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{{Adams
#REDIRECT [[IR 05000295/1996017]]
| number = ML20134H103
| issue date = 02/03/1997
| title = Insp Repts 50-295/96-17 & 50-304/96-17 on 961012-1206. Violations Noted.Major Areas Inspected:Licensee Operations, Maint & Engineering
| author name =
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| addressee name =
| addressee affiliation =
| docket = 05000295, 05000304
| license number =
| contact person =
| document report number = 50-295-96-17, 50-304-96-17, NUDOCS 9702110148
| package number = ML20134H066
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 31
}}
See also: [[see also::IR 05000295/1996017]]
 
=Text=
{{#Wiki_filter:.
                      U.S. NUCLEAR REGULATORY COMMISSION
~
                                  REGION III                                  i
                                                                              i
                                                                              l
                  Docket Nos:        50-295, 50-304                            i
                  License Nos:      DPR-39, DPR-48
                  Report No:          50-295/96-17, 50-304/96-17
                  Licensee:          Commonwealth Edison Company
                  Facility:          Zion Nuclear Plant, Units 1 and 2
                  Location:          Opus West III
                                      1400 Opus West III
                                      Downers Grove IL 60515                -
                  Dates:            October 12 through December 6, 1996
                    Inspectors:      R. A. Westberg, Acting Senior Resident
                                        Inspector
                                      D. R. Calhoun, Resident Inspector
                                      E. W. Cobey, Resident Inspector
                                      M. E. Parker, Senior Resident Inspector,
                                        Palisades
                                      A. Vegel, Senior Resident Inspector,
                                        Fermi
                                      J. Yesinowski, Illinois Department of
                                        Nuclear Safety Inspector
                    Approved by:    Marc L. Dapas, Chief
                                      Reactor Projects Branch 2
  9702110148 970203  5
  DR  ADOCK 0500
 
                                      __
.
                                    EXECUTIVE SUMMARY
                          Zion Nuclear Plant, Units 1 and 2
c                  NRC Inspection Reports 50-295/96 17; 50-304/96 17
  This inspection included aspects of licensee operations, maintenance, and
  engineering. The report covers an eight-week period of inspection activities
  by the resident staff.
  Licensee performance during this inspection period was characterized by
  recurrent events caused by personnel errors, lack of a questioning attitude.
  the failure to follow procedures, and inadequate procedures. Of particular
  concern was the identification by NRC inspectors of several instances where
  the licensee's evaluation of degraded plant conditions was untimely.            :
                                                                                  !
  Operations
  .      Inappropriate operator response to a material condition problem with the
        valve position indication for a residual heat removal system valve
        resulted in a 400 gallon water spill and a violation for failing to
                                                                                  ,
                                                                                  l
        follow equipment control procedures.    (Section 01.1)                  '
  .      The inspectors identified several material condition deficiencies on
        safety-related components that were indicative of poor attention to
        detail during post-maintenance restoration and system engineering
        walkdowns.    (Section 02.1)
  .      Operators unknowingly caused the common unit emergency diesel generator
        (EDG) to be inoperable for approximately two days. Operator training
        deficiencies and the initial failure of operators to question if an
                                                                                  ,
                                                                                  i
        operating procedure was correct when the procedure was in conflict with
        requirements in the Zion Operability Determination Manual contributed
        to the error. As a result. Technical Specification action requirements
        for an inoperable EDG were not followed, resulting in a violation.
        (Section 04.1)
  .      The inspectors identified a violation involving the failure to implement
        corrective actions for insufficient monitoring of the 011 125 Volt-D.C.
        battery exhaust ventilation system. The licensee's practice of not
        tracking level 4 problem identification form actions to completion
        contributed to this error. (Section 07.1)
  Maintenance
  .      The inspectors identified a violation regarding the licensee's failure
        to address operability of a safety-related battery when surveillance
        test acceptance criteria were exceeded on several occasions. The
        inspectors identified another violation involving the incorrect
        determination of average cell voltage during a battery surveillance.
        (Section M1.1)
  .      The inspectors identified two examples of inconsistencies between the
        condition of structures, systems, or components described in completed
                                            2
 
.
  .
          work documentation and the actual plant configuration.  (Section M1.2)  !
  . .    The inspectors identified a violation involving a compressed gas
          cylinder that was improperly secured to a seismically qualified          .
          scaffold. (Section M1.3)                                                I
    .    Five protective trips of the 2A emergency diesel generator occurred      j
          during post-maintenance testing due to poor work practices and          i
          inadequate maintenance procedures. Two examples of a violation for      l
          inadequate procedures were identified for the associated maintenance
          activities.  (Section M3.1)                                            !
    .    A violation was identified involving an inadequate maintenance 3rocedure l
          which resulted in damage to the 1A auxiliary feedwater pump tur)ine      '
          inboard bearing during post-maintenance testing. (Section M3.2)          i
    Engineering
    .    The inspectors identified three examples of a violation involving the
          failure to address operability of degraded safety-related piping        ;
          supports in a timely manner. (Section El.1)                              l
                                                                                  ;
                                                                                  i
                                            3
 
                                        .__            _    _          _
_
                                    Report Details
- Summary of Plant Status
                                                                                  i
  Unit 1 operated at or near 100 percent power during the inspection period.
                                                                                  '
  Unit 2 remained shut down during the inspection period in support of the 14th
  refueling outage.
  Licensee performance continued to be characterized by recurrent events caused
  by personnel errors, lack of a questioning attitude, the failure to follow
  procedures, and inadequate procedures.      Of particular concern was the
  identification by NRC inspectors of several instances where the licensee's
  evaluation of degraded plant conditions was untimely. Although the licensee
  identified the violation pertaining to the inoperable emergency diesel
  generator, some examples of the failure to follow procedures, and examples of
  inadequate procedures, these licensee identified issues are included in the
  cited violations because they stem from previously identified performance
  problems which the licensee has not yet effectively addressed.
                                    I. Ooerations
  01    Conduct of Operations
  01.1 Doeration of Out-of-Service (00S) Component Resulted in a Soill of        1
        Anoroximately 400 Gallons of Water
    a.  Insoection Scope (71707)
        On November 3 during the fill and vent of the 2B train of the
        residual heat removal (RHR) system, the licensee spilled approximately
        400 gallons of water in the Unit 2 letdown heat exchanger room. The
        inspectors interviewed operations department personnel, reviewed        '
        applicable procedures, and reviewed the results of the licensee's        !
        investigation.
    b.  Observations and Findinas
        On November 3. during the performance of System 0)erating Instruction
        (S0I) 5F " Filling and Venting RHR Train B with tle Unit Defueled Using
        the RWST [ refueling water storage tank]." Revision 4. the licensee
        identified water flowing from the partially disassembled Unit 2 letdown
        heat exchanger to the Auxiliary Building sump. Radiological
        consequences were minimal since contamination levels were not
        significantly above the levels in the room before the spill. Based on
        the results of the licensee's investigation of this event, the licensee  l
        concluded that the spill resulted from operation of an 00S valve.        !
        On November 1, an operator closed RHR system heat exchanger "A"
        discharge to letdown heat exchanger valve 2RH-8734A and placed an 00S
        tag on the valve to indicate that it was part of the isolation boundary
                                            4
                                                                                j
 
                                                                      _
.
        for maintenance on the Unit 2 letdown heat exchanger. The operator
        identified that the valve position indicator (VPI) on the reach rod
.
        c)erator incorrectly indicated that valve 2RH-8734A was in mid-position.
        T1e shift engineer directed the operator to first verify the valve's
        )osition locally at the valve and then to hang the 00S tag on the valve
        )ody.  However, no action was taken by the licensee to disable the reach
        rod operator or to identify that the valve needed to be operated locally
        due to the material condition deficiency with the VPI.
        On November 2 during the 3erformance of S01-5E. " Filling and Venting
        RHR Train A with the Unit )efueled Using the RWST," the operator
        conducting the evolution did not recognize that valve 2RH-8734A was an
        00S component, due to the location of the DOS tag. Consequently, when
        the operator opened valve 2RH-8734A with the reach rod operator, a flow
        path was created which resulted in the s)ill. In addition, when valve
        2RH-873A was repositioned open, the reac1 rod VPI broke. The operator
        did not identify the broken VPI as a condition which required
        verification of valve position locally and no action was taken to
        correct the deficient condition.
    c.  Conclusions
        Inappropriate operator response to the identification of a material
        condition problem resulted in a spill when another operator re)ositioned
        a valve that had been tagged 00S. When an operator tasked wit 1
        performing an OOS, identified that the indicated valve position on the
        reach rod VPI was incorrect, no action was taken by the licensee to
        disable the reach rod operator or to identify that the valve needed to
        be operated locally due to this material condition deficiency.
        Similarly, after the reach rod VPI pin broke during valve operation, the
        operator manipulating the valve did not verify the valve position
        locally or initiate action to resolve the deficiency.
        Zion Administrative Procedure (ZAP) 300-06. "Out-of-Service Process,"
        Revision 9, Section E.6 requires, in part. that once an 00S is in place,
        physical operation of an 00S component is prohibited. The operation of
        valve 2RH-8734A. which was an 00S component, is considered a violation
        of TS 6.2.1.a. as described in the attached Notice of Violation
        (50-304/96017-01).
  01.2 Licensed Steadv State Thermal Power
    a.  Insoection Scope (71707)
        On October 23 the inspectors identified that average nuclear power
        instrumentation was indicating greater than 100% power. The inspectors
        interviewed operations personnel and reviewed applicable documentation.
                                          5
 
