IR 05000295/1997019

Insp Repts 50-295/97-19 & 50-304/97-19 on 970719-0829. Violations Noted.Major Areas Inspected:Operations,Maint & Engineering

ML20217F109
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	09/30/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20217F076	List: IR 05000295/1997019 ML20217F072 ML20217F086
References
50-295-97-19, 50-304-97-19, NUDOCS 9710070372
Download: ML20217F109 (21)

Text

-.

-

.

. _ _ _

-....

........ _ _._- -

-_~

_

=

U.S. NUCLEAR REGULATORY COMMISSION

.,

REGION Ill Docket Nos:

50 295;50 304

License Nos:

DPR 39; DPR-48

Report Nos:

50-295/97019(DRP); 50 304/97019(DRP)

>

,

Licensee:

Commonwealth Edison Company

Facility:

E3n Nuaear Plant, Units 1 and 2 i

Location:

101 Shiloh Boulevard Zion,IL 60099 Dates:

July 19 through August 29,1997 L

Inspectors:

A. Vogel, Senior Resident inspector E. Cobey, Resident inspector

. J. Schapker, Reactor inspector j

J. Yesinowski, Illinois Department of i

Nuclear Safetyinspector Approved by:

A. M. Stone, Acting Chief Reactor Projects Branch 2

...

9710070372 970930 PDR ADOCK 05000295 G

PDR A

=---------- -

r-

--

y

-. -. -

EXECUTfVE SUMMARY Zion Nuclear Plant, Units 1 and 2

- NRC inspection Report 50-295/97019(DRP); 50-304/97019(DRP)

This inspecuon included aspects of licensee oprations, maintenance, and engineering. The report covers a six week period of inspection adivities by the resident staff and a region based inspector.

During this six-week inspection period, an adver se trend was identified in the area of operator procedural adherence, as reflected in the six inspector identified examples of procedural non-compliance. These examples indicate that predous corrective actions, including the Phoenix training program, have been less than fully effecuve in resolving this operator performance problem. In addition, the suspension of the Operational Readiness Demonstration Program, numerous equipment problems, and some surveillance test failures indicated inadequate support from maintenance and engineering personnel to schedule and correct equipment problems in a timely manner. This resulted in unnecessary challenges for the control room operators.

Operations The licensee suspended the Operational Readiness Demonstration Program because

.

significant weaknesses were identified in the areas of work scheduling, command and control, and communications. (Section 01.1)

. Following inspectors' identification of an adverse trend in configuration control of plant

.

systems and equipment and of a service water valve out-of-position on the 2A emergency diesel generator, the licensee initiated a significant effort to re-establish configuration control of plant systems and equipment. (Section 01.2)

The inspectors identified six examples of violations involving operators' failure to follow

.

procedures during the performance of surveillance testing and operating special procedures. The multiple inspector-identified violations indicated that operator procedural compliance remained problematic. (Section 01.3)

The licensee considered the 1A and common emergency diesel generators inoperable

.

due to the failure to perform Technical Specification surveillance tests within the specified time interval. This resulted in the plant being in an unanalyzed condition with no operable

- emergency power supply for the Unit i service water pumps. (Section 01.4)

The inspectors identified a decline in the material condition and general housekeeping of.

.

the plant based on inspedor-identified deficiencies and the occurrence of numerous equipment failures. (Section O2.1)

Maintenance The inspectors identified a violation involving inadequate foreign material exclusion work

.

practices during maintenance on the 1A service water pump. (Section M1.1)

The inspectors identified a violation involving an inadequate quality control inspection of

.

an emergency diesel generator starting air check valve during maintenance. The inadequate work practices and quality control inspection contributed to the delay in

.

s inadequate work practices and quality control inspection contributed to the delay in

,

'

restoring the 18 emergency diesel generator to service following maintenance.

(Section M7.1)

Enaineenna

An inadvertent engineered safety feature actuation occurred when an engineer operated

.

a test switch out-of sequence during surveillance testing due to poor communications

,

during the evolution, (Section E1.1)

i w

3

-

.

.. - - -. - - - - -.. -.- -.- -

- -.. -

_-.--._---.- -.-

l

%

,

..,

Report Details

Summary of Plant Status

,

!

During this inspection period, the licensee maintained Unit 1 in a defueled status and Unit 2 in a

-

-

cold shutdown, depressurized condition pendmg completion of restart actions delineated in the

'

Zion Recovery Plan.

.

l. Operations

'

Conduct of Operations

01.1 Operational Readiness Demonstration Proaram Ima!ementation a.

inspection Scope (71707)

I The inspectors observed licensee implementation of the Operational Readiness

,

Demonstration Program (ORDP). The inspectors observed control room activities,

.

attended ORDP daily debriefs, interviewed operators, and reviewed applicable documentation..

L i

b.

Qbservations and Findinos

"

On July 19,1997, the licensee suspended the ORDP. As previously documented in NRC Inspection Report 50-295/97-16; 50 304/97-16, the licensee initiated the ORDP on July 7, i

1997, to verify that: (1) the operators and shift crews can implement management's.

'

expectations for plant operations: (2) management supports operations through day-to-

day plant activities and that communication and direction for shift operations is effective;

and (3) plant readiness to operate.

.

