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{{Adams
#REDIRECT [[IR 05000298/1998022]]
| number = ML20199E169
| issue date = 01/07/1999
| title = Insp Rept 50-298/98-22 on 981116-1208.Violations Noted.Major Areas Inspected:Licensee Performance in Completing Engineering Strategy Action Item 3.2.e
| author name =
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
| addressee name =
| addressee affiliation =
| docket = 05000298
| license number =
| contact person =
| document report number = 50-298-98-22, NUDOCS 9901200342
| package number = ML20199E157
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 31
}}
See also: [[see also::IR 05000298/1998022]]
 
=Text=
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                                                                  ENCLOSURE 2
                                                                                                            {
                                                                                                              l
                                  U.S. NUCLEAR REGULATORY COMMISSION                                          i
                                                                      REGION IV                            '
        -
                                                                                                            i
            Docket No.:        50-298
                                                                                                              1
            License No.:        DPR 46                                                                      i
            Report No.:        50-298/98-22
            Licensee:          Nebraska Public Power District                                              !
                                                                                                            i
            Facility:          Cooper Nuclear Station                                                        i
                                                                                                              l
            Location:          P.O. Box 98
                                Brownville, Nebraska
            Dates:              November 16 through December 8,1998
            Inspectors:        David P. Loveless, Sr. Project Engineer
                                William M. McNeill, Reactor Engineer
                                James F. Melfi, Project Engineer
            Approved By:        Charles S. Marschall, Chief
                                Project Branch C
l                              Division of Reactor Projects
f
l          ATTACHMENTS:
;          Attachment 1      Supplemental Information
            Attachment 2      Work Item Sample Selections Reviewed
!
j          Attachment 3      Documents Reviewed
            Attachment 4      Unauthorized Modification Review Program
i
  ~
!
!
                                                                                                              '
i
!.
                                                                                                              l
1
                                                  ,
          9901200342 990107
-
          PDR      ADOCK 05000298
          G                    PDR                                                                            l
i                                                                                                            i
s
 
      -.-    -.      - . - - ~ -              - - -. - - - .                        ..~ -_- - -      . - -
  ~
                                                                                                              .
  .
                                            EXECUTIVE SUMMARY
                                            Cooper Nuclear Station
                                      NRC Inspection Report 50-298/98-22
    This focus inspection was conducted to evaluate the licensee's performance in completing
    Engineering Strategy Action item 3.2.e," Complete the Unauthorized Modification Review," as                1
                                                                                                              '
    documented in the Cooper Nuclear Station Strategy for Achieving Engineering Excellence,
    Revision 2. This program had been created to correct deficiencies identified in previous
    escalated enforcement. This focus inspection was the first inspection of a completed
    engineering improvement strategy item. The team identified that the program had not identified
    all unauthorized modifications, nor had all identified unauthorized modifications been properly
    evaluated and dispositioned. The specific safety significance of items identified by the team              '
    was considered to be relatively low. However, the findings indicated a lack of adequate                    1
    management oversight of the program. Corrective actions to prevent recurrence of
    unauthorized modifications via the maintenance work order process were effective.                          4
    Maintenance
    =
            The licensee's changes made to their procedures and processes for handling                        I
            maintenance work requests (MWRs) effectively precluded unauthorized modifications.                  !
l          The work planners and maintenance craftsmen were sensitive to potential configuration              '
            changes, and a review of recently completed MWRs did not identify any unauthorized
l          modifications (Section M3.1).
    *
            The existence of 318 items identified by the licensee as potential unauthorized
            modifications, that had not been identified through MWR review, indicated that past
          weaknesses in other licensee programs may have also resulted in unauthorized
            modifications (Section M3.1).
j  Enaineerina
    =
            Licensee personnel had failed to identify seven unauthorized modifications identified by
            the team. This failure was the first example of a violation for the failure to take adequate
            corrective actions to the problem identified as Violation 50-298/9604-1013. The safety
            significance of the items identified by the team was low. However, the findings indicated
            a lack of program oversight (Section E1.1).
    *      Licensee engineers failed to properly evaluate all of the conditions adverse to quality
            identified by the unauthorized modification review program. This failure was an
            additional example of a violation for the failure to take adequate corrective actions
            regarding Violation 50-298/9604-1013. The safety significance of items identified by the
l          team was low (Section E1.2).
;
!  *      Licensee management oversight for the unauthorized modification review program was
!          insufficient to identify and correct problems identified by the team. Licensee engineers
            failed to utilize their design control process in resolving a majority of the unauthorized
            modifications documented. This failure resulted in one example of a violation. Also,
j          program coordinators made a decision to leave the backlog items open without a
;
;
!
i
!
                                                                                                              ,
 
      . . , - . . . .                    - _ .                . - -          - --      -. . - . - - - - -
    .
    .
                                                            2-
                      complete understanding of the scope and potentialimpact of each item
                      (Sections E1.1, E1.2, and E7.1).
l
f
!
l
l
,
l
2
4
  i
W
 
    -  ---._-.,- - - -.- - -                                                    - -.    -- _ _          _ - - - . _
      .
                                                                Report Details
                                                                ll. Maintenance
        M3                  Maintenance Procedures and Documentation
        M3.1 Maintenance Proaram Chanaes to Prevent Unauthorized Modifications                                          ;
          a.                Inspection Scope (62702)
                            The team reviewed the changes made to maintenance procedures and processes to
                            assess if these changes should preclude future unauthorized modifications. Interviews
                            were conducted with maintenance department working level personnel. The team
l                          evaluated a random sample of MWRs completed after corrective actions were                  i
                            implemented to determine if they contained unauthorized modifications.                      l
          *                Backaround                                                                                  i
                                                                                                                        l
                            On November 8,1995, the NRC team identified that the main steam tunnel blowout
I                          panel sections did not appear to be consistent with diagrams in applicable design          l
                            calculations. A structurally significant coating had been placed on the secondary          1
l                          containment side of the panel sections, potentially altering their material characteristics
l                          and strengthening the blowout panel . sections. Increased structural strength would have    ,
                            been nonconservative for the blowout panel's design basis function. In addition, the        '
                            design configuration of the panel sections had not been maintained in associated
                            documents and drawings. An apparent violation was identified for the failure of the
                            licensee to pedorm an evaluation in accordance with 10 CFR 50.59 on this modification
                            to the steam tunnel blowout panel sections. The resulting enforcement action issued
                            Notice of Violation 96004-01013.
                          The licensee's response dated May 17,1996, committed to review MWRs according to
                            a sampling plan. The review would detect modifications installed without performance of
                            safety evaluations. The sample size initially consisted of 10 percent of a se!ecteo
                            population of MWRs from 1974 to 1996. The review of this sample of 2090 MWRs
                            resulted in the identification of 128 unauthorized modifications.
                            As a result of these findings, the licensee expanded the scope of their sampling to
                            include all of the remaining MWRs from 1973 - 1996. In an effort to identify all
                            unauthorized modifications in the plant, the licensee established a population of
l                          95,736 MWRs written since initial licensing until June 12,1996. June 12,1996, was the
(                          date of implementation of the corrective actions to eliminate the possibility of making an
;                          unauthorized modification by means of the MWR process. The licensee divided these
.                          MWRs into two groups. One group of 22,834 MWRs written before 1980 were available
j                          on microfilm. A second group of 72,902 MWRs written after 1980 were available on
;                          microfilm copy and documented in an electronic data base. The electronic data base
i                          allowed the licensee to do a " key word' search of those MWRs written after 1980. From
j                          the keyword search, the 72,902 MWRs were reduced by 51,994 MWRs to
;                            20,908 MWRs.
  !
!
;
 