    - . - . - . - . - - - - . - - . - - - . - - - . - _ . _ . ~ . - -
                                                                                                                                  ,
                                                                                                                                  !
                                                                                                                                  ;
    .
                                b.    Observations and Findinos                                                                  !
    -
                                        During a routine review of control room activities, the inspectors                        !
                                        identified that average nuclear power instrumentation was indicating                      !
                                        greater than 100% power, specifically 100.2%. Further review of the                      1
                                        " Power History Log,'' PT-0 Revision 12 Appendix P, indicated that                        ;
                                        actual power as determined by an hourly secondary calorimetric, was -less                  i
                                        than 100% power, specifically 99.8%. However, the inspectors noted that                    I
                                      -the hourly calorimetric readings recorded in the log for 4:00 a.m. and
                                        5:00 a.m. indicated that reactor power was at 100.1%.
                                                                                                                                  l
                                      The inspectors determined that reactor power did not exceed the
j                                      licensee's administrative limits specified in procedure PT-0, which                        :
!                                      stated-
                                        1.            When o)erating at full power, reactor power should be maintained
                                                      such tlat the 60 minute calorimetric indicates an average power
                                                      level of less than or equal to 100.0% power.
l
                                                      E any 60 minute calorimetric is greater than 100.0% power, THEN              l
l
                                                      a)propriate action and/or monitoring should be performed to ensure          '
l                                                    tie next 60 minute calorimetric is LESS THAN or EQUAL to 100.0%              :
                                                      power.
t
                                                      E the 60 minute calorimetric is greater than 100.0% power for two          I
                                                      consecutive readings in a row, THEN immediately reduce power to              i
                                                      less than or equal to 100.0% power to restore the next 60 minute            l
.                                                    calorimetric to less than or equal to 100.0% power. (NRC letter              t
l                                                      from E. L. Jordan dated 8/22/80, Tech Spec Interpretation 94-03).          i
!
                                        2.            E either a 10 minute or 60 minute calorimetric indicates greater
                                                      than 100.5% power, THEN immediately take action to reduce reactor            ,
                                                      power until a 10 minute calorimetric indicates less than or equal
-
l                                                    to 100.0% power.                                                            i
l                                      The licensee maintained that the reactor could be operated above 100%                      !
                                        power, up to 100.5%, with a 1.5% uncertainty, and still be within the                      l
                                        appropriate design basis (102%). A review of the uncertainty analyses
                                                                                                                                  '
l
'
                                        confirmed that the instrument uncertainties were within 2 percent
                                        (actual                  1.47%). The ins)ector's initial review to determine if the
                                        licensee had operated the Jnit I reactor above 100% power using this
                                        operating 3ractice identified several other instances, in which, reactor
r                                      power had )een above 100% for periods of time u) to three hours before
                                        action was taken to reduce reactor power to witlin licensed thermal
                                        power limits.
                                        The inspectors reviewed Ap)endix P of PT-0 in evaluating tile licensee's
                                        position on this issue wit 1 respect to information in design basis
                                        documents, including Appendix K to 10 CFR Part 50 and the Updated Final
i'                                      Safety Analysis Report (UFSAR). Aopendix K "ECCS [ emergency core
                                        cooling system] Evaluation Models " assumes that the reactor has been
;                                      operating continuously at a power level of at least 1.02 times the
;
                                                                                      6
l
  _                      , . ,-                        .      - - .              .-          .  . - - -- ,-  ..  - - . - .- _
 
                                                                                    l
1
                                                                                    l
l
  .
          licensed power level to allow for such uncertainties as instrumentation  l
          error. Also Section 14.1.3 of the UFSAR, " Analysis Performed at
  -
          3250 MWt." states that the initial conditioris for transient analysis are
          based on steady-state operations at 3250 MWt with a reactor power
          uncertainty of 2 percent applied to ensure conservative analysis. The
          licensee's operating procedure (PT-0. Appendix P) allowed reactor power  l
          to reach 100.5%. before requiring immediate action to reduce reactor      l
          power.
          This issue is considered an Unresolved Item (50-295/96017-02) pending    ,
          further NRC review of the licensee's practice against other pertinent    '
          licensing documents such as the Zion Facility Operating License.
      c. Conclusions                                                              j
          After the inspectors discussed this issue with the licensee, additional
          operating instructions were provided to licensed operators. These
          instructions required operators to maintain reactor power at or below
          3250 MWt (licensed thermal limits) at all times, and to take immediate    l
          action to reduce reactor power if any 60 minute calorimetric indicated
          greater than 100% power.
          The licensee's response to this issue was timely. The licensee had
          taken prompt action, upon identification by the inspectors, to ]rohibit
          further operation above licensed thermal power limits. Althoug1 the
          licensee's corrective action was timely, the inspectors expressed
          concern with non-conservative past operating practices.
    02    Operational Status of Facilities and Equipment
    02.1 Enaineered Safety Feature System Walkdowns
      a. Insoection Scone (71707)
          The inspectors conducted walkdowns of accessible portions of the
          following safety systems:
          -
                Emergency Diesel Generators (EDGs) 1A, 1B. O, 2A, 2B
          -
                Unit 1 Containment Spray System
          -
                Shared Unit 1 and 2 Service Water System
      b. Observations and Findinos
          During the system walkdowns, the inspectors identified numerous
          discrepancies. Specifically:
          .      On October 14, the inspectors identified that the 1A EDG supply
i                fan was missing one of six support rod vibration isolators. The
l                licensee corrected the problem on the same day and performed an
                o)erability assessment. The licensee subsequently determined that  l
                t1e fan was operable even though the support was missing.          l
                                            7
 
  .
          .      On October 15. the inspectors identified that the 2A service
                water pump motor was leaking water at a rate of approximately
  .
                20-30 drops per minute. After engineering
                condition and declared the pump inoperable.      personnel
                                                              the pump      evaluated the
                                                                      was taken
                out-of-service. The licensee determined that the leak was from
                the oil cooler supply line. The line was repaired and the pump
                was returned to service.
          .      On November 20, the inspectors identified numerous valve packing
                leaks on the Unit 1 containment spray system. The inspectors
                informed engineering personnel of the discrepancies and the
                licensee initiated appropriate corrective actions.
      c. Conclusions
          In addition to the above observations, the inspectors identified
          numerous other discrepancies, including oil leaks and missing fasteners
          on the EDGs. Additional material condition discrepancies and the
          licensee's response to them are discussed in sections M1.2 and El.1 of
          this report. The failure of the licensee's staff to identify these
          material condition problems was indicative of poor attention to detail
          during post-maintenance restoration and system engineering walkdowns.
    04    Operator Knowledge and Performance
    04.1 Missed Technical Specification (TS) Action Reauirements for an
          InoDerable EDG
      a. Inspection Scope (71707)
          On October 28. the licensee identified that the 0 EDG had been
          inoperable for approximately two days and that required TS actions had
          not been performed. The inspectors interviewed operations and
          engineering department personnel and reviewed operations department
          training, applicable procedures, and the results of the licensee's root
          cause investigation,
      b. Observations and Findinas
          On October 28. during shift turnover, the Unit 2 nuclear station
          operator noticed that the Unit 2 control switch for the 0 EDG was in the
          pull-to-lock (PTL) position. After further review of the diesel
          starting logic and control circuit design by system engineering
          personnel, the licensee determined that the 0 EDG is rendered inoperable
          whenever the Unit 1 or Unit 2 control switch for the 0 EDG is in the PTL
          position. With the 0 EDG inoperable. TS 3.15.2.C requires that the two
          remaining Unit 1 EDGs be demonstrated operable and that the availability
          of two sources of off-site power be demonstrated. However, since the
l        licensee did not recognize that the 0 EDG was inoperable, the TS
          requirements were not met.
          The licensee determined that the Unit 2 control switch for the 0 EDG was
                                            8
!
l
 