Based on two weeks of observations, the licensee concluded that, in general, shift crews

were implementing the Zion Operations Department Standards. However, overall operator performance was censidered not acceptable due to command and control and i

communications problems, in addition, problems were encountered with implementation of the work schedule, which resulted in the ORDP special demonstration tasks not being

'

performed. Specifically, inadequate pre-planning and the failure to resolve scheduling

,

. and equipment problems in a timely manner resulted in the control room operators being

distracted and the planned ORDP activities not being performed, in addition, the licensee

identified inconsistencies between the shift crews in the performance of shift tumovers and briefs, and communication of expectations. Untimely communication of issues between the shift crews and operations management was also identified.

Following the suspension of the ORDP, the licensee initiated actions to correct the

. performance problems identified during the ORDP. The licensee's corrective actions included the development of action plans to improve work schedule adherence and communications, and to establish criteria for the restart of the ORDP.

!-

j

.

4 I

<

k

.., <

,,-w

-- ~ ~-

-.

-nv

,

.

,-

-

-- - - - ~,

-.. - - - - - -

.. - - - -.

-. -

. -.. - -. -

j

.

c.

Conclusion

,

,

The inspectors concluded that the Schnt.oe's decision to suspend the ORDP was

'-

appropriate considering the performance problems that were identified during the program implemertibn. Of padicular concern was the inability of the licensee staff to effectiveb/ FAe,. and implomoni the ORDP. In addition, line management, site quality

ver% cation, and corporate overs'ght activities failed to recognize that the staff and the i

p*,ent were not ready to implemen,' the ORDP. Consequently, the ORDP, by default, was

' '

affective in demonstrating that the licensee staff and the plant were not ready for restart.

}

01.2 Confiouration Control of Pa* Sstems and Eculoment

'

a.

Inspection Scope (71707)

The inspectors reviewed licensee actions in response to an adverse trend in configuration control of plant systems and equipment. The inspectors interviewed operations personnel and reviewed applicable documentation.

j'

b.

Observations and Findinas As previously documented in NRC Inspection Report 50-295/97-16; 50-304/97-16, the

.

4 -

inspectors identified an adverse trend in configuration control of plant systems and

'

equipment. Subsequently, the licensee acknowledged that configuration control problems

existed and actions were initiated to address the problem. On July 25,1997, the Shift Operations Supervisor, issued a site-wide memorandum to communicate expectations i

concoming the operation and control of plant equipment, and control room operators were briefed on the impodance of configuration control.

On August 9,1997, the inspectors identified a valve out-of-position in the 2A emergency diesel generator (EDG) room. Specifically, the inspectors found the 2A EDG lube oil cooler service water (SW) inlet pressure indication isolation valve, 2SW1814, out-of-

~;

position open, in accordance with System Operating instruction (SOI) 11, Appendix B-2,

" Diesel Generator Service Water Sys, tem Essential Valve Lineup " valve 2SW1814 was

-

required to be closed. The failure of the licensee to control the position of.

'

valve 2SW1814 in accordance with procedure SOI-11, Appendix B-2 is an example o' te violation of 10 CFR Part 50,' Appendix B, Criterion V (50-304/97019-01a), as described y the attached Notice of Violation.

On August 27,1997, a non-licensed operator observed an engineering contractor operating the 2C SW pump lower bearing supply isolation valve,2SWO624, without

'

authorization. During the process of checking the position of the other SW valves in the crib house, the licensee identified that the 28 SW pump lower bearing supply isolation

,

valve,2SWO622, was also out-of-position. The licensee's immediate corrective actions also included disciplinary action against the contractor, re-enforcing the configuration management policy within system engineering, initiating problem identification form

_

(PIF) Z1997-01431, and resetting the station event clock.

Zion Administrative Procedure (ZAP) 300-01, " Conduct of Operations," Revision 4,Section X.A, states that the operations department is responsible for and has operational authority over all plant systems and equipment, except as stated in Station Policy 211,

i

. - - -. - - - -. - - -. - - - -. - -

- - -. - -. - _ - - - -

"

..

.- Configuration Control." Station Policy 211, " Configuration Control," dated April 7,1997,

"

states that plant equipment may be operated by personnel outside of their operational

'!

,

,

'

- authority if the equipment has been verified to be wuhin a placed out-of service boundary,

-

specifically held for that work group, or the menigation is controlled by an applicable

_

>

.

procedure or work instruction that requires and provides a record of specified information

-

including the licensed shift supervisor's determination of the final position. The

'

engineering contractor's operation of 2SWO624, without complying with the requirements

,

'

of Station Policy 211, is a violation of Technical Specification (TS) 6.2.1.a

- (50 304/97019-02), as described in the attached Notice of Violation.

,,

!

Following tha inspector's identification of valve 28W1814 being out-of-position, the

'

licensee identified on Au ylst 11,1997, eight additional valves on the EDGs that were either not in the proper p(osition or the position required by the 801 was not corr

i-current plant wi,ditions. In response to these additional configuration control discrepancies, the licensee initiated additional valve line-up verifications for fifteen i

j systems. The licensee selected these systems based on shutdown probabilistic risk

"

assessment worth, and included portions of the residual heat removal (RHR), SW, and component cooling water (CC) systems. The licensee completed the fifteen system valve line-up verificetions and identified approximately 40 examples of valves not be;ng in the proper positions. At the end of this inspection period, the licensee was in the process of evaluating the safety significance of each discrepancy. In addition, at the end of this inspection period, the licensee's formal root cause investigation for the adverse trend in configuration control, identified in NRC Inspection Report 50 295/97-16; 50 304/97-16, was also in progress. Pending NRC review of the licensee's root cause investigation for

- the configurellon control deficiencies, Unresolved item 50 295/97016-02; 50-304/97016-02 remains open, c.

