IR 05000237/2019003
| ML19305B804 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 11/01/2019 |
| From: | Kenneth Riemer Division Reactor Projects III |
| To: | Bryan Hanson Exelon Generation Co, Exelon Nuclear |
| References | |
| IR 2019003 | |
| Download: ML19305B804 (28) | |
Text
November 1, 2019
SUBJECT:
DRESDEN NUCLEAR POWER STATION, UNITS 2 AND 3 - INTEGRATED INSPECTION REPORT 05000237/2019003 AND 05000249/2019003
Dear Mr. Hanson:
On September 30, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Dresden Nuclear Power Station, Units 2 and 3. On October 8, 2019, the NRC inspectors discussed the results of this inspection with Mr. P. Karaba and other members of your staff. The results of this inspection are documented in the enclosed report.
One finding of very low safety significance (Green) is documented in this report. This finding did not involve a violation of NRC requirements.
If you disagree with a cross-cutting aspect assignment or a finding not associated with a regulatory requirement in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region III; and the NRC Resident Inspector at Dresden. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA/
Kenneth R. Riemer, Chief Branch 1 Division of Reactor Projects
Docket Nos. 05000237 and 05000249 License Nos. DPR-19 and DPR-25
Enclosure:
As stated
Inspection Report
Docket Numbers:
05000237 and 05000249
License Numbers:
Report Numbers:
05000237/2019003 and 05000249/2019003
Enterprise Identifier: I-2019-003-0063
Licensee:
Exelon Generation Company, LLC
Facility:
Dresden Nuclear Power Station, Units 2 and 3
Location:
Morris, IL
Inspection Dates:
July 01, 2019 to September 30, 2019
Inspectors:
L. Alvarado Guilloty, Resident Inspector
R. Elliott, Resident Inspector
M. Garza, Emergency Preparedness Inspector
J. Havertape, Resident Inspector
A. Nguyen, Senior Resident Inspector
C. Phillips, Project Engineer
M. Porfirio, Illinois Emergency Management Agency
Approved By:
Kenneth R. Riemer, Chief
Branch 1
Division of Reactor Projects
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at Dresden Nuclear Power Station, Units 2 and 3 in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.
List of Findings and Violations
Inadequate Work Instructions for Operationally Critical Work Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events Green FIN 05000249,05000237/2019003-01 Open/Closed
[H.2] - Field Presence 71152 A self-revealed finding of very low safety significance was identified for the licensees failure to provide adequate work instructions for maintenance activities on multiple occasions in accordance with procedures MA-AA-716-010, Maintenance Planning, and MA-AA-716-010-1015, Planning Operational Critical Component (OPCC) Tasks. Specifically, between December 2018 and May 2019, two instances of inadequate work instructions were identified as being primary causes of improper maintenance performed on OPCC systems that caused operational transients.
Additional Tracking Items
Type Issue Number Title Report Section Status LER 05000237/2019-002-00 LER 2019-002-00 for Dresden Nuclear Power Station, Unit 2 Scram Due to Main Turbine Low Oil Pressure Trip.
71153 Closed
PLANT STATUS
Unit 2 began the inspection period at rated thermal power. On July 13, 2019, the unit was down powered to 70 percent for a control rod pattern adjustment. The unit returned to full power on July 14, 2019. On August 3, 2019, the unit was down powered to 68 percent for a control rod pattern adjustment. The unit returned to full power on August 4, 2019. Unit 2 began coast down for the upcoming scheduled refueling outage, D2R26, on August 14, 2019, and ended the inspection period in coast down.
Unit 3 began the inspection period at rated thermal power. On September 23, 2019, the unit performed an emergent down power and was taken off-line to repair an oil leak on the Unit 3 Main Power Transformer. During the forced outage (D3F52) for the transformer repairs, the unit maintained approximately 20 percent thermal power output without being connected to the grid.
The unit synchronized back to the grid on September 27, 2019, and returned to full power on September 29, 2019. The unit remained at rated thermal power for the rest of the inspection period.
INSPECTION SCOPES
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed plant status activities described in IMC 2515 Appendix D, Plant Status and conducted routine reviews using IP 71152, Problem Identification and Resolution. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
REACTOR SAFETY
71111.04Q - Equipment Alignment
Partial Walkdown Sample (IP Section 03.01) (3 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
- (1) Unit 2 isolation condenser alternate injection sources (primary out of service for maintenance) on September 3, 2019
- (2) Unit 2 core spray system on September 17, 2019
- (3) Unit 2 high pressure coolant injection system (HPCI) on September 19, 2019
71111.04S - Equipment Alignment
Complete Walkdown Sample (IP Section 03.02) (1 Sample)
- (1) The inspectors evaluated system configurations during a complete walkdown of the cooling water systems on July 16 - 18, 2019.
71111.05A - Fire Protection (Annual)
Annual Inspection (IP Section 03.02) (1 Sample)
- (1) The inspectors evaluated fire brigade performance during a drill in the administration building on July 18, 2019.
71111.05Q - Fire Protection
Quarterly Inspection (IP Section 03.01) (6 Samples)
The inspectors evaluated fire protection program implementation in the following selected areas:
- (1) Fire Zone 8.2.1B, Unit 3 Condensate Pump Floor, Elevation 469 on July 9, 2019
- (2) FZ 8.2.2B, Unit 3 CCSW Pump Floor, Elevation 495 on July 9, 2019
- (3) FZ 1.1.2.3, Unit 2 Reactor Building General Area, Elevation 545 on July 31, 2019
- (4) FZ 8.2.6A, Unit 2 Reactor Feed Pump Ventilation and Hydrogen Seal Oil Area, Elevation 538 on July 31, 2019
- (5) FZ 8.2.5.C, Unit 2/3 EHC Reservoir and Condensate Demineralizer Areas, Elevation 517' on September 9, 2019
- (6) FZ 8.2.6.C, Unit 2/3 Lube Oil Reservoir and Common Mezzanine Areas, Elevation 534' on September 9, 2019
71111.07A - Heat Sink Performance
Annual Review (IP Section 02.01) (1 Sample)
The inspectors evaluated readiness and performance of:
- (1) 2A and 2C shutdown cooling heat exchangers
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance
Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01) (1 Sample)
- (1) The inspectors observed and evaluated licensed operator performance in the Control Room during an emergent down power on Unit 3 to take the turbine off-line for repairs to the Main Power Transformer on September 24, 2019.