    _ - _ __                __ _ . _ _ _ _ _ .__ _ _ _ _ _ _._ _
a
                                                                                    I
<                                                                                  ,
!                                                                                    l
  -
                                                                                    J
,          placed in the PTL Josition on October 26, during performance of S01-63G,
4          "Deenergizing 4KV ESF [ Engineered Safety Feature] Buses," Revision 1.
'
1 -
          This S0I was conducted to de-energize bus 247 to support a scheduled bus  i
            outage. The licensee determined during a follow-u) investigation that    !
            the S0I requirement to place the EDG control switc1 in the PTL position  j
          was not necessary to support the bus outage.
j
          The licensee determined that with the Unit 2 (Unit 1) control switch in
i
;
            the PTL position, the 0 EDG could not be manually started with the Unit  ;
            1 (Unit 2) control switch. However, the 0 EDG would start in response    i
:          to either a safet/ injection (SI) actuation or undervoltage (UV)
          condition signal, and would run until the SI signal is manually reset or  l
                                                                                    -
            the UV condition cleared. Once the emergency start signal had cleared,
i
            the 0 EDG would initiate a 15 minute cooldown cycle and then shut down
            since the seal-in circuit would be bypassed with the control switch in
;          the PTL position,
j          The response of the 0 EDG following the shutdown depends upon the event
i
'
            scenario. The most risk significant scenario involves a UV condition.
'
          The 0 EDG would start on undervoltage and power the loads secuenced onto
            the associated unit safeguards bus. Once the EDG was alignec to the
            bus, the UV signal would clear and the diesel would initiate a 15 minute
;          cooldown cycle. At the end of the cooldown cycle, the diesel would
i          coast down under load until the bus voltage reached the undervoltage
4          setpoint, at which time the 0 EDG would receive another emergency start  i
i
~
            signal on undervoltage. The load sequencer would strip the bus loads    l
            and then sequence loads onto the bus. The 0 EDG would then enter
;          another cooldown cycle. The degraded voltage condition on the
i          safeguards bus resulting from coastdown of the EDG at the end of the      ,
.
            cooldown cycle, could adversely affect the operation of equipment        1
            powered by the bus.
:          The inspectors determined through several interviews that control room
-
            operators did not understand how the position of the 0 EDG unit specific
i'          control switches affected the ability of the 0 EDG to perform its        l
l          intended safety function. Most operators knew that the EDG would start  {
;          on an emergency signal, but they did not understand why. In addition,
!          all of the operators interviewed understood the general operability
            requirements contained in the Zion Operability Determination Manual
            (ZODM), including the specific recuirement that equipment listed in the
            Technical Specifications be consicered inoperable when the respective
            control switch was in the PTL position. However, during performance of
            S01-63G on October 26 the operators placed the 0 EDG control switch in
            PTL without recognizing or questioning the impact of their actions on
            the operating unit.
            The inspectors reviewed licensed operator training records pertaining to
            coeration of the 0 EDG control circuit. Initial licensed operator
            t' raining included operation of the control circuit per lesson
            plan LO-PSC-31. This lesson plan covered both the normal and emergency
            start sequences. However, operation of the unit specific control
            switches was not specifically addressed, with the exception of one
                                                                  9
                                                                                      l
                                                                                    !
                                                                                    J
 
                                                                                  1
                                                                                    1
                                                                                    \
-
                                                                                    l
        instructor's note which indicated that the emergency start of the 0 EDG    ;
        was not affected by the control switch being in PTL. This note.            l
.      however, did not discuss the ability of the EDG to perform its intended    ~
        safety function with either unit control switch in PTL.
        In addition, the inspectors reviewed the training conducted for            )
        modification M22-0-88-09 which installed controls for the 0 EDG on the    i
        Unit 2 control board in September 1989. The training consisted of a        i
        brief description of the scope of the modification, however, it did not    l
        include any discussion of the impact of the modification on EDG control    i
        circuit operation. This training was promulgated to the licensed          I
        operators in the form of a required reading package.
    c.  Conclusions                                                                i
                                                                                    i
        Operators unknowingly rendered the 0 EDG inoperable for approximately
        two days. Operator training deficiencies and the failure of operators      1
        to question if an operating procedure was correct when the 3rocedure was  i
        in conflict with requirements in the ZODM, contributed to t1e error.        '
                                                                                  1
        Technical Specification 3.15.2.C permits reactor operation with the        ,
        0 EDG inoperable for 72 hours, provided that the two remaining EDGs for    i
        the associated unit are demonstrated to be operable and that two sources  i
        of off-site lower are demonstrated to be available. The failure to        :
        demonstrate )oth the operability of the two remaining Unit 1 EDGs and
        the availability of two sources of off-site power is considered a          i
        violation of TS 3.15.2.C (50-295/96017-03: 50-304/96017-03), as
        described in the attached Notice of Violation.
  07    Quality Assurance in Operations
  07.1 Failure to Imolement Corrective Actions for Inocerable Batterv Exhaust
        Ventilation System
    a. Insoection Scooe (40500)                                                  .
        On October 15, the inspectors reviewed the licensee's~ corrective actions  i
        for high ambient temperature in the 011 125 Volt-D.C. battery room.        l
        This issue was previously documented in NRC Inspection Report              :
        50-295/96014: 50-304/96014. The inspectors interviewed operations and      j
        regulatory assurance department personnel and reviewed applicable          '
        documentation, including Problem Identification Form (PIF) 2402.
    b. Observations and Findinas
        While conducting followup inspection activities for high ambient
        temperature in the 011 125 Volt-D.C. battery room (refer to
        Section E8.2), the inspectors identified that PIF-2402 had been closed    l
        without completion of the specified corrective actions and with no other
        tracking mechanism in place to ensure their completion. Problem
        Identification Form 2402 recommended that the Unit 2 Equipment Operator
        Checklist, Appendix S of PT-0, be changed to require verification of air
                                          10
                                                                                  ,
 
  -.-. __-                      - - - - - - - . .                  - -.- -...              . - - _ - _ _ - _ - - -
                                                                                                                        l
                                                                                                                        1
      .
1                            flow in the battery room. Past practice had been to verify that the
i                            exhaust fan was energized, however, this did not ensure that the battery                  '
!
'
      -
                              exhaust ventilation system was operable. In response to the inspectors'                  I
                              concerns, the licensee re-opened the PIF and implemented the recommended
                              corrective actions,
j              c.            Conclusions
                                                                                                                      .
                                                                                                                        .
i                            Based on interviews with regulatory assurance personnel, the inspectors                  l
                              concluded that corrective actions for deficiencies identified in PIFs
4
                                                                                                                        l
                              and categorized as significance level 4 were not required to be formally
                                                                                                                        '
L
!                            tracked through completion, and as a result, the actions were not always
                              completed. The failure to implement corrective actions for an
4
                              identified condition adverse to quality, specifically, insufficient
                              monitoring of the battery exhaust ventilation system, is considered a
4
                              violation of 10 CFR Part 50, Appendix B, Criterion XVI (50-295/96017-04:
;                            50-304/96017-04), as described in the attached Notice of Violation.
              07.2 Lack of Overtime Control
l
                a.            Insoection Scoce (40500)
l
!                            On November 14, the Site Quality Verification (SOV) Audit Group
!                            identified a significant recurring deficiency with the control of
;                            overtime. The inspectors interviewed station management SOV and staff
.                            personnel, reviewed applicable procedures, and evaluated available data
                              on overtime deviations.
j              b.            Observations and Findinas
a
.                            During the period of November 21 through December 16, 1994, SOV
i                            personnel performed an audit in the area'of operations and radwaste
i                            packaging and transport. The audit team identified that 305 overtime                      l
?                            deviations occurred between January 1 and November 30, 1994. As a                        '
i                            result, the licensee initiated a Level III corrective action record
j                            (CAR) for overtime control (CAR 22-94-067).                                              !
!                            During a followup review of CAR 22-94-067 S0V identified that overtime
                              control continued to be a problem, as evidenced by 225 overtime
i                            deviations for 38 personnel during the period from July 17 to
                              October 25, 1996, of which only five deviations had been approved. In
;                            response to this finding, S0V initiated a Level II CAP. for overtime
,
                              control (CAR 22-96-053) and the licensee subsequently implemented some
a                            near term corrective actions. During a followup review to evaluate the
                              effectiveness of these actions, the licensee identified that
;                            unauthorized overtime deviations were continuing,
i                            The inspectors noted that the issue with control of overtime has been
<
                              addressed by the NRC on several occasions, both on a generic basis and
i                            specifically with the licensee. Generic Letter (GL) 82-12, ''Ruclear
;                            Power Plant Staff Working Hours," and GL 83-14. " Definition of Key
i                            Maintenance Personnel (Clarification of Generic Letter 82-12)," provided
i                                                              11
L
4
4
4
            w  . ,- - . , - ,                .    -
                                                      . . . _
                                                                -_.m-    , , , , , , -_ . ._  ;,,,-,,
 
  . _ _ . .  ._ ___                . _ _ _ . _ _ _ _ . _ _ _ _ . _ . _ . _ _ . _ _ _ _ _ . _ . . .._
            .                                                                                                                                  ,
j                          licensees with guidance on the control of overtime. In addition NRC
'
                            Inspection Report 50-295/88017: 50-305/88017 identified that sufficient                                            '
            -
                            measures were not in place to ensure that safety-related work was not
                            jeopardized by personnel working too many hours. In the licensee's
                            response to this inspection report, dated October 4, 1989, the licensee
                            committed to establish a corporate policy governing safety-related work                                            3
                            at Commonwealth Edison nuclear stations by April 30, 1990, in accordance
                            with the guidelines contained in GLs 82-12 and 83-14.
                            Additionally, the Diagnostic Evaluation Team (DET) inspection conducted
                            during June 1990 identified that overtime was not being managed or
                            controlled. In the licensee's response to the DET report dated
                            November 2, 1990, the licensee committed to control overtime through
                            additional staffing, improved work planning, and strict adherence to
                            overtime guidelines.
                        c.  Conclusions
                            At the conclusion of this inspection period the licensee was in the
                            process of conducting a root cause evaluation for the identified                                                    I
                            overtime deviations. This issue is considered an Unresolved Item
                            (50-295/96017-05: 50-304/96017-05) pending further NRC review of                                                    i
                            licensee actions implemented in response to NRC concerns with the                                                  '
                            control of overtime to determine if licensee commitments in this area
                            were met.
                    Os    Miscellaneous Operations Issues
                    08.1    (Closed) LER 50-295/96026: Exhaust air flow from the fuel handling                                                4
                            building bypassed the auxiliary building charcoal exhaust filters. This
                            issue is discussed in Section E2.1 of this report.                                                                  l
                    08.2 (Closed) LER 50-295/96024: Missed TS surveillances for ino)erable                                                    i
                            common diesel generator caused by management deficiency. T1is issue is
                          ' discussed in Section 04.1 of this report.
                    08.3 (00en) LER 50-304/96010: Inadvertent engineered safety features (ESF)
                            actuation. On November 20 a Unit 2 ESF actuation and containment
                            isolation inadvertently occurred during testing. The inspectors
                            interviewed operations and engineering personnel and reviewed applicable
                            test procedures.
                            While performing Technical Staff Surveillance Procedure 079-96,
                            " Response Time Test of Reactor Protection and Engineered Safeguards
                            Features Logic," Revision 7G a system engineer inadvertently shorted                                                l
                            test leads. The leads were connected across a relay's contact which
                            resulted in a containment isolation actuation. Reactor coolant drain
                            tank isolation valve 2A0V-DT1003 and containment radiation monitor
                            isolation valve 2FCV-PR24A closed.                                            In addition, five valves associated
i                          with the isolation valve seal water system opened. The licensee                                                    1
                            immediately suspended testing activities and verified that all of the                                              i
                            required components had properly operated during the ESF actuation.                                                !
                                                                                                      12
                                                                                                                                                ,
                                                . . _ , . _ _      . . - .        _.
                                                                                                        ._,
 
