IR 05000336/2010006

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IR 05000336-10-006 and 05000423-10-006; 02/08/10 - 02/25/2010; Millstone Power Station Unit 2 and Unit 3; Baseline Inspection of the Identification and Resolution of Problems
ML100920425
Person / Time
Site: Millstone  Dominion icon.png
Issue date: 04/02/2010
From: Diane Jackson
NRC/RGN-I/DRP/PB5
To: Heacock D
Dominion Resources
Jackson D E, RGN-I/DRP/PB5/610-337-5306
References
FOIA/PA-2011-0115 IR-10-006
Download: ML100920425 (28)


Text

April 2, 2010

SUBJECT:

MILLSTONE POWER STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000336f2010006 AND 05000423f2010006

Dear Mr. Heacock:

On February 25.2010, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Millstone Power Station Unit 2 and Unit 3. The enclosed inspection report documents the inspection results, which were discussed on February 25,2010. with Mr. A. J. Jordan, and other members of your staff.

This inspection was an examination of activities conducted under your license as they relate to the identification and resolution of problems, and compliance with the Commission's rules and regulations and conditions of your license. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.

On the basis of the sample selected for review, there were no findings of significance identified during this inspection. The team concluded that Dominion was generally effective in identifying, evaluating, and resolving problems. Dominion personnel identified problems and entered them into the corrective action program at a low threshold. Dominion prioritized and evaluated issues commensurate with their safety significance and corrective actions were generally implemented in a timely manner. However, some examples of minor problems were identified, including conditions adverse to quality that were not being entered into the corrective action program, condition report evaluations that were not properly prioritized or contained weaknesses, and corrective actions that were not fully effective. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of the NRC's document system (ADAMS). ADAMS is accessible from the NRC Web Site at http://www.nrc.gov/reading-rm/adams.html(the Public Electronic Reading Room).

nf~~--

Donald E. Ja n, Chief Projects Branch 5 Division of Reactor Projects Docket Nos.

50-336,50-423 License Nos. DPR-65, NPF-49 Enclosure: Inspection Report 05000336/2010006 and 05000423/2010006 w/Attachment: Supplemental Information ccw/encl:

Distribution via ListServ

SUMMARY OF FINDINGS

IR 05000336/2010006 and 05000423/2010006; 02/08/10 - 02125/10; Millstone Power Station

Unit 2 and Unit 3; Baseline Inspection of the Identification and Resolution of Problems.

This NRC team inspection was performed by one resident inspector and three regional inspectors. No findings of significance were identified. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 2006.

Identification and Resolution of Problems The team concluded that Dominion was generally effective in identifying, evaluating, and resolving problems. Workers identified problems, entered them into the corrective action program at a low threshold, and prioritized issues commensurate with the safety significance.

For most cases, Dominion appropriately screened issues for operability and reportability and performed causal analyses that appropriately considered extent of condition, generic issues, and previous occurrences. Corrective actions taken to address the problems identified in Dominion's corrective action process were typically implemented in a timely manner. However, some examples of minor problems were identified, including conditions adverse to quality that were not being entered into the corrective action program, condition report evaluations that were not properly prioritized or contained weaknesses, and corrective actions that were not fully effective.

The team concluded that. in general, Dominion adequately identified, reviewed, and applied relevant industry operating experience to Millstone operations. In additioo, based on those items selected for review by the team. Dominion's audits and self-assessments were thorough and probing.

Based on the interviews the team conducted over the course of the inspection, observations of plant activities, and reviews of individual corrective action program and employees concerns program issues, the team did not identify any concerns that site personnel were not willing to raise safety issues, nor did they identify conditions that could have had a negative impact on the site's safety conscious work environment.

NRC-Identified and Self-Revealing Findings

No findings of significance were identified.

Other Findings

A violation of very low safety significance, identified by Dominion, was reviewed by the team.

Corrective actions taken or planned by Dominion have been entered into Dominion's corrective action program. This violation and the corrective action tracking number are documented in Section 40A7 of this report.