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (2 Samples)
- (1) The inspectors observed and evaluated licensed operator requalification training with Emergency Preparedness requalification requirements in the control room simulator on August 29, 2019.
- (2) The inspectors observed and evaluated licensed operator requalification training with Emergency Preparedness requalification requirements in the control room simulator on September 12, 2019.
71111.12 - Maintenance Effectiveness
Routine Maintenance Effectiveness Inspection (IP Section 02.01) (2 Samples)
The inspectors evaluated the effectiveness of routine maintenance activities associated with the following equipment and/or safety significant functions:
- (1) Repetitive failures of the auxiliary electric equipment room (AEER) ventilation chiller compressors
- (2) Unit 2 and 3 125V DC Power system and Batteries
Quality Control (IP Section 02.02) (1 Sample)
The inspectors evaluated maintenance and quality control activities associated with the following equipment performance activities:
- (1) Unit 2 and 3 service water pump seal failures
71111.13 - Maintenance Risk Assessments and Emergent Work Control
Risk Assessment and Management Sample (IP Section 03.01) (4 Samples)
The inspectors evaluated the risk assessments for the following planned and emergent work activities:
- (1) Elevated plant risk and fire risk for emergent work on the service water (SW) and Unit 2 control rod drive (CRD) systems July 7 - 10, 2019
- (2) Elevated plant risk due to emergent leak on the Unit 2 stator water cooling system on July 25, 2019
- (3) Elevated plant risk due to emergent troubleshooting and repair of the Unit 2 channel
'B' fuel pool radiation monitor and the 3A service water pump on August 5, 2019
- (4) Unit 2 on-line risk increase to Yellow due to trip of 345 kV Line 1202 and emergent work on Unit 3 to troubleshoot and repair the 3A fuel pool radiation monitor on September 3-5, 2019
71111.15 - Operability Determinations and Functionality Assessments
Operability Determination or Functionality Assessment (IP Section 02.02) (4 Samples)
The inspectors evaluated the following operability determinations and functionality assessments:
(1)3A containment cooling service water (CCSW) keepfill system pressure below minimum limit
- (4) Potential vulnerability identified with torus vacuum breakers
71111.18 - Plant Modifications
Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02) (2 Samples)
The inspectors evaluated the following temporary or permanent modifications:
- (1) Unit 2 and Unit 3 Fuel Pool Cooling pumps trip logic (permanent modifications)
- (2) Defeating the Unit 2 'C' Moisture Separator High Level Switches Automatic Turbine Trip function (temporary modification)
71111.19 - Post-Maintenance Testing
Post-Maintenance Test Sample (IP Section 03.01) (5 Samples)
The inspectors evaluated the following post maintenance tests:
- (1) DOS 1300-05, 2/3 B isolation condenser makeup pump capacity test, after preventive maintenance on August 21, 2019
- (2) DFPS 4123-06, 2/3 diesel fire pump capacity test, after replacement on July 24 - 26, 2019
- (3) DOS 6600-01, Unit 3 emergency diesel generator surveillance test, after work on the lubricating oil system on September 16, 2019
- (4) DIS 1500-06, Unit 3 low pressure coolant injection recirculation loop select logic on September 3, 2019
- (5) WO 4962865-13, Electrical Testing of Main Power Transformer 3, after bushing replacement on September 25, 2019
71111.20 - Refueling and Other Outage Activities
Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)
- (1) The inspectors evaluated D3F52, Unit 3 forced outage to replace a leaking bushing on the Main Power Transformer, from September 23-27, 2019.
71111.22 - Surveillance Testing
The inspectors evaluated the following surveillance tests:
Surveillance Tests (other) (IP Section 03.01)
- (1) DIS 0260-12, U3 reactor core flow calibrated transmitter calibration on July 24, 2019
- (2) DES 8300-58, Unit 2 125V main station battery technical specification surveillance test on September 10, 2019
Inservice Testing (IP Section 03.01) (1 Sample)
- (1) Work Order 04936060-01, Unit 2 HPCI Inservice testing surveillance (IST) on September 18, 2019
71114.04 - Emergency Action Level and Emergency Plan Changes
Inspection Review (IP Section 02.01-02.03) (1 Sample)
- (1) The inspectors evaluated the following submitted Emergency Action Level and Emergency Plan changes.
- Evaluation 18-45; Exelon Nuclear Standardized Radiological Emergency Plan, Revision 30; February 7, 2019
This evaluation does not constitute NRC approval.
71114.06 - Drill Evaluation
Select Emergency Preparedness Drills and/or Training for Observation (IP Section 03.01) (1 Sample)
(1)3rd Quarter Emergency Preparedness Full Team Drill on August 20,
OTHER ACTIVITIES - BASELINE
===71151 - Performance Indicator Verification
The inspectors verified licensee performance indicators submittals listed below:
MS05: Safety System Functional Failures (SSFFs) Sample (IP Section 02.04)===
- (1) Unit 2, July 1, 2018 - June 30, 2019
- (2) Unit 3, July 1, 2018 - June 30, 2019
MS08: Heat Removal Systems (IP Section 02.07) (2 Samples)
- (1) Unit 2, July 1, 2018 - June 30, 2019
- (2) Unit 3, July 1, 2018 - June 30, 2019
MS09: Residual Heat Removal Systems (IP Section 02.08) (2 Samples)
- (1) Unit 2, July 1, 2018 - June 30, 2019
- (2) Unit 3, July 1, 2018 - June 30, 2019
MS10: Cooling Water Support Systems (IP Section 02.09) (2 Samples)
- (1) Unit 2, July 1, 2018 - June 30, 2019
- (2) Unit 3, July 1, 2018 - June 30, 2019
71152 - Problem Identification and Resolution
Annual Follow-up of Selected Issues (IP Section 02.03) (2 Samples)
The inspectors reviewed the licensees implementation of its corrective action program related to the following issues:
- (1) Complete loss of power to security equipment due to failure of the UPS batteries
- (2) Unit 2 turbine trip and reactor scram
71153 - Follow-up of Events and Notices of Enforcement Discretion Event Report (IP Section 03.02)
The inspectors evaluated the following licensee event reports (LERs):
- (1) LER 05000237/2019-002-00, Unit 2 Scram due to Main Turbine Low Oil Pressure Trip (ADAMS ML19189A087)
The circumstances surrounding this LER are documented in report Section 71152.
A Green finding related to this follow-up inspection is documented in the Results section.