1
  .
          The inspectors concluded that the licensee's immediate corrective
          actions to stop testing and investigate the causes for the event were
  .      appropriate. However, the inspectors noted that the licensee was slow
          to verify that all components operated properly as a result of the ESF
          actuation. The licensee did not have a full understanding that all
          components operated as required until November 22. At the end of the
          inspection period, the licensee was in the process of developing
          corrective actions to prevent recurrence. This item will remain open
          pending NRC review of the licensee's long-term corrective actions.
                                      II. Maintenance
    M1    Conduct of Haintenance
    M1.1 Failure to Address 00erability for Surveillance Tests with Parameters
          Outside Accentance Criteria
      a. Inspection Scone (61726)
          The inspectors reviewed the results of the November 1996 monthly
          surveillance test and all four 1996 quarterly surveillance tests for the
          011 125 Volt-D.C. station battery. The inspectors also interviewed
          several licensed operators, system engineers, and electrical maintenance
          personnel.
      b. Observations and Findings
          The inspectors identified that the licensee failed to recognize
          operability concerns and take appropriate actions for abnormal specific
          gravity readings obtained during surveillance tests for the 011 125
          Volt-D.C. station battery. The tests were conducted in accordance with
          Electrical Maintenance Surveillance Procedure (EMSP) 01. " Station
          Battery Monthly and Quarterly Surveillance," Revision 1, which
          implements the requirements of TS 4.15.1.E.2. This surveillance
          procedure s)ecifies an acceptance criteria for corrected s)ecific
          gravity of )etween 1.205 and 1.225. The Zion Operability Jetermination
          Manual (ZODM) requires that equipment which does not meet acceptance
          criteria specified in procedures be considered inoperable. The
          inspectors identified the following instances where the licensee did not
          evaluate the operability of either the battery or individual battery
          cells when specific gravity was not within test acceptance criteria.
l          .      On April 1.1996, the quarterly surveillance test results
                  indicated that the corrected specific gravity of one cell was less
                  than 1.205. As a result, the licensee initiated an equalizing
                  charge on April 2.
                                              13
 
  .
      .      On October 7, the quarterly surveillance test results indicated
              that the corrected specific gravity for four cells was less than
  .
              1.205. As a result, the licensee initiated an equalizing charge
              on October 10. On October 26. the licensee completed a partial
              surveillance test on the four cells. The s)ecific gravity for
              three of these cells was still outside of t1e acceptance range.
      .      On November 4, the monthly surveillance test results indiccted
              that the corrected specific gravity for the pilot cell was 109
              with a value of 1.199. The licensee did not initiate an
              equalizing charge.
      Licensee evaluation of the surveillance test results and battery
      conditions consisted of an informal review by a system engineer who
      recommended the actions described above. Based on interviews with the
      involved system engineer and the electrical group lead, the inspectors
      determined that the system engineer did not consider acceptance criteria
      specified in the surveillance test to be criteria for operability.
                                                                                  1
                                                                                '
      On November 11, after several discussions with various personnel in the
      operations and engineering departments about whether an operability
      assessment was required for low specific gravity, the inspectors raised  l
      the issue to the attention of the plant manager. Subsequently, on        l
      November 15, the licensee completed an operability assessment            -
      (No. ER9606326) and determined that the 011 125 Volt-D.C. station        i
      battery was operable. The inspectors reviewed the operability
      assessment and had no concerns.
      The inspectors noted that licensed operators were not required to review
      the monthly and quarterly station battery surveillance test results
      unless electrical maintenance personnel specified that an equalizing      i
      charge was needed. The licensee has imposed less stringent requirements
      for the review of battery surveillance test results relative to other
      TS-required surveillance tests which must be reviewed by licensed        I
      operators.
      In addition, the inspectors identified an error in the performance of    !
      the quarterly station battery surveillance test conducted per EMSP-01 on
      July 1. Due to an error in the calculation of average individual cell
      voltage, the licensee did not identify that an equalizing charge needed
      to be performed. The inspectors determined through interviews with
      system engineering and electrical maintenance department personnel that
      each group thought that the other was going to verify the accuracy of
      the calculations and consequently, no independent verification of the
      calculations was performed.
    c. Conclusions
l      The inspectors concluded that: (1) operability of the 011 125 Volt-D.C.
      station battery was not evaluated on several occasions when surveillance
        test results indicated that specific gravity was outside of prescribed  ;
        acceptance limits. (2) battery surveillance test results were subject to '
                                        14
 
  .
                                                                                  '
          less stringent operational reviews than other TS-required surveillance
          tests, and (3) due to the failure to independently verify the accuracy
  -
          of calculations performed for the quarterly surveillance test, the
          licensee did not identify that calculational errors existed which
          prevented the licensee from determining that an equalizing battery
          charge needed to be conducted.
          Section 5.1.B of ZODM-0, " Operability Determination Program,"
          Revision 8, requires that a system, subsystem, train, component, or
          device that fails to meet acceptance criteria specified in governing and
          a) proved 3rocedures, be considered inoperable. The failure to address
          t1e opera]ility of the 011 125 Volt-D.C. station battery in accordance
          with ZODM-0 when specific gravity was outside the acceptance criteria
          specified in surveillance procedure EMSP-01 on April 1, October 7 and
          26. and November 4. is considered an example of a violation of 10 CFR
          Part 50, Appendix B Criterion V (50-295/9G017-06a: 50-304/96017-06a),
          as described in the attached Notice of Violation.                        <
          Step 3.14 of EMSP-01 requires that average cell voltage be calculated    '
          and recorded. The failure to correctly calculate and record average
          cell voltage in accordance with EMSP-01 on July 1 is considered an
          example of a violation of 10 CFR Part 50 Appendix B Criterion V
          (50-295/96017-06b: 50-304/96017-06b), as described in the attached
          Notice of Violation.
    M1.2 Inconsistencies Between Completed Work Documentation and Actual Plant
          Configuration                                                            >
                                                                                  '
    a.  Insoection Stone (62707)
          The inspectors identified two examples where station personnel
          inappropriately signed off that work package criteria had been met. The
          inspectors reviewed applicable documentation and interviewed operations
          and engineering department personnel.
    b.  Observations and Findinas
                                                                                    i
          On November 4. the inspectors identified that fasteners on several        ;
          conduit supports did not meet minimum thread engagement criteria. These
                                                                                    '
          supports had been installed in January 1996 for ID steam generator
          feedwater isolation valve IMOV-FW0019 in accordance with Work Package
          No. 950020050-01. Instructions in the work package specified minimum
          thread engagement criteria and required cuality control (OC)
          verification of salected work steps per buclear Station Work Procedure
          E-03. The inspectors noted that the electrician and the OC inspector
          involved in the work activity had each signed off that the minimum
          thread engagement criteria had been met.
i        On November 27, the inspectors identified a loose environmental
'
          qualification (EO) union for containment air H monitor loop D isolation
          valve 2A0V-PR250. TheEQunionwaslooseattfieconnectiontothevalve
:          body.  The loose union was required to be torqued to between 45 and
.
                                            15
I
                                                                                    j
                                                                                    l
 