.1

REPORT DETAILS

OTHER ACTIVITIES (OA)

40A2 Problem Identification and Resolytion (711528) Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The team reviewed the procedures that describe Dominion's Corrective Action Program (CAP) at Millstone Power Station Unit 2 and Unit 3. Dominion identified problems for evaluation and resolution by initiating and processing condition reports (CR) using the Central Reporting System. Condition Reports were screened for operability and reportability, were aSSigned a significance level (1, most significant to 4, least significant), and were assigned a level of evaluation (based on significance level and type of deviating condition). When maintenance was necessary to correct a problem, the work management process was used to generate work orders.

To assess the effectiveness of the CAP at MlIIstone, the team reviewed performance in three primary areas; problem identification, prioritization and evaluation, and corrective action implementation. The team compared performance in these three areas to the requirements and standards contained in 10 CFR 50, Appendix 8. Criterion XVI.

"Corrective Action," and Dominion procedure, PI-AA-200, "Corrective Action." The scope of the team's review for each of these areas is described below. The CRs and other documents reviewed for the inspection are listed in the Attachment.

Effectiveness of Problem Identification The team reviewed a sample of CRs identified since the last NRC problem identification and resolution inspection performed in February 2008. The team considered risk insights from the station's risk analysis and ensured that the selected CRs were appropriately distributed across the seven cornerstones of safety and were representative of deficiencies in the emergency preparedness. engineering, maintenance, operations, chemistry, physical security, and radiation protection functional areas. The team expanded the corrective action review to five years for evaluation of the Millstone 2 service water system.

The team selected items from various processes at Millstone to verify that they were appropriately considered for entry into the CAP. Specifically, the team reviewed a sample of selfKassessments, audits, corrective and preventive maintenance work orders, operator and security Jogs, completed tests, and system health reports. The team completed several risk-informed field walkdowns of the accessible portions of safety related and important to safety systems and components at both units to ensure that Dominion identified issues at an appropriate threshold. The team also toured various security posts to assess the material condition, equipment and personnel readiness, and CAP engagement. The team observed several shift turnover meetings in the control room and portions of eqUipment operator daily rounds to assess Dominion's problem identification.

The team also verified that issues identified through internal self-assessments and audits and the operating experience (OpE) program were entered into the CAP for evaluation and resolution, as appropriate.

Effectiveness of Prioritization and Evaluation of Issues To assess Dominion's effectiveness in the prioritization of issues, the team observed several daily CR Review Team (CRT) screening meetings during the onsite weeks and reviewed the associated CR packages. During these daily meetings, the CRT members reviewed new CRs for priority, significance, and department assigned.

The issues and CRs reviewed encompassed the full range of evaluations, including root cause evaluations (RCE) and apparent cause evaluations (ACE). Condition reports that were assigned lower levels of significance and did not include formal cause evaluations were also reviewed by the team to ensure they were appropriately classified and processed. The team's review included determining the appropriateness of the assigned significance, the scope and depth of the causal analysis, and the timeliness of resolution. The team assessed whether the evaluations identified likely causes for the issues and whether Dominion developed appropriate corrective actions to address the identified causes. Further, the team reviewed eqUipment operability determinations, reportability assessments, and extent-of-condition reviews for selected problems to verify these evaluations adequately addressed equipment operability, reporting of issues to the NRC, and the extent of problems.

Finally, the team reviewed Corrective Action Review Board (CARB) actions and attended two CARB meetings during the inspection. DuringCARB meetings, Dominion managers review RCEs and certain ACEs, review associated corrective action assignments, and assess corrective action effectiveness.

Effectiveness of Corrective Actions The team reviewed completion of corrective actions for a sample of CRs issued since the last NRC problem identification and resolution inspection (February 2008) to determine whether the actions addressed the identified causes of the problems.

Corrective actions were verified to have been completed through documentation, and, in some cases, field walkdowns. The team also reviewed a sample of CR corrective actions that were open for greater than two years. The team selected these items based on risk significance. verified appropriate interim actions were in place and that the basis for not completing the remaining corrective actions were appropriately justified and documented.