Conclusions The inspectors concluded that following NRC identification of the adverse trend in configuration control and after NRC identification of an EDG SW valve being out-of-position, the licensee initiated a significant effott to confirm plant configuration through the performance of a large number of valve line-up verifications. These line-up verifications were effective in identifying numerous valve line-up discrepancies and reestablishing configuration control of components in systems important to shutdown safety. The inspectors considered the non-licensed operators identification and reporting of the improper valve manlaulation by the engineering contractor, as an example of good operator awareness. However, the contractor's manipulation of 2SWO624 without authorization, after the issuance of a site memorandur a configuration control expectations, demonstrated that the licensee's immedu..a corrective actions were not completely effective.

01.3 Adverse Trend in Operators Adherence to Procedures a.

insoection Scope f71707)

The inspectors identified several examples of operators failure to follow procedures. The inspectors interviewed operations department personnel and reviewed applicable -

procedures and documentation.

-

,. _

..

- - _ -.

. -

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

.

-..

,

<

bc Qh.Jervations and Findinas-During this inspection period, the inspectors identified several examples of operators

_ failure to follow procedures. Spec'llcally:.

n Operators Failure to Follow PrMn Durina Safety IrMM (SI) Pumo Testina As previously documented in NRC inspection Repor150 295/9716; 50-304/97-16 on June 9,1997, during the licensee's performance of periodic test (PT) 2A-RT, the 2A SI

.

pump failed the surveillance due to the pump head being higher than the set value range.

.

'

~ Based on the measured pump dischsye pressure, the licensee determined the

'

calculated pump head to be 3,392.7 feet. The pump head set value prescribed by the

_

i-procedure was 3,249 to 3,381 fer The licensee initiated PlF Z1997 00131 to document this discrepancy and track correctro actions. The cause for the pump head being above

l the set value range was under inv6W tation during this inspection period.

On August 7,1997, during me inspecicrs review of procedure PT-2A-RT, Revision 0,

.

which was utilized to perform the test rt June 9,1997, thz inspectors identified that the

,

operators performing the test did not (cfm the procedural guidance. Specifically, after-f the operators identified in Step 22 of Sec'im 5.1 that the calculated pump head exceeded

the pump head set value by 11.2 feet, they failed to perform the actions required by the j

next step (Step 23) to stop the pump. Based on interviews with the operators involved in the test, the inspectors determined that the operators did not comply with Step 23

l because approximately 20 minutes after they discovered that the pump head was out of the acceptable range, the pump head unexpectedly drifted back into the set value range.

The licensed operators discussed the changing parameters with shift management and

the decision was made to re-perform Step 22 of the procedure to verify the data and

.

i

continue the test. Subsequently, the operators determined that the newly calculated

!

pump head was considered acceptable and the test was completed. However, I_

operations personnel concluded that since the acceptance criteria was not met, the test

!

-was marked as failed.

The inspectors concluded that the operators failed to follow PT-2A-RT when they did not stop the 2A SI pump when the pump head was outside the set value range. Of particular concem was the failure of the licensee staff to identify this issue during post test reviews.

The failure of the operators to follow PT-2A RT is a violation of TS 6.2.1.a (50-304/97019-03a), as described in the attached Notice of Violation.

Operatino Special Procedure (OSP) Not Revised Acoropriatgjy On July 19,1997, during the performance of OSP 97-023, " Flushing the Component

'

Cooling Water Surge Tanks / System for Reduction in Copper Concentration," Revision 0, the Unit 2 CC surge tank drained very slowly due to the lack of a proper vent path. in an effort to expedite the tank draining, a non-licensed operator manually operated the tank vacuum breaker to provide a vent path. During performance of the evolution on the next operating shift, the licensee disconnected the surge tank chemical addition flange to provide a vent path for the surge tank. However, OSP 97 023 did not allow either of these actions. On July 20,1997, the licensee subsequently initiated a procedure change to allow the use of the chemical addition flange to vent the surge tank during draining,

.

-n--r

=---

w,

--e,-

- - - -

-

~

m---m

,----v---

r

<\\

v

-

e-w

_ _ _. -

. _ _ _. _.. _ _ _ _. _ _ _ _ _ _ _ _ _ _. _ _ _. _ _ _. _

_

_.

.

.

i

."

b ZAP 100-07, "Use of Proced're," Revision 4, Section 2, requires, in part, that if the procedure cannot be performed as written, stop the evolution, place the system in a

,

l

stable and safe condition, and, if the needed procedure change is not editorialirevise the

procedure prior to continuing with the evolution. The failure of the operators to stop the

'

evolution, place the system in a safe and stable condition, and revise OSP 97-023 as

' required by ZAP 100-07, prior to continuing with the evolution when the surge tank * ss

'

not draining property is a violation of TS 6.2,1.a (50-295/97019-04a; 50 304/97019-04a),

,

as described in the attached Notice of Violation.

,

'

On July 19 and 22,1997, the licensee initiated two PlFs, Z1997-00785 and Z1997-00823, which documented equipment problems experienced during the performance of i

. OSP 97-023.1 However, neither of these PlFs identified the above procedural adherence discrepancy, Consequently, the event screening committee closed these PlFs as

,

!

conditions not adverse to quality.' On August 19,1997, in response to the inspectors questions, the licensee initiated PlF Z1997-01306 to address the procedural adherence

,

aspects of this issue.