    ___                                                            __                  .
1 -
                                                                                                      1
                                                                                                      1
  .
                                                    -2-                                                i
                                                                                                      l
                                                                                                      1
          Licensee personnel screened 14,740 of the 20,908 MWRs by evaluating whether the            ,
          documents contained changes that may have been unauthorized modifications. This            l
          was referred to as the first screening criteria. Approximately 5,712 MWRs were
          screened, utilizing the same criteria, by contract personnel. Of the 20,908 MWRs
          screened,2,956 were considered to be potential unauthorized modifications.
l
          In addition to the MWR review, the licensee also evaluated past problem identification      l
l          reports (PIRs) to determine if any documented potential unauthorized modifications. An
          additional 318 items were considered to be examples of potential unauthorized
          modifications. However, it was not determined if these were associated with MWRs.
          The team considered the existence of 318 items considered potential unauthorized
,
          modifications to be a serious question of the logic used by the licensee. It was originally
l          assumed by the licensee that all unauthorized modifications were associated with
          weaknesses in the MWR process. Therefore, an exhaustive review of MWRs should
          have revealed all unauthorized modifications. Licensee management committed to
          further review and evaluate the cause of the unauthorized modifications documented in
          these 318 PIRs.
          In accordance with the licensee's program, all potential unauthorized modifications were    j
          given a second, more detailed screening. Of the 3,274 potential unauthorized                !
          modifications (2,956 MWRs and 318 PIRs), project personnel concluded that 1,023 did        l
          not document unauthorized modifications. This resulted in a final tally of 2,251            1
          unauthorized modifications identified by the project and requiring disposition. The team    i
          documented an accounting of the screening process discussed above in Attachment 4.
        b. Observations and Findinas
          As corrective action to prevent recurrence of the unauthorized modification problem,
          licensee personnel combined the requirements of several procedures. Maintenance
          personnel deleted Procedures 7.0.1.3," Maintenance Work Request Planning -
          Documentation of Work," and 7.0.1.6, " Maintenance Work Request - Minor
          Maintenance." For unauthorized modifications, the licensee changed Administrative
          Procedure 0.40, " Work Control Program," combining these requirements into this
          procedure. The licensee also added instructions into Maintenance Procedure 7.0.4,
          " Conduct of Maintenance," to obtain an engineering evaluation for configuration control
          changes.
          The maintenance craftsmen interviewed were cognizant of the unauthorized
          modification issues and the need to verify that replacement components were exactly
          the same. If the components were different, the maintenance craft would obtain an
          engineering evaluation for the change.
          The team observed portions of the work planning process to verify that an unauthorized
          modification would not occur. The work planners properly evaluated potential
          configuration changes and used a planners' desk guide to prescreen MWRs for those
          requiring an engineering review. The team also observed the planners' discussion at a
l
l
 
  _ _ _ _ _ _ _          ---
                              _ _ _ _ _ _ _ _ _ -..                  _____ _ _ _ _ __            _ _ _ .. _    _ . _ _
      .
      .
                                                                  -3-
                      routine meeting to review emergent work. The personnel at the meeting were sensitive
                      to the potential for unauthorized configuration changes and the need for engineering
                      review of these changes.
                      To verify that these procedure changes were effective and the knowledge of the workers            i
                      was adequate, the team reviewed a random sample of 60 MWRs completed after these
                      procedure changes were implemented. A listing of the MWRs is included in
                      Attachment 2. The team did not identify any unauthorized modifications documented
                      within this sample.
                c.    Coriciusions
                      The team concluded that the changes made to licensee procedures and processes for
                      MWRs effectively precluded unauthorized modifications. The work planners and
                      maintenance craft were sensitive to potential configuration changes, and a review of
                      recent MWRs did not identify any unauthorized modifications. However, the team found
                      that the existence of 318 items identified by the licensee as potential unauthorized
                      modifications, that had not been identified through MWR review, indicated that past
                      weaknesses in other licensee programs may have resulted in unauthorized
                      modifications.
                                                          Ill. Engineering
                E1    Conduct of Engineering
                E1.1  Review of MWRs for Unauthorized Modifications
                a.    Inspection Scope (37551)
                      The team assessed the scope and quality of the licensee's efforts involving the                    1
l                      unauthorized modification review program as defined in "CNS Strategy for Achieving
                      Engineering Excellence," Revision 2, dated July 8,1998. Samples of MWRs were
                      ovaluated to determine if they contained unauthorized modifications not identified by the
                      licensee's efforts. The team also conducted interviews with key personnel and
                      management involved in the review,
                b.    Observations and Findinos
,                      The team selected statistically significant samples from each of five populations
l                      according to the method utilized by licensee personnelin determining if unauthorized
i                      modifications existed. The populations are described end the specific examples listed in
i                      Attachment 2 to this inspection report. The following are the findings of the team related
l                      to each sample:
                      1.        The team drew a sample (Sample 1) of 60 MWRs from the population of
                                  22,834 MWRs worked prior to mid 1980 to verify proper sorting of the MWRs.
                                  The goal of the team was to review only those MWRs determined by the licensee
                    _                    _        --
 
  . . . . .      _        .._    . -          - - - - - . _ - . - - - . - .                . -    - - -
                                                                                                            i
                                                                                                            l
                                                                                                            '
                                                          -4-
                not to include unauthorized modifications (rejected). However, the total
                population of 22,834 MWRs was sampled because the project coordinators had
                not tracked the exact number of MWRs rejected from this population. The team
6
                sampled the entire population, and the 3 MWRs previously identified by licensee
                personnel to document unauthorized modifications were verified to be included                j
                on the list of 2,251 unauthorized modifications identified by the licensee.                  j
                                                                                                            l
                a      The team identified one MWR from Sample 1 that represented an                        1
                        unauthorized modification. Based on the team's sampling method, the
                        identification of one MWR documenting an unauthorized modification that
                        had not been identified by the licensee's process was statistically
l                        significant. The MWR identified was worked on May 11,1978. At that
I
                        time, craftsmen manufactured and installed a guard over the fire system
l
                        flushing pump ventilation openings to prevent recurrence of bird's nests.
                        Licensee personnel concurred with the team's findings and issued
                        PIR 3-40350 to document the failure to identify and correct this specific
                        unauthorized modification.
            2. The team drew a sample (Sample 2) of 60 MWRs from the population of
,
'
                51,994 MWRs. These MWRs represented the population of MWRs that were
                screened by computer searching techniques and determined not to be
                unauthorized modifications. Licensee personnel had utilized a keyword search
                to identify MWRs that were likely to have involved changes to the facility, while
                ruling out those that were properly authorized by appropriate design change
                documents. No unauthorized modifications were identified by the team from
                Sample 2.
                The team used a statistical tolerance sampling plan with a minium sample size
                that would give a high degree of assurance that the licensee's screening process
                was effective. The lack of identified unauthorized modifications from Sample 2
                indicated a 95 percent confidence that 95 percent of the population did not
                contain unauthorized modifications.
            3. The team drew two samples (Samples 3 and 4, respectively) from the population
                of 20,462 MWRs. These represented the MWRs from 1980 through 1996 that
                had not been rejected via computer screening techniques, but were not
                considered potential unauthorized modifications by the licensee staff making the
,
                reviews. These items had been rejected using the licensee's first screening
l              criteria as defined in Section M3.1.b of this inspection report. Sample 3                    i
i              consisted of 60 MWRs selected from those screened by permanent plant
l              personnel. Sample 4 consisted of 60 MWRs selected from those screened by
i
                the licensce's contractor. No unauthorized modifications were identified by the
i              team from Sample 3.
i            4. The team identified four MWRs from Sample 4 that represented unauthorized
                modifications. Based on the team's sampling method, the identification of four
{                                                                                                          .
!
i
4
                                                                                                          __
                                                                            . _ _ _              _
 