INSPECTION RESULTS
Inadequate Work Instructions for Operationally Critical Work Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events
Green FIN 05000249,05000237/2019003-01 Open/Closed
[H.2] - Field Presence 71152 A self-revealed finding of very low safety significance was identified for the licensees failure to provide adequate work instructions for maintenance activities on multiple occasions in accordance with procedures MA-AA-716-010, Maintenance Planning, and MA-AA-716-010-1015, Planning Operational Critical Component (OPCC) Tasks. Specifically, between December 2018 and May 2019, two instances of inadequate work instructions were identified as being primary causes of improper maintenance performed on OPCC systems that caused operational transients.
Description:
On May 9, 2019, Dresden Unit 2 turbine tripped on low oil pressure which resulted in a reactor SCRAM. The turbine was inspected and found to have severe damage to the spline interface between the Main Gear Quill Shaft and the High Pressure turbine rotor. This led to a loss of power transfer between the main turbine and the Main Shaft Oil Pump (MSOP)which supplies bearing header pressure at rated speed, thus causing the low oil trip. The licensee performed a root cause analysis subsequent to this event and identified that the cause of the spline damage was due to oil starvation because of an improperly fabricated gasket that blocked oil lubrication feeding the Quill Shaft. The root cause was determined to be improper work order instructions that lacked detail needed to prevent human error during installation of the Quill Shaft Oil Nozzle. The work order instructions contained one step for the installation of the oil spray nozzle, which simply instructed workers to install the oil spray nozzleand verify the nozzle is centered. The actual work needed to complete this step involved identifying the proper gasket and fabricating it appropriately to fit the oil block, verifying proper oil flow after installation, and aligning the nozzle to ensure the oil lubrication traveled to all the correct components. Also, it was identified that a post-maintenance test (PMT) was never completed for the work (all work collectively) on the turbine front standard which could have included verifying proper lubrication of components. The contributing cause was determined to be inadequate supervision which failed to catch the missing work step details and provide intrusive observations during the work activity.
Exelon procedure, MA-AA-716-010, Maintenance Planning, Revisions 21-26, section 4.10 describes the level of detail required for work instructions. Level 1 work packages are for complex, infrequently performed work that presents high risk of single failure or errors that could cause a unit/generator trip or transient. These packages should contain minimal reliance on skill of the craft, must clearly provide acceptance criteria, such as clearances and torque values, and shall have technical human performance standards incorporated to prevent human performance errors, which include having steps to verify new parts satisfy fit, form, and functions and assuring appropriate detail to install components is provided. This procedure also provides the definition of a Critical Activity, which is an activity where the quality of the work cannot be fully assured through a PMT or the PMT can only be performed in a condition where the correction of any failure would cause a down power, dose impact, or impact outage critical path. Procedure MA-AA-716-010-1015, Planning Operational Critical Component (OPCC) Tasks, Revisions 0-5, provide the definition of OPCCs and the categories of work for OPCC tasks. An Operational Critical Component (OPCC) is a critical component whose failure alone has or could have directly led to a significant (>20%) plant power transient. Operational Critical Component Work Requirement Standards are additional work controls administered through verification, oversight, technical review, or additional or more restrictive tolerances, that are incorporated into the work instructions for an OPCC that reduce the risk of introducing latent issues or operational failures because of improperly performed work.
For the turbine front standard work, as described above, the one large step of installing the oil spray nozzle did not meet the requirements of MA-AA-716-010 for a Level 1 package. Clear acceptance criteria were not provided, technical human performance standards were not adequately incorporated, and Critical Activities throughout the work package were not identified since no PMTs were required to validate the system configuration after maintenance. Also, the planning standards for OPCC work were not put into the work package, such as having additional verification, technical oversight, and supervisory oversight.
An additional example of a lack of adherence to proper work planning practices was identified that was similar in nature to the turbine front standard work. The inspectors determined that these items together (along with other equipment issues that did not have operational consequences) were indicative of programmatic issues with the licensee failing to follow the Maintenance Planning and Planning of OPCC Tasks procedures. The additional example is described below.
On December 20, 2018, it was identified that a leak on the Unit 3 electro-hydraulic control (EHC) skid had degraded significantly to a steady stream of approximately 10 gallons per day (from 2 gallons per day). At this time, the decision was made to emergently down power the unit to affect repairs to a leaking fitting on the suction line that leads to the accumulators on the EHC skid. An equipment cause evaluation was performed and determined that one of the causes of the event was maintenance leadership missed an opportunity for proper work order instruction challenge and oversight to support execution. During the prior refueling outage (October 2018), the EHC system had maintenance performed on it by supplemental employees which included replacing this fitting. The work package for this work was not considered a Level 1 work package and the EHC system was not flagged as an operationally critical system or component. However, further investigation revealed that the EHC system was, in fact, classified as an OPCC back in 2009 but the information for the system was not updated appropriately to account for this. Due to those facts, the package did not receive extensive reviews or challenges during the work planning process. Another cause identified for the leak was that the wrong material was selected for the fitting due to a lack of procedural guidance. There was operating experience available for proper material selection that was not incorporated into the work planning process. If the work package had been categorized differently, the more robust work planning standards of ensuring proper parts that satisfy form, fit, and function and work packages that contain minimal reliance on skill of the craft, would have been included in the work planning process. Also, additional supervisor oversight and reviews would have been required prior to and during the work.
Corrective Actions: For the turbine trip root cause, the licensee implemented corrective actions to prevent recurrence (CAPRs) which included updating the model work orders for maintenance on turbine front standards to ensure all steps had proper level of detail for work execution with minimal reliance on skill of the craft and added PMT steps for verifying proper oil flow for the front standard components. Another corrective action for this issue included developing a Key Steps process where all OPCC work orders, as a minimum, will have steps identified that require supervisor sign-offs and oversight, because of the execution significant or risk significant nature of the step.
For the EHC leak issue, the licensee implemented a Supplemental Worker Oversight Plan to improve work order challenges and increase the level of oversight at the time of work execution. Another corrective action for this issue included developing procedural guidance, including material selection and appropriate tightening methods, for flared fittings used in the EHC system.
