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s
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                                                                                  ENCLOSURE 2                                                                  I
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                                                          U.S. NUCLEAR REGULATORY COMMISSION                                                                   i
4
lj -                                                                                  REGION IV
,
1
s
                                                                                                                                                                !
.
!.
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                                                                                                                                                                '
ENCLOSURE 2
l                        Docket No.:                   50-483
I
;.                                                                                                                                                             i
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j                       License No.:                 NPF-30                                                                                                   i
lj -
U.S. NUCLEAR REGULATORY COMMISSION
i
REGION IV
!
1
!.
l
Docket No.:
50-483
'
;.
i
j
License No.:
NPF-30
i
'
i
:
Report No.:
50-483/96-14
'
'
                                                                                                                                                                i
:                        Report No.:                  50-483/96-14                                                                                            '
                        Licensee:                    Union Electric Company
]
]
l                       Facility:                     Callaway Plant                                                                                           t
Licensee:
                                                                                                                                                                '
Union Electric Company
:                       Location:                     Junction Highway CC and Highway O
t
                                                      Fulton, Missouri
l
Facility:
Callaway Plant
'
:
Location:
Junction Highway CC and Highway O
q
q
                                                                                                                                                                i
Fulton, Missouri
l*                      Dates:                       November 24,1996, through January 4,1997
i
i                       inspectors:                   D. G. Passehl, Senior Resident inspector                                                                 i
l
j                                                     F. L. Brush, Resident inspector
Dates:
November 24,1996, through January 4,1997
*
i
i
inspectors:
D. G. Passehl, Senior Resident inspector
j
F. L. Brush, Resident inspector
;4
;4
                                                      H. F. Bundy, Reactor Engineer
H. F. Bundy, Reactor Engineer
                                                                                                                                                                l
G. M. Good, Senior Emergency Preparedness Analyst
                                                      G. M. Good, Senior Emergency Preparedness Analyst
i
i                       Approved By:                 W. D. Johnson, Chief, Project Branch B
Approved By:
1
W. D. Johnson, Chief, Project Branch B
:.
1
                                                                                                                                                                *
: .
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*
i
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                                                                                                                                                                  I
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                        ATTACHMENT: Supplemental Information                                                                                                   :
ATTACHMENT: Supplemental Information
:
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l
                      9701220099 970116
9701220099 970116
                      PDR       ADOCK 05000483
PDR
                      G                               PDR
ADOCK 05000483
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PDR
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                  -. --         . . .     ,.             . , , .                                               -                             - --           "
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                                        EXECUTIVE SUMMARY
.
                                          Callaway Plant
EXECUTIVE SUMMARY
                                NRC Inspection Report 50-483/96-14
Callaway Plant
  Operations
NRC Inspection Report 50-483/96-14
  *      The license's decision to shutdown the plant to repair a feedwater isolation valve
Operations
          actuator was appropriate (Section 01,1).
The license's decision to shutdown the plant to repair a feedwater isolation valve
  *      The control room staff response to a turbine trip during reactor startup was good
*
          (Section 01.2). There were no problems during the subsequent startup
actuator was appropriate (Section 01,1).
          (Section 01.3).
The control room staff response to a turbine trip during reactor startup was good
  *      An equipment operator was thorough during rounds. The plant material condition
*
          was good (Section O2.1).
(Section 01.2). There were no problems during the subsequent startup
  *      An equipment operator inadvertently pulled the wrong fuses on a bus in the main
(Section 01.3).
          circulating water and service water pump house. This resulted in a partialloss of
An equipment operator was thorough during rounds. The plant material condition
          circulating water flow to the main condenser and required the operators to reduce
*
          plant power. This was a violation caused by a personnel error (Section 04.1).
was good (Section O2.1).
  Maintenance
An equipment operator inadvertently pulled the wrong fuses on a bus in the main
  *      The licensee's actions to determine the reason for the main feed water isolation
*
          valve hydraulic actuator leaks were thorough. The licensee installed incorrect
circulating water and service water pump house. This resulted in a partialloss of
          0-rings due to inadequate material control which was a noncited violation
circulating water flow to the main condenser and required the operators to reduce
          (Section M1.3).
plant power. This was a violation caused by a personnel error (Section 04.1).
    "iant Suncort
Maintenance
  *      The commitment to perform onshif t dose assessments was clearly described in the
The licensee's actions to determine the reason for the main feed water isolation
          emergency plan and implementing procedures (Section P3.1).
*
valve hydraulic actuator leaks were thorough. The licensee installed incorrect
0-rings due to inadequate material control which was a noncited violation
(Section M1.3).
"iant Suncort
The commitment to perform onshif t dose assessments was clearly described in the
*
emergency plan and implementing procedures (Section P3.1).


    .-_ _ .     --                       .       .   _.           .     .     -                   - . _ ..
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                                                      Report Details
Report Details
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4
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            Summary of Plant Status
Summary of Plant Status
i                                                                                                               j
i
            The plant was at 100 percent power at the beginning of the report period.
j
The plant was at 100 percent power at the beginning of the report period.
.
.
On December 1,1996, due to hydraulic oilleaks on the actuator for feedwater isolation
'
'
            On December 1,1996, due to hydraulic oilleaks on the actuator for feedwater isolation
Valve D, the licensee shut down the unit. At 12:48 p.m. on December 5,1996, the plant
            Valve D, the licensee shut down the unit. At 12:48 p.m. on December 5,1996, the plant
was brought back online. However, the turbine tripped a few minutes later due to a hi-hi
            was brought back online. However, the turbine tripped a few minutes later due to a hi-hi
steam generator water level. At 8:25 p.m. on December 5,1996, the license returned the
            steam generator water level. At 8:25 p.m. on December 5,1996, the license returned the
unit online. The unit reached full power on December 6,1996.
            unit online. The unit reached full power on December 6,1996.
At 4:41 p.m. on December 18,1996, the licensee reduced plant power to 92 percent
            At 4:41 p.m. on December 18,1996, the licensee reduced plant power to 92 percent
when an equipment operator inadvertently tripped a main circulating water pump. The
            when an equipment operator inadvertently tripped a main circulating water pump. The
plant was returned to full power approximately four hours later and operated near
            plant was returned to full power approximately four hours later and operated near
100 percent power for the remainder of the report period.
4
4
            100 percent power for the remainder of the report period.
I. Operations
                                                        I. Operations
'
'
            01     Conduct of Operations
01
                                                                                                                l
Conduct of Operations
                                                                                                                l
01.1 Plant Shutdown
            01.1 Plant Shutdown                                                                                 <
<
              a.     Inspection Scone (71707)                                                                   i
a.
1                                                                                                               l
Inspection Scone (71707)
                    On December 1,1996, the inspectors observed control room operations during                 l
i
                    portions of the plant shutdown for a forced outage.                                         l
l
                                                                                                                l
1
              b.   Observations and Findinas                                                                   l
On December 1,1996, the inspectors observed control room operations during
                    The licensee shut down the unit due to hydraulic fluid leaks on the actuator for main
portions of the plant shutdown for a forced outage.
                    feedwater isolation Valve AEFV0042. The actuator repair effort is discussed in
b.
                    paragraph M1.2. The licensee's decision to shut down the unit was appropriate.
Observations and Findinas
                    The licensee would have been required to enter and exit facdwater isolation valve
The licensee shut down the unit due to hydraulic fluid leaks on the actuator for main
                    Technical Specification action statement 3.7.1.6 repeatediy in order to repair the
feedwater isolation Valve AEFV0042. The actuator repair effort is discussed in
                    valve.
paragraph M1.2. The licensee's decision to shut down the unit was appropriate.
                                                                                                                l
The licensee would have been required to enter and exit facdwater isolation valve
                    The shift supervisor held good briefings prior to starting the power reduction and
Technical Specification action statement 3.7.1.6 repeatediy in order to repair the
                    removing major equipment from service. Licensee management was present in the
valve.
                    control room and ensured personnel were aware of expectations. There was good
The shift supervisor held good briefings prior to starting the power reduction and
                    communication between the control room operators. The shift supervisor exhibited
removing major equipment from service. Licensee management was present in the
                    good command and control. Operators did self-checking prior to manipulating plant
control room and ensured personnel were aware of expectations. There was good
                    components. The inspectors did not note any problems.
communication between the control room operators. The shift supervisor exhibited
                    In addition, the inspectors verified compliance to the Technical Specifications and
good command and control. Operators did self-checking prior to manipulating plant
                    Final Safety Analysis Report requirements by reviewing logs, touring main control
components. The inspectors did not note any problems.
                    boards and reviewing status boards.
In addition, the inspectors verified compliance to the Technical Specifications and
Final Safety Analysis Report requirements by reviewing logs, touring main control
boards and reviewing status boards.