                                                    _ _ _ _ _ _ _ _ _ _
                                        5-
    MWRs documenting unauthorized modifications that had not been identified by
    the licensee's process was statistically significant. The following represents the
    unauthorized modifications identified by the team:
    *
              MWR 94-4167 documented an unauthorized modification to computer
              consoles in the main control room. On January 10,1992, craftsmen
              installed a 9% foot section of 1-inch square tube steelin the center of the
              main control room. The tube steel was installed as a protective barrier to
              existing power cables. Licansee personnel concurred with the team's
              findings and issued PIR 4-00022 to document the failure to identify and
              correct this specific unauthorized modification.
    *
              MWR 90-2588 documented an unauthorized modification to an indicator
              isolation valve in the auxiliary steam system. On May 23,1990,
              craftsmen replaced a leaking auxiliary steam petcock with a needle valve.
              The MWR documented that a different type of valve was used and that
              the equipment data file needed to be updated. After NRC identification,
              licensee review found that they failed to update the equipment data file.
            The valve installed was similarly rated for system pressure and the
            system was not safety related. Licensee personnel concurred with the
            team's findings and issued PIR 3-40341 to document the failure to
            identify and correct this specific unauthorized modification.
  *
            MWR 86-2979 documented an unauthorized modification to a pump
            instrument rack in the spent fuel pool cooling system. On August 7,
            1986, craftsmen installed two pipe clamps to fix vibrating instrument and
            controls piping. Licensee personnel concurred with the team's findings
            and issued PIR 3-40338 to document the failure to identify and correct
            this specific unauthorized modification.
  *
            MWR 91-4738 documented an unauthorized modification to a steam
            tunnel fire protection suppression piping hanger. On August 23,1994,
            craftsmen reinstalled a pipe hanger utilizing instructions provided by the
            planner. The component was modified by relocating the hanger,
            enlarging the support plate holes, drilling holes in the steam tunnel wall,
            and using larger anchor bolts. Licensee personnel concurred with the
            team's findings and issued PIR 3-40351 to document the failure to
            identify and correct this specific unauthorized modification.
5. The licensee's program prompted engineers to perform a second screening of
  the potential unauthorized modifications identified by the first screening utilizing
  different criteria. During the second screening, engineers reviewed the
  3,274 items identified as potential unauthorized modifications, reducing the total
  to 2,251 considered by the licensee as documenting unauthorized modifications.
  The team sampled 60 MWRs (Sample 5) from the 1,023 MWRs rejected to verify
  the effectiveness of the second screening process. The team identified two
  MWRs from Sample 4 that represented unauthorized modifications. Based on
  the team's sampling method, the identification of two MWRs documenting
 
    _ _ _.    ~.        . _ _    _ . _ - . _ - _ _ _ _                              . . _    _ - - - _ - . -
      -
                                                                                                                  .
                                                                                                                  !
      .
                                                                                                                  :
                                                                                                                  '
                                                              .6-
                            unauthorized modifications that had not been identified by the licensee's process
                            was statistically significant. The following represents the unauthorized
                            modifications identified by the team:                                                j
                            *
                                    MWR 76-3-71 documented an unauthorized modification to the drywell              I
                                    high pressure annunciator associated with the drywell pump-around
                                    system. Setpoints for the system air compressor automatic function and
                                    the associated annunciator were changed. This system has been
                                    abandoned in place except for testing purposes. Licensee personnel
                                    disagreed with the team's findings because the changing of setpoints on
                                    an abandoned system was not considered to constitute an unauthorized
                                    modification under the licensee's review process. However, the team
                                    determined that the setpoint changes had been made without appropriate
                                    design controls. PIR 3-53069 was issued to document the team's finding
                                    and to further evaluate the concern.
                                                                                                                  1
                            *
                                    MWR 79-5-51 documented an unauthorized modification to the reactor            )
                                                                                                                  '
                                    high water level turbine trip circuitry. On May 18,1979, craftsmen
;                                  installed a capacitor in parallel with a reactor feedwater pump control
l                                  circuit. The capacitor was installed to reduce noite in the control
l                                  circuitry. The engineers performing tha second level screening had
                                    decided that this was not an unauthorized modification because they
                                    thought that the capacitor had been removed in accordance with an              i
.
                                    approved design modification. However, in response to the team's
l                                  questions, engineers performed additional visual inspections, revealing        ,
)                                  that a capacitor had been installed and remained in the circuitry.
l                                  Licensee personnel disagreed with the team's findings because the item
i                                  had been addressed by the " white paper." However, the team noted that
                                    the item was clearly documented in the " white paper" as not being an
,                                  unauthorized modification when the addition of a capacitor to the circuit
I
'
                                    met the definition of an unauthorized modification. Licensee engineers
                                    documented the team's findings on PIR 3-40352 to further evaluate the
                                    concern.
                  During the review of Samples 1 through 5, the team identified seven unauthorized
                  modifications that had not been identified by the licensee's review process. These
                  seven were identified from three populations with a sample of 60 MWRs from each
                  population. This represented an error rate greater than 2 percent from the total
                  300 MWRs reviewed by the team members. The evaluation of MWRs in Samples 2 and
                  3 produced no unauthorized modifications not previously identified by the licensee. This
,
                  indicated a high level of confidence in the computerized screening process and in those
i
  .
                  initially screened directly by licensee personnel. To the contrary, the team identified
l                seven MWRs from Samples 1,4, and 5 that represented unauthorized modifications.
:                Based on the team's sampling method, the identification of these seven MWRs
    ;            documenting unauthorized modifications that had not been identified by the licensee's
  i              process was statistically significant. The safety significance of the seven unauthorized
'
                  modifications identified by the team was low. However, the findings indicated a lack of
                  program oversight.
i
1
F
            n-      n  ,            -g:-                                                                        -
 
  _ _ _ ___      __...___.____-.____._______m._
                                                                                                                  '
    .
    .
                                                                  -7-                                            +
                                                                                                                  i
                    The team concluded that the failure of the licensee's program to identify these seven
                    unauthorized modifications constituted inadequate corrective action taken as a result of
                    Violation 50-298/9604-1013. This failure to take adequate corrective action is the first
                    example of a violation (50-298/9822-01). This violation is being cited because it was
                    identified by the inspectors and, th 3refore, does not meet the criteria for discretion as
                    documented in the NRC Enforcement Criteria. A response is required for this violation        i
                    because the issue was not entered into the licensee's corrective action program until
                    after the inspection was complete. Additionally, the licensee's corrective actions will be
                    reviewed for applicability to the closure of other engineering strategy items.
                                                                                                                  i
            c.    Conclusions
                                                                                                                  i
                    The team identified seven unauthorized modifications from three populations with              l
                    samples of 60 MWRs from each population. This represented a greater than 2 percent            I
                    hit rate from the total 300 MWRs the team members reviewed. The failure of licensee
                    personnel to identify these unauthorized modifications during their review was the first
                    example of a violation for the failure to take adequate corrective actions for the problem    :
l                  identified as Violation 50-298/9604-1013. The safety significance of the items identified      I
                    by the team was low. However, the findings indicated a lack of program oversight.              !
l                                                                                                                  l
            E1.2    Evaluation of Identified Unauthorized Modifications
!
            a.    Inspection Scope (37551,37001)
                                                                                                                  l
                    The team reviewed samples of items identified by the licensee as being unauthorized
                    modifications. Th9 adequacy of the licensee's evaluation and corrective actions for
l                  these identified una Jthorized modifications were assessed. Team members reviewed
                    documentation and ,mocedures, performed visual inspections of plant components, and
                    interviewed person iel t<> assess the adequacy of the licensee's review.
            b.    Observations and Findinas
                    The team selected statistically significant samples from each of three populations
                    according to the method utilized by licensee personnel in evaluating and dispositioning
                    the identified unauthorized modifications. The three populations were categorized as:
                    (1) unauthorized modifications dispositioned by the licensee's generic " white paper;"
                    (2) items dispositioned by generic engineering evaluations addressing multiple
                    unauthorized modifications; and (3) unauthorized modifications dispositioned by item
                    specific evaluations or reviews. The team described the populations and listed the
(                  specific examples in Attachment 2. The following are the findings of the team related to
                    each sample:
,                    1.            The team drew a sample of 60 MWRs (Sample 6) from the population of 1,107
l                                  unauthorized modifications that were dispositioned by the " white paper."
l                                  Program coordinators had grouped potential unauthorized modifications into one
;                                  of seven categories. Each category was then resolved on a generic basis.
j                                  While reviewing Sample 6, the team identified three examples of inadequate
j                                  resolution of design documentation errors that resulted from the unauthorized
i
                                                                                                                    I
                                                                            , , - - - -
 