,

_

l Failure to Maintain the Volume Control Tank (VCT) Pressure in Atwdance with an OSP l-On August 6,1997, the inspectors identified that the Unit 2 VCT pressure was j

approximately 10.8 psig. However, since the reactor coolant system pressure was i-approximately 45 psig, PT 0, Appendix E-3, " Operating Surveillance Checklist,"

Revision 9,= Section 14, specified that OSP 97-014, " Mitigating Actions to Prevent a

'

Nitrogen Bubble Forming in the Reactor Head," be performed, which required in -

Section 5.6.b that VCT pressure be maintained less than 2 psig. The inspectors raised

)

this issue to the attention of operations department management. As a result, the

!

licensee revised OSP 97-014 on August 7,1997, to specify that VCT pressure be i

maintained less than 10 psig,

'

i i

The failure of the control room operators to maintain VCT pressure less than 2 psig as j.

required by OSP 97-014 is a violation of 10 CFR Part 50, Appendix B, Cnteria V

(50 304/97019-01b), as described in the attached Notice of Violation.

I Imoroner Use of Not Acolicable (N/A) Durina the Performance of an OSP

!

On August 13,1997, the inspectors identified that OSP 97-014, " Mitigating Actions to -

l Prevent a Nitrogen Bubble Forming in the Reactor Head," Revision 2, Step 6, which l

provided guidance for maintaining letdown flow and VCT temperature end pressure, was l

marked as N/A without any justification or approval.- The inspectors interviewed the

control room operators argi determined that the Nuclear Station Operators believed that

_

the step was not required h be performed since there was no indication that a gas bubble had been forming in th' sector vessel head as demonstrated during the most recent

periodic vent of the tector vessel head. - In addition, the Unit Supervisor was unaware that the step had been marked as N/A.. ZAP 100-07, "Use of Procedures," Revision 4,

-

Section 6, requires, iri part, that steps without conditional statements marked as N/A shall j

be approved by a management supervisor, the reason that the step was marked N/A be L

annotated, and the annotation be signed and dated. The inspectors were concemed that

'

the control room operators had failed to obtain proper authorization prior to not performing a required step in a safety related procedure. In response to the inspectors

questions, the licensee initiated PlF Z1997-01208 to document this issue.

i p-

'

i l

.

.

.. -...

m

....

v

,.,..

._,

,,__..__._._r-

,. -

m-

.,.

,,

,

_._ _

_.. _ _ _ _ _ _ _ _ _ _.. _ _..

_

_

_. _. _ _ _ _ _ _ _ _

__

_

_.

!

..

.

'

The failure of operators to implement the requirements of ZAP 100-07 for the use of N/A

.

'

'

on steps without conditional statements is s violation of TS 6.2.1.s (50-304/97019-04b),

as described in the attached Notice of Violation.

.

Imoroner Use of N/A Durino the Performance of Surve!!!ance Testina

.

On August 29,1997, during review of the completed Technical Specification Surveillance (TSS) 3.8.1.10-1, " Loss of Offsite Power Testing of Diesel Generato s During Refueling for Unit 1," for both the 1A and 0 EDGs, the inspectors identified severa: examples of the

i improper use of N/A. Step 12 of Section 8.2.A was not a conditional staten:Snt and i

'

required the operators to secure or verify secure contairsment ventilation and purge, On both July 24 and 29,1997, operations personnel annotated Step 12 as N/A but did not i

document authortzation orjustification for the N/A The failure of operators to implement the requirements of ZAP 100-07 for the use of N/A on steps without conditional statements is a violation of TS 6.2.1.a (50-295/97019-04c), as described in the attached Notice of Violation.

,

Also, Section 8.2.C contained the conditional statement, "lE another section of this test will be performed next, THEN steps 25 and 26 may be N/A'd." Step 26 required

j operators to place the " Fire Alarm" control switch in the * Normal" position. On July 29 j

1997, operators incorrectly anr.otated Step 26 as N/A. - Since no further testing was planned, the operators should have performed the step. The failure to perform TSS

3.8.1.10-1, Section 8.2.C, Step 26 by marking the step as N/A without meeting the I

conditional statement is a violation of TS 6.2.1.a (50-295/97019-03b), as described in the

!

attached Notice of Violation.

The inspectors determined that these examples of the licensee's improper use of N/A

.

were of minor safety consequences. However, the inspectors were concemed that

!

continued failure to thoroughly evaluate the impact of not performing steps in safety related procedures could potentially have adverse consequences, if not corrected,

,

j in addition, during review of the completed TSS 3.8.1.10-1, the inspectors noted that the test summary for Section 7.2, documented a test failure on July 25,1997, due to the

'

performance of Step 7.2.B.4.b out-of-sequence. However, at the end of the inspection

.

period, the licensee had been unable to provide any further details into the circumstances

surrounding this test failure. This issue is an Unresolved item (50-295/97019-05; I

' 50-304/97019-05) pending inspectors' review of the results of the licensee's investigation l

Into this test failure.

c.

Conclusions

~

.

The inspectors concluded that even though procedural compliance had been heavily

'

'

emphasized during the recently completed Phoenix training program, operator

!

compliance with procedures remains problematic. The inspectors were concemed that the licensee did not recognize these procedure adherence examples.

J

_

_

.

!

7

. _. _,

.

_

,,,.....,. _...

_

.

....

-.

-

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

-

- - -

-

___

-

,

.

,

,

'

'01.4 Missed Technical Soecification Surve!!!ences

.

,

a.

Inspection Scope (6Q2f}

- The inspectors reviewed the circumstances surrounding the missed TS Surveillance

<

'

Requirements associated with the 1A and 0 EDGs. The inspectors interviewed operations and engineering personnel and raviewed applicable procedures and documentation.