The team reviewed CRs for adverse trends and repetitive problems to determine whether corrective actions were effective in addressing broader issues. The team reviewed Dominion's timeliness in implementing corrective actions and effectiveness in preventing recurrence for significant conditions adverse to quality. The team also reviewed a sample of CRs associated with selected NRC non-cited violations (NCV) and findings to verify that Dominion properly evaluated and resolved these issues. In addition, the corrective action review was expanded to five years to evaluate Dominion's actions related to system performance issues identified for the Millstone 2 service water system.

b. Asse§sment Effectiveness of Problem Identification The team concluded that, in general, Dominion identified problems and entered them into the CAP at a low threshold. Station workers accurately characterized and documented problems in CRs. The team observed that the CRT members appropriately challenged those CRs that lacked relevant or sufficient information. The team also observed that Dominion trended equipment performance and programmatic issues in order to identify emerging issues at a low level.

Based on the results of plant tours, the team found that Dominion maintained acceptable standards for housekeeping, cleanliness, and material condition with very few exceptions. The team found the boric acid corrosion control program was effective in identifying and resolving leaks. Workers identified boric acid issues at a low threshold and took actions to minimize boric acid deposit buildup. In addition, the team found fire doors to be generally well maintained and functional. Some minor challenges were identified by the team relative to hardware deficiency tags (some remained in place, however, the work had been completed) and the use of catch containers for leaks (some were in place without an associated deficiency tag or CR reference). The team noted that deficiency tags and catch containers left hanging after work completion potentially mask repeat or additional degraded conditions should they occur in the area. Dominion initiated CR 369332 to evaluate this issue.

The team noted some instances where conditions adverse to quality were not entered into the corrective action program. Examples are as follows:

  • Maintenance documented an *unanticipated failure" of a jacket water (JW) banjo bolt on emergency diesel generator (EDG) 3B in work order (WO) 53102270827; however, Dominion reviewed and closed the WO without taking any additional actions (see Section 40A2.1.c for additional details).
  • On December 15, 2009, maintenance implemented WO 53102283742 to address a 120 drop per minute JW leak on the No. 1 cylinder cooling water jumper that operators identified during an October 2009 test on EDG3B. Dominion proactively planned for and replaced the gaskets and o-rings on all 14 cylinders (not just the leaking one). Maintenance documented the as-found condition on EDG 38 as "reliability degraded" and noted that the gaskets and o-rings on al/ the cylinder water jumpers were hard and brittle. Dominion reviewed and closed the WO without taking any additional actions. The team inquired about the extent-of-condition relative to the redundant EDG 3A and was informed that Dominion had previously replaced all the gaskets and o-rings on EDG 3A during its 10-year preventive maintenance overhaul in 2003. In response to the team's questions, on February 24, 2010, Dominion initiated CR 369971 to identify that 1 O-year preventive maintenance on EDG 38 had not been performed (should have been done circa 2003). Based upon the information reviewed, including a review of EDG 38 performance, the team did not identify any EDG 3B failures since 2003 that could be attributed to the missed 10-year preventive maintenance activity. Based upon the guidance in IMC 0612, Appendix E, "Examples of Minor Issues," the team determined that Dominion's failure to perform the recommended preventive maintenance on EDG 38 was not a more than minor performance deficiency because EDG operability was not impacted.
  • In December 2009, maintenance documented in WO 53102283742 that the as-found EDG 36 mechanical governor speed setting was 22.3 and the as-left governor setting was 22.7. Dominion reviewed and closed the WO without taking any additional actions. Since maintenance changed the mechanical governor setting as part of the EDG run-in activity, the team assessed the operability of the EDG. The normal monthly EDG test was used as the post-maintenance test for the maintenance, but it did not verify governor response to confirm the design basis loading capability of the EDG. The team determined that maintenance did not comply with procedure MP 3720CD. "Slow Speed Start and Run-In of EDG Following Maintenance," which instructed technicians to ensure the mechanical governor speed control as-left setting was the same as its as-found position, or if different, to forward the as-left setting to Operations. As a result of the technicians' failure to follow MP 3720CD and an ineffective review of the WO documentation, the as-left EDG mechanical governor setting was not assessed for EDG continued operability.