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                                                  -2-
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                                                                                                !
-2-
                                                                                                1
01.2 Plant Startuo with Turbine Trio, Feedwater System isolation and Motor-Driven
                                                                                                !
Auxiliary Feedwater System Actuation
  01.2 Plant Startuo with Turbine Trio, Feedwater System isolation and Motor-Driven
.
          Auxiliary Feedwater System Actuation
l
                                                                                                .
a.
                                                                                                l
Insoection Scoce (71707,93702)
    a.   Insoection Scoce (71707,93702)                                                       l
l
                                                                                                l
On December 5,1996, the inspectors observed portions of the plant startup
          On December 5,1996, the inspectors observed portions of the plant startup             l
following the forced outage discussed in Section 01.1.
          following the forced outage discussed in Section 01.1.                               i
During the startup, a hi-hi water levelin Steam Generator B resulted in a main
          During the startup, a hi-hi water levelin Steam Generator B resulted in a main       l
'
                                                                                                '
turbine trip, feedwater system isolation, and motor-driven auxiliary feedwater
          turbine trip, feedwater system isolation, and motor-driven auxiliary feedwater
actuation. The inspectors observed the control room operator response to the trip.
          actuation. The inspectors observed the control room operator response to the trip.   ,
,
                                                                                                l
b.
    b.   Observations and Findinos
Observations and Findinos
                                                                                                l
l
          During the startup prior to entering Mode 2, the control room supervisor held good   :l
During the startup prior to entering Mode 2, the control room supervisor held good
          briefings. There was good communication among operations personnel. Licensee
:l
          management was in the control room and discussed their expectations with onshift
briefings. There was good communication among operations personnel. Licensee
          personnel.
management was in the control room and discussed their expectations with onshift
          At approximately 18 percent power, while transferring feed flow control from the
personnel.
          feedwater flow bypass valves to the main feedwater regulating valves, the steam
At approximately 18 percent power, while transferring feed flow control from the
          generator water levels began to oscillate. A main turbine trip and engineered safety
feedwater flow bypass valves to the main feedwater regulating valves, the steam
          features actuations occurred when the level in Steam Generator B reached the hi-hi
generator water levels began to oscillate. A main turbine trip and engineered safety
          setpoint of 78 percent. The magnitude of the level oscillations in the steam
features actuations occurred when the level in Steam Generator B reached the hi-hi
          generators were exacerbated by the positive moderator temperature coefficient
setpoint of 78 percent. The magnitude of the level oscillations in the steam
          present at low power levels during this early stage in core life.
generators were exacerbated by the positive moderator temperature coefficient
          Operator response following the turbine trip and feedwater isolation was good. In
present at low power levels during this early stage in core life.
          order to rapidly establish normal steam generator level, the operators manually
Operator response following the turbine trip and feedwater isolation was good. In
          started the turbine-driven auxiliary feedwater pump and used control rods to rapidly
order to rapidly establish normal steam generator level, the operators manually
          reduce power. This prevented a reactor trip on low steam generator level due to
started the turbine-driven auxiliary feedwater pump and used control rods to rapidly
          the isolation of the main feedwater system. The shift supervisor exhibited good
reduce power. This prevented a reactor trip on low steam generator level due to
          command and control.
the isolation of the main feedwater system. The shift supervisor exhibited good
    c.   Conclusions
command and control.
          The control room staff's response to the turbine trip was good. Operator
c.
          communications were good during the startup and subsequent trip. The shif t
Conclusions
          supervisor exhibited good command and control. Licensee management ensured
The control room staff's response to the turbine trip was good. Operator
          that plant personnel followed expectations.
communications were good during the startup and subsequent trip. The shif t
  01.3 Second Plant Startuo on December 5,1996(71707)
supervisor exhibited good command and control. Licensee management ensured
          Following the trip noted in paragraph 01.2, the licensee reviewed the methods of
that plant personnel followed expectations.
          starting up and increasing power with a positive temperature coefficient. For the
01.3 Second Plant Startuo on December 5,1996(71707)
          second startup on December 5,1996, the licensee changed the method for
Following the trip noted in paragraph 01.2, the licensee reviewed the methods of
starting up and increasing power with a positive temperature coefficient. For the
second startup on December 5,1996, the licensee changed the method for


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l
  .
.
l
l
i
i
                                                    -3-
-3-
                                                                                                      ,
,
I
I
'
'
                                                                                                      I
I
                                                                                                      l
transferring from the main feedwater bypass valves to the main feedwater
            transferring from the main feedwater bypass valves to the main feedwater
regulating valves.
                                                                                                      )
Rather than continuing to increase main generator load just after synchronizing to
            regulating valves.
the grid, the licensee held the main generator output to approximately 60 MWe.
            Rather than continuing to increase main generator load just after synchronizing to
When steam generator water levels had stabilized and the feedwater bypass valves
            the grid, the licensee held the main generator output to approximately 60 MWe.           I
were approximately 90 percent open, using the steam dumps, the licensee
            When steam generator water levels had stabilized and the feedwater bypass valves
increased the main generator output at approximately one half percent per minute.
            were approximately 90 percent open, using the steam dumps, the licensee
;
            increased the main generator output at approximately one half percent per minute.       ;
This allowed a smooth transition from the feedwater bypass to the main feedwater
            This allowed a smooth transition from the feedwater bypass to the main feedwater
regulating valves. There were no steam generator level deviation alarms during this
            regulating valves. There were no steam generator level deviation alarms during this
startup. The inspectors did not identify any significant issues.
            startup. The inspectors did not identify any significant issues.
1
                                                                                                      l
O2
      O2   Operational Status of Facilities and Equipment                                           1
Operational Status of Facilities and Equipment
      02.1 Plant Tours
02.1 Plant Tours
                                                                                                      i
i
                                                                                                      '
'
        a.   Inspection Scope (71707)
a.
            The inspectors accompanied an equipment operator during rounds of the auxiliary
Inspection Scope (71707)
            and fuel buildings. This was to determine the thoroughness of his inspections and
The inspectors accompanied an equipment operator during rounds of the auxiliary
            his sensitivity to equipment and plant housekeeping problems.                           l
and fuel buildings. This was to determine the thoroughness of his inspections and
                                                                                                      l
his sensitivity to equipment and plant housekeeping problems.
        b.   Observations and Findinas
b.
                                                                                                      I
Observations and Findinas
            The operator was appropriately sensitive to the condition and operating status of all   1
The operator was appropriately sensitive to the condition and operating status of all
            equipment inspected. The inspectors noted that the operator wiped oil                   l
1
            accumulatior, from safeguards pumps, which was considered a good practice. The           I
equipment inspected. The inspectors noted that the operator wiped oil
            inspectors also noted that any leaks were appropriately identified with work request
accumulatior, from safeguards pumps, which was considered a good practice. The
            tags.
inspectors also noted that any leaks were appropriately identified with work request
            The operator noted that chemical and volume control system to centrifugal charging       ,
tags.
            Pump A discharge to reactor coolant pump seals throttle Valve BGHV8357A,had             l
The operator noted that chemical and volume control system to centrifugal charging
            an accumulation of boric acid crystals. The operator stated that this did not meet       ;
,
            expectations from both housekeeping and corrosion control standpoints. The               I
Pump A discharge to reactor coolant pump seals throttle Valve BGHV8357A,had
                                                                                                      '
an accumulation of boric acid crystals. The operator stated that this did not meet
            inspectors followed up and found that the valve is being tracked by the licensee's
expectations from both housekeeping and corrosion control standpoints. The
            boric acid leak tracking program iad will be worked at an appropriate time. The
'
            inspectors observed that the operator was thorough in his inspections and was           ,
inspectors followed up and found that the valve is being tracked by the licensee's
            particularly sensitive to determining the status of previously identified fluid leaks.   )
boric acid leak tracking program iad will be worked at an appropriate time. The
                                                                                                      l
inspectors observed that the operator was thorough in his inspections and was
            The inspectors observed that material, tools, and equipment were properly stored.
particularly sensitive to determining the status of previously identified fluid leaks.
            With the exception of clutter in the hot tool and radwaste staging areas, the
,
            buildings were clean and free of debris. The clutter observed in the noted areas
l
            was not unexpected in that refueling outage cleanup was still in progress.
The inspectors observed that material, tools, and equipment were properly stored.
With the exception of clutter in the hot tool and radwaste staging areas, the
buildings were clean and free of debris. The clutter observed in the noted areas
was not unexpected in that refueling outage cleanup was still in progress.