      - .      . _ .  .    -.        _- -          . . . .    _ - . _ -          .      - - . - .      _ - _ - .
    *
l
    .                                                                                                              ;
l                                                            -8-                                                    :
                    modification. These represented examples of unauthorized modifications
                    identified by the licensee that were not properly dispositioned.                              i
                                                                                                                    i
                    Also, during the team's review of Sample 6, the licensee staff issued
                    PIR 3-40349 to identify that the " white paper" was not a controlled design                    ,
                    document nor were the dispositions of all MWRs associated with the " white                    I
                    paper" resolved in accordance with the design process. The failure to use an                  l
                    approved design process to make or accept design modifications was in violation
!                    of 10 CFR Part 50 Appendix B, Criterion Ill. However, the specific examples
                    identified by the team were cited in the Notice of Violation as a failure to take
                    adequate corrective action. The following documents the specific issues
                    identified by the team:
;
                    *
                              MWR 76-4-108 documented an unauthorized modification of an offgas
                              control room ventilation system solenoid. On April 30,1976, craftsmen
                              installed two snubbers on the cooling water lines. This was identified by
                              the licensee as an unauthorized modification. However, the current
i                              drawings were not updated to reflect the change. Engineers had
!
                              determined, as documented in the " white paper," that no documentation
l                              changes were required. The licensee agreed that this condition was
                              improperly evaluated and issued PIR 3-40353 to document and correct it.
                    *
                              MWR 76-6-13 documented an unauthorized modification of a
l                              temperature control valve temperature element in the main generator
                              exciter. On October 15,1976, craftsmen relocated a temperature
                              element in the main generator exciter to improve the sensing capability of
                              the element. However, the current drawings still do not reflect the
!
'
                              change. The expert panel had determined that no documentation
                              changes were required. The licensee agreed that this condition was
                              improperly evaluated and issued PlR 4-00020 to document and correct
                              the condition.
                    *
                              MWR 77-3-158 documented an unauthorized modification of the air wash
l                              systems for various plant ventilation systems. On March 28,1977,                      l
l
'
                              craftsmen removed from the reactor building, turbine, and other buildings'            l
                              ventilation systems an air wash subsystem that did not work. These
l
                              subsystems were designed to remove particulate from the air supply.
                              This was identified by the licensee as an unauthorized modification.
                              However, the associated drawings have not been consistently updated.
                              Currently, this is a configuration control problem, but the disposition
                              stated that no configuration documents required updates. The licensee
                              agreed that this condition was improperly evaluated and issued PIR 4-
                              00068 to document and correct the condition.
i          2.      The team drew a sample of 88 MWRs (Sample 7) from the population of
                    approximately 545 unauthorized modifications that were dispositioned by generic
  j                  engineering evaluations. The team determined that these MWRs were
                    associated with the 15 engineering evaluations documented in Table S-7.1 in
r
I
i
                                                                                                                    I
          .
 
.
. .
                                            9
        Attachment 2. The team reviewed the engineering evaluations for adequacy and
        assessed the adequacy of these evMuations to address the unauthorized
        modifications documented in the ar,s:)ciated MWRs. The team identified one
        problem with the adequacy of assumptions used in an engineering evaluation in
        Sample 7. This was an additional example of an unauthorized modification
        identified by the licensee that was not properly dispositioned. The following
      documents the specific issue identified by the team:
      a
                item E97-0244 documented a visualinspection of plant anchor bolt
                installations that had been conducted by licensee engineers. One of
                these anchor bolt installations was the mounting for a reactor building
                room partition that was not part of the original design. This had been
                identified by the licensee as an unauthorized modification. Engineering
                Evaluation 98-048 concluded that Calculation NEDC 97-093 was
                adequate to address and resolve this unauthorized modification.
                Calculation NEDC 97-093 addressed the partition and determined that it
                was acceptable for a use-as-is disposition. This acceptance was despite
                the indication that the anchor bolts in the partition were inadequate
                because an assumption was made that the partition would not hit any
                safety-related equipment should it fall over. A team visual inspection
                revealed that the 7-foot tall partition was less than 5 feet from a hydrogen
                analyzer. The licensee has agreed that this condition was improperly
                evaluated and initiated PIR 3-40342.
    3. The team drew a sample of 60 MWRs (Sample 8) from the population of an
      estimated 599 unauthorized modifications that were dispositioned by item-
      specific evaluations and assessments. Three problems were identified in
      Sample 8 associated with the licensee's proper identification of the design basis.
      These were additional examples of unauthonzcd modifications identified by the
      licenseo that were not properly dispositioned. The fo!!owing documents the
      specific issues identified by the team:
      a
                item E97-0101 documented an unauthorized modification to multiple
                plant components consisting of the attachment of drip pans. Licensee
                engineers had reviewed multiple installations of drip pans attached
                directly to plant process components. A calculation had been prepared
                for the resolution of pans attached to nonsafety-related equipment.
                However, the subject closure package stated that the calculation was
                also applicable to the resolution of safety-related penetrations. The team
                noted that the calculation only addressed Seismic Category 11 component
                interactions as opposed to the more stringent requirements of Seismic      I
                Category I applied to safety-related components. The licensee agreed
                that the results were inconclusive and that specific locations were not
                evaluated, and PIR 4-00029 was issued to further review the problem.        l
      *
                MWR 75-4-228 documented an unauthorized modification to the residual
                heat removal system pump seal water lines. Craftsmen had fabricated
                and installed two stiffener brackets. Although the licensee identified this
 
                                            -10-
                  as an unauthorized modification, they determined that no additional
                  corrective action was required solely because the resolution was
                  addressed in a General Electric service information letter. The closure
                  documentation stated that the expert panel determined the service
                  information letter to be the design basis. The licensee has concurred that
                  vendor information does not become part of the design basis without an      ,
                                                                                              '
                  appropriate review and safety evaluation. The licensee planned to
                  address this as a generic problem with their process for handling service
                  information letters. They documented the concern in PIR 4-00041.
          =      MWR 77-11-68 documented an unauthorized modification to the refueling
                  machine fuel handling grapple. Craftsmen had modified the fuel grapple
                  by removing the support spring and replacing several other components.
                  Although the licensee identified this as an unauthorized modification, they
                  determined that no additional corrective action was required solely
                  because the resolution was addressed in a General Electric service
                  information letter. The closure documentation stated that the expert
                  panel determined the service letter to be the design basis. The licensee
                  concurred that vendor information does not become part of the design
                  basis without an appropriate review and safety evaluation. This concern
                  was documented in PIR 4-00041. As stated previously, the licensee
                  planned to address a generic problem with the handling of service
                  information letters.
  During the review of MWRs and associated items included in Samples 6,7, and 8, the
  team identified seven items that the licensee had not properly evaluated once they
  identified that an unauthorized modification existed. The team identified problems with
  items in each sample, indicating a lack of confidence in each of the statistically
  significant samples. The team found that the safety significance of inadequate
  evaluation of these seven items was low. However, the findings indicated a lack of
  program oversight.
  The team concluded that the failure of the licensee to properly evaluate and resolve
j these seven unauthorized modifications constituted inadequate corrective actions taken
  as a result of the problem identified as Violation 50-298/9604-1013. This failure to take
'
  adequate corrective action is a second example of a violation (50-298/9822-02).
  Additionally, the team reviewed the licensee's backlog of items to be completed
  following closure of the unauthorized modification review program. The team evaluated
  those unauthorized modifications from Sample 6 that contained backlog items, as
! documented in Table S-6 of Attachment 2. The program coordinators had characterized
  the backlog as requiring only minor procedural or drawing updates. However, the team
  found that many items required visual inspection to fully assess the scope of the
  problem and that the coordinators required contractor support to better explain the open
  issues. The team concluded that the licensee's decision to leave the backlog open was
  made without a complete understanding of the scope and potentialimpact of each item.
  The program coordinators initiated PIR 3-40348 to document this issue and evaluate the
 