                -    _.              . _ - -    -_- -    ..  .  . _ - - - - .
:
4
            55 ft-lbs as specified in Work Package No. 930028776-01. In
  ,        February 1995, the involved electrician and OC inspector both
    -
            signed off that the union had been torqued to 50 ft-lbs.
        c.  Conclusions
                                                                                      ;
,          The inspectors concluded that the safety consequences of the              ;
i            installation deficiencies were minimal. However, as described in NRC
l            Inspection Report 50-295/96006-04: 50-304/96006-04, dated May 17, 1996,  ,
'          a violation was issued for the difference between the condition of a
            structure, system, or component (SSC) as described in completed work      '
            documentation and the actual plant configuration. In the case of the
:          two examples identified during this inspection period, the work
2
            activities during which the problem originated were conducted before the
            violation was issued. As a result, a violation is not being cited for
"
            these examples.    However, the inspectors were concerned with the
            identification of additional examples of inconsistencies between the
            condition of SSCs described in completed work documentation and the
            actual )lant configuration. These inconsistencies indicate a lack of
7
            thoroug1 ness on the part of maintenance workers and OC personnel in
'
            verifying that work package criteria for safety-related equipment has    l
.
            been met before signing off the work package.
:
l      M1.3 Gas Cylinder Imoronerly Secured to Scaffold
!
;      a.  Insnection Scone (62707)
j          On November 6, the inspectors identified that a compressed gas cylinder
            was secured to a seismic scaffold. The inspectors interviewed the night
,          shift scaffold supervisor, a regulatory assurance engineer, and a member
            of the corporate safety oversight office.
:
'
        b.  Observations and Findinas
;          During an inspection of the fuel Handling Building, the inspectors
            identified that a compressed gas cylinder was secured to a seismic
.!
            scaffold. The questionable scaffold configuration was associated with
            Scaffold Log Nos. A-617-096 and A-617-176.    The inspectors were
            concerned that the seismic scaffold evaluation was invalidated by
i            increased loading from the gas cylinder.
;          The licensee initially informed the ins)ectors that it was acceptable to
l          secure a gas cylinder to a scaffold. T1e ins)ectors asked the licensee
            if the seismic evaluation had accounted for t1e additional weight of the
            gas cylinder. The licensee subsequently determined that the evaluation
            did not account for any external loads, such as gas cylinders, and
            concluded that the gas cylinder should not have been attached to the
            scaffold. The inspectors were also concerned that maintenance personnel
            did not understand the requirements of Zion Administrative Procedure
            (ZAP) 900-06, " Compressed Gas Cylinder Control," Revision 1, which did
            not allow gas cylinders to be secured to scaffolding. In followup to
            the inspectors concerns, corporate safety personnel identified
                                              16
 
                                                                                    ,
          additional examples where gas cylinders had been improperly secured to
,        scaffolds.
  .
      c. Conclusions
          Maintenance personnel did not understand site gas cylinder control
          requirements. In addition, the licensee's staff was slow to recognize
          the impact of gas cylinders secured to a scaffold on the seismic
          qualification of that scaffold. The failure to control gas cylinders,      :
          as required by ZAP 900-06, which resulted in gas cylinders being secured
          to a seismic scaffold, is considered a violation of 10 CFR Part 50,
          Appendix B, Criterien V (50-295/96017-06c: 50-304/96017-06c), as
          described in the attached Notice of Violation.
                                                                                      l
    M3    Maintenance Procedures and Documentation                                    ;
                                                                                      I
    M3.1 Poor Work Practices and Inadeauate Maintenance Procedures Resulted in
          Five Protective Trios of the 2A EDG                                        1
      a. Insoection Stone (62707)                                                    l
                                                                                      !
          On October 14. the 2A EDG was removed from service for replacement of
          the generator and modification of the diesel governor. During
          post-maintenance testing, the 2A EDG experienced five protective trips.
          The inspectors observed selected portions of the maintenance,
          interviewed engineering and maintenance department personnel, and
          reviewed applicable maintenance procedures,                                j
      b. Observations and Findinas
          During a followup inspection of the EDG trips, the inspectors noted the
          following maintenance and manufacturing errors:
          Generator Leads Wired Backwards
          On October 31, during startup of the 2A EDG in accordance with S01-11A,
          " Local Operator Setup of Diesel Generator," Revision 5, and S01-11C,
          " Local Starting of Diesel Generator," Revision 6, in preparation for
          Technical Staff Surveillance Procedure (TSSP) 82-94, the EDG trip)ed on
          generator phase differential a) proximately two seconds after the EDG had
          been started. The licensee su)sequently identified that the generator
          leads from the current transformers (CT) and potential transformers (PT)
          had been wired incorrectly. The improperly landed leads resulted in the
          output of the PT being connected to one of the inputs for the
          differential current protection circuit, which normally received input
          from the CT. Consequently, when the field flashed on startup, the
          differential current protection circuit sensed a differential input
          which caused a trip signal to be generated.
          The generator leads from the CT and PT were disconnected and reconnected
          per Work Request No. 950117181-01 which governed the generator'
          replacement work. However, the wire numbering for the new generator was
                                            17
 
  .-- - . --          .
                          . - - . .  - - - - - - - - -                      - _ - - - - . - - . -
l
i-          different from the wire numbering for the original generator. Upon                          !
I
  o          identifying this discrepancy, maintenance workers involved in the                          !
1  -
            generator re)lacement activity informed their supervisor. The-
.
            supervisor,10 wever, directed the workers to connect the leads using the
{            wire numbering scheme for the new generator without properly resolving                      i
>
            the issue. As a result, the leads were installed incorrectly. This
i            issue is considered an Unresolved Item (50-304/96017-07) pending NRC                        l
                                                                                                        -
i
            review of the results of the licensee *s investigation of the quality                      l
+
            assurance requirements associated with the purchase order and the                          i
            vendor's quality assurance program, to determine the root causes for the                    ;
            improperly configured wiring harness.                                                      !
                                                                                                        l
            Imoronerly Disconnected Generator Neutral Ground Lead                                      i
                                                                                                        i
            During troubleshooting activities following the generator phase                            1
            differential trip, the licensee identified that the generator neutral                      i
            ground lead was improperly disconnected. With this lead lifted, single                      i
            phase ground faults could not be identified and cleared before the
            ground caused damage due to excessive heating.                                              i
            Although the neutral ground lead had to be disconnected for removal of
            the generator, work instructions in Work Request No. 950117181-01 did                      i
            not specify that the subject lead be disconnected. Consequently,                            '
            disconnection of the lead was not documented on a lifted lead data                          l
            sheet. During subsequent reassembly of the generator, the involved                          !
            electrical maintenance (EM) technician identified that the generator                      ,l
            neutral ground lead was disconnected. The EM technician reconnected the
            lead, completed his work tasks, and then informed the maintenance                          i
            supervisor that he had reconnected the lead upon discovery that it was
            disconnected.. The supervisor informed the EM technician that the                          ,
            neutral ground lead needed to be disconnected to support                                    i
            post-maintenance generator inspections, and as a result, the EM                            :
            technician disconnected the lead. The inspectors noted that the work                        !
            activities involving lifting and re-landing the generator neutral ground                    i
            lead were conducted without any work controls.
            During the subsequent generator inspections, conducted in accordance                        i
            with P/E009-2N, " Diesel Generator Inspection and Maintenance "                            !
            Revision 17, the licensee did not identify that the generator neutral                      !
            ground lead was disconnected.              In reviewing 3rocedure P/E009-2N in              ;
            preparation for the generator inspections, t1e work analyst deleted the                    ;
            steps which specified that the lead be disconnected since the lead had                      l
            already been lifted. The maintenance supervisor who also reviewed                          i
            P/E009-2N, deleted the procedure steps for reconnecting the lead since                      i
              the work analyst had previously deleted the steps for disconnecting it.                    ;
            Machinina Imoerfection in Governor Actuator                                                ,
            On November 2 during the initial loading of the 2A EDG to support                          l
            TSSP 82-94, the EDG immediately tripped on reverse power.                    Based on
              indications, the licensee suspected that the newly installed governor                      '
              actuator was causing excessive hunting resulting in a reverse power
                                                        18
                                                                                                  _ _ _u
 
  .      . - - -      -._              -.---              ------              .. -.- - - . - _ - - -
                                                                                                                              :
                                                                                                                              ,
        .
      *
                        trip. After consulting with a vendor representative, the licensee                                    !
      .                adjusted the governor response and then attempted to load the EDG. The                                !
        -
                        EDG tripped again on reverse power. The licensee readjusted the                                      !
                        governor response, started the EDG, and attem)ted to load it. The EDG
'
                        tripped for a third time on reverse )ower. Tie licensee then directed
                        that testing be stopped until a trou)leshooting plan had been developed
                        and approved.
                                                                                                                              l
                        The licensee determined that due to a machining imperfection, the
                        governor actuator was not sitting flush with its baseplate. When the                                  ;
                        maintenance technician had originally installed the governor actuator,
                        he did not question the existence of this condition. As a result, when
                        the maintenance technician secured the governor actuator to the base                                  ,
                        plate, the misalignment caused mechanical binding of the governor                                      I
                        actuator, resulting in the observed reverse power trips. The licensee                                i
l
'
                        decided to replace the governor actuator since the licensee could not                                  l
                        determine if the actuator had been damaged by the binding.                                            l
                        Hisalioned Governor Actuator                                                                          i
                        On November 4. the licensee installed a new governor actuator per a
                        field change to Work Request No. 940029891-01. The work instructions in
                        this field change consisted of the statement " Install new governor."
                        The instructions did not address correctly positioning the terminal
                        lever on the terminal shaft, and as a result, the governor actuator was
                        misaligned. When the licensee attempted to start the EDG, it tripped on
                        overspeed because excessive fuel was supplied to the engine due to the
                        misaligned actuator.
                    c.  Conclusions
                        The inspectors concluded that:      (1) lack of a questioning attitude and
i
'
                        failure to address identified discrepancies resulted in missed                                        l
                        opportunities to prevent each of the EDG trips: (2) inadequate work                                    '
                        instructions for the generator replacement. and the practice of not
                        documenting the disconnection of all leads, contributed to the failure
                        to reconnect the generator neutral ground lead: and (3) inadecuate work
I
                        instructions for the governor actuator replacement contributec to the                                .
                        overspeed trip of the 2A EDG. The inspectors also concluded that                                      !
,                        safety-related equipment was unnecessarily challenged due to poor                                      l
l                        maintenance practices and inadequate maintenance procedures.
                                                                                                                                l
                        The failure of Work Request No. 950117181-01 to provide appropriate
                        guidance to control the configuration of the generator neutral ground
                          lead, and the failure of the field change to Work Request No.
                        940029891-01 to provide appropriate guidance to control the alignment of
                        the governor actuator, are considered two examples of a violation of
                        10 CFR Part 50. Appendix B. Criterion V (50-304/96017-08a and                                          >
                        50-304/96017-08b, respectively), as described in the attached Notice of
.
                        Violation.
                  M3.2 Inadeouate Maintenance Procedure Resulted in Damaae to the 1A Auxiliarv
:                                                            19
    g                      g-- --e                <  -e        4 -m-y-- -,nq                        e e-, v- --- + - + -'
 