      - -                 .-             .-     -     -                                         - _ _ . -
- -
.-
.-
-
-
-
_
_ . -
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    .
.
    .
.
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'
                                                        -4-
-4-
  -
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                                                                                                              I
I
          c.   _ Conclusions
c.
                                                                                                              I
_ Conclusions
                The equiprnent operator was thorough in his inspections and particularly sensitive to
The equiprnent operator was thorough in his inspections and particularly sensitive to
                determining the status of existing fluid leaks. The plant material condition was
determining the status of existing fluid leaks. The plant material condition was
                good.                                                                                         i
good.
                                                                                                              i
i
          02.2 Cold Weather Preparations
i
          a.   Inspection Scone (71707)
02.2 Cold Weather Preparations
                The inspectors reviewed the licensee's cold wcather preparations,
a.
          b.   Observations and Findinas
Inspection Scone (71707)
                The licensee performed a plant walkdown using Procedure OTS-ZZ-00007,                         i
The inspectors reviewed the licensee's cold wcather preparations,
                Revision 3, " Plant Cold Weather," to ensure that equipment required during cold             I
b.
                weather was operational. During the walkdown, the licensee identified a few
Observations and Findinas
                deficiencies which were corrected. The inspectors did not note any problems
The licensee performed a plant walkdown using Procedure OTS-ZZ-00007,
                during subsequent cold weather conditions.
i
I
Revision 3, " Plant Cold Weather," to ensure that equipment required during cold
weather was operational. During the walkdown, the licensee identified a few
deficiencies which were corrected. The inspectors did not note any problems
during subsequent cold weather conditions.
l
l
                                                                                                              l
04.1 Worker Protection Tao Placed on the Wrona Component which Trioned Main
i
'
'
          04.1 Worker Protection Tao Placed on the Wrona Component which Trioned Main                        i
j
j              Circulatina Water Pumo B and Service Water Pumo B                                             j
Circulatina Water Pumo B and Service Water Pumo B
                                                                                                              1
j
            a. Insoection Scope (71707)                                                                     !
1
                The inspectors reviewed a December 18,1996, event, which occurred when an
a.
                equipment operator inadvertently pulled the metering and relay fuses for electrical           ;
Insoection Scope (71707)
                Bus PB122. The bus supplied power fo, main circulating water Pump B and service               i
The inspectors reviewed a December 18,1996, event, which occurred when an
                water Pump B. When the fuses were pulled, the pump undervoltage protective                   i
equipment operator inadvertently pulled the metering and relay fuses for electrical
                circuits tripped the two pumps. The equipment operator was supposed to pull the               l
Bus PB122. The bus supplied power fo, main circulating water Pump B and service
                instrument potential transformer secondary fuses for electrical Bus PB121.
water Pump B. When the fuses were pulled, the pump undervoltage protective
            b. Observations and Findinas
circuits tripped the two pumps. The equipment operator was supposed to pull the
                While intending to place a worker protection tag on an instrument potential
l
                transformer secondary fuses for electrical Bus PB121, an equipment operator
instrument potential transformer secondary fuses for electrical Bus PB121.
!               incorrectly placed the worker protection tag on the metering and relay fuses for
b.
                electrical Bus PB122. This action caused main circulating water Pump B and
Observations and Findinas
l               service water Pump B to trip. Main circulating water Pump A and service water
While intending to place a worker protection tag on an instrument potential
l               Pump A were already secured to allow maintenance on Bus PB121. This left only
transformer secondary fuses for electrical Bus PB121, an equipment operator
                service water Pump C and main circulating water Pump C in service.
!
                When the equipment operator pulled the metering and relay fuses, the control room
incorrectly placed the worker protection tag on the metering and relay fuses for
                operators received a number of indications alerting them that the pumps had
electrical Bus PB122. This action caused main circulating water Pump B and
                tripped. Control room personnel immediately commenced reducing power to
l
                prevent a turbine trip on loss of main condenser vacuum. Condenser pressure
service water Pump B to trip. Main circulating water Pump A and service water
l
Pump A were already secured to allow maintenance on Bus PB121. This left only
service water Pump C and main circulating water Pump C in service.
When the equipment operator pulled the metering and relay fuses, the control room
operators received a number of indications alerting them that the pumps had
tripped. Control room personnel immediately commenced reducing power to
prevent a turbine trip on loss of main condenser vacuum. Condenser pressure
t
t


                                                                                      1
1
.
.
.
.
                                          5-                                         I
5-
  increased and stabilized at approximately 4.5 inches Hg after reactor power was
increased and stabilized at approximately 4.5 inches Hg after reactor power was
  reduced to 92 percent. The condenser pressure turbine trip setpoint was 7.5 inches
reduced to 92 percent. The condenser pressure turbine trip setpoint was 7.5 inches
  Hg. The operators started essential service water Pump A to provide an adequate
Hg. The operators started essential service water Pump A to provide an adequate
  service water supply.
service water supply.
  After determining that the fuses were inadvertently pulled, the licensee restored
After determining that the fuses were inadvertently pulled, the licensee restored
  both Bus PB121 and Bus PB122 and restarted main circulating water Pump B.
both Bus PB121 and Bus PB122 and restarted main circulating water Pump B.
  Service water Pump A was also started and essential service water Pump A was
Service water Pump A was also started and essential service water Pump A was
  secured. The plant was returned to 100 percent power.
secured. The plant was returned to 100 percent power.
  The licensee initiated an investigation of the event using the corrective action
The licensee initiated an investigation of the event using the corrective action
  process.
process.
  The licensee identified the following major causes:
The licensee identified the following major causes:
  *      Failure to perform self-checking of the worker protection tag against the
Failure to perform self-checking of the worker protection tag against the
          component labeling.
*
                                                                                      l
component labeling.
  *      Many of the fuses outside the power block were not consistently labeled.
Many of the fuses outside the power block were not consistently labeled.
  The licensee's corrective actions included reviewing proper tcgout techniques with 1
*
                                                                                      '
The licensee's corrective actions included reviewing proper tcgout techniques with
  equipment operators. This includes the expectation that field supervisors resolve
1
  any discrepancies between tagout sheet nomenclature and component labels in the
equipment operators. This includes the expectation that field supervisors resolve
  field. The licensee was also reviewing the adequacy of fuse labeling for
'
  components outside the power block. Fuse labeling problems inside the power
any discrepancies between tagout sheet nomenclature and component labels in the
  block were identified and corrected at an earlier time.
field. The licensee was also reviewing the adequacy of fuse labeling for
  The inspectors agreed with the licensee's findings.
components outside the power block. Fuse labeling problems inside the power
  Administrative Procedure ODP-ZZ-00310,"Workmac.'s Protection Assurance
block were identified and corrected at an earlier time.
  Tagging", Revision 2, Step 4.1.10.3, required that the method and order specified
The inspectors agreed with the licensee's findings.
  on the tagout control sheet be followed when hanging tags.
Administrative Procedure ODP-ZZ-00310,"Workmac.'s Protection Assurance
  The tagout control sheet for Workman's Protection Assurance 21672, Tag 10,
Tagging", Revision 2, Step 4.1.10.3, required that the method and order specified
  specified that a tag be hung on the potential transformer secondary fuses for
on the tagout control sheet be followed when hanging tags.
  Bus PB121. Failure to adhere to this requirement is considered a violation of the
The tagout control sheet for Workman's Protection Assurance 21672, Tag 10,
  licensee's administrative procedure.
specified that a tag be hung on the potential transformer secondary fuses for
  NRC Inspection Report 50-483/9611 identified a similar occurrence when an
Bus PB121. Failure to adhere to this requirement is considered a violation of the
  equipment operator pulled incorrect fuses and rendered centrifugal charging Pump A
licensee's administrative procedure.
  inoperable. This licensee-identified and corrected violation is being treated as a
NRC Inspection Report 50-483/9611 identified a similar occurrence when an
  cited violation due to a repeat occurrence of a recent event (483/9614-01).
equipment operator pulled incorrect fuses and rendered centrifugal charging Pump A
inoperable. This licensee-identified and corrected violation is being treated as a
cited violation due to a repeat occurrence of a recent event (483/9614-01).


    _ ._   _       . . _ _ .     _ _ . _ . . _ . . _ _ - _ . . _ _ _ - _ _ _           _ . _ _ _ _ _ - .
_ ._
  .
_
  .
. . _ _ .
                                                                                -6-
_ _ . _ . . _ . . _ _ - _ . . _ _ _ - _ _ _
          c.   Conclusions
_
                The inspectors concluded that the failure to pull the correct fuses was due to
. _ _ _ _ _ - .
                personnel error.
.
          08     Miscellaneous Operations issues
.
          08.1 Technical Specification interpretations (71707)
-6-
                During a review of Callaway Technical Specification Interpretations, the inspectors
c.
                noted that NRC personnel were identified as giving concurrence for the positions
Conclusions
                taken in two of them:
The inspectors concluded that the failure to pull the correct fuses was due to
                *
personnel error.
                              Technical Specification interpretation 1 - Emergency Core Cooling System
08
                              Accumulators, and
Miscellaneous Operations issues
                *            Technical Specification Interpretation 4 - Turbine Overspeed Protection.
08.1 Technical Specification interpretations (71707)
                The inspectors informed the licensee that this form of NRC involvement is not
During a review of Callaway Technical Specification Interpretations, the inspectors
                recognized by the Commission and is not an acceptable practice. However, the
noted that NRC personnel were identified as giving concurrence for the positions
                referencing of official NRC correspondence in a licensee Technical Specification
taken in two of them:
                Interpretation is acceptable. The inspectors requested that the licensee remove any
Technical Specification interpretation 1 - Emergency Core Cooling System
                informal references to NRC review and/or approval from their Technical
*
                Specification Interpretations. The licensee's Onsite Review Committee had already
Accumulators, and
                approved removing these interpretations from the Technical Specifications.
Technical Specification Interpretation 4 - Turbine Overspeed Protection.
                                                                          II. Maintenance
*
l-        M1     Conduct of Maintenance
The inspectors informed the licensee that this form of NRC involvement is not
recognized by the Commission and is not an acceptable practice. However, the
referencing of official NRC correspondence in a licensee Technical Specification
Interpretation is acceptable. The inspectors requested that the licensee remove any
informal references to NRC review and/or approval from their Technical
Specification Interpretations. The licensee's Onsite Review Committee had already
approved removing these interpretations from the Technical Specifications.
II. Maintenance
M1
Conduct of Maintenance
l-
i
i
i
i
          M 1.1 General Comments - Maintenance
M 1.1 General Comments - Maintenance
          a,   inspection Scope (62707)
a,
                The inspectors observed or reviewed portions of the following work activities:
inspection Scope (62707)
                *            Work Activity P541890- Centrifugal Charging Pump A Motor Bearing Oil
The inspectors observed or reviewed portions of the following work activities:
                              Sight Glass Leaks,
Work Activity P541890- Centrifugal Charging Pump A Motor Bearing Oil
                  *          Work Activity W175769- Rebuild Spare Feedwater Isolation Valve Actuator,
*
Sight Glass Leaks,
Work Activity W175769- Rebuild Spare Feedwater Isolation Valve Actuator,
*
;
;
                  *          Work Activity P548345- Clean and inspect Feeder Circuit Breaker to Motor-
Work Activity P548345- Clean and inspect Feeder Circuit Breaker to Motor-
*
l
l
                              Driven Auxiliary Feedwater Pump A,
Driven Auxiliary Feedwater Pump A,
                  *          Work Activity P548864- Calibrate Auxiliary Feedwater Flow to Steam
Work Activity P548864- Calibrate Auxiliary Feedwater Flow to Steam
*
Generator B Feed Flow Transmitter, and
,
,
                              Generator B Feed Flow Transmitter, and