    _ . _ _ _ _ - _          _ ___-                        _ ._-      ___        - . _ . _ . _      _ _ _ _ . _ _ _ . _ . .
  .
  -
                                                                  -11-
                                                                                                                                l
                                                                                                                                i
                        need for corrective action, including properly identifying the scope of work remaining to
                        close each action.
l
                    c.  Conclusions
l
l                        The team identified seven MWRs that were not properly evaluated once the licensee
;                        determined that they documented unauthorized modifications. The engineers' failure to
l                        properly evaluate and correct the conditions adverse to quality identified by the
l                        unauthorized modification review program was an additional example of a violation for
l                        the failure to take adequate corrective actions for the problems identified as
                                                                                                                                )
l                        Violation 50-298/9604-1013. The safety significance of items identified by the team was
                        low. However, the findings indicated a lack of program oversight. The lack of proper
                        design control for the issues resolved by the " white paper" and the licensee's decision to
                        leave the backlog items open having been made without a complete understanding of
                        the scope and potentialimpact of each item were considered additional examples of a
                        lack of program oversight.
                    E7  Quality Assurance in Engineering Activities
                    E7.1 Oversiaht of the Unauthorized Modification Review Proaram and the Enaineerina
                        Strateav
                    a.  Inspection Scope (37551)
                        The team reviewed and evaluated documented licensee assessments of the
                        unauthorized modification review program. Line management involved in the oversight
                        and closure review of the process were interviewed. Additionally, the team observed
                        routine engineering strategy review meetings.
                    b.  Observations and Findinas
                        Following NRC identification of an unauthorized modification associated with the steam
                        tunnel blowout panel and other related problems, the quality assurance organization                    ;
                        conducted a special audit to determine the nature and scope of the problems. This
                        special audit resulted in a review of MWRs for potential unauthorized modifications. The
                        team reviewed those quality assurance audits and surveillances documented in
                        Attachment 3 to this inspection report. Additionally, the team summarized the scope
                        and findings of each review as documented in Attachment 3.
                        Licensee personnel had conducted quality assurance audits and performed
                        management oversight of the unauthorized modification review program. Problems with
                        the first-level screening of MWRs conducted by the contractor were identified during one
                        surveillance and corrective actions were proposed. A followup surveillance activity,
                        performed about 6 weeks later, conc;uded that the problems had been corrected. No
i                        other significant items were noted in the audits or surveillances. However, quality
l                        assurance auditors did not further evaluate the effectiveness of corrective actions
!
                                      _    -_-
 
                                    _ - _____________ _ ___-__
  k
                                                              -12-
                    throughout the process. The team noted that the final quality assurance audit of the
                    program completion had not been performed at the time of the onsite inspection.
                    A required part of the team's sample selection process, documented in Soctions E1.1
                  and E1.2 of this inspection report, was to fully understand and characterize the
                    populations of MWRs and the screening, processing, or evaluation techniques used for
                    each. It took program coordinators, working with contract personnel several days to
                    fully charactenze the disposition and size of each population listed in Attachment 4 to
                  this inspection report. The team also noted problems in characterizing the extent of the
                  backlog and the proper design control of unauthorized modifications dispositioned in the
                  " white paper." The team concluded that oversight of the program End the contractor's
                  activities associated with the unauthorized modification review program was weak.
                  To better understand the oversight provided for the unauthorized modification review
                  program, the team observed a routine engineering strategy review meeting. The status,
                  preparation, schedule, and support needed for the implementation of each item was
                discussed by the strategy owner. This discussion and the feedback from other strategy
                item owners indicated a questioning attitude and a continuous evaluation of
                implementation.
                Through interviews, the team evaluated the reviews conducted by the task owner,
                strategy owner, and independent reviewer on the unauthorized modification review
                program, Engineering Strategy Action item 3.2.e. The task owner and strategy owner
                reviews were both probing supervisory-level reviews of the package contents. The
                independent reviewer had not been directly involved in the program and conaucted a
                review of the closure package, including an evaluation of the appropriateness of actions
                conducted. However, no independent evaluation of the process, input, or data of the
                issue were conducted. The team found it positive, based on the issues identified during
              this inspection, that the program closure package had not made it through the senior
              engineering manager's closure process.
    c.        Conclusions
              The team concluded that licensee management had provided some level of oversight
              over the unauthorized modification review program. However, the team identified
              several problems, in addition to two examples of a violation, that indicated insufficient
              program oversight.
    E8        Miscellaneous Engineering issues
    E8.1      Evaluation of Special Test Procedures (37001)
                10 CFR 50.59 allows licensees to make changes to their plants without prior NRC
              approval, provided certain conditions are satisfied such as an evaluation to establish
              that an unreviewed safety question does not exist. The unauthorized modifications
              review reviewed MWRs to identify modifications made to the plant that were not
              authorized and not reviewed in accordance with 10 CFR 50.59. During this inspection,
f        -----____ _
 
            _-                                _ _ _ _ _ _ _ _ _ _ _ _ _
b
?
                                                                        -13-
      the team selected and reviewed a sample of 30 procedure changes and 30 special test
      procedures previously performed that had required evaluation in accordance with
      10 CFR 50.59. The team identified that eight of the special test procedures did not have
      a record of a 10 CFR 50.59 safety evaluation. These procedures had been performed
      prior to 1979, indicating that the programmatic problems were not current. The
      procedures reviewed were documented in Attachment 3 to this inspection report.
      Licensee staff issued PIR 3-40340 to document the problem of not being able to provide
      evidence that 10 CFR 50.59 safety evaluations were performed for these eight
      procedures. The failure to conduct and document safety evaluations for these tests is
      considered unresolved (50-298/9822-02).
                                          V. Management Meetings
  X1  Exit Meeting Summary
    The team presented the interim inspection results to members of licensee management
    at an exit meeting on November 20,1998. A final exit meeting was conducted via
    telecon on December 8 to discuss the findings contained in the report and additional
    issues identified in the interim.
    The team asked the licensee whether any materials examined during the inspection
    should be considered proprietary. No proprietary information was identified.
  X3 Focus Meeting Summary
    On December 17,1998, a focus meeting was conducted between members of licensee
    management and the NRC staff to discuss the status of the licensee's engineering
    improvement strategy. During that meeting, licensee management discussed the
    findings of this inspection and their preliminary conclusions. The exchange of
    information during the meeting was candid and informative.
                          _ _ _ _ _ _ _ _
 
                                            _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ - _
.
.
                                                  ATTACHMENT 1
                              PARTIAL LIST OF PERSONS CONTACTED
  Licensee
    *P. Adelung, Senior Civil / Structural Engineer
    *K. Billesbach, Quality Assurance Assessment Auditor i
    M. Boyce, Plant Engineering Manager
  *P. Caudill, General Manager, Technical Services
    J. Dykstra, Senior Quality Assurance Engineer
  *T. Gifford, Design Engineering Manager
  *B. Houston, Nuclear Licensing and Safety Manager
    M. Kaul, Shift Supervisor / Operations
    D. Kunsemiller, Consultant, Licensing
    J. Long, Nuclear Projects Manager
  *D. Mangan, Licensing Engineer
    R. Pearson, Lead Project Controls Engineer, Enercon
  *B. Rash, Senior Manager of Engineering
  *N. Sanjanwala, Acting Civil Design Engineering Supervisor
    B. Toline, Quality Assurance Auditor Supervisor
  NRC
  C. Marschall, Chief, Project Branch C, Region IV
  V. Gaddy, Senior Resident inspector, Acting
  C. Skinner, Resident inspector
  * Indicates persons attending both the November 20 and December 8 meetings.
                                  INSPECTION PROCEDURES USED
  IP 37551: Onsite Engineering
  IP 37001: 10 CFR 50.59 Evaluations
  IP 62702: Maintenance Observation
  IP 92903: Followup - Engineering
                            ITEMS OPENED, CLOSED, AND DISCUSSED
  Opened
  50-298/9822-01          VIO    Inadequate corrective action regarding the implementation of the
                                  unauthorized modification review program (Sections E1.1 and
                                  E1.2)
  50-298/9822 02          URI    Performance of special tests without a documented safety
                                  evaluation (Section E8.1)
 
