significance

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CORRECTIVE ACTIONS

Out-of-service process for design changes modified

Confirmed that the management control of the modification process has improved

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Nine safety-related design changes subsequently closed documenting completion of

modification testing requirements

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Testing documentation found for seven safety related changes - changes had to be

re-reviewed, were deemed acceptable, and signed off

For one test - documentation had to be reviewed, test requirement was deleted, and

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document was signed off

One design change required completion of previously scheduled testing

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Modification close-out area established

Training to reeducate Engineering personnel on modification process

Established design change closure schedule

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SPECIFIC ENFORCEMENT ISSUES

CRITERION XVI. " CORRECTIVE ACTIONS"

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VIOLATION 7a

IDENTIFICATION OF OUT-OF-TOLERANCE ROOT CAUSE

RESTATEMENT OF VIOLATION EXAMPLE

Failure to identify the root cause of repetitive out-of-tolerance conditions on the Containment Spray

System sodium hydroxide Spray Additive Tank level indicators (PIFs 295-201-95-CAT 4-1227,295-

201-96-CAT 4-0010,295-201-96-CAT 4-0011,295-201-96-CAT 4-0916, and 295-201-96-CAT 4-

1044).

CAUSE(S)

Possibility of damaging obsolete components

Reliance on compensatory measures

Zion aware of situation

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Plan to replace indicators already in development

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Had increased calibration periodicity

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Maintaining higher tank level to compensate

SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

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Regulatory significance

CORRECTIVE ACTIONS

Increased calibration frequency based on out of calibration results

Identify other components in similar circumstance

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Will replace levelindicators

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VIOLATION 7b

4kV BREAKER NO 1412 FAILURES

RESTATEMENT OF VIOL ATION EXAMPLE

Breaker No.1412 failed on numerous occasions and a root cause of nonconforming conditions and

appropriate corrective actions were not determined to preclude repetition.

CAUSE(S)

Lack of a questioning attitude by station personnel

Inadequate analysis of related work requests /PIFs

Inadequate priority regarding added value of equipment trending

SAFETY SIGNIFICANCE

No actual significance

Minimal potential consequences

Regulatory significance

CORRECTIVE ACTIONS

Determined root cause(s) of failures and repaired breaker

Improve questioning attitude / corrective action culture

Increased management involvement in corrective action process

Prompt assessment of component status

Ensure corrective actions are effective

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SUMMARY

BROAD ISSUES / BROAD ROOT CAUSE CATEGORIES /

ASSOCIATED CORRECTIVE ACTIONS

WEAK MANAGEMENT OVERSIGHT

Clarification of management expectations provided to workforce (50.59,

Configuration Management / Design Control, Procedure Adherence, Corrective Actions, OAs)

Additional checks and balances (50.59)

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Additional in-line reviews (50.59)

Safety Evaluation Review Committee (50.59)

Department Head approvals (50.59)

Consistency reviews of operability assessments (OAs)

Department Head approval / Engineering Manager review (OAs)

Site VP letter to all employees emphasizing management expectation for initiation of PIFs

(Procedure Adherence)

Management initiatives reinforcing requirement to follow all procedures (Procedure

Adherence)

Clarified management expectations regarding priority of Maintenance Rule activities

(Procedure Adherence)

Engineering Manager monitoring Maintenance Rule information update status (Procedure

Adherence)

Reemphasis of management expectations for attention to detail (Procedure Adherence)

SELF ASSESSMENTS

Developing / implementing management follow-up and expectation feedback mechanisms

(Procedure Adherence)

Initiated dual independent reviews of tests performed during Z2R14 (subsequent to the work

stoppage)(Procedure Adherence)

Modified audits and surveillances will include broader assessments of performance to

properly characterize significance (SQV)

Increased SQV coverage in Engineering Programs (and other areas as necessary) (SQV)

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SUMMARY

BROAD ISSUES / BROAD ROOT CAUSE CATEGORIES /

ASSOCIATED CORRECTIVE ACTIONS

IsACK OF EFFECTIVE PRIORITY SYSTEM

Management reordering of priorities (50.59)

Clarification of management expectatioru provided to workforce (50.59,

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Configuration Management / Design Control, Procedure Adherence, Corrective Actions, OAs)

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Clarified management expectations regarding priority of Maintenance Rule activities

(Procedure Adherence)

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LACK OF ACCOUNTABILITY

Clarification of management expectations provided to workforce (50.59,

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Configuration Management / Design Control, Procedure Adherence, OAs)

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Work stoppage (Procedure Adherence)

Site VP letter to all employees emphasizing management expectations for initiation of PIFs

(Procedure Adherence)

Management initiatives reinforcing requirement to follow all procedures (Procedure

Adherence)

Clarified management expectations regarding priority of Maintenance Rule activities

(Procedure Adherence)

Engineering Manager monitoring Maintenance Rule information update status (Procedure

Adherence)

Reemphasis of management expectations for attention to detail (Procedure Adherence)

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SUMMARY

BROAD ISSUES / BROAD ROOT CAUSE CATEGORIES /

ASSOCIATED CORRECTIVE ACTIONS

KNOWLEDGE DEFICIENCY

Training reassessment / modification (50.59)

Prompt assessment of component status (Corrective Actions)

Expanding skills (SQV)

Future training to reeducate Engineering personnel on modification process (Procedure

Adherence)

Management initiatives reinforcing requirement to follow all procedures (Procedure

Adherence)

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Trained licensed operators regarding revised / deleted TSis (Procedure Adherence)

INEFFECTIVE ROOT CAUSES/ CORRECTIVE ACTION PROGRAM

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Site VP letter to all employees emphasizing management expectations for initiation of PIFs

(Procedure Adherence)

Increased management involvement in Corrective Action process implementation

(Corrective Actions)

Prompt assessment of component status (Corrective Actions)

Increased management involvement in Corrective Action process implementation

(Corrective Actions)

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REGULATORY ASSESSMENT

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10 C.F.R. # 50.59

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No USQs resulted from additional reviews

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No instances of exceeding FSAR analysis

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No impact on operability because of 50.59 deficiencies

One 50.59 prepared for a procedure change led to a technical specification violation

Several 50.59s should have led to conservative / clarifying Technical Specification

amendments

Operability Assessment Process

Reviewed open operability assessments - conclusions still valid

One closed operability assessment being validated by vendor test

Configuration Controlfrestine Procrams

7 safety related and six non safety related modifications declared operable after locating and

re-reviewing test requirements

One safety related modification declared operable after redefining test requirements

One safety related modification and one non safety related modification declared operable

af ter further testing

Twelve non safety related modifications confirmed to be in an acceptable interim

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configuration

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Procedure Adequaev And Adherence

TSis reviewed line-by-line

Revisions / deletions / amendments required

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No issues warranting reporting (50.72,50.73)

Enforcement Policy

Issues have collective regulatory significance

No individual immediate safety significance

Minimal or no individual potential consequences

Many issues identified as part of Zion initiatives

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Acknowledge that Zion response to findings was slow

Some violation examples appear to be duplicative

Same issue cited different ways

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CLOSING REMARKS

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