.
.
.
                                                  -7-
.
          *      Work Activity P576360- Cold Weather Preparations.
-7-
    b.   Observations and Findinas
Work Activity P576360- Cold Weather Preparations.
          Except as noted in paragraph M1.3, the inspectors found no concerns with the
*
          maintenance observed. All work observed was performed with the work packages
b.
          present and in active use. The inspectors frequently observed supervisors and
Observations and Findinas
          system engineers monitoring job progress, and quality control personnel were
Except as noted in paragraph M1.3, the inspectors found no concerns with the
          present when required. Housekeeping and foreign material exclusion controls were
maintenance observed. All work observed was performed with the work packages
          satisfactory.
present and in active use. The inspectors frequently observed supervisors and
  M1.2 General Comments - Surveillance
system engineers monitoring job progress, and quality control personnel were
    a.   Inspection Scope (61726)
present when required. Housekeeping and foreign material exclusion controls were
          The inspectors observed all or portions of the following test activities:
satisfactory.
          *      Surveillance Procedure OSP-EF-P001 A- Emergency Service Water Train A
M1.2 General Comments - Surveillance
                Operability,
a.
          *      Surveillance Procedure OSP-NE-0001 A- Standby Diesel Generator A Periodic
Inspection Scope (61726)
                Tests, and
The inspectors observed all or portions of the following test activities:
          *      Surveillance Procedure OSP-SA-0017A- Train A Safety injection System -
Surveillance Procedure OSP-EF-P001 A- Emergency Service Water Train A
                Containment Spray Actuation System Slave Relay Test.
*
    b.   Observations and Findinas
Operability,
          Surveillance testing observed during this inspection period was conducted
Surveillance Procedure OSP-NE-0001 A- Standby Diesel Generator A Periodic
          satisfactorily in accordance with the licensee's approved programs and the
*
          Technical Specifications.
Tests, and
  M 1.3 Feedwater Isolation Valve Actuator Hydraulic Leaks
Surveillance Procedure OSP-SA-0017A- Train A Safety injection System -
    a.   Insnection Scooe (62707)
*
          On November 29,1996, the actuator on feedwater isolation Valve AEFV0042 for
Containment Spray Actuation System Slave Relay Test.
          Steam Generator D, developed a hydraulic leak on both hydraulic system trains.
b.
          Each train is capable of independently closing the feedwater isolation valve upon
Observations and Findinas
          receiving a feedwater system isolation signal. The inspectors reviewed the
Surveillance testing observed during this inspection period was conducted
          licensee's efforts to repair the actuator and determine the root cause of the leaks.
satisfactorily in accordance with the licensee's approved programs and the
    b.   Observations and Findinas
Technical Specifications.
          The licensee discovered that the wrong size O-rings had been installed on both
M 1.3 Feedwater Isolation Valve Actuator Hydraulic Leaks
          hydraulic system trains for the actuator on Valve AEFV0042. Although the inside
a.
Insnection Scooe (62707)
On November 29,1996, the actuator on feedwater isolation Valve AEFV0042 for
Steam Generator D, developed a hydraulic leak on both hydraulic system trains.
Each train is capable of independently closing the feedwater isolation valve upon
receiving a feedwater system isolation signal. The inspectors reviewed the
licensee's efforts to repair the actuator and determine the root cause of the leaks.
b.
Observations and Findinas
The licensee discovered that the wrong size O-rings had been installed on both
hydraulic system trains for the actuator on Valve AEFV0042. Although the inside


  _ - _ - - _ . - - - .                   .--- - - -                       .~~.-               -- ------     -
_ - _ - - _ . - - - .
        .                                                                                                       f
.--- - - -
      -
.~~.-
        .
-- ------
                                                                                                                [
-
                                                                -8-                                             !
f
                                                                                                                I
.
                        diameter of the O-rings was correct, the thickness was incorrect. As the hydraulic       ;
-
                        pressure'in the actuator cycled during normal operation, the O-ring material wore '
.
                                                                                                                '
[
                        away which established a leak path outside the valve.                                   ;
-8-
                        The licensee ' determined the root cause to be a maintenance error during
!
                        refurbishment of a spare hydraulic actuator for Valve AEFV0042. Workers
I
                        refurbished the spare actuator just prior to the recent refueling outage. This
diameter of the O-rings was correct, the thickness was incorrect. As the hydraulic
                                                                                                                '
;
                        refurbishment included installing new O-rings on the hydraulic trains on October 8,
pressure'in the actuator cycled during normal operation, the O-ring material wore '
                        1996. However, some of the O-rings were the incorrect size. The licensee later-           i
'
                        replaced the existing actuator on AEFV0042 with the newly refurbished spare (with         l
away which established a leak path outside the valve.
                        the iicorrect 0-rings) during the refueling outage as part of an overall preventive       i
;
                        maintenance task.                                                                          l
The licensee ' determined the root cause to be a maintenance error during
                                                                                                                  l
refurbishment of a spare hydraulic actuator for Valve AEFV0042. Workers
                                                                                                                  I
refurbished the spare actuator just prior to the recent refueling outage. This
                        In December 1996, during the licensee's followup investigation after the leak was
refurbishment included installing new O-rings on the hydraulic trains on October 8,
                        discovered, the licensee inspected several dozen 0-rings and found a total of 17
'
                        incorrect 0-rings that had been installed in both hydraulic trains in Valve
1996. However, some of the O-rings were the incorrect size. The licensee later-
                        AEHVOO42. The licensee replaced these with the correct 0-rings.
i
                        The licensee held a multidisciplinary review to determine the root cause of and            '
replaced the existing actuator on AEFV0042 with the newly refurbished spare (with
                        corrective actions for this event. As a result, the licensee initiated a case study of
the iicorrect 0-rings) during the refueling outage as part of an overall preventive
                        this event due to the broad scope of potential corrective actions.
i
                        The licensee's short term corrective actions included successfully repairing the valve
maintenance task.
                        and testing a representative sample of O-rings in stock to ensure no other O-ring
                        problems existed. No incorrect 0-rings were identified.
                        The licensee's long term corrective actions include the case study, which
                        addresses:
                        *
                                Ensuring correct drawings are specified and available in work packages,
                        *      Reviewing material control wording to clear up confusing nomenclature on          I
                                parts sizing,
                        *      Ensuring adequate work planning and coordination for complex maintenance
                                efforts, and                                                                        i
                        *      Conducting training on the results of the case study for the various
                                disciplines involved in maintenance activities.
l
l
                        The inspectors reviewed the work package used to refurbish the actuator on
In December 1996, during the licensee's followup investigation after the leak was
                        AEFV0042 just prior to the refueling outage. The inspectors found that the
discovered, the licensee inspected several dozen 0-rings and found a total of 17
i                       supervisor in charge of the job did not thoroughly review the work package for
incorrect 0-rings that had been installed in both hydraulic trains in Valve
AEHVOO42. The licensee replaced these with the correct 0-rings.
The licensee held a multidisciplinary review to determine the root cause of and
'
corrective actions for this event. As a result, the licensee initiated a case study of
this event due to the broad scope of potential corrective actions.
The licensee's short term corrective actions included successfully repairing the valve
and testing a representative sample of O-rings in stock to ensure no other O-ring
problems existed. No incorrect 0-rings were identified.
The licensee's long term corrective actions include the case study, which
addresses:
Ensuring correct drawings are specified and available in work packages,
*
Reviewing material control wording to clear up confusing nomenclature on
*
parts sizing,
Ensuring adequate work planning and coordination for complex maintenance
*
efforts, and
Conducting training on the results of the case study for the various
*
disciplines involved in maintenance activities.
l
The inspectors reviewed the work package used to refurbish the actuator on
AEFV0042 just prior to the refueling outage. The inspectors found that the
i
supervisor in charge of the job did not thoroughly review the work package for
I
I
                        information on replacement 0-rings. Information on replacement 0-rings of the
information on replacement 0-rings. Information on replacement 0-rings of the
                        correct size and material was available in the work package.
correct size and material was available in the work package.
i
i
l
l
                                                                                    ._ _
._ _