In response, engineering determined that the EDG operability was not adversely impacted due to the small magnitude of the setting discrepancy and the fact that the mechanical governor is a backup to the electronic governor speed control, which had remained fully functional. Based upon the guidance in !MC 0612, Appendix E, "Examples of Minor Issues," the team determined that Dominion's failure to adequately control and evaluate EDG 38 mechanical governor setting was not a more than minor performance deficiency because EDG operability was not impacted in this case. Dominion initiated CR 370621 for this issue.

Effectiveness of Prioritization and Evaluation of Issues The team found that, in general, Dominion appropriately prioritized and evaluated issues commensurate with the safety significance of the identified problem. CRs were screened for operability and reportability, categorized by significance, and assigned to a department for evaluation and resolution. In addition, the CRT members considered human performance Issues, radiological safety concerns, repetitiveness. and potential adverse trends during their review of CRs.

The team found that causal analyses appropriately considered extent~of*condition, generic issues, and previous occurrences. Dominion's RCEs and ACEs were generally thorough and accurate, and the associated corrective and preventive actions addressed the identified causes. The corrective actions were adequately tracked within the CAP, and were generally implemented in a timely manner.

The team identified some minor weaknesses associated with issue prioritization and evaluation of issues, which are listed below:

  • . The team identified an instance where Dominion did not thoroughly evaluate a potentially degraded condition related to the "C' phase of the Unit 3 main generator breaker that failed in December 2009. In June 2009, the control room received a mechanical closing disagreement alarm on the main generator breaker. After an initial verification of plant conditions with limited instrumentation in the vicinity of the breaker and discussions with the vendor and another nuclear facility, Dominion concluded that the alarm was false even though they could not confinn that the alarm did not indicate a degraded condition. Dominion did not consider additional actions to thoroughly evaluate this potentially degraded condition, such as thermography or long term monitoring in response to the disagreement alarm. However, there was no conclusive indication that the June 2009 alarm was directly related to the December 2009 breaker failure, so no performance deficiency was identified.
  • The team noted that Dominion did not adequately prioritize the corrective action (CA 142992) to overhaul or replace the Unit 2 turbine driven auxiliary feedwater (TDAFW)pump steam trap (ST-156). On July 24. 200S, the TDAFW pump oversped and tripped during a steam supply valve test. Dominion determined that the apparent cause of the overspeed event was the inability of ST-156 to effectively remove condensate from the TDAFW steam supply line. The assigned corrective action for this apparent cause was to overhaul or replace the steam trap because it was not operating properly. Dominion originally prioritized this action as a medium priority and established a 90 day due date. As the action approached its original due date of November 11, 200S, the action was re-characterized as a long term corrective action and the due date was extended to January 2009. The team noted that Dominion extended this corrective action numerous additional times prior to another TDAFW overspeed event that occurred on July 24, 2009. Dominion identified the inability of ST-156 to effectively remove condensate from the TDAFW steam supply line as the apparent cause and self-identified their less than adequate corrective actions for the 2008 trip. The team noted that the overspeed event in July 2009 resulted in approximately 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br /> of unplanned unavailability on the TDAFW. (See Section 40A7 for documentation of the associated licensee-identified violation).

Effectiveness of Corrective Actions The team concluded that corrective actions for identified deficiencies were typically conducted in a timely fashion and were adequately implemented. Administrative controls were in place to ensure that corrective actions were completed as scheduled and reviews were performed to ensure the actions were implemented as intended. In some cases, Dominion appropriately self-identified ineffective or improper closeout of corrective actions and re-entered the issue into the CAP for further action. For significant conditions adverse to quality, the team noted that Dominion's actions were comprehensive and thorough. and generally successful at preventing recurrence. The team also concluded that Dominion performed in-depth effectiveness reviews for significant issues to verify that implemented corrective actions were effective. The CARB meetings observed by the team were characterized by probing and critical reviews of completed CR evaluations and aSSOCiated corrective actions.

Performance in the area of long-standing issues was, in general, adequate. The team noted that Dominion effectively addressed a long-standing degraded condition that had repeatedly impacted the Unit 2 charging pumps. Due to the potential for gas binding of the charging pumps, Dominion replaced a/l previously installed nitrogen filled bladder equipped pulsation dampeners with large, spherical liquid filled pulsation dampeners.