.
.
                                      ATTACHMENT 2
                                                                    .
                      WORK ITEM SAMPLE SELECTIONS REVIEWED
                                          Table S-1
                                  Maintenance Work Orders
  Samole 1:
  Population: 22,834 MWRs written prior to mid 1980.
  Sample Size: 60
  73-12-170            75-4-58                  76-12 86  78-2-189
  74-2-37              75-7-3                  76-12-103 78-3-161
  74-3-36              75-9-33                  77-1-102  78-4-107
  74-4-180            75-10-173                77-1-189  78-5-122
  74-5-248            75-11-129                77-5-259  78-6-25
  74-6-114            75-12-47                77-8-3    78-6-38
  74-6-294            75-12-283                77-8-49  78-9-147
  74-8-292            76-1-141                77-8-250  N79-1 63  ;
  74-9-125            76-1-184                77-9-172  79-1-141
  74-9-153            76-2-48                  77-10-1  79-1-148
  74-9-188            76-3-165                77-10-35  79-4-148  l
  74-11-64            76-5-166                77-10-215 N79-9-30
  75-1-47              76-6-197                77-10-359 79-9-147
  75-1-106            76-8-61                  77-12-193 80-9 13
  75-3-229            76-8-184                78-1-127  N80-10-9  l
                                                                      l
                                                                      l
                                                                      !
 
    . . . _ .        . - . .      .
                                                    . ~ . .      -        . -      . .    . _ - - . - - - . . _ - . _ - - . . .        _ - .
                                                                                  2-
                                                                              Table S-2
                                                                    Maintenance Work Orders
                    Samole 2:
              ',
                    Population: 51,994 MWRs rejected by computer search.
                    Sample Size: 60
                    80-0040                                86-0502                    90-1136                                94-2522
                    81-1184                                86-2921                    90-2344                                94-0711
                    82-0857                                86-4081                    90-3472                                94-5585
                    83-0611                                86-5257                    91-0033                                94-1031
                    83-2070                                87-0744                  91-1255                                95-1023
                    84-0233                                87-0611                  91-2519                                95-0204
                    84-1377                                87-3111                  91-3669                                95-1665
                    84-2506                                88-1547                  92-0538
  '
                                                                                                                              95-0525
l                    85-0266                                88-2810                  92-2139                                95-2406
                    85-1437                                88-3954                  92-3307                                95-0901
                    85-2593                                89-0045                  93-0683                                95-3821
                    85-3690                                89-1265                  93-1927                                95-4239
                    86-0064                                89-2504                  93-0820                                96-0432
l                    86-0226                                89-3609                  93-4276                                96-1024
                                                                                                                                              !
                    86-0231                                89-4638                  94-1131                                96-0700          '
l'
                                                                                                                                              i
!                                                                                                                                              l
;                                                                                                                                              l
                                                                                                                                              I
,
;.                                                                                                                                            ,
t
1
i                                                                                                                                            :
<
                                                                                                                                              !
>
i
:
                  _      __          _ _ _ . . _ _                _ _ _        .      -                ..                  ._    ,.
 
    ._ __    __ - ._ .        _ . _ _ _ . . . - _ - . .          _ _ _ . _ . _ _ _ . _ . _ . . _ . _ _ _ _ _ _ . _ . _ _ . _ _ _
                                                                                                                                            ,
                                                                                                                                            '
o
  4
                                                                      -3-
                                                                                                                                            1
                                                                Table S-3                                                                    ,
                                                                                                                                              '
                                                          Maintenance Work Orders
            Samole 3:
            Population: 14,750 MWRs rejected from first screening by NPPD
            Sample Size: 70
                                                                                                                                              i
            0-09155                  86-1135                              89-2328                                              92-2833    I
            1-24148                  86-2172                              89-3194                                              92-3496      l
            81-0244                  86-3201                              89-3998                                              93-0468
                                                                                                                                              i
            81-1869                  86-4211                              90-0075                                              93-1095      l
                                                                                                                                            ;
            82-0695                  86-5033                              90-0825                                              93-1759
            82-2260                  87-0492                              90-1706                                              93-2303      ,
                                                                                                                                            4
            83-1068                  87-1390                              90-2593                                              93-2925
            83-1996                  87-2318                              90-3397                                              93-3591
            84-0085                  87-3184                              90-4295                                              93-4169      l
                                                                                                                                            1
            84-1071                  88-0180                              91-0606                                              94-0120
            84-2070                  "20986                              91-1334                                              94-0722
            84-2976                  88-1713                              91-2076                                              94-1294
'
            85-0509                  88-2476                              91-2896                                              94-1937
            85-1367                  88 3311                              91-3671                                              94-2525
            85 2249                  88-4185                              92-0179                                              94-3155
            85-3097                  88-5015                              92-0910                                              94-3839
l
            85-4077                  89-0641                              92-1543
,
            86-0337                  89-1521                              92-2284
l
i
?        .                                                                                                                              _-
 
.o
.
                                                -4-
                                            Table S-4
                                  Maintenance Work Orders
  Samole 4:
  Population: =5,712 MWRs rejected from first screening by Enercon
  Sample Size: 63
    0-07309              92-1936                  94-6534          95-2100
    82-0691              92-3234                  94-6713          95-2334
    84-2058              93-0649                  94-6897          95-2606
    85-1303              93-2691                  94-6967          95-2832
    85-4074              94-4089                  94-7040          95-2875
    86-1134              94-4267                  95-0041          95-3003
    86-2979              94-4548                  95-0255          95-3183
    88-2456              94-4738                  95-0460          95-3396
    89-0639              94 4914                  95-0700          95-3545
    90-0720              94-5104                  95-0904          95-3724
    90-2588              94-5312                  95-1099          95-3988
    90-3054              94-5551                  95-1305          95-4299
    91-3288              94-5643                  95-1317          95-4570
    91-3670              94-5792                  95-1480          96-0017
    91-4167              94-6062                  95-1642          96-0267
    92-0699              94-6269                  95-1882          96-0755
                                                                            1
                                                                            ,
                                                                            f
 
    . - . -    . - --.-_  -    .-    ..=...--- - -- -...-..                                  .. - - - -                        - -- - --
o
            .
a                                                                                                                                        .
                                                                                                                                          i
                                                                                  5
                                                                                                                                          i
                                                                    Table S-5
                                                            Maintenance Work Orders                                                      ,
                                                                                                                                          ,
                Samole 5:
              . Population: 1,023 MWRs rejected from second level screening                                                              !
                Sample Size: 60
                                                                                                                                          i
                    74-2-142            75 8-123                                  76-3-141                      78-9-148                l
                    74-2-211            75-8-216                                  76-3-260                      79-5-51
                    74-6-314            75-9-23                                    77-2-10                        N79-10-98
                    74-8-292            75-9-152                                  77-3-161                      80-4-4
                    75-1-139            75-9-318                                  77-4-343                      N80-245                l
                    75-3-36            75-10-14                                    77-6-54                      83-1735
l
l                  75-3-126            75-10-60                                    77-6-121                      84-0562
i                                                                                                                                        .
L                  75-4-224            75-10-68                                    77-6-214                      84-1805
<
                    75-4-247            75-10-132                                  77-12-101                    89-1538
l.                  75-6-13            75-10-323                                  78-1-158                    89-1658
!                  75-6-215            75-12-92                                    78-3-34                      91-0311
                    75-7-56              76-1-285                                  78-4-251                      91-2256
                    75-7-263            76-1-353                                  78-5-149                      91-4099
                    75-7-328            76-2-187                                  78-5-178                      92-1660
                    75-8-15            76-3-71                                    78-7-196                      93-2773
i
r
                                                                                                                                          I
!. '                                                                                                                                        I
  r
  ).
*i
?
l                                                                                                                                          ,
                                                                                                                                          '
i
:
.
      - - -                ,      -                          .-  . - ~ . . . -  ,            - - , , y-- -
                                                                                                                r.      _    -w
 