    _____           ._   . _ _ _ .   _ . _._ _ _ _ _ _ _                 . . _ _ _ _ _ _ _ _ _ _ . . _ _ _ ,
_____
  ..
._
. _ _ _ .
_ . _._ _ _ _ _ _ _
.
. _ _
_ _ _ _ _ _ _ _ . . _ _ _ ,
..
l
l
  .
.
l                                                                                                                                         i
l
!                                                                     .g.                                                               '
i
o                                                                                                                                         ,
!
.g.
'
o
,
i
i
                                                                                                                                          i
i
                                                                                                                                          '
'
l
l
l
                                                                                                                                          '
'
'
'
'
                Criterion V of Appendix B to 10 CFR Part 50 requires, in part, that activities                                           ;
Criterion V of Appendix B to 10 CFR Part 50 requires, in part, that activities
                affecting quality shall be prescribed by documented instructions, procedures, and                                         i
;
                drawings appropriate to the circumstances and shall be accomplished in accordance
'
                with these instructions, procedures, or drawings. The failure to adhere to this                                           l
affecting quality shall be prescribed by documented instructions, procedures, and
                requirement is considered a violation of Criterion V of Appendix B to 10 CFR                                             r
i
                Part 50. This licensee-identified and corrected violation is being treated as a                                           ,
drawings appropriate to the circumstances and shall be accomplished in accordance
                noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy
with these instructions, procedures, or drawings. The failure to adhere to this
                (483/9614-02).
l
i           c. Conclusions
requirement is considered a violation of Criterion V of Appendix B to 10 CFR
                The inspectors concluded that the licensee's actions to determine the reason for the
r
                leak were thorough. The inspectors also found the licensee's repair of the leaking
Part 50. This licensee-identified and corrected violation is being treated as a
                hydraulic components to be satisf actory. The licensee's control of O-ring material
,
                for rebuilding the feedwater isolation valve actuator was lacking.
noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy
                                                          Ill. Enaineerina
(483/9614-02).
          E1   Conduct of Engineering
i
          E1.1 fnaineerina Involvement in Plant Activities (37551)-
c.
                The inspectors noted that engineering was appropriately involved in plant activities
Conclusions
                during this inspection period. The inspectors noted that system engineers
The inspectors concluded that the licensee's actions to determine the reason for the
                conducted plant walkdowns of assigned systems for cold weather preparations as
leak were thorough. The inspectors also found the licensee's repair of the leaking
                discussed in Section O2.2 of this report. Expectations were included on a
hydraulic components to be satisf actory. The licensee's control of O-ring material
                management policy entitled " System Walkdowns," NE-System Walkdown-01,
for rebuilding the feedwater isolation valve actuator was lacking.
                Revision 1. In addition, plant engineers participated in the multidisciplinary case
Ill. Enaineerina
                study team and root cause evaluation for the failure of feedwater isolation Valve                                         l
E1
                AEFV0042 (Section M1.3). The inspectors had no concerns,                                                                   j
Conduct of Engineering
          E2   Engineering Support of Facilities and Equipment
E1.1
                                                                                                                                          :
fnaineerina Involvement in Plant Activities (37551)-
          E2.1 Review of Facility Conformance to Uodated Final Safety Analvsis Report
The inspectors noted that engineering was appropriately involved in plant activities
                Commitments                                                                                                               j
during this inspection period. The inspectors noted that system engineers
                A recent discovery of a licensee operating their f acility in a manner contrary to the
conducted plant walkdowns of assigned systems for cold weather preparations as
                Final Safety Analysis Report description highlighted the need for a special focused
discussed in Section O2.2 of this report. Expectations were included on a
                review that compares plant practices, procedures, and/or parameters to the Final
management policy entitled " System Walkdowns," NE-System Walkdown-01,
                Safety Analysis Report description. While performing the inspections discussed in
Revision 1. In addition, plant engineers participated in the multidisciplinary case
                this report, the inspectors reviewed the applicable portions of the Final Safety
study team and root cause evaluation for the failure of feedwater isolation Valve
                Analysis Report that related to the areas inspected. No inconsistencies were noted
AEFV0042 (Section M1.3). The inspectors had no concerns,
                between the wording of the Updated Safety Analysis Report and the plant practices,
j
                procedures, and/or parameters observed by the inspectors,
E2
                                                                                                                                          i
Engineering Support of Facilities and Equipment
E2.1
Review of Facility Conformance to Uodated Final Safety Analvsis Report
Commitments
j
A recent discovery of a licensee operating their f acility in a manner contrary to the
Final Safety Analysis Report description highlighted the need for a special focused
review that compares plant practices, procedures, and/or parameters to the Final
Safety Analysis Report description. While performing the inspections discussed in
this report, the inspectors reviewed the applicable portions of the Final Safety
Analysis Report that related to the areas inspected. No inconsistencies were noted
between the wording of the Updated Safety Analysis Report and the plant practices,
procedures, and/or parameters observed by the inspectors,
i
,
,
,
                                                                                                                                          ,
_ _ . . .
                                                                                                                                  . . _ ,
. . _
                                            _ _ . . .           . . _                                 ..
..
                                                                                                                  _ _ . _ _ - _ _
_ _ . _ _ - _ _
. . _ ,


.
.
i
i
e
e
                                                -10-
-10-
                                        IV. Plant SuDDort
IV. Plant SuDDort
  R1   Radiological Protection and Chemistry (RP&C) Controls
R1
  R 1.1 Radioloaical Protection Proaram Observations
Radiological Protection and Chemistry (RP&C) Controls
        The inspectors toured various areas of the radiologically controlled areas of the
R 1.1
        plant. Health physics personnel were observed routinely touring the radiologically
Radioloaical Protection Proaram Observations
        controlled areas. Licensee personnel observed performing work in radiological
The inspectors toured various areas of the radiologically controlled areas of the
        control areas exhibited good radiation worker practices. Contaminated areas and
plant. Health physics personnel were observed routinely touring the radiologically
        high radiation areas were properly posted. Area surveys posted outside rooms in
controlled areas. Licensee personnel observed performing work in radiological
        the auxiliary building were current.
control areas exhibited good radiation worker practices. Contaminated areas and
  P3.1 Licensee Onshift Dose Assessment Capabilities
high radiation areas were properly posted. Area surveys posted outside rooms in
    a.   Insoection Scoce (Tl 2515/134)
the auxiliary building were current.
        Using Temporary Instruction 2515/134,the inspectors gathered information
P3.1
        regarding:
Licensee Onshift Dose Assessment Capabilities
        *      Dose assessment commitment in emergency plan,
a.
        *       Onshift dose assessment emergency plan implementing procedure, and
Insoection Scoce (Tl 2515/134)
        *       Onshift dose assessment training.
Using Temporary Instruction 2515/134,the inspectors gathered information
    b.   Observations and Findinas
regarding:
        On December 17,1996, the inspectors conducted an inoffice review of the
Dose assessment commitment in emergency plan,
        emergency plan and implementing procedures to obtain the information requested
*
        by the temporary instruction. The inspectors also conducted a telephone interview
Onshift dose assessment emergency plan implementing procedure, and
        with the licensee on December 17,1996, to verify the results of the review. Based
*
        on the documentation review and the licensee interview, the inspectors determined
Onshift dose assessment training.
        that the licensee had the capability to perform onshift dose assessments using real-
*
        time effluent monitor and meteorological data and that the commitment was clearly
b.
          described in the emergency plan and implementing procedures.
Observations and Findinas
    c.   Conclusion
On December 17,1996, the inspectors conducted an inoffice review of the
          The commitment to perform onshift dose assessments was clearly described in the
emergency plan and implementing procedures to obtain the information requested
          emergency plan and implementing procedures. Further evaluation of the information
by the temporary instruction. The inspectors also conducted a telephone interview
          obtained using the temporary instruction will be conducted by NRC Headquarters
with the licensee on December 17,1996, to verify the results of the review. Based
          personnel.
on the documentation review and the licensee interview, the inspectors determined
                                                                                              I
that the licensee had the capability to perform onshift dose assessments using real-
time effluent monitor and meteorological data and that the commitment was clearly
described in the emergency plan and implementing procedures.
c.
Conclusion
The commitment to perform onshift dose assessments was clearly described in the
emergency plan and implementing procedures. Further evaluation of the information
obtained using the temporary instruction will be conducted by NRC Headquarters
personnel.
I


..   . - . . - -     . - - - . . -         . . - . - - . - - -       - - - _ . - . . . . . - _ . - . - ~ . . - . . . - - -
..
r.                                                                                                                             !
. - .
. - -
. - - - . . -
. . - . - - . - - -
- - - _ . - . . . . . - _ . - . - ~ . . - . . . - - -
r.
!
:
.
.
;
;
    :
i
*
*
t
t
l                                                                 -11-                                                         )
l
-11-
)
e
e
                                                                                                                                i
;                                                                                                                              i
i
i
I                                                         V. Manaaement Meetinas
;
            X1     Exit Meeting Summary
i
                  The exit meeting was conducted on January 3,1997. The licensee expressed a
i
                  position on the subject of the violation in this report.
I
                  During the discussion of the equipment operator inadvertently pulling the wrong
V. Manaaement Meetinas
                  fuse which caused operators to reduce plant power (Section 04.1), the licensee
X1
                  stated that the event was not significant enough to merit a violation for the
Exit Meeting Summary
                  following reasons:
The exit meeting was conducted on January 3,1997. The licensee expressed a
                  *            The licensee disagreed that a procedure violation occurred given a literal
position on the subject of the violation in this report.
                                interpretation of the equipment control tagging procedure,
During the discussion of the equipment operator inadvertently pulling the wrong
                  *            The licensee stated that 10 CFR 50, Appendix B, did not apply to the non-
fuse which caused operators to reduce plant power (Section 04.1), the licensee
                                safety related fuse, and
stated that the event was not significant enough to merit a violation for the
                  *            The licensee stated that the equipment control tagging procedure was a
following reasons:
                                reference-use procedure.
The licensee disagreed that a procedure violation occurred given a literal
                  The inspectors asked the licensee whether any materials examined during the
*
                  inspection shou!d be considered proprietary. No proprietary information was
interpretation of the equipment control tagging procedure,
                  identified.
The licensee stated that 10 CFR 50, Appendix B, did not apply to the non-
                                                                                                                                .
*
                                                                                                                                1
safety related fuse, and
                                                                                                                                !
The licensee stated that the equipment control tagging procedure was a
                                                                                                                                I
*
                                                                                                                                l
reference-use procedure.
The inspectors asked the licensee whether any materials examined during the
inspection shou!d be considered proprietary. No proprietary information was
identified.
.