The team noted that the new pulsation dampeners also eliminated several related operator burdens, including additional compensatory charging pump pressure decay tests. There were, however, some long-standing problems for which corrective actions, to date, have not been fully effective:

  • The team reviewed three root cause evaluation reports associated with the Unit 2 and Unit 3 circulating water pumps (Unit 2 CR 04-05733, Unit 2 M-OS-00753, and Unit 3 RCE-07-11S13). The individual evaluations were generally thorough. and appropriately considered extent-of-condition, generic issues. industry operating experience, and previous occurrences. However, Dominion recently completed a study that determined that excessive component outage time for circulating water pumps and motors results in a single point vulnerability for the circulating water system and required corrective action (CR 109596). The r,t and 2nd Quarter 2009 health reports for the circulating water system revealed that the rating was "Yellow" for Unit 2 due to pump failure trends, increasing adverse impacts on reliability and resources, and an increasing number of modifications to compensate for graphitic corrosion aging of the pump casings. While not specifically covered in this inspection, on February 26, 2010 (See NRC Inspection Report 05000423/2010002).

operators initiated a manual reactor trip of Unit 2 due to a loss of an circulating water to one of the main condenser waterboxes. The '0' pump was out-of-service to facilitate maintenance work in the '0' pump bay. While preparations were being made to de-water the '0' pump bay, a high screen differential pressure occurred on the 'C' circulating water pump screen due to storm conditions, and the 'C' pump tripped automatically. The loss of both ofthese pumps required the operators to manually trip the Unit 2 reactor in accordance with plant procedures. The team concluded that unscheduled pump overhauls, increased maintenance activities and increased failure rates of the Unit 2 circulating water pumps due to long-term issues continued to cause increased system unavailability and resulting challenges.

  • The east 480 VAC vital switchgear room fan discharge damper (2-HV-274), which is safety-related. has had several issues, including CR 03-08199 (damper found failed),

CR 06-06396 (missed preventive maintenance), CR 06-06182 (damper 2-HV-274 stuck shut), and CR 367451 (broken control linkages and a preventive maintenance deferral which resulted in a failure). This damper is normally closed and opens when the associated fan starts to provide airflow to the vital switchgear room. The failure of this damper only causes a loss of a redundant ventilation system train in the east 480 VAC switchgear room, which is serviced by two ventilation systems. Dominion established appropriate compensatory actions each time the 2-HV-274 damper failed.

The team's review of the associated CRs revealed that this damper has a history of failures and that preventive maintenance deferrals have contributed to some of these failures since 2003. Dominion recognized that the damper has not been weI/

maintained and requires replacement; and replacement of the damper is planned per work order 53M2-07-08994.

The team concluded that performing required preventive maintenance activities beyond the prescribed intervals has increased the failure rate of damper 2-HV-274 due to long-term material degradation issues. However, individual damper failures have not resulted in associated Maintenance Rule functional failures due to component and design redundancy. Based upon the guidance in IMC 0612, Appendix E, "Examples of Minor Issues," the team determined that this issue was not a more than minor performance deficiency because switchgear room ventilation was not rendered inoperable due to individual component failures.

  • The team noted that operations at Unit 2 and Unit 3 have made some progress in their configuration control improvement plan; however, configuration control issues continued. Operations self-identified that actions from a 2006 ACE (CR 06-8350)

I, were not fully effective eliminating all their configuration control challenges. In January 2008, operations initiated CR 08-00914 to perform industry benchmarking and to take additional actions focused on improving their configuration control performance. The team noted that operations completed the majority of the actions stemming from this self-critical trend review CR; however, Dominion extended the due date for one of the action items and re-assigned the task numerous times over the past two years (current due date is April2010). The original action item was to conduct plant walkdowns to identify and then proactively protect (cover) all switche~

that were deemed bump hazards. The team did not identify any sensitive switches r

on the targeted list that factored into any plant events since January 2008; however, the team noted that Dominion did not properly prioritize this assignment given configuration control challenges at both units.

c. Findings

Unit 3 Degraded 8anjo 80lts on Emergency Diesel Generator 38

Introduction:

An unresolved item (URI) was identified because additional information from Dominion and additional NRC review and evaluation is needed to assess the existence of a performance deficiency and its associated characterization (Le., more than minor, and whether the issue constitutes a violation).