Corrective Action References: ARs 4204937 and 4247636
Performance Assessment:
Performance Deficiency: The inspectors determined that the licensees failure to follow procedures MA-AA-716-010, Maintenance Planning, and MA-AA-716-010-1015, Planning Operational Critical Component (OPCC) Tasks, was a performance deficiency. Specifically, on two separate occasions, equipment failures on OPCC systems occurred that caused operational transients (either needed emergent down powers for repair or caused a plant trip). The causes of the equipment failures were determined to be inadequate work instructions. The aforementioned procedures delineate the requirements for the level of detail needed in Level 1 work packages and also needed for OPCC work activities.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Procedure Quality attribute of the Initiating Events cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, on two separate occasions, equipment failures on OPCC systems, caused by inadequate work instructions, occurred that caused operational transients (either needed emergent down powers for repair or caused a plant trip).
Significance: The inspectors assessed the significance of the finding using Appendix A, The Significance Determination Process (SDP) for Findings At-Power. The finding was screened against the Initiating Events cornerstone and determined to be of very low safety significance (Green) because even though one of the events caused a reactor trip, mitigating equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition was not lost.
Cross-Cutting Aspect: H.2 - Field Presence: Leaders are commonly seen in the work areas of the plant observing, coaching, and reinforcing standards and expectations. Deviations from standards and expectations are corrected promptly. Senior managers ensure supervisory and management oversight of work activities, including contractors and supplemental personnel. Specifically, for the events related to this finding, it was identified that management oversight of the work planning and execution processes was lacking and contributed to the events that occurred. It was determined that oversight of supplemental workers was lacking as a whole, including reviewing work packages and performing supervision of field activities. The licensee generated corrective actions from these events, as well as others, to address the intrusiveness, standards, and expectations of supervisors going forward and clearly defining their roles and responsibilities in the work planning process.
Enforcement:
Inspectors did not identify a violation of regulatory requirements associated with this finding.
Observation: Loss of Power to all Security Equipment due to UPS Battery Failure 71152 On November 4, 2018, power for critical security equipment was being transferred from the security diesel generator back to its normal power supply. As part of this evolution, an uninterruptible power supply (UPS) carries the loads for a certain period of time. It was during this time on the UPS system that a loss of power occurred to all the loads being carried by the UPS. Appropriate compensatory measures were put into place, power was restored after the initial inspection of equipment, and an equipment cause analysis was performed after the event. Two causes were identified during the causal review: 1) the licensee failed to properly monitor the UPS battery conditions which prevented identification of the degraded battery and 2) improper technical rigor was used during the engineering change that replaced the batteries after a similar failure occurred in 2014. The inspectors reviewed the supporting information for these cause determinations and concluded the most likely causes were failure to properly monitor the UPS battery conditions and inappropriate corrective actions taken for previously identified conditions (i.e. battery environment) from the 2014 failure. The licensee also had operating experience available in the 2014 and subsequent time frames to be able to identify that the batteries were not being maintained properly from both environmental conditions and from monitoring and control perspectives.
The licensee agreed with the inspectors that their actions taken from previous events could have mitigated, if not prevented, this failure and are taking appropriate actions to incorporate the lessons learned into their CAP process. The inspectors reviewed the licensee's corrective actions for this event and determined that they were written to address the identified causes properly and were executed in a timely manner in accordance with their safety significance. There was a performance deficiency identified by the inspectors for this event. It will be documented in Inspection Report 2019-0411.
Observation: Review of Root Cause for Unit 2 Turbine Trip 71152 On Thursday, May 9, 2019, Dresden Unit 2 turbine tripped on low oil pressure which resulted in a reactor SCRAM. The turbine was inspected and found to have severe damage to the spline interface between the Main Gear Quill Shaft and the High Pressure turbine rotor. This led to a loss of power transfer between the main turbine and the Main Shaft Oil Pump (MSOP) which supplies bearing header pressure at rated speed, thus causing the low oil trip.
The licensee performed a root cause analysis subsequent to this event to review the turbine inspection information, prior work history for the main turbine, and relevant operating experience. It was identified that the cause of the spline damage was due to oil starvation because of an improperly fabricated gasket that blocked oil lubrication feeding the Quill Shaft.
The root cause was determined to be improper work order instructions that lacked detail needed to prevent human error during installation of the Quill Shaft Oil Nozzle. The contributing cause was determined to be inadequate supervision which failed to catch the missing work step details and provide intrusive observations during the work activity. The inspectors reviewed the work order and the licensees procedures for work and maintenance planning and determined that the root cause was reasonable. The work order instructions contained one step for the installation of the oil spray nozzle, which simply instructed workers to install the oil spray nozzleand verify the nozzle is centered. The actual work needed to complete this step involved identifying the proper gasket and fabricating it appropriately to fit the oil block, verifying proper oil flow after installation, and aligning the nozzle to ensure the oil lubrication travels to all the correct components. Also, it was identified that a post-maintenance test (PMT) was never completed for the work (all work collectively) on the turbine front standard which could have included verifying proper lubrication of components.
The licensee determined that a PMT was not standard practice for this type of work activity..
The licensee implemented corrective actions to prevent recurrence (CAPRs) which included updating the model work orders for maintenance on turbine front standards to ensure all steps had proper level of detail for work execution with minimal reliance on skill of the craft and added PMT steps for verifying proper oil flow for the front standard components. The inspectors concluded that these CAPRs seemed appropriately focused to address the root cause and preclude repetition. The CAPRs were also being implemented in a timely fashion prior to start of the next refueling outage when turbine front standard work will be conducted.
Another corrective action included developing a Key Steps process where all operationally critical (OPCC) work orders, as a minimum, will have steps identified that require supervisor sign-offs and oversight, because of the execution significant or risk significant nature of the step. This action addressed both the root cause and the contributing cause. The inspectors will ensure the effectiveness of this corrective action when reviewing work orders for the next refueling outage to ensure the process is utilized appropriately.
The licensee also performed an extent of cause and extent of condition review for this event.
It was determined that the work order for the turbine front standard work was classified as a Level 1 work package on an OPCC component. Per the licensees work and maintenance planning processes, Level 1 package should include sufficient detail with minimal reliance on skill of the craft and can include Critical Activities to ensure a high level of maintenance work execution. As corrective actions to address this, the licensee reinforced the standards for planning and reviewing Level 1 OPCC work packages and performed a comprehensive review of other work on the turbine and generator systems prior to the next refueling outage to ensure Critical Activities were identified for component work that had the potential to impact the proper operation of the systems once returned to service (i.e. ensuring design features that could block or resist flow were properly fabricated and assembled). The licensee also shared this operating experience with the other sites within the fleet that could be impacted by work on GE turbines done by supplemental workers. The inspectors determined that the licensee appropriately performed the extent of condition and cause assessments, although it was noted that other systems, not just the turbine and generator systems, could be considered Level 1 OPCC activities that could be completed by supplemental workers and should be considered when reviewing work packages for identifying Critical Activities and Key Steps. This was discussed with the licensee and these work packages are currently under review prior to the next refueling outage. The inspectors determined that the corrective actions for the extent of cause and condition seemed reasonable, were being implemented in a timely manner, and were appropriately shared within the fleet as operating experience to address any potential generic implications when conducting this type of maintenance.