                                                                                                                .
.
                                                                                                                  - -
- -
i *                                                                                                                   ,
i *
    1
,
    o
1
                                                  ATTACHMENT
o
                                        SUPPLEMENTAL INFORMATION
ATTACHMENT
                                    PARTIAL LIST OF PERSONS CONTACTED
SUPPLEMENTAL INFORMATION
      Licensee
PARTIAL LIST OF PERSONS CONTACTED
      J. D. Blosser, Manager, Operations Support
Licensee
      H. D. Bono, Supervising Engineer, Licensing Fuels and Site Licensing
J. D. Blosser, Manager, Operations Support
      D. G. Cornwell, General Supervisor, Maintenance
H. D. Bono, Supervising Engineer, Licensing Fuels and Site Licensing
      R. T. Lamb, Superintendent, Operations
D. G. Cornwell, General Supervisor, Maintenance
l     J. V. Laux, Manager, Quality Assurance
R. T. Lamb, Superintendent, Operations
      D. W. Neterer, Shif t Supervisor
l
      J. R. Peevy, Manager, Emergency Preparedness and
J. V. Laux, Manager, Quality Assurance
              Organizational Support                                                                                 :
D. W. Neterer, Shif t Supervisor
      G. L. Randolph, Vice President, Nuclear Operations
J. R. Peevy, Manager, Emergency Preparedness and
      M. A. Reidmeyer, Engineer, Quality Assurance
Organizational Support
      R. R. Roselius, Superintendent, Chemistry and Rad Waste
G. L. Randolph, Vice President, Nuclear Operations
      J. D. Schnack, Engineer, Quality Assurance
M. A. Reidmeyer, Engineer, Quality Assurance
R. R. Roselius, Superintendent, Chemistry and Rad Waste
J. D. Schnack, Engineer, Quality Assurance
!
!
      T. P. Sharkey, Supervising Engineer, Nuclear Operations
T. P. Sharkey, Supervising Engineer, Nuclear Operations
                                        INSP_fCTION PROCEDURES USED
INSP_fCTION PROCEDURES USED
      IP 37551:           Onsite Engineering
IP 37551:
      IP 61726:           Surveillance Observations
Onsite Engineering
      IP 62707:           Maintenance Observations
IP 61726:
i     IP 71707:           Plant Operations
Surveillance Observations
IP 62707:
Maintenance Observations
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IP 71707:
Plant Operations
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      IP 93702:           Prompt Onsite Response to Events at Operating Power Reactors
IP 93702:
      Tl 2515/134         Licensee Onshift Dose Assessment Capabilities
Prompt Onsite Response to Events at Operating Power Reactors
                                    ITEMS OPENED CLOSED, AND DISCUSSED
Tl 2515/134
Licensee Onshift Dose Assessment Capabilities
ITEMS OPENED CLOSED, AND DISCUSSED
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        Ooened
Ooened
        9614-01                 VIO       Equipment Operator Pulled Incorrect Fuse (Section 04.1)
9614-01
        9614-02                 NCV       Leaking 0-Rings On Feedwater isolation Valve AEFV0042
VIO
                                            For Steam Generator D (Section M1.3)
Equipment Operator Pulled Incorrect Fuse (Section 04.1)
9614-02
NCV
Leaking 0-Rings On Feedwater isolation Valve AEFV0042
For Steam Generator D (Section M1.3)
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Closed
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l       9614-02                 NCV       Leaking O-Rings On Feedwater Isolation Valve AEFV0042
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9614-02
                                            For Steam Generator D (Section M1.3)
NCV
Leaking O-Rings On Feedwater Isolation Valve AEFV0042
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For Steam Generator D (Section M1.3)
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-2-
                                LIST OF DOCUMENTS REVIEWED
LIST OF DOCUMENTS REVIEWED
    Emeroency Plan imolementina Procedures
Emeroency Plan imolementina Procedures
    EIP-ZZ-00101               Classification of Emergencies         Revision 19
EIP-ZZ-00101
    ElP-ZZ-00102               Emergency implementing Actions       Revision 15
Classification of Emergencies
    EIP-ZZ-01211               Management Action Guides for         Revision 18
Revision 19
                                  Nuclear Emergencies
ElP-ZZ-00102
    Other Documents
Emergency implementing Actions
    Callaway Radiological Emergency Response Plan                   Revision 20
Revision 15
                                                                      CN 96-02
EIP-ZZ-01211
                                                                                        l
Management Action Guides for
Revision 18
Nuclear Emergencies
Other Documents
Callaway Radiological Emergency Response Plan
Revision 20
CN 96-02
}}
}}

Latest revision as of 07:38, 12 December 2024

Insp Rept 50-483/96-14 on 961124-970104.Violations Noted. Major Areas Inspected:Operations,Maint & Plant Support
ML20133L664
Person / Time
Site: Callaway Ameren icon.png
Issue date: 01/16/1997
From:
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20133K956 List:
References
50-483-96-14, NUDOCS 9701220099
Download: ML20133L664 (16)


See also: IR 05000483/1996014

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ENCLOSURE 2

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U.S. NUCLEAR REGULATORY COMMISSION

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REGION IV

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Docket No.:

50-483

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License No.:

NPF-30

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Report No.:

50-483/96-14

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Licensee:

Union Electric Company

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Facility:

Callaway Plant

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Location:

Junction Highway CC and Highway O

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Fulton, Missouri

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Dates:

November 24,1996, through January 4,1997

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inspectors:

D. G. Passehl, Senior Resident inspector

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F. L. Brush, Resident inspector

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H. F. Bundy, Reactor Engineer

G. M. Good, Senior Emergency Preparedness Analyst

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Approved By:

W. D. Johnson, Chief, Project Branch B

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ATTACHMENT: Supplemental Information

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9701220099 970116

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ADOCK 05000483

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EXECUTIVE SUMMARY

Callaway Plant

NRC Inspection Report 50-483/96-14

Operations

The license's decision to shutdown the plant to repair a feedwater isolation valve

actuator was appropriate (Section 01,1).

The control room staff response to a turbine trip during reactor startup was good

(Section 01.2). There were no problems during the subsequent startup

(Section 01.3).

An equipment operator was thorough during rounds. The plant material condition

was good (Section O2.1).

An equipment operator inadvertently pulled the wrong fuses on a bus in the main

circulating water and service water pump house. This resulted in a partialloss of

circulating water flow to the main condenser and required the operators to reduce

plant power. This was a violation caused by a personnel error (Section 04.1).

Maintenance

The licensee's actions to determine the reason for the main feed water isolation

valve hydraulic actuator leaks were thorough. The licensee installed incorrect

0-rings due to inadequate material control which was a noncited violation

(Section M1.3).

"iant Suncort

The commitment to perform onshif t dose assessments was clearly described in the

emergency plan and implementing procedures (Section P3.1).

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Report Details

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Summary of Plant Status

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The plant was at 100 percent power at the beginning of the report period.

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On December 1,1996, due to hydraulic oilleaks on the actuator for feedwater isolation

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Valve D, the licensee shut down the unit. At 12:48 p.m. on December 5,1996, the plant

was brought back online. However, the turbine tripped a few minutes later due to a hi-hi

steam generator water level. At 8:25 p.m. on December 5,1996, the license returned the

unit online. The unit reached full power on December 6,1996.

At 4:41 p.m. on December 18,1996, the licensee reduced plant power to 92 percent

when an equipment operator inadvertently tripped a main circulating water pump. The

plant was returned to full power approximately four hours later and operated near

100 percent power for the remainder of the report period.

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I. Operations

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Conduct of Operations

01.1 Plant Shutdown

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a.

Inspection Scone (71707)

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On December 1,1996, the inspectors observed control room operations during

portions of the plant shutdown for a forced outage.

b.

Observations and Findinas

The licensee shut down the unit due to hydraulic fluid leaks on the actuator for main

feedwater isolation Valve AEFV0042. The actuator repair effort is discussed in

paragraph M1.2. The licensee's decision to shut down the unit was appropriate.

The licensee would have been required to enter and exit facdwater isolation valve

Technical Specification action statement 3.7.1.6 repeatediy in order to repair the

valve.

The shift supervisor held good briefings prior to starting the power reduction and

removing major equipment from service. Licensee management was present in the

control room and ensured personnel were aware of expectations. There was good

communication between the control room operators. The shift supervisor exhibited

good command and control. Operators did self-checking prior to manipulating plant

components. The inspectors did not note any problems.

In addition, the inspectors verified compliance to the Technical Specifications and

Final Safety Analysis Report requirements by reviewing logs, touring main control

boards and reviewing status boards.

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01.2 Plant Startuo with Turbine Trio, Feedwater System isolation and Motor-Driven

Auxiliary Feedwater System Actuation

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a.