,

,

i b.

Observations and Findinas At 11:59 p.m. on July 24,1997, the licensee concluded that the 1A EDG was inoperable due to the failure to met TS Surveillance Requirement 4.15.1.B.3.s within 125 percent of the surveillance interval. The licensee was required to perform TSS 3.8.1.10-1, " Loss of

'

Offsite Power Testing of Diesel Generators During Refueling for Unit 1" to satisfy TS 4.15.1.B.3.a. The licensee had attempted to perform TSS 3.8.1.101 earlier in the day; however, the evolution resulted in an inadvertent Engineered Safety Feature (ESF)

actuation due to the manipulation of a test switch out-of sequence (See Section E1.1).

.

On July 25,1997, the licensee again attempted to perform TSS 3.8.1.10-1; however, the

'

safe shutdown loads failed to start due to the failure of relay M42718. At 11:59 p.m. on July 25,1997, the licensee also concluded that the O EDG was inoperable for failure to perform the same test within 125 percent of the surveillance interval.

,

Since the 1B EDG was out-of-service for maintenance, all three EDGs associated with Unit 1 were considered inoperable. The lack of an operable Unit 1 EDG resulted in all of the Unit 1 SW pumps also being inoperable. With no operable Unit 1 SW pumps, the SW

'

system was inoperable since the system was unable to meet the single passive failure

criteria. Consequently, the common unit CC system was also declared inoperable since SW was a necessary support system. Therefore, the Unit 2 RHR system was also

,

inoperable since the CC system was a necessary support system. As a result, the

'

licensee entered TS Action Statement 3.3.1.A.S.a for having one cperable RHR loop (one reactor coolant system loop capable of natural circulation), which required immediate corrective action to retum the inopercble RHR loop to an operable status as soon as possible. In addition, the licensee notified the NRC of this condition in accordance with 10 CFR Part 50.72. On July 28,1997, TSS 3.8.1.10-1 was successfully completed for

,

the O EDG; and as a result, the SW, CC, and RHR systems were declared operable.

'

The inspectors subsequently reviewed the regulatory basis for performing TS Surveillance Requirement 4.15.1.B.3.a. Technical Spe-ification 3.15 required the EDGs

,

to be operable prior to reacte critically. In Zion Station Technical Specification

'

, Interpretation 91-03, "Auxilia. Electrical Power System Technical Specification Applicability," Revision 1, tlw licensee clarified the mode applicability for TS 3.15 as being Modes 1 through 4 aml 7. Since Unit 1 was defueled (no defined mode of operation) and Unit 2 was in cold shutdown (Mode 5), the surveillance requirement was not applicable.

Consequently, the surveillance was not required to have been performed within 125

.

percent of the survei!!ance interval; and as a result, the EDGs were not required to have i

been declare Maperable solely based on this missed surveillance requirement.

a

,

,

i

,. - - - - -.,, - -

-

---.e

.

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

._.. _ _ _ _ _

_

. - _ _. _ _. _ _ _ _ _.... _

l

.-

,

c.

Conclusions

-

.-

,-

. The inspedors concluded that TS Surveillance Requirement 4.15.1.B.3.a was not

.

required to have boort completed in the current plant conditions. However, the licensee's

.

failure to perform the testing for the 1A and 0 EDGs as scheduled was due to work

-

.

scheduling problems, delays caused by poor test control, and a lack of management

'

i priority on C;.g Unit 1 surveillance tests.

O2 Operational Status of Facilities and Equipment

.

02.1 Eautoment Material Condition and Houedamo!na Deficiencies a.

Insoodion Scone (7170M

.

The inspectors identified several equipment material condition and housekeeping deficiencies in the auxiliary building and noted an adverse trend in the occurrence of equipment failures. The inspectors discussed the deficiencies with operations and -

maintenance personnel and reviewed applicable documentation, b.

Observations and Findinas

-.

During this inspection period, the inspectors identified the following equipment material condition deficiencies:

numerous cable tray loading issues

numerous cable tray covers improperly fastened e

trapeze pipe support missing threaded rod

missing 'U' bolt supports on the lower bearing supply line on each Unit 2 SW

'

pump disconnected conduit support -

leaking control room ventilation ducting

missing fasteners on a fire protection panel cover

The safety consequences of the above deficiencies were minimal; however, these problems were indicative of a lack of licensee staff attention to identify and correct deficient conditions. In addition to the material condition problems, the inspectors identified numerous housekeeping deficiencies in the auxiliary building, EDG rooms, and the crib house includhg:

improper ladder and equipment (e.g., carts, filters, and mops) stowage in the

-*

control room ventilation equipment room rags and a bag of clothes adrift in the _ control room ventilation equipment room

a bucket collecting leaking oil from the 1 A EDG

threaded plugs adrift on a RHR instrument rack -

.-

wood boards lying adrift on ventilation ducting

• -

. miscellaneous equipment (e.g., threaded plugs, fasteners, and insulation

• -

strapping) adrift in the Unit 2 containment spray room a gum wrapper in the Unit 2 containment spray room

large puddles of water in the crib house due to the motor fire pump seal leakage

.

..

.

. _. -

-..

.~.

--

_... ___

-

_._._ _ _ _... _. _ _

_. _ _

_ _ _ _ _ __. _

_.

_.

>

c Y

A in a6d6 tion to the above deficiencies, numerous equipment problems occurred which

further demonstrated that the material condition of the plant was declining. For example:

.

