EA-96-355 - Zion 1 & 2 (Commonwealth Edison Co.)

March 12, 1997

EA 96-355

Mr. J. H. Mueller
Site Vice President
Zion Station
Commonwealth Edison Company
101 Shiloh Boulevard
Zion, IL 60099

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $100,000 (NRC Inspection Report Nos. 50-295/96011; 50-304/96011)

Dear Mr. Mueller:

This refers to the engineering and technical support inspection conducted from July 22 through August 22, 1996, at the Zion Nuclear Generating facility. The inspection included a review of engineering processes and modifications. The report documenting this inspection was sent to you by letter dated October 22, 1996. A closed predecisional enforcement conference was conducted in Region III on November 11, 1996.

Based on the information developed during the inspection and the information that you provided during the conference, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) and the circumstances surrounding them are described in detail in the subject inspection report.

The violations in Section I of the Notice involved: 1) examples of a failure to perform adequate 10 CFR 50.59 analyses for modifications on safety-related systems; 2) examples of failure to follow procedures in the areas of modifications, corrective actions, operations and maintenance; 3) examples of failure to conduct tests to demonstrate systems would perform satisfactorily following modification; and 4) examples of failure to take prompt corrective action for significant conditions adverse to quality involving repetitive out-of-tolerance settings for containment spray system sodium hydroxide spray additive tank level indication and repetitive failures of a 4KV breaker.

These violations provide examples where your staff's processes for performing engineering activities on safety-related and non-safety-related structures, systems and components were either weak or were not adequately implemented. NRC identified that a number of 10 CFR 50.59 safety evaluations for modifications were inadequate, the process for closing modification packages was deficient, and that the status of post-modification testing was, in many cases, indeterminate. For example, 9 safety-related and 19 non-safety-related modifications were installed and placed in service from the mid-1980s through 1996 without verifying that the modification packages were completed. For the majority of these packages, the status of post-modification testing could not be determined because the documentation in the package regarding post-modification testing was inadequate or missing entirely. The NRC also identified weak operability assessments, inappropriate Technical Specification interpretations, and that the Updated Final Safety Analysis Report conformance review deficiencies were not properly documented in the corrective action program.

Of further concern was the fact that internal assessments by your Safety Assessment and Quality Verification (SAQV) organization had documented similar 10 CFR 50.59 evaluation and engineering process problems and that corrective actions to the findings were either untimely or not implemented at all. The root cause of these problems was attributed to weak management involvement and oversight, a lack of a questioning attitude in both the operations and engineering staffs, and a poor corrective action program associated with engineering problems.

Your staff indicated at the predecisional enforcement conference that the individual violations were not safety significant and that safety consequences were minimal. However, your staff acknowledged that the violations had regulatory significance because of the fact that safety-related systems were modified and returned to service without adequate safety evaluations, completion of the modification packages, or knowledge of the status of post-modification testing. Lacking this important information regarding the modifications, Commonwealth Edison Company could not establish that the modified systems would function as expected and would not impact other safety-related systems with regard to their ability to perform as intended. In addition, weak operability assessments, inappropriate Technical Specification interpretations and poor followup of Final Safety Analysis Report conformance issues further questioned the ability of systems to perform as intended.

Collectively, the NRC considers that these violations represent a significant breakdown in the control of licensed activities involving a number of violations that are related and represent a significant lack of attention by your staff toward engineering activities. Therefore, in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, these violations are classified in the aggregate as a Severity Level III problem.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $50,000 is considered for a Severity Level III problem. Because your facility has been the subject of escalated enforcement actions within the last two years,¹ the NRC considered whether credit was warranted for Identification and Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Credit was not warranted for Identification because the NRC identified the violations. As to the factor of Corrective Action, credit was warranted because your corrective actions, once the violations were identified by the NRC, were considered prompt and comprehensive. These actions, which were discussed during the conference, included: 1) a review of 10 CFR 50.59 evaluations for quality and content and a review of operability evaluations for consistency; 2) clarification of management expectations for the operations and engineering staffs; 3) addition of several checks and balances for reviewing engineering activities including additional in-line reviews and initiation of a Safety Evaluation Review Committee; 4) initiation of a dual independent review of system engineering tests during the Unit 2 refueling outage; 5) revision of relevant procedures; and 6) improvements in training for the operations and engineering staffs regarding operability evaluations and engineering activities related to modifications and post-modification testing.