Insoection Scoce (71707,93702)

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On December 5,1996, the inspectors observed portions of the plant startup

following the forced outage discussed in Section 01.1.

During the startup, a hi-hi water levelin Steam Generator B resulted in a main

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turbine trip, feedwater system isolation, and motor-driven auxiliary feedwater

actuation. The inspectors observed the control room operator response to the trip.

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b.

Observations and Findinos

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During the startup prior to entering Mode 2, the control room supervisor held good

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briefings. There was good communication among operations personnel. Licensee

management was in the control room and discussed their expectations with onshift

personnel.

At approximately 18 percent power, while transferring feed flow control from the

feedwater flow bypass valves to the main feedwater regulating valves, the steam

generator water levels began to oscillate. A main turbine trip and engineered safety

features actuations occurred when the level in Steam Generator B reached the hi-hi

setpoint of 78 percent. The magnitude of the level oscillations in the steam

generators were exacerbated by the positive moderator temperature coefficient

present at low power levels during this early stage in core life.

Operator response following the turbine trip and feedwater isolation was good. In

order to rapidly establish normal steam generator level, the operators manually

started the turbine-driven auxiliary feedwater pump and used control rods to rapidly

reduce power. This prevented a reactor trip on low steam generator level due to

the isolation of the main feedwater system. The shift supervisor exhibited good

command and control.

c.

Conclusions

The control room staff's response to the turbine trip was good. Operator

communications were good during the startup and subsequent trip. The shif t

supervisor exhibited good command and control. Licensee management ensured

that plant personnel followed expectations.

01.3 Second Plant Startuo on December 5,1996(71707)

Following the trip noted in paragraph 01.2, the licensee reviewed the methods of

starting up and increasing power with a positive temperature coefficient. For the

second startup on December 5,1996, the licensee changed the method for

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transferring from the main feedwater bypass valves to the main feedwater

regulating valves.

Rather than continuing to increase main generator load just after synchronizing to

the grid, the licensee held the main generator output to approximately 60 MWe.

When steam generator water levels had stabilized and the feedwater bypass valves

were approximately 90 percent open, using the steam dumps, the licensee

increased the main generator output at approximately one half percent per minute.

This allowed a smooth transition from the feedwater bypass to the main feedwater

regulating valves. There were no steam generator level deviation alarms during this

startup. The inspectors did not identify any significant issues.

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Operational Status of Facilities and Equipment

02.1 Plant Tours

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Inspection Scope (71707)

The inspectors accompanied an equipment operator during rounds of the auxiliary

and fuel buildings. This was to determine the thoroughness of his inspections and

his sensitivity to equipment and plant housekeeping problems.

b.

Observations and Findinas

The operator was appropriately sensitive to the condition and operating status of all

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equipment inspected. The inspectors noted that the operator wiped oil

accumulatior, from safeguards pumps, which was considered a good practice. The

inspectors also noted that any leaks were appropriately identified with work request

tags.

The operator noted that chemical and volume control system to centrifugal charging

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Pump A discharge to reactor coolant pump seals throttle Valve BGHV8357A,had

an accumulation of boric acid crystals. The operator stated that this did not meet

expectations from both housekeeping and corrosion control standpoints. The

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inspectors followed up and found that the valve is being tracked by the licensee's

boric acid leak tracking program iad will be worked at an appropriate time. The

inspectors observed that the operator was thorough in his inspections and was

particularly sensitive to determining the status of previously identified fluid leaks.

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The inspectors observed that material, tools, and equipment were properly stored.

With the exception of clutter in the hot tool and radwaste staging areas, the

buildings were clean and free of debris. The clutter observed in the noted areas

was not unexpected in that refueling outage cleanup was still in progress.

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_ Conclusions

The equiprnent operator was thorough in his inspections and particularly sensitive to

determining the status of existing fluid leaks. The plant material condition was

good.

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02.2 Cold Weather Preparations

a.

Inspection Scone (71707)

The inspectors reviewed the licensee's cold wcather preparations,

b.

Observations and Findinas

The licensee performed a plant walkdown using Procedure OTS-ZZ-00007,

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Revision 3, " Plant Cold Weather," to ensure that equipment required during cold

weather was operational. During the walkdown, the licensee identified a few

deficiencies which were corrected. The inspectors did not note any problems

during subsequent cold weather conditions.

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04.1 Worker Protection Tao Placed on the Wrona Component which Trioned Main

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Circulatina Water Pumo B and Service Water Pumo B

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a.

Insoection Scope (71707)

The inspectors reviewed a December 18,1996, event, which occurred when an

equipment operator inadvertently pulled the metering and relay fuses for electrical

Bus PB122. The bus supplied power fo, main circulating water Pump B and service

water Pump B. When the fuses were pulled, the pump undervoltage protective

circuits tripped the two pumps. The equipment operator was supposed to pull the

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instrument potential transformer secondary fuses for electrical Bus PB121.

b.

Observations and Findinas

While intending to place a worker protection tag on an instrument potential

transformer secondary fuses for electrical Bus PB121, an equipment operator

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incorrectly placed the worker protection tag on the metering and relay fuses for

electrical Bus PB122. This action caused main circulating water Pump B and

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service water Pump B to trip. Main circulating water Pump A and service water

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Pump A were already secured to allow maintenance on Bus PB121. This left only

service water Pump C and main circulating water Pump C in service.

When the equipment operator pulled the metering and relay fuses, the control room

operators received a number of indications alerting them that the pumps had

tripped. Control room personnel immediately commenced reducing power to

prevent a turbine trip on loss of main condenser vacuum. Condenser pressure

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increased and stabilized at approximately 4.5 inches Hg after reactor power was

reduced to 92 percent. The condenser pressure turbine trip setpoint was 7.5 inches

Hg. The operators started essential service water Pump A to provide an adequate

service water supply.

After determining that the fuses were inadvertently pulled, the licensee restored

both Bus PB121 and Bus PB122 and restarted main circulating water Pump B.

Service water Pump A was also started and essential service water Pump A was

secured. The plant was returned to 100 percent power.

The licensee initiated an investigation of the event using the corrective action

process.

The licensee identified the following major causes:

Failure to perform self-checking of the worker protection tag against the

component labeling.

Many of the fuses outside the power block were not consistently labeled.

The licensee's corrective actions included reviewing proper tcgout techniques with

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equipment operators. This includes the expectation that field supervisors resolve

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any discrepancies between tagout sheet nomenclature and component labels in the

field. The licensee was also reviewing the adequacy of fuse labeling for

components outside the power block. Fuse labeling problems inside the power

block were identified and corrected at an earlier time.

The inspectors agreed with the licensee's findings.

Administrative Procedure ODP-ZZ-00310,"Workmac.'s Protection Assurance

Tagging", Revision 2, Step 4.1.10.3, required that the method and order specified

on the tagout control sheet be followed when hanging tags.

The tagout control sheet for Workman's Protection Assurance 21672, Tag 10,

specified that a tag be hung on the potential transformer secondary fuses for

Bus PB121. Failure to adhere to this requirement is considered a violation of the

licensee's administrative procedure.

NRC Inspection Report 50-483/9611 identified a similar occurrence when an

equipment operator pulled incorrect fuses and rendered centrifugal charging Pump A

inoperable. This licensee-identified and corrected violation is being treated as a

cited violation due to a repeat occurrence of a recent event (483/9614-01).

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c.

Conclusions

The inspectors concluded that the failure to pull the correct fuses was due to

personnel error.

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Miscellaneous Operations issues

08.1 Technical Specification interpretations (71707)

During a review of Callaway Technical Specification Interpretations, the inspectors

noted that NRC personnel were identified as giving concurrence for the positions

taken in two of them:

Technical Specification interpretation 1 - Emergency Core Cooling System

Accumulators, and

Technical Specification Interpretation 4 - Turbine Overspeed Protection.

The inspectors informed the licensee that this form of NRC involvement is not

recognized by the Commission and is not an acceptable practice. However, the

referencing of official NRC correspondence in a licensee Technical Specification

Interpretation is acceptable. The inspectors requested that the licensee remove any

informal references to NRC review and/or approval from their Technical

Specification Interpretations. The licensee's Onsite Review Committee had already

approved removing these interpretations from the Technical Specifications.

II. Maintenance

M1

Conduct of Maintenance

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a,

inspection Scope (62707)

The inspectors observed or reviewed portions of the following work activities:

Work Activity P541890- Centrifugal Charging Pump A Motor Bearing Oil

Sight Glass Leaks,

Work Activity W175769- Rebuild Spare Feedwater Isolation Valve Actuator,

Work Activity P548345- Clean and inspect Feeder Circuit Breaker to Motor-

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Driven Auxiliary Feedwater Pump A,

Work Activity P548864- Calibrate Auxiliary Feedwater Flow to Steam

Generator B Feed Flow Transmitter, and

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Work Activity P576360- Cold Weather Preparations.

b.

Observations and Findinas

Except as noted in paragraph M1.3, the inspectors found no concerns with the

maintenance observed. All work observed was performed with the work packages

present and in active use. The inspectors frequently observed supervisors and

system engineers monitoring job progress, and quality control personnel were

present when required. Housekeeping and foreign material exclusion controls were

satisfactory.

M1.2 General Comments - Surveillance

a.