      . _ _ _ _ . _ . .            _ _ _ . _ _ _ _      . _ _ . _    ._ _      _    __      ..  . _
                        Feedwater (AFW) Pumo Turbine Inboard Bearina
    ~
l    -
                      a. Insoection Scone (62707)                                                    '
                        The insf.ectors observed selected portions of maintenance activities
,
                        related to the 1A AFW pump. The inspectors interviewed mechanical            !
                        maintenance, operations, and engineering department personnel: reviewed
                                                                                                      ~
i
                        selected maintenance procedures: and inspected the 1A AFW pump,              ;
                        including the turbine inboard bearing assembly.                              ,
                      b. Observations and Findings
                                                                                                      '
i                        The inspectors evaluated the following issues with respect to the AFW
l                        pump work:
                        AFW Pumn Turbine Bearina Water Intrusion
                                                                                                      ,
i
                        On November 25 the 1A AFW pump was removed from service for scheduled
;                        maintenance. While replacing the oil in the turbine inboard bearing,
                        the licensee identified approximately one-half gallon of water in the        '
                        turbine inboard bearing oil reservoir, which has a capacity of five and
                        one-half quarts. Based on an investigation by system engineering
                        personnel, the licensee identified three possible sources of water: the      ;
l                        installed oil cooler, turbine steam migrating to the bearing along the
'
                        shaft, and leakage from the oil cooler that was in service before
                        December 1995. Based on the results of a hydrostatic test of the
                        installed cooler and inspection of the pump turbine, the licensee
                        concluded that the source of the water was most likely from the cooler
                        in service before December 1995.
                        System engineering personnel concluded that the water had been present
                        in the oil reservoir before the cooler was installed in December 1995        -
                        and had not been detected due to improper performance of the oil change      i
                        preventive maintenance (PM) task. System engineering personnel
                        maintained that the fuel handlers who performed this PM activity had
                        drained oil from the reservoir via the sightglass instead of the drain
                        plug, resulting in the removal of approximately one quart of oil from
                        the upper portion of the reservoir. This practice resulted in the
                        majority of the oil and whatever water was present, remaining in the
                        reservoir.                                                                  i
l
'
                        However, the inspe tors noted that the explanation by system engineering
                        personnel of why the presence of water in the oil reservoir had not been
                        detected, conflicted with statements by the fuel handlers responsible        '
!                        for performing the PM activity. When the inspectors discussed this
                          issue with operations management and a fuel handling supervisor
                        responsible for completing the oil change PM, these individuals informed
                        the inspectors that the oil change had always been conducted using the
                        drain plug. This information did not support the conclusion by system
                        engineering personnel that the source of the water was from the oil
                        cooler in service before cooler replacement in December 1995. This
                          issue is considered an Unresolved Item (50-295/96017-09) pending NRC
  '
                                                                20
                                                                                                      ,
 
                                            - - . - . - - . - . - - . - . - . - - -
                                                                                                  I
  .                                                                                                ,
-
      review of the licensee's evaluation of the source of the water and the                      !
      adequacy of the oil change PM task.                                                        !
      AFW Pumo Turbine Bearina Damaae                                                            ,
                                                                                                  i
      As a result of water beina identified in the bearing reservoir, the -                      .
      licensee expanded the scope of the scheduled maintenance to include an                      l
      inspection of the turbine inboard bearing assembly. During this                            ,
      inspection, the licensee discovered that the bearing was wiped. Because                    i
      bearing damage was limited to a discrete portion of the bearing surface,
      the licensee concluded that the damage was not the result of water                          ;
      intrusion. The licensee's investigation to determine the root cause for
      the bearing damage was still in progress at the end of the inspection                      i
      period.                                                                                    .
      Incorrect Installation of AFW Pumo Turbine Bearina Slinaer Rinas
                                                                                                  ,
      On November 28. the licensee replaced the turbine inboard bearing in
      accordance Work Request No. 960110430-01, Revision 1.                        No guidance on
      installation of the oil slinger rings was provided in the work
      instructions associated with this work request. During installation of
      the new bearing, the maintenance staff incorrectly installed the slinger
      rings. Consequently, on November 29. during post-maintenance testing of
      the 1A AFW pump, elevated turbine inboard bearing temperature
      necessitated tripping the pump. The 11ensee identified significant
      bearing damage during an inspection of the bearing and attributed this
      damage to inadequate lubrication caused by the improperly installed oil                    .
      slinger rings. The licensee replaced the damaged bearing and
      satisfactorily retested the AFW pump. The inspectors noted that the
      work activity involving installation of the oil slinger rings was
      observed by a mechanical maintenance supervisor.
    c. Conclusions
      The inspectors concluded that the work instructions used to install the
      1A AFW pum) turbine inboard bearing were not appropriate for the skill
      level of t1e mechanics performing the maintenance activity. The failure
      to provide sufficient work instructions for installation of the turbine
      bearing is considered an example of a violation of 10 CFR Part 50,
      Appendix B Criterion V (50-295/96017-08c), as described in the attached
      Notice of Violation.
                                          21
                                                                              _
 
i
i
l
l
                                  III. Enaineerina
  El    Conduct of Engineering
  El.1 Failure to Address Operability for Deficiencies in Safety-Related Pioino
l
        Suonorts in a Timely Manner
    a. Insoection Scone (37551)
        The licensee did not evaluate three NRC identified safety-related piping
        support deficiencies in a timely manner. The inspectors interviewed
        operations and engineering personnel and evaluated the licensee's
        resolution of the degraded pipe support conditions.                      j
    b. Observations and Findings
        On October 25. the inspectors identified that a "U" bolt style piping
        support was missing on both the 1A and the 0 EDGs. The licensee
        documented this condition on Problem Identification Form (PIF) 96-3713
        and initiated an operability assessment per Appendix A. " Initial
        Operability Assessment " of the Zion 0)erability Determination Manual
        (ZODM) 0. Based on this initial opera)ility determination, which was
;
'
        completed on October 26, the licensee concluded that the EDGs were
        operable. The licensee is also required to perform an operability
        evaluation per Appendix B. " Operability Issue Form." of ZODM-0. whenever
        an operability issue has been identified. The licensee completed the
        Appendix B evaluation on November 8, which specified that a detailed
        calculation be completed by November 15 to determine if the jacket water
        cooling system remained seismically qualified. On November 8, the
        engineering supervisor responsible for approving the Appendix B          l
        evaluation identified that the timeliness requirements specified in the  i
        ZODM-0 had not been met.                                                  ;
        On November 7. the inspectors notified engineering personnel that a      l
        " trapeze" style piping support for eight service water lines in the
,      Unit 1 containment spray room was partially disassembled. in that, one
l
'
        of two support rods was not attached. An engineer did not inspect the
        support until November 14. After inspecting the support, the engineer
,
        initiated a PIF (96-4217), and an operability assessment )er Appendix A
        of the ZODM-0 was completed. Based on this initial opera)ility
        determination, the licensee concluded that the affected equipment was
        operable. The required Appendix B operability evaluation was completed
l      on November 15.
l      On October 16, the inspectors informed a system engineer that a pi]e
        support was missing on high pressure N2 backup pressure control va ve
                                                        ,
        IPCV-NT10. The system engineer informed the inspectors that the missing
        support had been identified three years ago and that there was not an
        operability concern based on an evaluation performed at that time. The
*
        engineer, however, could not produce the documented evaluation. In
        response to the inspectors concerns, the licensee performed an
        operability assessment for the missing pipe support on November 27 and
                                          22
 