On July 25, the loss of offsite power testing on the 1A EDG failed due to the -

.

failure of relay M42718_.

'

On August 2, two of three service bus undervoltage logic tests failed due to the

.

failure of the bus 143 undervoltage relay

<

,

i On August 3, the 0 EDG 'B' starting air compressor (SAC) failed to start due to

.

>

pressure switch problems On August 4, the licensee identified degraded ventilation flow in the 111 mad 112

.

.

battery rooms

- On August 6, the O EDG 'B' SAC failed to start due to pressure switch circuit -

.

i Proolems

'

On August 13, the O EDG failed to start due to speed sensor selector module

.

Problems On August 15, the 0 EDG 'B' SAC failed to trip due to pressure switch problems

.

+

t On August 18, the DB fire pump failed its surveillence test due to a sparking

.

solenoid

On August 21, the 1B EDG 'A' SAC failed to meet test acceptance criteria due to

a solenoid valve problem

,

,

'

In addition, to the above equipment problems, the following additional equipment problems occurred during this.'nspection period:

,

J

.

2C auxiliary feedwater pump lube oil cooler leak

.

2B Si pump room coolerleak

.

2A containment spray room cooler leak

.

1 A and 2A SW pump pre-lube supply line zebra mussel fouling

__

.

The licensee initiated actions to address these problems through the issuance of action requests. Of particular concem was the occurrence of zebra mussel fouling of the 1A and 2A SW pumps. This issue is an Unresolved item (50-295/97019-06; 50-304/97019-06) pending inspectors' review of the licensee's evaluation into the causes -

of the infestation of zebra mussels in the SW system, and the evaluation of the impact of the zebra mussels on SW system performance.

c.

Cortclusions -

The inspectors concluded that the housekeeping and material condition of plant equipment declined as reflected in the numerous equipment failures and inspector-

_

~

identified deficiencies. The safety consequences of the deficiencies were minimal due to the current plant operational status (cold shutdown). However, the inspectors were concemed that the continued occurrence of plant equipment failures unnecessarily challenged the operations staff.

.

-

. - -

.-.

- _ _ -,.

--.

-.

.

.-

-._

-

.

.

.. -..

.

-_ _

.

ll, Maintenance

,

M1 Conduct of Maintenance M1.1 Inconsistent lmolementation of Forelon Material Exclusion (FME) Controls a.

Inspectior Scope (62707)

During this inspection period, the inspectors observed the implementation of FME work

.

practices for selected work activities, interviewed maintenance and construction personnel, and reviewed applicable procedures and documentation.

b.

Observations and Findinas From July 16 through August 29,1997, the inspectors observed selected portions of the five year overhaul on the 1B EDG, The inspectors identified that the FME controls associated with this maintenance activity were effective in preventing foreign material

from entering the EDG or its support systems.

In contrast, on August 28,1997, the inspectors identified that FME covers were not

.

Installed on the upstream side of the lower and upper bearing supply line flanges for the 1 A SW pump while the area was unattended. These flanges were disconnected on

-

August 23 and 24,1997, to support the performance of inspection and cleaning of the SW pre-lube piping in accordance with Work Package No. 970085580-01 The ZAP 400-018, " Foreign Material Exclusion (FME) Program," Revision 4, Section G.2.a(5),

required that all system and equipment openings be protected with a suitable FME device during work and while the FME zone is unattended. The failure to install a suitable FME device during the 1 A SW pump maintenance is a violation of 10 CFR Part 50, Appendix B, Criterion V (50-295/97019-01c), as described in the attached Notice of Violation, in response to the inspectors questions, the licensee installed FME covers on the flange openings on August 29,1997,

in addition, during this inspection period, the licensee initiated five PlFs (Z1997-01074, 01111, 01183, 01339, and 01453) involving: (1) debris found in the forebay; (2) debris in the spent fuel pool and transfer canal; (3) debris found during maintenance on an auxiliary steam flow control valve; and (4) two procedures goveming the FME program.

,

'

On September 3,1997, Site Quality Verification personnel initiated a level I corrective action record, CAR 22 97-050, for the continued ineffective implementation of the FME program as demonstrated by the continuation of events,

>

c.

Conclusions The inspectors concluded that the licensee's implementation of FME controls was inconsistent.

i

,

,

.-

..

]-

M1.2 Review of Bern & Patterson in.orvice inspection and 55tenance a.

intoection Scone (73755)--

The inspedors conduded a review of documentation associated with in service inspection and maintenance of Borg & Patterson snubbers. The inspedors reviewed Berg & Patterson snubber work request packages, Wyle Laboratories reports of inspection, dist.ssembly, rebuild, test data, and applicable procedures. The following Berg & Patterson snubbers were reviewed for compliance to procedure and Code requirements.

Snubber Number Work Reauest Number 1A-S01 950022395-01 1B-S07 950022382-01-1B 805 950022404-01 1A SO4 950022402-01 1B-S08 950022385 01 1A S02 950022398-01 1A-S06 9500223C1-01 2D-S32 960001674-01

.

28-S24 960001679-01 b.

Observations and Findinos The inspectors reviewed the Zion Nuclear Station Steam Generator Snubber Test Procedure, No. TSS 15.6.86, Revision 3, Wyle Laboratories Snubber Test Procedure, No. 43569, dated October 4,1993, and the referenced snubber test data packages and inspection reports. The Wyle Laboratories visual inspector certification and test instrument calibration records were also reviewed. Inspection and process records were reviewed for completion of required data and appropriate signatures as required by procedure and Code requirements, - No concems were noted.

c.