In accordance with the civil penalty assessment process, a base civil penalty in the amount of $50,000 would normally be issued in this case. However, I have been authorized after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regulatory Effectiveness, Program Oversight, Investigations, and Enforcement, to exercise discretion and escalate the base civil penalty in accordance with Section VII.A.1 of the Enforcement Policy. The NRC is taking this discretionary action because of: 1) the fact that the root causes of the problem existed for an extended duration and 2) past ineffective corrective action, including failures to effectively address several of these same root causes when they were identified by your own organization. Therefore, to emphasize the importance of performing thorough engineering activities in accordance with NRC requirements, responding to findings of your own self-assessments with effective corrective actions, and providing appropriate management oversight of your engineering organization, a civil penalty of $100,000 is being proposed.

The violation described in Section II of the Notice addresses a failure to indicate by the use of a suitable process the status of tests for safety-related systems, structures and components. This violation was classified in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, as a Severity Level IV violation.

You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. The NRC will use your response, in part, to determine whether further enforcement action is necessary to ensure compliance with regulatory requirements.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response will be placed in the NRC Public Document Room.

Sincerely, Original signed by A. Bill Beach A. Bill Beach Regional Administrator

Docket Nos. 50-295; 50-304
License Nos. DPR-39; DPR-48

Enclosure:
Notice of Violation and Proposed
Imposition of Civil Penalty

cc w/encl:
T. J. Maiman, Senior Vice President
Nuclear Operations Division
D. A. Sager, Vice President
Generation Support
H. W. Keiser, Chief Nuclear
Operating Officer
R. Starkey, Plant General Manager
R. Godley, Regulatory Assurance
Supervisor
I. Johnson, Acting Nuclear
Regulatory Services Manager
Richard Hubbard
Nathan Schloss, Economist
Office of the Attorney General
Mayor, City of Zion
State Liaison Officer, Wisconsin
State Liaison Officer
Chairman, Illinois Commerce Commission
Document Control Desk - Licensing

---

NOTICE OF VIOLATION
AND
PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company Docket No. 50-295; 50-304 Zion Generating Station License No. DPR-39; DPR-48 EA 96-355

During an NRC inspection conducted on July 22 through August 22, 1996, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the NRC proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:

I. Violations Assessed A Civil Penalty

A. 10 CFR 50.59(a)(1) states, in part, that a licensee may make changes in the facility as described in the safety analysis report without prior Commission approval unless the change involves a change in the technical specification incorporated in the license or an unreviewed safety question. 10 CFR 50.59(b)(1) states, in part, that the licensee shall maintain records of changes in the facility and of changes in the facility made pursuant to this section, to the extent that these changes constitute changes in the facility and in procedures as described in the safety analysis report. These records must include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question.

1. The Zion Updated Final Safety Analysis Report (UFSAR) at Section 6.3 describes the safety injection system and Figure 6.3-1 indicates that there is no heat tracing installed on the safety injection (SI) pumps' minimum flow recirculation piping.

   Contrary to the above, on March 18, 1996, the licensee did not perform an adequate safety evaluation to determine whether temporary alteration 96-014, "Installation of Heat Tracing and Insulation on the SI Recirculation Line," constituted an unreviewed safety question. Specifically, the safety evaluation was deficient because it did not provide the basis for the determination that the installation of heat tracing did not change the SI system operating characteristics. (01013)

2. The Zion UFSAR at Table 6.2-4 states that there is no seal water system function for containment penetration P-4.

   Contrary to the above, as of October 1995, the licensee did not perform an adequate safety evaluation to determine whether the safety related plant change implemented by E22-1(2)-5-218, "MOV SI-8803A/B Bypass Line Addition," constituted an unreviewed safety question. Specifically, the evaluation was deficient in that it took credit for the seal water system as a containment isolation function for penetration P-4. (01023)

3. The Zion UFSAR at Section 6.3.2 describes the safety injection tanks and Section 5.4.11.2 describes the pressurizer relief tank. In addition, the UFSAR did not describe the acceptability of leaving temporary scaffolding in the containment during power operation.

   Contrary to the above, as of November 16, 1995, the licensee did not perform an adequate safety evaluation to determine whether safety evaluation 50.59/0166/95, which authorized temporary scaffolding to remain in the containment (around the safety injection tanks and in contact with the pressurizer relief tank), constituted an unreviewed safety question. Specifically, the evaluation failed to consider the effect the scaffolding could have on piping and instrumentation, pipe break effects, and/or thermal growth. (01033)

B. 10 CFR 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," states, in part, that activities affecting quality shall be appropriate to the circumstances and shall be prescribed by documented instructions, procedures, or drawings and shall be accomplished in accordance with these instructions, procedures and drawings.