During the conduct of 38 EDG routine testing on February 11, 2010, a significant JW system leak occurred at a JW fitting to one of the 14 EDG cylinders. These fittings are referred to as "banjo bolts* due to their physical configuration resembling a bolt through the body of a banjo.

Description:

On July 22,2009, Dominion initiated CR 343051 to address minor JW leakage from the No. 13 cylinder on EDG 38. Dominion estimated the leak rate at approximately 60 drops per minute and determined that it did not have the potential to impact EDG operability. Dominion closed the CR to WO 53102270827. On September 22, 2009, operators tagged out EDG 38 for preventive maintenance on the service water side of the heat exchangers (WO 53102241548). Maintenance completed the planned work on the EDG and operators completed their pre-job briefing for EDG post maintenance testing. As operators were clearing tags and aligning the EDG for testing, maintenance called to report that during the performance of EDG minor maintenance under WO 53102283391 (to check the leak tightness of No. 13 cylinder banjo bolt), they had discovered that "the gasket appeared crushed or the JW fitting could be possibly cracked." They recommended that an immediate repair be pursued. Since the JW banjO bolt tightness check was performed as minor maintenance and not planned into the work window, there were no contingency parts on hand and a corrective maintenance work order was not ready in case of scope expansion. The emergent failure required draining the JW system and resulted in extending the EDG 38 unavailability beyond the original planned unavailability (although still within the technical specification allowed outage time). On September 22, 2009, maintenance repaired the JW leak by replacing a degraded banjo bolt on No. 13 cylinder using the original banjo bolt WO 53102270827. Maintenance documented an "unanticipated failure" of the broken banjo bolt in the WO package. Operations and maintenance supervision reviewed and closed WO 53102270827 with no additional actions taken.

On February 11, 2010, operations noted excessive JW leakage from No.3 cylinder during the EDG 38 monthly test, immediately declared the EDG inoperable, performed a I

controlled shutdown of the EDG, and iniUated CR 368610. The team walked down EDG 36 shortly after it was shut down and noted that operations had made an appropriate operability decision based on amount of JW that spilled on the floor and the magnitude of the JW leak rate with the EDG shutdown. Dominion determined that the JW leak was from a cracked banjo bolt. The cracked banjo bolt resulted in approximately 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> of unplanned unavailability on EDG 38. Maintenance replaced the banjo bolt on NO.3 cylinder and operations declared theEDG operable on February 12 following post maintenance testing. On February 22,2010, maintenance replaced the banjo bolts on all 14 cylinders on EDG 3B, resulting in approximately ten more hours of EDG unavailability. On February 23,2010, preliminary results from a magnetic particle inspection of the removed EDG 38 banjo bolts revealed seven additional cracked bolts (CR 369856). On February 23, 2010, maintenance replaced aI/ the banjo bolts on the redundant EDG 3A to address the extent-of-condition. Dominion's initial review of the banjo bolts removed from EDG 3A did not identify any degraded bolts similar to those removed from EDG 38.

The team noted that Dominion took prompt and appropriate corrective actions following the emergent banjo bolt failure on February 11: however, the team identified that Dominion had not initiated a corrective action CR in September 2009 when they had identified the first failed banjo bolt. The team noted that this represented a missed opportunity to evaluate the deficiency within Dominion's CAP, and may have precluded the emergent EDG unavailability in February 2010. Specifically, Dominion procedure PI M-200, "Corrective Action," Attachment 1, listed examples of conditions that require a CR, several of which were applicable to the "unanticipated failure" of the banjo bolt, including 1) deficiencies or adverse conditions identified during performance of work. 2)a component failure that is outside of what would normally be expected, and 3)documentation of eqUipment failures. The team identified that Dominion did not initiate a new CR for the increased JW leakage that potentially impacted EDG operability or for the failed bolt in September 2009, did not re-open and re-screen the July 2009 CR (CR 343051), and did not initiate a CR to perform a Maintenance Rule (MR) functional failure evaluation for the banjO bolt failure. The team noted that the failure to initiate a CR for the failed banjo bolt was a missed opportunity because Dominion proactively addressed other JW leaks on EDG 38 during an additional planned unavailability in December 2009 that required draining the JW system. If Dominion had evaluated the banjo bolt failure within their CAP, they may have inspected a sample of banjo bolts and/or proactively replaced all the banjo bolts on the 3B EDG during the December work window.