This event and cause evaluation was reviewed by the inspectors for a potential performance deficiency. A finding was identified for failure to provide adequate work instructions to perform the work, as described by the identified root cause above. This finding is documented in the results section.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
- On October 8, 2019, the inspectors presented the integrated inspection results to Mr. P. Karaba and other members of the licensee staff.
- On October 3, 2019, the inspectors presented the Exit Meeting for EP Inspection per IP 71114, Attachment 4 inspection results to Mr. L. Baker, EP Fleet Programs Manager and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
71111.04Q Corrective Action
Documents
2509721
Water Leaking Out of Capped End of 2/3-4399-41B
06/02/2015
4144225
Isolation Condenser 2-1301-3 Valve Troubleshooting
06/04/2018
231262
Solenoid Buzzing on 2-1301-20 Valve
03/19/2019
277181
OPS Services Crew Clock Reset - Tagout Special
Instructions
09/03/2019
Drawings
M-27
Diagram of Core Spray Piping
AAN
M-28
Diagram of Isolation Condenser Piping
LR
M-51
Diagram of High Pressure Coolant Injection Piping
CV
M-51
High Pressure Coolant Injection System and Instrumentation
Miscellaneous
Tagout: 02-43-
2019043-001
Disassemble & Inspect 2-4399-73, Iso Fill Check Valve
09/03/2019
Procedures
DOP 1300-M1/E1
Unit 2 Isolation Condenser System Checklist
DOP 1400-E1
Unit 2 Core Spray System Electrical Checklist
DOP 1400-M1
Unit 2 Core Spray System
DOP 2300-M1/E1
Unit 2 HPCI System Checklist
DOS 1300-02
Isolation Condenser Valve Operability Check
Corrective Action
Documents
1671923
06/17/2014
2603789
U2 TBCCW TCV Tube Track Support for Air Lines Not
Secured
2/22/2015
2647884
Degraded Flex Hose for 3A CB Casing Eqz ISO Valves
03/30/2016
29005
MO 2-3903-B Will Not Close From Remote Control Switch
10/17/2016
4059747
TBCCW Piping at 3B Cond Pump in Contact - Needs
Support
10/02/2017
4165056
U3 EHC TBCCW TCV has Corrosion
08/17/2018
4190724
3-3903-A Did Not Operate From the Control Room
11/01/2018
4191332
3A TBCCW HX Tube Side Vent Plugged
11/02/2018
4191334
3B TBCCW HX Vent Line Plugged
11/02/2018
4193329
Packing Leak Noted on 3-3903-B
11/09/2018
216616
Packing Leak on U2 'B' TBCCW HX SW Inlet Valve
2/02/2019
231347
3B TBCCW Heat Exchanger Tube Plugging
03/20/2019
231399
3B TBCCW Heat Exchanger Flange Corrosion
03/20/2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
249402
3-3399-451B 3B TBCCW HX Tube Side Drn Vlv Leaking By
05/15/2019
264483
2A TBCCW Pump Seal Leak
07/16/2019
265165
3B RBCCW HC TCV is Full Open and Bouncing
07/18/2019
Engineering
Changes
2648
RBCCW/TBCCW Tube Plugging Evaluation
01/2018
Procedures
DOP 3700-M2/E2
Unit 2 RBCCW System Checklist
DOP 3800-1
Unit 3 Turbine Building Closed Cooling Water System
Checklist
DOP 3800-M1
Unit 2 Turbine Building Closed Cooling Water System
Checklist
Fire Plans
FZ N/A
Administration Building, 1st Floor
Procedures
Fire Drill Performance
71111.05Q Corrective Action
Documents
277837
Work Not Performed Due to Leaky Isolation
09/09/2019
Drawings
M-23
Diagram of Fire Protection Piping
AJ
Fire Plans
FZ 1.1.2.3
Unit 2 Reactor Building General Area, Elevation 545
FZ 8.2.1B
Unit 3 Condensate Pumps Floor, Elevation 469
FZ 8.2.2B
Unit 3 CCSW Pumps Floor, Elevation 495
FZ 8.2.5.C
Unit 2/3 EHC Reservoir Area Elevation 517'
FZ 8.2.5.C
Unit 2/3 Cond. Demin. Area Elevation 517'
FZ 8.2.6.C
Unit 2/3 Lube Oil Reservoir Area Elev. 534'
FZ 8.2.6.C
Unit 2/3 Heat Exchanger Area Elevation 534'
FZ 8.2.6A
Unit 2 Reactor Feed Pump Ventilation and Hydrogen Seal
Oil Area, Elevation 538
Miscellaneous
Tagout: 00-41-
2019041-005
2/3 Cable Tunnel Fire Protection Strainer Inspection and
Misc. Work
09/09/2019
Procedures
Fire Protection System Impairment Control
Control of Transient Combustible Material
Corrective Action
Documents
268275
07/31/2019
274841
FM Retrieved From 2C SDC Heat Exchanger
08/27/2019
282295
Results of SPC 4268275-04
07/31/2019
Miscellaneous
Eddy Current Examination Final Report for 2A Shutdown
Cooling Heat Exchanger
July 2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
DTP 75
Heat Exchanger Inspection Program
Service Water Heat Exchanger Inspection Guide
Work Orders
00847755
Eddy Current Test on 2A SDC HX
08/20/2011
01477606
07/30/2019
71111.11Q Corrective Action
Documents
281544
Steam Leak From 3B1 FW Heater Upstream of 3-3607A
09/23/2019
281563