1. Zion administrative procedure (ZAP) 510-02, "Plant Modification Program" (Rev 5(G) dated December 19, 1995), at Steps G.6.d, "Quality Control," G.6.e, "System Engineer," G.7.c, "Modification Coordinator," and G.7.d, "System Engineer Supervisor," required verification by each respective individual or department that the plant modification was complete prior to placing the effected equipment in service.

   Contrary to the above, as of August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that the following safety-related modifications were not accomplished in accordance with ZAP 510-02. Specifically the components associated with each modification listed below were "declared operable" before the required verifications by either the Quality Control department, System Engineer, Modification Coordinator, or System Engineer Supervisor were complete. (01043)

   a. Modification E22-1-90-016B, "NIS source and intermediate range replacement with accident monitoring qualified instrumentation;"

   b. Modification E22-1(2)-93-248, "Change steam supply to auxiliary feed pump traps to choke traps;"

   c. Modification M22-0-84-001, "Process radiation monitor signal (OP1A-PR29) to control room isolation and safety injection;" and

   d. Modification M22-1(2)-84-052, "Receptacle on battery charger and test switch."

2. Zion administrative procedure (ZAP) 700-08, 0, "Problem Identification Process" (Rev 1 dated June 29, 1996), at Item 16 of Appendix A, required generation of Problem Identification Forms (PIFs) for events or conditions identified by an assessment group.

   Contrary to the above, as of August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that approximately 114 deficient conditions identified by the UFSAR conformance review group (an assessment group) were not documented on PIFs as required by Item 16 to Appendix A of ZAP 700-08. (01053)

3. ZAP 920-01, "Site Scaffolding Procedure" (Rev 1 dated November 7, 1995), at step F.16 requires monthly inspections of installed scaffolding.

   Contrary to the above, from November 15, 1995, to August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that a monthly inspection of scaffolding installed around the safety injection accumulators was not performed as required by step F.16 of ZAP 920-01. (01063)

4. ZAP 500-13A, "Perform Monitoring, Evaluation, and Goal Setting Within the Maintenance Rule" (Rev 0 dated July 10), at step G requires system engineering to perform monthly updates of the material condition data base.

   Contrary to the above, as of August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that the material condition data base for the Auxiliary Power system was not updated as required by ZAP-500-13A. (01073)

5. 5. ZAP 510-02, "Plant Modification Program" (Rev 5(G) dated December 19, 1995), at Section G.7 requires that all drawings or diagrams affected by a design package shall be updated.

   Contrary to the above, as of August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that diagrams of safety related degraded voltage relays were not updated subsequent to relay revisions as required by ZAP 510-02. Specifically, diagrams 22E-1-4000H, 22E-1-4000J, 22E-2-4000H, 22E-2-4000J, 22E-1-4000C, and 22-E-2-4000C had not been revised. (01083)

6. 6. ZAP 130-02, "Technical Specification Interpretation" (Rev 0 dated October 18, 1995), at step G.1.h requires that a Technical Specification (TS) Interpretation (TSI) shall not change the intent of the applicable TS.

   Contrary to the above, as of August 22, 1996, the licensee failed to follow procedures, for activities affecting quality, in that the following TSIs had not been reviewed to determine if the TSI altered the intent of the applicable TS as required by ZAP 130-02. (01093)

   a. TSI 89-03 altered the intent of TS 4.3.1.A.4.b. by allowing the use of narrow range steam generator water level to determine reactor coolant loop operability. TS 4.3.1.A.4.b. specified the use of wide range steam generator water level in determining reactor coolant loop operability.

   b. TSI 95-03 altered the intent of TS 3.13.1.A.4 by suspending residual heat removal operation for up to one hour in an eight hour period during core alterations. TS 3.13.1.A.4 requires at least one residual heat removal pump and heat exchanger be in operation during core alteration.

   c. TSI 89-02 altered the intent of TSs 3.7.2 and 4.7.2 by permitting auxiliary feedwater flowpath valve verification instead of auxiliary feedwater flowrate when verifying auxiliary feedwater pump operability.

   d. TSI 91-05 altered the intent of TSs 3.8.7.A, B, and C by increasing the time limit that the licensee can take to place the unit in hot shutdown if service water pumps become inoperable.

   e. TSI 86-03 altered the intent of TSs 3.22.1.A, 3.22.2.A, 4.22.1.A.3 and 4.22.2.A.3 by permitting a visual examination instead of an engineering evaluation for components that were attached to a snubber that had failed a functional test.

C. 10 CFR 50, Appendix B, Criterion XI, "Test Control," states, in part, that a test program shall be established to assure that all testing required to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. Test results shall be documented and evaluated to assure that test requirements have been satisfied.