Conclusions The inspectors concluded that the licensee had completed the required inspections, maintenance and satisfactorily tested the referenced steam generator snubbers in accordance with applicable procedures and Code requirements.

M7 Quality Assurance in Maintenance Activities

~

M7.1 Inadeouate Quality Control (QC) Inspection Durina 1B EDG Startina Air Check Valve Maintenance a.

Inspection Scope (62707)

~

The inspectors reviewed the circumstances related to the improper restoration of the 1B EDG train 'A' star %g air check valve,1DG0121, following maintenance activities. The inspectors interviewed maintenare and site quality verification personnel and reviewed the applicable maintenance and QC instructions;

_ _ - - - _ _ - _ _ _ _ -

. - - -

. - -. - - -

- _ _. -. _. - - - - - - - - _. - -

_ - -

. -

.

..

.

l

b.

. Observations and Findinos -

On July 26,1997, mechanical maintenance personnel removed valve 1DG0121 for inspection in accordance with Work Request No. 960026810-01, " Disassemble and inspect for Loose Disc O Ring per CV [ Check Valve] Program," and Maintenance

- Procedure M03017. " Anderson Graenwood Check Valves, inspection and Overhaul."

'

The valve was inspectad with satisfactory results and was installed back into the system

,

in accordance with M03017, Section 8.5, " Valve installation." The installation of the

check valve included placing the valve between two flanges, installing two gaskets, and installing and torquing the flange stud nuts. The installation of the valve was witnessed l

by a QC inspector.

.

On August 16,1997, the licensee discovered an air leak emanating from the check valve.

,

l The licensee subsequently determined that the air leak was caused by a manufacturers

.

material specification tag that had been inadvertently torquod into place between the l-check valve gasket and the inlet flange. The licensee repaired the air leak by taking the train 'A' starting air system from service and removing the tag from between the check

,

j.

valve and the pipe flange. The starting air system was subsequently retumed to service

--

satisfactorily.

The inspectors determined that during the check valve installation activities on July 26, 1997, the mechanical maintenance personnel failed to notice that the manufacturars material specification tag, which was attached by wire to the top of the check valve, had fallen in between the check valve and the pipe flange.' The QC inspector witnessing the

.

Installation also failed to identify the discrepancy. The failure of the QC inspection to -

!

verify conformance with the documented instructions for the instalistlon of

'

valve 1DG0121 is a violation of 10 CFR Part 50, Appendix D, Criterion X (50-295/97019-07), as described in the attached Notice of Violation.-

,

i c.

Conclusions

The inspectors concluded that the air leak from the 1B EDG train 'A' starting air system -

L was caused by a lack of attention to detail by the mechanical maintenance personnel who installed valve 1DG0121 'on July 26,1997, in addition, the QC inspector did not identity

that the manufacturers matarial specification tag was lodged between the check valve

,-

'

and the pipe flange.' The combination of these two performance deficiencies contributed -

to the 1B EDG retum to service being delayed.

• MS Miscellaneous Maintenance issues

.

L M8.1 (Closed) Licensee Event Report (50-295/97003)zz: Non-compliance with EDG TS due to

!l Programmatic Deficiencies.

p

.

'

'

On January 17,1997, the licensee identified that the EDG hot restart testing, which had

!

been completed during previous refueling outages on both units, had not been performed

as specified in TS Survdllance Requirement 4.15.1.B.3.f. TS Surveillance

Requirement 4.15.1.B.3.f stated that within five minutes of shutting down the EDG after i

being operated for a minimum of 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> loaded to greater than or > qual to 3,600 KW i

. and less than or aqual to 4,000 KW, each EDG shall be started and verified to achieve

?

. minimum required voltage and frequency. However, PT 11-R1, " Diesel Generator

'

't i

>

l

--

- -

-.

.-

.

.-

.

.

--

.

_

_

_

.-

__

_ _ _ _.

.

.

t Loading, Load Rejection, and Hot Restart Test," which implemented this surve:llance

requirement, specified that the EDG operate with a load of not less than 4,000 KW, Consequently, the licensee invoked TS 4.0.3 to allow 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> for completion of the missed surveillance requirement on Unit 1 which was operating at full power (Unit 2 was in cold shutdown)._ The licensee subsequently revised the procedures and completed the missed surveillances for the 1 A,1B, and 0 EDGs on January 18,1997, in addition, the surveillance requirement was completed for the 28 EDG on January 22,1997, and for the 2A EDG on February 20,1997.

The failure to maintain EDG load between 3,600 and 4,000 KW while performing EDG hot restart testing during previous refueling outa9es on both units is a violation of TS Surveillance Requirement 4.15.1.B.3.f (50-295/97019-08; 50-304/97019-08). This event had minimal safety significance. This non-repetitive, licensee identified and corrected violation is being treated as a Non-Cited Violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy.

Ill. Enoineerina E1 Conduct of Engineering

,

E1.1 Inadvertent Enaineered Safety Feature (ESF) Actuation a.

inspection Scope (61726 and 37551)

,

The inspectors reviewed the circumstances surrounding the inadvertent ESF actuation during tne loss of offsite power testing of the 1 A EDG. The inspectors interviewed operations and engineering personnel and reviewed applicable procedures and documentation,

,

b.