Inspection Scope (61726)

The inspectors observed all or portions of the following test activities:

Surveillance Procedure OSP-EF-P001 A- Emergency Service Water Train A

Operability,

Surveillance Procedure OSP-NE-0001 A- Standby Diesel Generator A Periodic

Tests, and

Surveillance Procedure OSP-SA-0017A- Train A Safety injection System -

Containment Spray Actuation System Slave Relay Test.

b.

Observations and Findinas

Surveillance testing observed during this inspection period was conducted

satisfactorily in accordance with the licensee's approved programs and the

Technical Specifications.

M 1.3 Feedwater Isolation Valve Actuator Hydraulic Leaks

a.

Insnection Scooe (62707)

On November 29,1996, the actuator on feedwater isolation Valve AEFV0042 for

Steam Generator D, developed a hydraulic leak on both hydraulic system trains.

Each train is capable of independently closing the feedwater isolation valve upon

receiving a feedwater system isolation signal. The inspectors reviewed the

licensee's efforts to repair the actuator and determine the root cause of the leaks.

b.

Observations and Findinas

The licensee discovered that the wrong size O-rings had been installed on both

hydraulic system trains for the actuator on Valve AEFV0042. Although the inside

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diameter of the O-rings was correct, the thickness was incorrect. As the hydraulic

pressure'in the actuator cycled during normal operation, the O-ring material wore '

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away which established a leak path outside the valve.

The licensee ' determined the root cause to be a maintenance error during

refurbishment of a spare hydraulic actuator for Valve AEFV0042. Workers

refurbished the spare actuator just prior to the recent refueling outage. This

refurbishment included installing new O-rings on the hydraulic trains on October 8,

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1996. However, some of the O-rings were the incorrect size. The licensee later-

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replaced the existing actuator on AEFV0042 with the newly refurbished spare (with

the iicorrect 0-rings) during the refueling outage as part of an overall preventive

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maintenance task.

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In December 1996, during the licensee's followup investigation after the leak was

discovered, the licensee inspected several dozen 0-rings and found a total of 17

incorrect 0-rings that had been installed in both hydraulic trains in Valve

AEHVOO42. The licensee replaced these with the correct 0-rings.

The licensee held a multidisciplinary review to determine the root cause of and

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corrective actions for this event. As a result, the licensee initiated a case study of

this event due to the broad scope of potential corrective actions.

The licensee's short term corrective actions included successfully repairing the valve

and testing a representative sample of O-rings in stock to ensure no other O-ring

problems existed. No incorrect 0-rings were identified.

The licensee's long term corrective actions include the case study, which

addresses:

Ensuring correct drawings are specified and available in work packages,

Reviewing material control wording to clear up confusing nomenclature on

parts sizing,

Ensuring adequate work planning and coordination for complex maintenance

efforts, and

Conducting training on the results of the case study for the various

disciplines involved in maintenance activities.

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The inspectors reviewed the work package used to refurbish the actuator on

AEFV0042 just prior to the refueling outage. The inspectors found that the

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supervisor in charge of the job did not thoroughly review the work package for

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information on replacement 0-rings. Information on replacement 0-rings of the

correct size and material was available in the work package.

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Criterion V of Appendix B to 10 CFR Part 50 requires, in part, that activities

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affecting quality shall be prescribed by documented instructions, procedures, and

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drawings appropriate to the circumstances and shall be accomplished in accordance

with these instructions, procedures, or drawings. The failure to adhere to this

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requirement is considered a violation of Criterion V of Appendix B to 10 CFR

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Part 50. This licensee-identified and corrected violation is being treated as a

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noncited violation, consistent with Section Vll.B.1 of the NRC Enforcement Policy

(483/9614-02).

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c.

Conclusions

The inspectors concluded that the licensee's actions to determine the reason for the

leak were thorough. The inspectors also found the licensee's repair of the leaking

hydraulic components to be satisf actory. The licensee's control of O-ring material

for rebuilding the feedwater isolation valve actuator was lacking.

Ill. Enaineerina

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Conduct of Engineering

E1.1

fnaineerina Involvement in Plant Activities (37551)-

The inspectors noted that engineering was appropriately involved in plant activities

during this inspection period. The inspectors noted that system engineers

conducted plant walkdowns of assigned systems for cold weather preparations as

discussed in Section O2.2 of this report. Expectations were included on a

management policy entitled " System Walkdowns," NE-System Walkdown-01,

Revision 1. In addition, plant engineers participated in the multidisciplinary case

study team and root cause evaluation for the failure of feedwater isolation Valve

AEFV0042 (Section M1.3). The inspectors had no concerns,

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Engineering Support of Facilities and Equipment

E2.1

Review of Facility Conformance to Uodated Final Safety Analvsis Report

Commitments

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A recent discovery of a licensee operating their f acility in a manner contrary to the

Final Safety Analysis Report description highlighted the need for a special focused

review that compares plant practices, procedures, and/or parameters to the Final

Safety Analysis Report description. While performing the inspections discussed in

this report, the inspectors reviewed the applicable portions of the Final Safety

Analysis Report that related to the areas inspected. No inconsistencies were noted

between the wording of the Updated Safety Analysis Report and the plant practices,

procedures, and/or parameters observed by the inspectors,

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IV. Plant SuDDort

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Radiological Protection and Chemistry (RP&C) Controls

R 1.1

Radioloaical Protection Proaram Observations

The inspectors toured various areas of the radiologically controlled areas of the

plant. Health physics personnel were observed routinely touring the radiologically

controlled areas. Licensee personnel observed performing work in radiological

control areas exhibited good radiation worker practices. Contaminated areas and

high radiation areas were properly posted. Area surveys posted outside rooms in

the auxiliary building were current.

P3.1

Licensee Onshift Dose Assessment Capabilities

a.

Insoection Scoce (Tl 2515/134)

Using Temporary Instruction 2515/134,the inspectors gathered information

regarding:

Dose assessment commitment in emergency plan,

Onshift dose assessment emergency plan implementing procedure, and

Onshift dose assessment training.

b.

Observations and Findinas

On December 17,1996, the inspectors conducted an inoffice review of the

emergency plan and implementing procedures to obtain the information requested

by the temporary instruction. The inspectors also conducted a telephone interview

with the licensee on December 17,1996, to verify the results of the review. Based

on the documentation review and the licensee interview, the inspectors determined

that the licensee had the capability to perform onshift dose assessments using real-

time effluent monitor and meteorological data and that the commitment was clearly

described in the emergency plan and implementing procedures.

c.

Conclusion

The commitment to perform onshift dose assessments was clearly described in the

emergency plan and implementing procedures. Further evaluation of the information

obtained using the temporary instruction will be conducted by NRC Headquarters

personnel.

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V. Manaaement Meetinas

X1

Exit Meeting Summary

The exit meeting was conducted on January 3,1997. The licensee expressed a

position on the subject of the violation in this report.

During the discussion of the equipment operator inadvertently pulling the wrong

fuse which caused operators to reduce plant power (Section 04.1), the licensee

stated that the event was not significant enough to merit a violation for the

following reasons:

The licensee disagreed that a procedure violation occurred given a literal

interpretation of the equipment control tagging procedure,

The licensee stated that 10 CFR 50, Appendix B, did not apply to the non-

safety related fuse, and

The licensee stated that the equipment control tagging procedure was a

reference-use procedure.

The inspectors asked the licensee whether any materials examined during the

inspection shou!d be considered proprietary. No proprietary information was

identified.

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ATTACHMENT

SUPPLEMENTAL INFORMATION

PARTIAL LIST OF PERSONS CONTACTED

Licensee

J. D. Blosser, Manager, Operations Support

H. D. Bono, Supervising Engineer, Licensing Fuels and Site Licensing

D. G. Cornwell, General Supervisor, Maintenance

R. T. Lamb, Superintendent, Operations

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J. V. Laux, Manager, Quality Assurance

D. W. Neterer, Shif t Supervisor

J. R. Peevy, Manager, Emergency Preparedness and

Organizational Support

G. L. Randolph, Vice President, Nuclear Operations

M. A. Reidmeyer, Engineer, Quality Assurance

R. R. Roselius, Superintendent, Chemistry and Rad Waste

J. D. Schnack, Engineer, Quality Assurance

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T. P. Sharkey, Supervising Engineer, Nuclear Operations

INSP_fCTION PROCEDURES USED

IP 37551:

Onsite Engineering

IP 61726:

Surveillance Observations

IP 62707:

Maintenance Observations

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IP 71707:

Plant Operations

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IP 93702:

Prompt Onsite Response to Events at Operating Power Reactors

Tl 2515/134

Licensee Onshift Dose Assessment Capabilities

ITEMS OPENED CLOSED, AND DISCUSSED

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Ooened

9614-01

VIO

Equipment Operator Pulled Incorrect Fuse (Section 04.1)

9614-02

NCV

Leaking 0-Rings On Feedwater isolation Valve AEFV0042

For Steam Generator D (Section M1.3)

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Closed

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9614-02

NCV

Leaking O-Rings On Feedwater Isolation Valve AEFV0042

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For Steam Generator D (Section M1.3)

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LIST OF DOCUMENTS REVIEWED

Emeroency Plan imolementina Procedures

EIP-ZZ-00101

Classification of Emergencies

Revision 19

ElP-ZZ-00102

Emergency implementing Actions

Revision 15

EIP-ZZ-01211

Management Action Guides for

Revision 18

Nuclear Emergencies

Other Documents

Callaway Radiological Emergency Response Plan

Revision 20

CN 96-02