Contrary to the above, the licensee failed to establish an effective testing program as evidenced by the following examples: (01103)

1. As of August 22, 1996, the licensee's test program did not assure that all testing required to demonstrate that the following modifications would perform satisfactorily was completed prior to placing the modified systems in service.

   a. Modification E22-1-90-016B, "Replace NIS Source and Intermediate Range with Accident Monitoring Qualified Instrumentation," was placed in service in January 1994, however, the test documentation and loop calibrations for the NIS loop drawers could not be located.

   b. Modification E22-1(2)-93-248, "Replacement of Turbine Driven Auxiliary Feed Pump Steam Traps," was placed in service in February 1996 without performing the testing specified in Modification E22-1(2)-93-248.

   c. Modification M22-0-84-001, "Process Radiation Monitor Signal (OP1A-PR29) to Control Room Isolation and Safety Injection," was placed in service in 1989 without performing the testing specified in Modification M22-0-84-001.

   d. Modification M22-1(2)-84-052, "Battery Charger Receptacle and Test Switch," was placed in service in 1986 without performing any post-modification testing.

2. As of August 22, 1996, the emergency core cooling system full flow test procedure TSS 15.6.84, "Charging and Safety Injection Flow Test" (Rev 24 dated October 25, 1995), that was performed on October 22, 1995, failed to incorporate acceptance criteria to address the Small Break Loss of Coolant Accident (LOCA) flow requirements contained in RSA:92-217, "Zion Small Break LOCA Analysis."

D. 10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.

Contrary to the above, the licensee failed to establish measures to assure that significant conditions adverse to quality are promptly identified and corrected as evidenced by the following examples (01123):

1. As of August 22, 1996, measures were not taken to determine the cause of and correct a significant condition adverse to quality pertaining to the repetitive out of tolerance settings for the containment spray sodium hydroxide spray additive tank level indication.

2. As of August 22, 1996, measures were not taken to correct a significant condition adverse to quality pertaining to the repetitive failures of 4KV Breaker No. 1412, "Reserve Feed Breaker," for the Unit 2 Engineering Safeguard Feature Busses.

This is a Severity Level III problem (Supplement I).
Civil Penalty - $100,000

II. Violation Not Assessed a Civil Penalty

10 CFR 50, Appendix B, Criterion XIV, "Inspection, Test, and Operating Status," states, in part, that measures shall be established to indicate, by the use of markings or other suitable means, the status of inspections and tests performed upon individual items of a nuclear power plant. These measures shall provide for the identification of items which have satisfactorily passed required inspections and tests, where necessary to preclude inadvertent bypassing of such inspections and tests.

Contrary to the above, as of August 6, 1996, the following safety-related modifications did not contain measures to status tests performed upon individual items of the modifications and did not provide for the identification of items that had satisfactorily passed testing required by the modifications prior to placing them in service where necessary to preclude inadvertent bypassing of such tests. (02014)

A. Modification E22-1-90-016B, "Replace NIS Source and Intermediate Range with Accident Monitoring Qualified Instrumentation;"

B. Modification E22-1(2)-93-248, "Replacement of Turbine Driven Auxiliary Feed Pump Steam Traps;"

C. Modification M22-0-84-001, "Process Radiation Monitor Signal (OP1A-PR29) to Control Room Isolation and Safety Injection;" and

D. Modification M22-1(2)-84-052, "Battery Charger Receptacle and Test Switch."

This is a Severity Level IV violation (Supplement I).

Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice of Violation and Proposed Imposition of Civil Penalty (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order or a Demand for Information may be issued as why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.

Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, money order, or electronic transfer payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part, by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an "Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice, in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.

In requesting mitigation of the proposed penalty, the factors addressed in Section VI.B.2 of the Enforcement Policy should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.

Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.

The response noted above (Reply to Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: James Lieberman, Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, One White Flint North, 11555 Rockville Pike, Rockville, MD 20852-2738, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III.

Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the disclosure of information will create an unwarranted invasion of personal privacy or provide the information required by 10 CFR 2.790(b) to support a request for withholding confidential commercial or financial information). If safeguards information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.

Dated at Lisle, Illinois,
this 12th day of March 1997

---

^1. A Severity Level III violation with a $50,000 civil penalty was issued on August 23, 1996 (EA 96-216) for a series of eight operational errors and unplanned changes to the status of safety related equipment; and a $50,000 civil penalty was issued on February 21, 1996, (EA 95-283) for failure to properly maintain emergency lighting.