On February 24. Dominion initiated CR 369962 to perform a MR evaluation for the banjo bolt failure discovered in September 2009. Based on the team's concerns, Dominion initiated CR 370566 for not identifying the degraded JW banjo bolt condition in the CAP in September 2009 and to evaluate their work order documentation review process to address potential generic concerns in this area.

The team determined that the degraded condition identified in September 2009 (the broken banjo bolt) was unantiCipated and represented an operability concern in contrast to the relatively minor JW leak identified in July 2009. Also the team was concerned that the failure to document the September 2009 failure and take actions to prevent recurrence could have allowed the February 2010 failure during surveillance testing.

However, the team concluded that additional information is needed to fully evaluate and characterize the potential performance deficiency. An unresolved item is an issue of concern about which more information is required to determine if a performance deficiency exists, if the performance deficiency is more than minor, or if the issue of concern constitutes a violation. Therefore, this issue will be treated as an URI.

Information necessary to complete the NRC's review is as follows:

  • The failure mechanism of the banjo bolts, including common cause{s);
  • Dominion's assessment of EDG 38 prior operability (Le., prior to the February 11 monthly test). including the associated reportability determination;
  • Confirmation of maintenance history for banjo bolts on both EDG 3A and 38 (Le., preventive maintenance such as torquing, repairs for leaks, replacement, etc.);
  • Assessment regarding the extensive degradation of banjo bolts on EDG 38 (9 out of 14) VS. none on EDG 3A; and
  • Dominion's assessment/communication regarding 10 CFR Part 21 applicability.

Upon availability of the above information, additional NRC review will be required to independently assess Dominion's associated causal analyses for the issue, and determine the appropriate characterization. Specifically, the NRC will assess 1) whether the issue was reasonably within Dominion's ability to foresee and correct prior to February 2010,2) the banjo bolt failure mechanism, 3) EDG fault exposure, and 4) any associated violations. (URI 05000423/2010006-01, Broken Jacket Water Banjo Bolt Adversely Impacted EDG 3B Operability).

. 2 Assessment of the Use of Operating Experience

a. Inspection Scope

The team selected a sample of industry operating experience (OpE) issues to confirm that Dominion evaluated OpE information for applicability to Millstone and took appropriate actions when warranted. The team reviewed OpE documents to verify that Dominion properly considered the underlying problems associated with the issues for resolution using the corrective action and OpE programs. The team also observed CRT and CARB meetings to determine if industry OpE was considered during the CR screening and resolution processes. The documents reviewed are included in the to this report.

b. Assessment The team determined that Dominion appropriately considered and evaluated OpE information for applicability to Millstone, and used the information to develop corrective actions to prevent similar problems. Overall, the team concluded that Dominion appropriately applied and incorporated relevant OpE insights into station operations.

Dominion also appropriately screened issues at Millstone for external OpE distribution.

The team observed that OpE was routinely considered during the performance of plant activities. For example, Millstone personnel routinely discussed relevant OpE during pre-job briefs, daily turnover meetings. and CRT activities. The team noted that system engineers generally demonstrated an effective use and thorough evaluation of industry OpE in their respective system health reports. In addition, Dominion personnel appropriately considered relevant OpE in their corrective action RCEs and ACEs.

The team reviewed CR 316191 as it relates to operating experience associated with an EDG tripping during a semi-annual test. The cause of the trip, while the EDG was in a test mode, was that the manufacture failed to include a pipe support clamp during original plant installation. The missing pipe clamp was located on a line providing pilot air for the crankcase ejector. Dominion's walkdown of the Millstone EDGs observed that the pipe support clamps were also missing on the 'A' and 'B' EDGs at Unit 2.