Observations and Findinas

- On July 24,1997, during the performance of TSS 3.8.1,10-1, " Loss of Offsite Power Testing of Diesel Generators During Refueling for Unit 1," Revision 3, Section 8.2, " Loss of Offsite Power Start of D/G [ emergency diesel generator) 1A," an engineer manipulated a test switch out of sequence which resulted in an inadvertent ESF actuation. While the test communicator was briefing the Unit 1 Nuclear Station Operator on the sequence of component manipulations and the expected response, the engineer, who was located remotely to operate the test switch, overheard the conversation and failed to recognize that it was a briefing and not the actual test. Consequently, the engineer placed the test switch SS1 in " Test"(Step 8.2.B.2.b) prior to the main feed to bus 148 being deenergized (Step 8.2.8.2.a). The premature manipulation of the test switch resulted in all five reactor containment fan coolers auto-starting and the SW isolation valves to the turbine building closing. However, since bus 148 was never deenergized, the loads on bus 148 were not shed, the 1 A EDG did not start, and the safe shutdown loads did not sequence onto the bus. The licensee notified the NRC of this event in accordance with 10 CFR Part 50.72.

The failure to follow a surveillance test procedure for the 1A EDG is a violation of TS 6.2.1.a (50-295/97019-03c), as described in the attached Notice of Violation. The licensee'c immediate corrective actions included suspension of the test, restoration of

.

l l

-

.

.

..

.

.

.

- - -

.

.

-.

.

-

.-

o

.

plant equipment, and initiation of PlF Z1997-00879. On July 29,1997, the test was

-

'

successfully completed on the 1A EDG. At th( end of the inspection period the licensee's root cause investigation was stillin progress, c.

Conclusions

The inspectors concluded that the inadvertent ESF actuation occurred due to poor communication during the test evolution.

,

V. Manaaement Meetinas X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on September 5,1997. 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.

-

.

.

e

4

. _ _ - - _ _ _ _ _ _ _ -

.

.

e Partial List of Persons Contacted

.

Ucensee J. Brons, Site Vice President R. Starkey, Plant General Manager K Dickerson, Executive Assistant to she Vice President

-

T. Sakselski, Executive Assistant to Site Vice President

,

!

D. Bump, Restari Manager R. Zyduck, Site Quality Verifx stion Manager E. Katzrnan, Radiation Protection Manager

T. O'Connor, Operations Manager L. Schmeling. Training Manager R. Thorson, Electrical Maintenance Superintendent

.

C. Winters, Shift Oper6 ting Supervisu J. Brandes, Assistant Shift Operating Supervisor D. Beutel, Regulatory Assurance F. Jones, Regulatory Assurance IEG

.

l A. Vogel, Senior Resident inspector E. Cobey, Restdent inspector lDMS i

J. Yesinowski

_

r

\\\\

._

_.

.-

.

-.-

.

--- - _.

I o

.

c List of Inspection Procedures Used IP 37551 Engineering IP 61726 Surveillance Observations IP 62707 Maintenance Observations IP 71707 Plant Operations IP 73755 Inservice inspection Data Review and Evaluation List of items Opened. Closed. and Discussed

,

2P.1014 50-004/97019-01a VIO Failure of SW valve to be in the 80111 required position 50-304/97019-01b VIO Failure to maintain VCT pressure in accordance with OSP 97-014 50 295/97019-01c VIO Failure to implement FME controls in accordance with ZAP 400-01B during 1 A SW pump maintenance 50-304/97019-02 VIO Failure to control the configuration of plant equipment 50 304/97019-03a VIO Fallure to follow test procedure during the 2A Si pump testing 50 295/97019-03b VIO Failure to follow test procedure during the 1 A EDG testing 50 295/97019 03c VIO Failure to follow test procedure during the 1 A EDG testing 50 295/304 97019-04a VIO Failure to follow administrative procedure for procedural adherence during performance of OSP 97 023 50 304/97019 04b VIO Failure to follow administrative procedure for the use of N/A during performance of OSP 97 014 50-295/97019-04c VIO Failure to follow administrative procedure for the use of N/A during performance of 1 A EDG testing 50-295/304 97019-05 URI Review flhe results of the licensee's investigation into the O EDG test failure 50-295/304 97019-06 URI Review the licensee's investigation and corrective actionc for the zebra mussel fouling of the SW system 50 295/97019-07 VIO Failure cf a QC inspection to verify conformance with work instructions for erae.gency diesel generator starting air check valve maintenance 50 295/304 97019-08 NCV Failure to perform TS 4.15.1.B.3.f at the required loading for each ;EDG

,

o

.

Closed

,

50 295/97003 LER Non-compliance with EDG TS due to programmatic deficiencies 50 295/304-97019-08 NCV Failure to perform TS 4.15.1.B.3.f at the required loading for each EDG Discusseq

,

50 295/304 97016 02 URI Review of licensee's root cause investigation for

.

configuration control deficiencies l

'

l

l

.

I

r

_-

o

• .

,

List of Aeronwms CC Component Cooling Water EDG Emergency Diesel Generator ESF Engineered Safety Feature

FME Foreign Material Exclusion

)

IP Inspection Procedure LER Licensee Event Report N/A Not Applicable l

NCV Non Cited Violation l

NRC Nuclear Regulatory Commission ORDP Opwatlanal Readiness Demonstration Progrcm OSP Operating Special Procedure POR Public Document Room PIF Prob;4m identification Form PT Periodic Test-QC Quality Control RHR Residual Heat Removal EAC Starting Air Compressor Si Safety injection

-

.

sol System Operating instruction SW Service Water TS Technical Specification TSS Technical Specification Surveillance URI Unresolved item VCT Vclume Control Tank VIO Violation ZAP Zion Administrative Procedure

.

l 21