    . _. _. _..      . . . _ . - . . _ . _ _ _ . _ _ _ .
                                    -
                                                                    . . . . . _ _ . _ . _ . _ .. _ _ .. _ . _ _ _ . _ _ .. _ - _ _ _ _ ... ._
O
    , .
                                                                                -6-                                                                  !
                                                                                                                                                    !
                                                                        Table S-6
                                                                                                                                                    '
                                                                Unauthorized Modifications
            Samole 6:
            Population: 1,107 ltems resolved by the White Paper                                                                                    l
            Sample Size: 60
                                                                                                                                              .
              74-1-235                                76-6-13                      N79-7-41                                        91-0249*
              74-1-87                                76-9-44                      N80-3-58                                        91-0911
                                                                                                                                                    '
              74-12-317                              76-10-30                      N80-6-111                                      92-0667
              74-2-100                                76-11-239'                    N80-9-161                                      92-2295
              74-4-424                                77-3 158                      81-1816                                        93-0140
              74-4-546                                77-4-70                      82-1223*                                      93-3758
              74-6-226                                77-6-212*                    83-1044                                        94-2353          I
              74-7-406                                77-7-134                      83-2677                                        95-0027
i
L            74-8-66*                                77-10-327                    84-0629                                        97-0017*        i
!
l
.
              74-9-127*                                77-12-103                    84-3244                                        E97-0072
              75-3-280                                78-3-49                      85-3126                                        E97-0174*
I
              75-6-30                                  78-4-208'                    86-3044                                        E97-0279*
              75-9-46                                  78-8-147                      89-3910                                        E97-0300*
l            75-10-294                                78-10-170                    90-1916*                                      E97-0371
!
              76-4-108                                79-4-94                      90-2425                                        E97-0378*
            * Items with open issues, " Backlog'
l
t
i
!
,
  (
.
4
i
i
!
<
                                                                                                        -.                                      -
                                                                                                                                                  e
 
  -        . - - . - - . . .          -      - _ - . .  .  - _ ._ -    _    - ... -.. - - -. - --  _
                                                                                                        l
                                                      -7-
                                                  Table S-7
                                                                                                        '
                                        Unauthorized Modifications
l                                                                                                        i
  Samole 7:
  Population: 545 Items resolved by generic engineering evaluations
  Sample Size: 88
    74-2-67                    78-5-42                  82-1604          92-0131
    74-2-360                  78-6-167                  83-0355          92-3034
    74-3-23                    78-9-119                  83-0918          94-0957
    74-9-204                  78-10-133                83-1689          94-4396
    75-5-149                , N79-1-6                  83-2214          94-4919
    75-7-184                  79-4-61                  83-2561          95-0774
    75-10-85                  79-5-5                    84-0844          95-1347
    76-11-253                  N79-5-195                84-2181          E97-0028
    76-2-259                  79-12-33                  84-2794          E97-0093
    76-5-176                  79-12-39                  85-0524          E97-0082
    76-6-118                  80-3-3                    85-3169          E97-0106
    77-1-151                  80-3-49                  86-1603          E97-0113
    77-4-121                  N80-3-90                  86-5330          E97-0117
    77-5-117                  80-5-7                    87-2933          E97-0171
  77 6-4                      80-0180                  88-2041          E97-0182
    77-8-352                  80-0340                  88-3648          E97-0200
  77-8 357                    81-0176                  89-4464          E97-0224
  77-12-104                  81-0668                  89-4486          E97-0242
  78-2-76                    81-1372                  90-1258          E97-0244
  78-2-104                    81-1898                  90-1941          E97-0255
  78-3-168                    81-2407                  90-2885          E97-0356
  78-4-236                    82-1005                  91-2573          E97-0364
l
l
!
!
                                                                      ,.                            ,
 
        .  .. . -..        . -- _        _ _ . - . - - - . - -          - -          . . - . - . .--
..
.o
+
                                                              8-
                                                Table S-7.1
                                        Enaineerino Evaluations
.a
.
  Generic engineering evaluations associated with Sample 7 MWRs
l  Sample Size: 15
    Engineering      Title / Description:
    Evaluation:
    98-136          Evaluation of Miscellaneous Essential Electrical and I&C Unauthorized
                                                                                                        '
                    Modifications                                                                      !
i
    98-132          Evaluation of Miscellaneous Essential Mechanical Unauthorized
                    Modifications
    98-098          Packing Replacements                                                              l
    98-032          Adding Load to Motor Control Centers MCC-LX & MCC-TX
    98-010          Qualify Existing 1/4" Tubing Betv'een Valves DW-V-147 and HPCI-V-284.
    98-009          Evaluation of Miscellaneous Essent;al Civil Unauthorized Modifications
    97-265          Nonseismic Bracing for 5 Hydraulic Control Units
    97-256          Nonessential Unauthorized Mechanical Modifications
    97-253          Various Self-Contained Breathing Apparatus installations in the Plant
    97-217          Chain Welded to Valve RF-V-29
    97-210          Temperature Indicators Mounted in the 125/250 VDC Battery Rooms                    i
    97-173          Rework of Hoist to the Main Lubricating Oil piping above the Reservoir
    97-094          Evaluation of Locked High Radiation Area Gates
    97-093          Unauthorized Concrete Anchor Installations
                                                                                                        i
    97-071          Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement                  i
 
  -.- . . . -              - - . - . - - -                - _    _ - . - - - -          _ . - -        . . . . - . . . . _
  o
i
b9
                                                                    -8-
:
1
                                                                Table S-7.1
;                                                      Enaineerina Evaluations
                                                                                                                              i
i
i              Generic engineering evaluations associated with Sarnple 7 MWRs
i              Sample Size: 15
)              Engineering        Title / Description:                                                                      '
>
                Evaluation:
i
                98-136              Evaluation of Miscellaneous Essential Electrical and l&C Unauthorized
                                    Modifications
                98-132              Evaluation of Miscellaneous Essential Mechanical Unauthorized
                                    Modifications
                98-098              Packing Replacements
                98-032              Adding Load to Motor Control Centers MCC-LX & MCC-TX
                98-010              Qualify Existing 1/4" Tubing Between Valves DW-V-147 and HPCI-V-284.                      l
                98-009              Evaluation of Miscellaneous Essential Civil Unauthorized Modifications
                                                                                                                              l
                97-265              Nonseismic Bracing for 5 Hydraulic Control Units                                          j
                97-256              Nonessential Unauthorized Mechanical Modifications
                97-253              Various Self-Contained Breathing Apparatus installations in the Plant
                97-217              Chain Welded to Valve RF-V-29
                97-210              Temperature Indicators Mounted in the 125/250 VDC Battery Rooms
                97-173              Rework of Hoist to the Main Lubricating Oil piping above the Reservoir
                97-094              Evaluation of Locked High Radiation Area Gates
                97-093              Unauthorized Concrete Anchor installations
                97-071              Toxic Gas Filtration Temperature Switch TGF-TS-26HFT Replacement
                                                                                                                              l
                                                                    _
 