Dominion's review and corrective actions appeared adequate to address this OE at Unit 2, however, the team determined the OpE evaluation did not include a 10 CFR Part 21 applicability assessment. To capture this missed opportunity for a formal 10 CFR Part 21 review, Dominion initiated CR 369167.

c. Findings

No findings of significance were identified.

. 3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The team reviewed a sample of audits, including the most recent audit of the CAP, and departmental self-assessments. These reviews were performed to determine if problems identified through these assessments were entered into the CAP, when appropriate, and whether corrective actions were initiated to address identified deficiencies. The effectiveness of the audits and assessments was evaluated by comparing audit and assessment results against self-revealing and NRC-identified observations made during the inspection. A list of documents reviewed is included in the to this report.

b. Assessment The team concluded that audits self-assessments and other internal Dominion assessments were generally critical, probing, thorough, and effective in identifying issues. The team observed that the audits and self-assessments were completed in a methodical manner by personnel knowledgeable in the subject. The audits and self assessments were completed to a sufficient depth to identify issues that were entered into the CAP for evaluation. In general, the associated corrective actions were implemented commensurate with their safety significance.

c. Findings

No findings of significance were identified. Assessment of Safety Conscious Work Environment

a. Inspection Scope

The team reviewed the safety conscious work environment (SCWE) at Millstone through conduct of the following activities:

During the inspection, the team conducted interviews with selected operations, maintenance, engineering, radiological controls and emergency preparedness staff. The

.4 team questioned individuals regarding their willingness to raise safety concerns,

knowledge of the avenues available for raising safety concerns, the effectiveness of actions taken by management to foster a SCWE at the site, and any knowledge of personnel who had experienced a negative reaction for raising a safety concern.

The team also reviewed implementation of the site employee concerns program (ECP)by reviewing applicable procedures and a sample of ECP files since February 2008 to assess the program's effectiveness at addressing potential safety issues.

b.

Assessment Based on interviews and reviews of the CAP and the ECP, the team determined that station staff was willing to identify and raise safety issues. The individuals interviewed demonstrated an adequate knowledge of the avenues available for raising safety concerns, including the CAP and ECP.

c. Findings

No findings of significance were identified.

40A6 Meetings. Including Exit On February 25,2010, the team presented the inspection results to Mr. A. J. Jordan, Site Vice President, and other members of the Millstone staff. The team confirmed that no proprietary information reviewed during the inspection was retained.

40A7 Licensee-Identified Violations The following violation of very low significance (Green) was identified by Dominion and is a violation of NRC requirements that meets the criteria of Section VI of the NRC Enforcement Policy, NUREG-1600, for being dispositioned as a NCV.

10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," requires, 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. Contrary to the above, from July 24, 2008, to July 24, 2009, Dominion did not take adequate corrective action to identify and correct a degraded Unit 2 TDAFW pump steam trap to preclude a repeat overspeed trip during TDAFW pump start-up due to excessive moisture in the steam supply line. Dominion identified the deficiency during a TDAFW valve ST, promptly initiated CR 342844, and performed a thorough and self-critical ACE. This issue was apparent during plant start-up (i.e., during TDAFW starts in Mode 3), when moisture accumUlation would be increased. During power operation, procedural controls were effective in removing moisture in the steam supply line as demonstrated during past surveillance tests while operating at power. The finding was more than minor because it impacted the equipment performance attribute of the Mitigating Systems cornerstone and the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). In accordance with NRC Inspection Manual Chapter (fMC) 0609, Attachment 4, the team performed a Phase 1 Significance Determination Process screening. Based on Table 4a in IMe 0609, Attachment 4, the team determined that the finding was of very low safety significance because it was not a design or qualification deficiency, did not represent an actual loss of system safety function, did not represent an actual loss of safety function of a single train for greater than the technical specification allowed outage time, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating events.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

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LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

05000423/2010006-01 URI Broken Jacket Water Banjo Boft Adversely Impacted EDG 3B Operability. (Section 40A2.1.c)

LIST OF DOCUMENTS REVIEWED