                                                            _._      _ . _ _ . - . . . . _ . _ . . -
                                                                                                        i
                                                                                                        .
.                                                                                                      .
.        concluded that the valve IPCV-NT10 was inoperable.
'
  -    c. Conclusions
          The inspectors concluded that engineering personnel did not evaluate                          '
          safety-related material condition deficiencies for operability in a
          timely manner. The failures to: (1) complete Appendix B of ZODM-0
          within the required time limit specified in ZODM-0 for missing jacket
          water cooling system pipe supports on the 1A and 0 EDGs: (2) complete
          operability assessments for a partially disassembled service water                            ,
          piping support )er Appendix A and B of ZODM-0 within the time limits
          specified in Z0)M-0: and (3) complete Appendix A within the required
          time limits of ZODM-0 for a missing pipe support on valve IPCV-NT10: are
          considered three examples of a violation of 10 CFR Part 50 Appendix B,
          Criterion V (50-295/96017-06d: 50-304/96017-06d. 50-295/96017-06e, and
          50-295/96017-06f respectively), as described in the attached Notice of
          Violation.
    E2    Engineering Support of Facilities and Equipment
    E2.1 Exhaust Air Flow From the Fuel Handlino Buildino (FHB) Bvoassed the
          Auxiliary Buildino (AB) Charcoal Exhaust Filters
      a. InsDeCtion SCODe (71707 and 37551)
          On November 7, the licensee identified that the plant may have operated
          in a condition outside of the plant's design basis as described in the
          Updated Final Safety Analysis Report (UFSAR). The condition pertained
          to a design basis fuel handling accident. The inspectors interviewed
          system engineer personnel and reviewed ap)licable documentation,
          including the Technical Specifications, t1e UFSAR, and a fuel building
          ventilation system safety evaluation (50.59/0213/96).
      b. Observations and Findinos
          Section 9.4.3.1 of the UFSAR assumes that for a fuel handling accident,                        ,
          all of the exhaust air from the FHB is routed through the AB charcoal                          i
          exhaust filters. To facilitate the movement of large equipment into and                        I
          out of containment during the Unit 2 refueling outage, the licensee                          i
          removed a shield block wall between the containment and FHB.        This
          created a ventilation exhaust path through a vertical pipe chase and                          !
          pipe tunnel which bypassed charcoal filters in the AB ventilation                            i
          system.
          In response.to a high radiation condition during a fuel handling
          accident, radiation monitors in the pi)e tunnel (2RT-PR07A and B) should
          actuate, realigning the ventilation ex1aust path through charcoal
          filters. However, per the Technical Specifications, the radiation
          monitors are not required to be operable in Mode 6 (refueling).
          Consequently, there was no assurance that the monitors would have been
          available to realign the pipe tunnel exhaust through charcoal filters.
          The licensee concluded that this condition could have resulted in
                                            23
                                                                  -                    .
 
.
-
        significant increases in offsite dose.
-
        To address this issue, the licensee initiated the following corrective
        actions:
        .      Periodic Test 19. " Auxiliary Building / Fuel Building Ventilation
                Test," Revision 5, was revised to configure the pipe tunnel
                exhaust through charcoal filters during fuel handling and crane
                movements over the spent fuel pool.
        .      Engineering requests were issued to perform a modification to -
                install' duct work between the pipe tunnel opening and the AB to
                prevent FHB exhaust air from bypassing charcoal filters
    c.  . Conclusions                                                              !
        Upon identification, the licensee initiated prompt corrective action.
        As of the end of this inspection period, the licensee was still in the    J
          3rocess of evaluating this-issue. This issue is considered an
          Jnresolved Item (50-295/96017-10: 50-304/96017-10) pending further NRC
        review to determine if this condition existed during actual fuel
        movements in the FHB and what previous opportunities existed for the        ,
        licensee to identify the ventilation system concern.                        I
  E2.2 Fuel Assembly Clearances Durina Fuel Moves                                  i
    a.  Insoection Scoce (71707)
        On November 24 the licensee identified a discrepancy between the actual    '
        plant configuration and the UFSAR description ~of the clearance between
        the bottom of a fuel assembly and the weir gate and the distance between
        the surface of the spent fuel pool' (SFP) and the top of a fuel assembly
        during fuel moves. The inspectors interviewed engineering and licensing
        department personnel and reviewed applicable documentation.
    b.  Observations and Findinas
          Section 12.3.2.2.3.1. " Spent Fuel Pool," of the UFSAR states that,
          "Using a clearance of six inches between the bottom of a spent fuel
          assembly and the base seal of the gate, a 10-foot 3 inch water shield is  i
          provided above the active length of the assembly during transfer." The
          licensee identified that the six inch clearance and water shield
          requirements were not met during fuel moves. The maximum clearance of a
          fuel assembly from the weir gate base was 2," and the SFP level would
          have to have been above the overflow value of 615' 5" in order to have
          maintained 10' 3" of water above the fuel assembly during fuel            ;
          transfers. The licensee's corrective actions in response to this issue    i
          included suspension of all fuel moves and the initiation of a change to  I
          the UFSAR.
                                                                                    l
                                            24
                                                                                    l
                                                                                    ,
                                                                                    l
 
l
l -
        c. Conclusions
: e
  -
          The licensee appropriately suspended fuel movement upon identification
          of this issue. The licensee was still in the process of evaluating the
          reason for and the significance of this UFSAR discre)ancy at the end of
          the inspection period. This issue is considered an lnresolved Item
.
          (50-295/96017-11: 50-304/96017-11) pending NRC review of the results of
l          the licensee's evaluation.
    E3    Engineering Procedures and Documentation
l
    E3.1 Review of UFSAR Commitments
:          The discovery of a licensee operating its facility in a manner contrary
          to the UFSAR description highlighted the need for a special focused
          review that compares plant practices, procedures, and/or parameters to
          the UFSAR descriptions. The inspectors reviewed the applicable portions  2
          of the UFSAR that related to the areas inspected. The following
          inconsistencies were noted between the wording of the UFSAR and the
          plant practices, procedures, and/or parameters.
        a. Fuel Handlina Accident Defined in UFSAR Incorrect
          On November 7, the licensee identified that the fuel handling accident,
          as described in UFSAR Section 9.4.3.1, was incorrect. This issue is
          discussed in Section E2.1 of this report.
        b. Fuel Assembly Clearances Durino Fuel Transfer Not Consistent With UFSAR
          On November 24, the licensee identified a discrepancy between the actual
          plant configuration and the UFSAR description of the clearance between
          the bottom of a fuel assembly and the weir gate and the distance between
          the surface of the SFP and the top of a fuel assembly during fuel moves.
          This issue is discussed in Section E2.2.
    E8    Miscellaneous Engineering Issues
    E8.1 (Closed) IFI 50-295 304/96014-07: Safety-related pi)ing support anchor
            )lates exceeded the specified gap criteria between tie plate and the
            Juilding structures                                                    i
                                                                                    l
          The inspectors reviewed the licensee's operability assessment            l
            (No. ER9604805) and supporting engineering calculations and determined  '
          that the licensee's conclusions regarding operability of the analyzed
          pipe supports were adequately justified. However, since the licensee's
          operability assessment was based on an inspection of a limited number of
          supports, of which approximately 50 percent exceeded the gap criteria,
          the inspectors determined that the licensee's conclusion that all large
          bore piping supports with excessive gaps were capable of performing
          their intended safety function, lacked a technical basis. In res)onse
          to the inspectors concern, the licensee informed the inspectors tlat in
          the future when deviations from the specified gap criteria were
                                            25
 
                _    _ . . _ . . . _ _ _ . . _ _ . _ . _ _ _ _ _ . _ _ _ _
                                                                                                            !
                                                                                                            ,
.
-
          identified, the licensee would either demonstrate that the condition is
.        bounded by operability assessment No. ER9604805, or perform an
  -
          additional evaluation of the condition. The inspectors had no further
          concerns with this issue and this item is closed.                                                  j
    E8.2 (Closed) IFI 50-295:304/96014-08:                              High ambient temperature in the 011 l
          125 Volt-D.C. battery room.                                                                        ;
                                                                                                            ,
          Per guidance in the Zion Operability Determination Manual, the licensee                            :
          considers the 011 125 Volt-D.C. battery to be operable for up to five                              l
          days without the battery room exhaust ventilation system in operation,                            i
          based on the calculated time for hydrogen concentration to exceed two
          percent without ventilation flow. The 3rojected time for hydrogen
          concentration to reach two percent was Jased on calculation No.
          NED-MSD-H-7. The inspectors reviewed this calculation and did not                                  l
          identify any concerns.
          The inspectors also reviewed the licensee's basis for allowing operation
          of the 125 Volt-D.C. batteries in an elevated ambient temperature
          environment. As documented in licensee internal correspondence
          (Chron iiu. 115671) dated May 5,1992. the licensee concluded that
          continued operation of the batteries in an elevated temperature
          environment would result in reducing the battery service life by
          approximately 25 percent. However, the reduced service life of the
          batteries would not increase the number of expected battery replacements
          before the expiration of the plant license. The licensee therefore,
                                                                                                            ,
                                                                                                            !
          concluded that a modification to the battery ventilation system to lower                          I
          ambient temperatures was not justified based on economic considerations.                          l
          The inspectors had no further safety concerns with this issue and this                            '
          item is closed,                                                                                    l
                                                                                                            l
    E8.3 (Closed) Unresolved item 50-295/304-96006-09 Unit 1 safety injection                                '
          (SI) pump suction pi)ing pressurized due to freezing of the
          recirculation line w1ere it traversed the containment purge supply duct.
                                                                                                            l
          At the time of the event Unit I was in Mode 5 (cold shutdown). The SI                              i
          system is not required to be operable in this plant condition. The
                                                                                                            '
          inspectors reviewed operating records for the past five years to
          determine if the SI system recirculation piping was susceptible to
          freezing due to plant conditions at a time when the SI system was
          required to be operable. The susceptibility of the recirculation pi)ing
          to freezing was dependent upon the outside ambient temperature, whetler
          the containment purge system was in service, and the accumulation of
          water in the recirculation line due to running of the SI pump during a
          previous surveillance test. The inspectors did not identify the
          existence of the recuired plant conditions during the past five years.
          The inspectors notec that the licensee completed a similar review on
          November 27, 1996, with the same results.
          The licensee addressed this equipment vulnerability concern during the
          current refueling outage by rerouting the Unit 2 SI system recirculation                          I
          piping away from the containment purge supply ducting. The exposed                                1
                                                                  26
 