    . _ _ _ __._._ _        ._              . . _ . _ . _ . - .          . . . . - _ _ . _ . _ . - _ -  ___ ._ . _ _    _ _ . _ . - .
                                                                                                                                        !
                                                                                    .g.
                                                                                                                                        *
                                                                          Table S-8
                                                        Unauthorized Modifications                                                        .
                                                                                                                                        !
          Samole 8:                                                                                                                      >
          Population: 599 Items with item-specific resolutions
          Sample Size: 57
                                                                                                                                        i
                                                                                                                                        !
            73-12-137              76-9-248                                              85-1753        E97-0101                        ,
            74-11-138            77-11-68                                              85-2363        E97-0119                        i
            74-3 198              77-3-42                                                86-4123        E97-0178
            74-3-391              77-8-253                                              88-0192        E97-0214
            74-5-185              77-9-269                                              89-1595        E97-0216
                                                                                                                                          !
            74-7-301              78-3-160                                              90-1226        E97-0263                        )
                                                                                                                                        I
i
            74-8-176.            78-4-149                                              92-0285        E97-0360
            75-11-218            78-7-88                                                92-1759        E97-0381
;          75-3-127              78-9-76                                                93-0512        N79-5-156
            75-4-228              79-7-2                                                94-0107        N79-5-75
l          75-8-230              80-0598                                                95-1305        N80-9-23
l          75-8-231              80-8-18                                                CR96-0020      TR80-0499
            76-12-154            81-1557                                                E97-0026
            76-5-300              83-1735                                                E97-0054                                        !
            76-8-178              83-2370                                              E97-0068
L
$
$
  '
:
.
                                    . . . . _ - . _ .          . - - - . ,      ,                                    - _        --
 
  .. .  -  -        . .      - - . . _                  _    . . _ -      - - -  . - - _ . - . . -  - - .- . -        _ - ..-
p
a
0
                                                                          -10-                                                      ;
                                                                                                                                    ;
                                                                  Table S-9
                                                          Maintenance Work Reauests                                                  l
                                                                                                                                    l
                                                                                                                                    !
        Samole 9:
        Population: 4,071 Corrective ma'ntenance MWRs worked following corrective actions
        Sample Size: 60
        96-1030                          96-2062                            97-0622                  97-2840
        96-1105                          96-2129                            97-0731                  97-2913
        96-1433                          96-2197                            97-0872                  97-3011
        97-0157                          96-2264                            97-0939                  98-0134                    l
        96-1300                          96-2331                            97-0972                  98-0448
                                                                                                                                    :
l        96-1384                          96-2400                            97-1175                  98-0677
        96-1426                          96-2465                            97-1132                  98-0636
        96-1635                          97-0341                            97-0824                  98-0998
!
        96-1574                          97-0136                            97-2015                  98-1344
        96-1626                          97-0294                            97-1433                  98-1535                    i
>
                                                                                                                                    !
                                                                                                                                    '
        96-1921                          97-0301                            97-1509                  98-1792
        96-1715                          97-0388                            97-2251                  98-1990                    l
        96-1832                          97-1111                            97-3057                  98-2382
'
        96-1977                          97-0522                            97-2638                  98-2868
        96-1969                          97-1256                            97-2739                  98-3171
i
i
h
l
:
<
                          . , , .            .  . . _ _ .                .._
                                                                                                                    .....m.
 
  . - . . _ .          -.
k
b
                                                      ATTACHMENT 3
                                                  DOCUMENTS REVIEWED
              SPECIAL TEST PROCEDURES
l
'
              NUMBER      DESCRIPTION                                                    REVISION
l            73-2          " Diesel Generator Reliability Testing Program,"                December 1,1973
L
              75-8          " Test Procedure for Lifting Adapter Assembly,"                March 16,1982
              76-1          " Drywall to Torus Leak Rate,"                                  February 27,1976  i
,
                                                                                                              I
,
              76-14        " Testing for Stuck Reed Relays in ARM Averaging cards September 16,1976          i
                                                                                                                '
                              in the Neutron Monitoring System,"
              77-17        "Taking Transformer Loss Compensator Out of Service," February 11,1982
                                                                                                              :
              77-28        * Recirculation Pump Start Without Bypass Valves,"              Date unknown      I
              77-4          "HPCI Run Test,"                                              January 28,1977
                                                                                                                l
              78-1          "RHR-MO-25 Valve Operability,"                                January 20,1978
              QUALITY ASSURANCE AUDITS AND SURVEILLANCES                                                      I
              DATE        AUDIT / SURVEILLANCE        GENERAL FINDINGS / COMMENTS
                                                                                                              .
                                                                                                                l
              4/30/96    96-07a, Unauthorized        Special audit of unauthorized modifications, resulting
                          Modifications                in 3 significant findings at the beginning of
                                                        unauthorized modification review program
              7/17/96    97-07, Design Control        Part of audit was to resolve design controlissues and
                                                        Updated Safety Analysis Report inaccuracies.
              9/4/97      S301-9701,                  Surveillance to assess the status of the unauthorized
                          Unauthorized                modification project. Identified several MWRs that
                          Modifications                were not properly screened.
              10/15/97    E301-9701                    Emergent Surveillance on Unauthorized
                                                        Modifications, to assess problems identified in
                                                        Surveillance S301-9701.
              10/22/97    97-15," Design Control"      Encouragement to complete screening on remaining
.
                                                        MWRs.
              9/10/98    98-14, " Engineering /      Status of unauthorized modification project. Note
                          Special Programs            that an audit will be done later to evaluate
                                                        effectiveness.
I
 
,. . - . - . .    __    - ... -.. _ - . -.~ -- - -_._--- . -          . . . . _ - - .          . . . . . - . . - .
i
'
P
b
b:                                                                                                                      i
I
ro
                                                                                                                      i
                                                                2                                                    )
              MAINTENANCE PROCEDURES REVIEWED
l              PROCEDURE NUMBER    PROCEDURE TITLE                                      REVISION                      .
                                                                                                                      1
i
'
                                                                                                                      :
              Procedure 0.40      Work Control Program                                Revision 15
                                                                                                                      1
                                                                                                                      ,
                                                                                                                      i
!              Procedure 7.0.4      Conduct of Maintenance                              Revision 12                  i
;
                                                                                                                      !
i
l                                                                                                                      l
I
                                                                                                                        l
!
!
!
                                                                                                                        l
!
!
!
!
!.
                                          - - ,              .  , _ .  . _ - -        , - _
 
  _ _ _ . .    ~
                          ,        .-          _. __-._.._____.._ _ _ _ _                    __-..._ . _ . . . _ . _ . _ . _._-
                                                      ATTACllMENT 4
                                      Unauthorized Modification Review Program
            Accounting of Maintenance Work Requests (MWRs):
                                                                                                                                  l
                    MWRs from 1973 - 1980                                22,834'                                                  1
                    MWRs from 1980 - 1996                                72,902
                                                                                                                                  i
            Total Population:                                                            95,736
                                                                                                                                  ]
                                                                                                                                  l
                    Screened via Keyword Search: (51,994)*
                            Exclude MDC, DC
            Total Documents Reviewed:                                                    43,742
                    Pre 1980 = 22,834
                    Post 1980 = 20,908
                    Initial Screening (1st) Criteria: (40,786)                                                                    i
                            NPPD:          (14,750)*                                                                            ;
                            Enercon:                      (~5,712)*                                                              l
                            Pre-1980                    (20,324)                                                                  !
,          Problem Identification Reports Added:                                          318
!
l          Potential Unauthorized Modifications:                                      3,274                                      l
                            Enercon:              2,828                                                                          !
                            NPPD:          128                                                                                    i
                            PIR (Non-MWR)          318                                                                          j
l
                    Non-safety significant (2nd) Criteria:                (1,023)*
            Unauthorized Modification Population:                                        2 2_51
                    White Paper Resolved:                1,107'
                    (Sample included verification of backlog)
                    Engineering Evaluation Resolved:                        545'
                    Other Resolution:                                      599*
!
            Total MWR Population 6/12/96 - Present:                              4,071*
                    (Corrective Maintenance Completed)
            * Samples selected from these populations as documented in Attachment 2 to this inspection
            report.
l
:
1
4
}}

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