Unexpected Alarm 903-3 F-1, Area Rad Monitor Downscale
09/23/2019
281573
U3 CRD H-06 Failure to Settle During Downpower
09/23/2019
Miscellaneous
LORT Simulator Guide with DEP Opportunity 19-01A
08/29/2019
Procedures
DGP 01-01
Unit Startup
197
Corrective Action
Documents
4082328
AEER Thermostat Not Controlling Proper AEER Temp
2/08/2017
4140956
U1 125 VDC Battery Terminal Corrosion
05/24/2018
4166399
U2/3 BOP 250 VDC Batt Sys Trouble
08/22/2018
4172858
U2 250VDC Charger DC Voltmeter
09/13/2018
4175775
U1 125 VDC Battery Discrepancy Found During Quarterly
Surveillance
09/22/2018
4183312
250 V Voltmeter at 903-8 Requires Calibration
10/13/2018
4183443
Compressor Trip Leads to DOA Entry (DOA 5750-01)
10/14/2018
4184691
AEER Condensing Unit Trip
10/17/2018
4186708
Aux Electric Equipment Room A/C Unit Keeps Tripping
10/23/2018
4187463
U3 250 VDC Battery Surveillance Descrepancies
10/25/2018
4189223
'B' AEER Compressor Not Running
10/30/2018
4193837
U2 250 VDC Batt Ground With U3 HPCI AOP Running
11/11/2018
4196472
U3 Alt Batt Elevated Intercell Resistance Reading
11/20/2018
4197461
U3 250VDC Cell 110 Voltage Low
11/25/2018
4197708
ETB Vent Performance Challenging U2 TS Battery
Temperatures
11/26/2018
4199704
TR-86 System Battery Has a Degraded Intercell Plate
2/03/2018
202901
MRule Function 5714-1 Needs (a)(1) Determination
2/13/2018
203895
TR-86 Relay House Battery Issues
2/17/2008
204924
Corrosion on U1 Batteries
2/20/2018
204986
U1 125 VDC Has 1 Cell With Voltage Low
2/20/2018
205733
'B' AEER Compressor Found Tripped
2/25/2018
206067
AEER HVAC B Compressor Needs Eval Due To Trip On
05/27/2018
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Low Oil
207078
U2 125 VDC Battery Ground - Unexpected Alarm
2/31/2018
207290
U3 250V Battery System Cable Insulation Cracked
01/01/2019
207616
Battery Cell Specific Gravities Found High
01/02/2019
209140
U3 125 VDC Ground
01/08/2019
209145
U3 24/28V A Negative Cell 4 Low Volts
01/08/2019
209605
Entered DOA 5750-01 for AEER Ventilation Failure
01/10/2019
212946
U2 125 VDC Battery Ground
01/22/2019
22849
Unexpected Alarm 902-8 C-9, U2 125 VDC Batt Ground
2/23/2019
24966
Unexpected Alarm: U2 125 VDC Ground
2/28/2019
25117
U2 125 VDC Ground Alarm, 902-8 C-9
03/01/2019
25524
Unexpected Alarm: Unit 2 125 VDC Ground Alarm
03/01/2019
26960
Unexpected Alarm 9902-8 C-9, U2 125 VDC Batt Ground
03/06/2019
234155
Unknown Substance Found Floating in Cell of Battery
03/29/2019
234682
U1 B 125VDC Charger
03/30/2019
236853
P-105B 1B Battery Charger Could Not Maintain Correct
Voltage
04/05/2019
247556
DOA 5750-01 Entry for AEER Temp Hi
05/08/2019
250039
Corrosion Found on U1 125VDC Batteries
05/18/2019
252768
U3 125VDC Discharge Rate High Alarm
05/30/2019
254008
Unexpected Alarm 903-8 C-9, 125 VDC Batt Ground
06/03/2019
255478
U3 125 VDC Batt Ground
06/08/2019
259821
Corrosion Identified During Battery Surveillance
06/27/2019
262209
U3 125 VDC Battery Ground
07/06/2019
262260
2/3 Service Water Pump Packing Degraded
07/06/2019
262914
Unexpected Alarm 903-8 C-9, 125 VDC Batt Ground
07/09/2019
264658
U1 125 VDC Battery Terminal Corrosion
07/17/2019
266014
U2 125 VDC Ground Alarm
07/22/2019
267550
Unexpected Alarm: U3 125 VDC Batt Ground
07/28/2019
268532
2A LPCI Room Cooler Inspection and Testing
07/31/2019
272610
2B Service Water Pump Mechanical Seal Leakage
Excessive
08/16/2019
273689
Quality Issue from EagleBurgmann Repair Facility
08/22/2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Drawings
DR-PSA-005.16
Figure 2-6, ECCS Room Cooling Water/Diesel Generator
Cooling Water
Miscellaneous
Maintenance Rule System Basis Document for Dresden
Unit 2, 39-1; Unit 0, 39-2; Unit 3, 39-2
08/12/2019
Maintenance Rule System Basis Document for Dresden
Unit 3, OOS-39-3
08/12/2019
Maintenance Rule System Basis Document for Dresden
Unit 2, 15-8
08/13/2019
Maintenance Rule System Basis Document for Dresden
Unit 2, Systems 83-1, 83-2, and 83-3
07/31/2019
U0 Auxiliary Electric Equipment Room HVAC Maintenance
Rule a(1) Action Plan
Maintenance Rule System Basis Document for Dresden
Unit 3, Systems 83-1, 83-2, and 83-3
07/31/2019
Design Consideration Summary: Service Water Pump
Mechanical Seal VTIP D1171 Revision
000
Design Considerations Summary: Addition of Eagle
Bergman Seals to the VTIP D1171 for Usage on Service
Water Pumps
000
Install 2/3 Service Water Pump Open Line Shaft Design with
Greene Tweed
000
Eagle Burgmann
Mechanical Seal
(M.S.)