.
-
        piping in the vicinity of the Unit 1 containment purge supply ducting
.      was heat-traced and the licensee implemented a standing order to check
  -
        temperatures-in the purge room each shift. The inspectors concludej
        that the licensee's corrective actions were adequate. This item is
        closed.
                                      IV. Plant Suocort
    F2  Status of Fire Protection Facilities and Equipment
    F2.1 Unaualified Fire Barriers
        On November 8, the licensee identified that "Cerifiber" fire seals
        installed in the plant did not conform to approved fire test reports.
        The licensee initiated an investigation to determine the fire seals'
        qualification, which was still in progress at the end of this inspection
        period.    In the interim, the licensee established compensatory measures
        including hourly fire watch tours of the affected areas. This is
        considered an Unresolved Item (50-295/96017-12: 50-304/96017-12) pending
        NRC review of the licensee's investigation results.
                                  V. Manaaement Meetinas
    X1  Exit Heeting Summary
        The inspectors 3 resented the inspection results to members of licensee
        management at tie conclusion of the inspection on December 6, 1996. The
        licensee acknowledged the findings presented. The inspectors asked the
        licensee whether any materials examined during the inspection should be
        considered proprietary. No proprietary information was identified.
    X3  Hanagement Heeting Summary
        NRC and Commonwealth Edison management met at the NRC Region III offices
        on November 19, 1996, to discuss the licensee's initiative to have an
          independent scfety assessment (ISA) of LaSalle County Station and Zion
        Station conducted by a contractor. At this meeting, the licensee
        described the purpose of each ISA, organization and staffing of the ISA
        team, the scope of each assessment, and the proposed schedule. The
          licensee stated that the ISA would consist of a comprehensive review of
          historical performance at each facility to determine why previous
          improvement initiatives had not been successful and to ensure the
          licensee was focusing resources on appropriate issues.
                                              27
 
                                                              !
                                                              l
  .
-
                            PARTIAL LIST OF PERSONS CONTACTED
'
                                                              i
  -
    Licensee
    J. Mueller, Site Vice President
    G. Schwartz, Station Manager
    G. VanderHayden, Operations Manager
    W. Stone, Regulatory Assurance Supervisor
    B. Fitzpatrick, Operations Manager
    B. Giffin Engineering Manager
    K. Hansing, Site Quality Verification Director
    W. Strodl, Radiation Protection Supervisor
    M. Weis, Services Director
    NRC
    M. Dapas. Chief, Reactor Projects Branch 2
    M. Parker Senior Resident Inspector, Palisades
    A. Vegel, Senior Resident Inspector Fermi
    R. Westberg, Senior Resident Inspector
                                                              !
                                                              l
                                                              l
                                                              l
                                                              l
                                            28
 
    ._. ._ _ . _ . - . _ . _ _ _ . _ _ _ . _ .                                                      . . _ _ . . _ _ . _ _ _ _ _ _ _ _
l
                                                            List of Insoection Procedures Used
  ,                                                                                                                                  .'
L-                IP.37551                        Onsite Engineering.                                                                    {
                  IP 40500                        Effectiveness of Licensee Controls in Identifying. Resolving, and
,
!
                                                  Preventing Problems
                  IP 61726                        Surveillance Observations                                                            >
l                IP 62707                        Maintenance Observation                                                                l
I
                  IP 71707                        Plant Operatione                                                                      1
                                                                                                                                        i
l                List of Items 00ened. Closed. and Discussed
                                                                                                                                        1
                00ened                                                                                                                  i
                                                                                                                                        ,
j
                  50-304-96017-01                              VIO      Operation of an 00S component which resulted in
!
                                                                        a spill of approximately 400 gallons of water
l                50-295-96017-02                              URI      Practice of allowing reactor power to knowingly
                                                                        exceed licensed thermal )ower limit
                  50-295/304-96017-03                          VIO      Failure to demonstrate tie operability of the
                                                                        two remaining EDGs and the availability of two
                                                                        sources of off-site power within one hour and at
!                                                                      least once per every eight hours thereafter
!                                                                      while the 0 EDG was inoperable
                  50-295/304-96017-04                          VIO      Failure to implement corrective actions for an
                                                                        identified significant condition adverse to                    i
;
'
                                                                        quality
                  50-295/304-96017-05                          URI      Control of overtime
                  50-295/304-96017-06a                        VIO      Failure to address operability of equipment when                I
                                                                        a TS required surveillance test discovered
                                                                        equipment parameters outside the acceptance
                                                                        criteria specified in the test
                  50-295/304-96017-06b                        VIO      Failure to correctly calculate average cell
                                                                        voltage during a battery surveillance
                  50-295/304-96017-06c                        VIO      Improperly attached gas cylinders to seismic
                                                                        scaffold which invalidated the seismic
                                                                        evaluation
                  50-295/304-96017-06d                        VIO      Failure to com)lete appropriate operability
:                                                                      assessment witlin five days of discovery of
i                                                                      missing piping supports on the 1A and 0 EDGs
                  50-295/304-96017-06e                        VIO      Failure to complete the appropriate operability
                                                                        assessments within 24 hours and five days for a
                                                                        partially disassembled service water piping
                                                                        support
                  50-295/304-96017-06f                        VIO      Failure to com)lete a)propriate operability
                                                                        assessment wit 11n 24 lours for a N 2backup
                                                                        pressure control valve
                  50-304-96017-07                              URI      Review of purchase order and vendor quality
                                                                        assurance program to determine cause of the
                                                                        improperly configured wiring harness on new
                                                                        generator
                  50-304/96017-08a                            VIO      Inadequate maintenance procedure resulted in the
r                                                                      loss of configuration control for the generator                  i
l                                                                      neutral ground lead                                            !
i                                                                                                                                        ,
1
                                                                                29                                                      l
!
                                                                                                                                        ,
                                                                                                                      _-
                                            _ _ _ _ _ _              _
                                                                              __        __. -  ,.          _ . _ _
 
                                                                            .-. ..
                                                                                    !
I  50-304-96017-08b    VIO Inadequate maintenance procedure resulted in the        1
.                          misalignment of the 2A EDG governor actuator
-
  50-295-96017-08c    VIO Inadequate maintenance instructions resulted in
                          the improper assembly of the 1A AFW turbine
                          inboard bearing
  50-295-96017-09    URI Review evaluation of source              d
                          adequacy of oil change PM or              turbine
                          inboard bearing
  50-295/304-96017-10 URI Review evaluatiori a                . Dypass flow
  50-295/304-96017-11 URI Review evaluation 0,              anbly
                          clearances during fuel  ...
  50-295/304-96017-12 URI Review fire barrier quali1 aon documentation
                                                                                  '
  Closed
  50-295/304-96006-09 URI SI pump recirculation line freezing
  50-295/304-96014-07 IFI Operability assessment and su) porting
                          engineering calculations for .)aseplate gaps
  50-295/304-96014-08 IFI Basis for 125 Volt battery operability without
                          battery room exhaust ventilation
  50-295-96024        LER Missed TS surveillances for inoperable common
                          EDG caused by manageiaent deficiency
  50-304-96026        LER FHB ventilation exhaust air flow bypassed the AB
                          charcoal exhaust filters
                                                                                    i
                                    30
 
  ,
*
                                  List of Acronyms
  -
    AB  Auxiliary Building
    AFW  Auxiliary Feedwater
    CAR  Corrective Action Record
    CT  Current Transformer
    DET  Diagnostic Evaluation Team
    EDG  Emergency Diesel Generator
    ECCS Emergency Core Cooling System
    EM  Electrical Maintenance
    EMSP Electrical Maintenance Surveillance Procedure
    E0  Environmental Qualification
    ESF  Engineered Safety Features
    FHB  Fuel Handling Building
    GL  Generic Letter
    IFI  Inspection Follow-up Item
    IP  Inspection Procedure
    LER  Licensee Event Report
    NCV  Non-Cited Violation
    NRC  Nuclear Regulatory Commission
    00S  Out-of-Service
    PDR  Public Document Room
    PIF  Problem Identification Form
    PM  Preventive Maintenance
    PT  Potential Transformer
    PTL  Pull-to-Lock
    OC  Quality control
    RHR  Residual Heat Removal
    RWST Refueling Water Storage Tank
    SI  Safety Injection
    SFP  Spent Fuel Pool
    SOI  System Operating Instruction
    SOV  Site Quality verification
    TS  Technical Specification
    TSSP Technical Staff Surveillance Procedure
    UFSAR Updated Final Safety Analysis Report
    URI  Unresolved Item
    UV  Undervoltage
    VIO  Violation
    VPI  Valves Position Indicator
    ZAP  Zion Administrative Procedure
    ZODM Zion Operability Determination Manual
                                            31
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