Manufacturer Operating Manual
7.0
Durametallic PSS
III, Split Seal
Installation Instructions from Manufacturer
Procedures
Maintenance Rule Implementation Per NEI 18-10
Maintenance Rule Implementation per NEI 18-10
Maintenance Rule 18-10 - Scoping
Maintenance Rule 18-10 - Failure Definition
Maintenance Rule 18-10 - Performance Monitoring and
Dispositioning Between (a)(1) and (a)(2)
Maintenance Rule 18-10 - Performance Monitoring and
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Dispositioning Between (a)(1) and (a)(2)
Maintenance Rule 18-10 - Expert Panel Roles and
Responsibilities
Plant Status and Configuration
OP-AA-108-112-
1001
Response to Identified Component Mispositionings
Corrective Action
Documents
246346
3-1705-16B Spiked Causing RBV Trip and SBGT Auto-Start
05/04/2019
255645
Water Leak Between 2A Stator Pump and Head Tank
06/10/2019
261968
3A SW Pump Packing Leak
07/05/2019
262149
2B Service Water Pump Mechanical Seal Leakage
Excessive
07/05/2019
262637
2A CRD Pump Inboard Seal Leak
07/08/2019
262824
Water Inside 2A CRD Feed Pump Breaker Cubicle
07/09/2019
263043
2/3 SW Pump Breaker Closing Springs Did Not Discharge
on R/O
07/10/2019
263049
Breaker does not Indicate Disconnected when Disconnected
07/10/2019
263271
2/3 Service Water Pump Overcurrent Relay
07/11/2019
263438
3B Service Water Pump Seal Leak
07/11/2019
266695
U2 SWC Leak Upstream of 2-7400-Y-85 and 2-7400-Y-87
07/24/2019
267145
Extent of Condition for U2 SWC Leak. PI 2-7400-YGA9
07/26/2019
267145
Extent of Condition for U2 SWC Leak. Remove PI 2-7400-
YGA9
07/26/2019
267147
Extent of Condition for U2 SWC Leak. Remove PI 3-7400-
YGA8
07/26/2019
267158
Extent of Condition for U2 SWC Leak. Remove PI 3-7400-
YGA9
07/26/2019
267161
Extent of Condition for U2 SWC Leak. PI 2-7400-YGA8
07/26/2019
268629
Excessive Packing Leakage on 3A SWP
08/01/2019
269595
Unexpected Alarm - U2 Fuel Pool CH B Rad Hi
08/05/2019
269658
Corp Eng Evaluate Fleet Fuel Pool Rad Monitor Trip Logic
08/05/2019
269675
2(3)-3 E-16, RX Building Fuel Pool CH B Rad Hi DAN
Enhancement
08/05/2019
276469
Unexpected Alarm - U3 Fuel Pool CH A Rad Hi
09/03/2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
276578
RB Vent Stack System Flow Rate Monitor INOP
09/03/2019
276626
Unexpected Alarm 903-3 C-16, RX Bldg Fuel Pool Ch A Rad
Hi
09/03/2019
277614
L1202 Trip Post-Job Critique
09/03/2019
Drawings
Schematic Diagram 345KV Switchyard Annunciator Panel 23-2
Y
M-22A
I
Miscellaneous
Protected Equipment Lists for Unit 2 and Unit 3 Risk
Significant Systems
Procedures
DAN 902(3)-7 B-
Stator Clg PP Trip
DAN 903-3 C-16
RX Bldg Fuel Pool Ch A Rad Hi
DAN 923-2 A-2
GCB 3-4 Trip
DAN 923-2 A-3
GCB 4-5 Trip
DAN 923-2, A-5
Line 1202 Transfer Trip
DOA 7400-01
Failure of the Stator Coolant System
Protected Equipment Program
OP-DR-201-012-
1001
Dresden On-line Fire Risk Management
WC-DR-104-1001 Dresden 345KV Switchyard Configuration Risk Assessment
Work Orders
04946790
Excessive Packing Leakage on 3A SWP
08/05/2019
04947812
Troubleshoot and Repair U2 Fuel Pool CH B Radiation High
Alarm
08/05/2019
04956357
Unexpected Alarm - U3 Fuel Pool CH A Rad Hi
09/03/2019
Corrective Action
Documents
209140
U3 125 VDC Ground
01/08/2019
212946
U2 125 VDC Battery Ground
01/22/2019
217329
Unexpected Alarm, U3 125 VDC Ground, Annunciator 903-8
C-9
2/05/2019
218106
903-8 C-9 U3 125 VDC Battery Ground During DES 0700-03
2/07/2019
24966
Unexpected Alarm: U2 125 VDC Ground
2/28/2019
25117
U2 125 VDC Ground Alarm, 902-8 C-9
03/01/2019
25524
Unexpected Alarm: Unit 2 125 VDC Ground Alarm
03/01/2019
25524
Unexpected Alarm: Unit 2 125 VDC Ground Alarm
03/01/2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
26960
Unexpected Alarm 902-8 C-9, U2 125 VDC Batt Ground
03/06/2019
29076
Unexpected Alarm 902-8 C-9, U2 125 VDC Batt Ground
03/13/2019
249714
Unexpected Alarm 902-8 C-9, U2 125 VDC Batt Ground
05/16/2019
252768
U3 125 VDC Discharge Rate High Alarm
05/30/2019
254008
Unexpected Alarm 903-8 C-9, 125 VDC Batt Ground
06/03/2019
256427
Low Pressure at Valve 3-151-77A (PI 3-1501-61A) CCSW to
06/12/2019
261991
Follow-up Investigation on IR 4256427
06/12/2019
262209
U3 125 VDC Battery Ground
07/06/2019
263744
EP Exercise Identifies Unanalyzed Condition
07/12/2019
267550
Unexpected Alarm: U3 125 VDC Batt Ground
07/28/2019
270286
Pressure Gauge Out of Tolerance During Power Labs
Calibration
08/07/2019
270818
Unexpected Alarm 902-8 C-9 U2 125 VDC Battery Ground
08/09/2019
Engineering
Changes
345321
Evaluate the Impact of Additional Weight due to Replacing
Hex Nuts with Hydraulic Nuts and Perform the Owner
Acceptance Review of the Vendor Report
Operability
Evaluations
00064004345
Containment Cooling Service Water (CCSW) System Water
Hammer/Loss of Keep-Fill Analysis
03/21/2001
Procedures
DAN 902(3)-8 C-
U2/3 125 VDC Battery Ground
DOP 6900-07
25 VDC Ground Detection - Unit 3
Corrective Action
Documents
273402
3B FPC Pump Trip During Train Swap
08/21/2019
283066
Unexpected Alarm 902-7 B-5 DEHC and 902-6 A-3 Level
High
09/28/2019
Drawings
Schematic Diagram Fuel Pool Cooling Pump Alarm Circuit
and Indication
S
M-362
Diagram of Fuel Pool Cooling Piping
BG
M-373
Diagram of Fuel Pool Filter & Demineralizing Piping
AG
Engineering
Changes
27310
Modify U3 A&B Fuel Pool Cooling Pump Trips
27311
Modify U2 A&B Fuel Pool Cooling Pump Trips
29532
Defeat the Automatic Turbine Trip From the 2C Moisture
Separator High Level
000
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
Temporary Configuration Changes
DAN 902(3)-5 B-8 Moisture Separator Lvl Hi-Hi
DAN 902(3)-7 B-5 Turbine Control Minor Trouble
DAN 9902(3)-6 A-
Unit 3 Moist Separator Lvl Hi
and 07
Work Orders
04889934
Modify U2B Fuel Pool Cooling Pump Trips
08/26/2019
04889935
Modify U3A Fuel Pool Cooling Pump Trips
08/21/2019
04889936
Modify U3B Fuel Pool Cooling Pump Trips EC 627310
08/20/2019
04964530
Defeat the Automatic Turbine Trip From the 2C Moisture
Separator High Level Switches
09/28/2019
Corrective Action
Documents
250799
U3 EDG Lube Oil Gallery Sightglass
05/21/2019
257556
U3 EDG Lower Lube Sightglass Still Empty 2 Shifts After
06/17/2019
267142
Incorrect Gaskets Installed on 2/3 DFP Oil Cooler
06/26/2019
268385
4.0 Critique - 2/3 DFP Capacity Run
07/27/2019
272885
2/3B Iso Cond M/U Pump Failed to Start Initially
08/19/2019
273328
Crack on Valve Cover
08/19/2019
273472
Increased Fuel Leakage Past 2/3B IC MU PP Inj Vent Valve
08/21/2019
273517
Overfilling of 2/3B ISO Condenser Coolant
08/21/2019
273842
Fuel Leak from Casing Vent on B ISCO Cond. Diesel Engine
08/21/2019
276621
dPIS 3-0261-34A Found OOT
09/04/2019
279832
U3 EDG Exhaust Manifold Cylinder #8 Temp High
09/16/2019
279835
U3 EDG Exhaust Manifold Cylinder #17 Temp Low
09/16/2019
280590
4.0 Critique on U3 EDG Work
09/19/2019
285704
Documentation of SFRA Testing of H3 Winding
09/26/2019
Drawings
Low Pressure Coolant Injection System and Instrumentation
LPCI Initiation Logic
20700LN001-001
Unit 2 Isolation Condenser System
20700LN001-011
Isolation Condenser Makeup Pump System
Fuel Pool Cooling System
Primary Containment Atmosphere Monitoring
M-478
Diagram of Diesel Generator Lube Oil Piping
Procedures
DIS 1500-06
LPCI System Recirculation Loop Break Detection
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
DOS 1300-05
2/3 A(B) Isolation Condenser Makeup Pump Capacity Test
MA-MW-773-035
Nuclear Operational Analysis Department Testing of Power
Transformers
Work Orders
01032433-01
D3 10Y PM Recirc Loop Brk LPCI Injection DPIS 34A
Replacement
09/04/2019
01930470
D2/3 2Y Com 'B' Iso Cond Make-up Pump Capacity Test
08/21/2019
04811173
PMT Replaced Pump
07/27/2019
04915930-01
Diesel Generator Fast Start Operability Surv.
09/17/2019
04924706
D2/3 Qtr Com 'B' Iso Con Make-up Pump Operability
08/21/2019
04933408-03
Replace U3 D/G Lube Oil Cooler Outlet Check Valve
09/17/2019
04933409-02
WR to install Ultrasonic Flowmeter U2 EDG Pre-Lube Oil
Line
09/16/2019
04962865-13
Elec Testing of Main Power Transformer 3
09/25/2019
Corrective Action
Documents
281463
MPT 3 Oil Leak Identified
09/23/2019
281514
U2 and U3 Main Generator Output Spikes
09/23/2019
281858
D3F52 LL - Storage Requirements for MPT Transformer
09/24/2019
282111
U3 MPT TR 3 Neutral H0 Bushing as Found
09/25/2019
282233
U3 Main Turbine Turning Gear Will Not Engage
09/25/2019
282235
U3 Turbine Bearing Lift Pump Trip Alarm
09/25/2019
282614
903-7 B-5 Turbine Control Minor Trouble
09/26/2019
282910
U3 Main Turbine Bearing #1 Thermocouple 3-5600-T1
Degraded
09/27/2019
283118
3B RFP Discharge Valve Failed to Open During Pump Start
09/28/2019
283235
Unexpected Alarm 903-3 A-2, MN Steam Line Rad Hi
09/28/2019
283285
Furmanite Box Leaking in U3 RFP Room
09/29/2019
Engineering
Changes
443003
Fabricate Expansion Plate for Dresden U3 MPT
Miscellaneous
Protected Equipment List for Unit 3 TR32
09/24/2019
Work Orders
04938495
Replace VSVA Card 3-5650-31-5-S1-10
09/25/2019
04962865
Repair/Replace U3 MPT High Side Neutral Bushing
09/25/2019
Corrective Action
Documents
4175530
SJAE Anomalies Noted during HPCI Surveillance on Unit 2
09/20/2018
4177295
Unit 2 HPCI Oil
09/26/2018
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
4179417
U3 HPCI Surveillance 4.0 Critique
09/12/2018
278206
U2 1125VDC Ground Alarm
09/10/2019
281159
Crew 4 Clock Reset - U2 HPCI IST Run 4.0 Critique
09/18/2019
Procedures
DES 8300-58
Unit 2 125 Volt Main Battery Modified Performance Test
DIS 0260-12
Reactor Core Flow Calibrated Transmitter Calibration
DOS 6600-08
Diesel Generator Cooling Water Pump Quarterly and
Comprehensive/Preservice Test for Operational Readiness
and In-Service Test (IST) Program
Work Orders
04678506-01
D3 24M TS RX Core Flow Calibrated Transmitter CAL
07/24/2019
04706728
D3 2Yr Diesel Generator Cooling Water Pump
Comprehensive Test for IST Program
09/16/2019
04936060-01
D2 Qtr TS HPCI Pump Oper Test and IST Surv
09/18/2019
Miscellaneous
Evaluation
Number 18-45
Exelon Nuclear Standardized Radiological Emergency Plan,
Revision 30
2/14/2019
Corrective Action
Documents
273314
3rd Quarter 2019 Drill Issue
08/20/2019
283661
3Q19 EP Drill Unsatisfactory Demonstration Criteria
09/30/2019
Miscellaneous
3rd Quarter 2019 Emergency Preparedness Full Drill Manual
71151
Miscellaneous
Unit 2 and Unit 3 MSPI Validation Packages for HPCI, ISO,
LPCI, Emergency AC Power, EDG and SDC
July 1, 2018
- June 30,
2019
Regulatory Assessment PI Guidance
Corrective Action
Documents
204937
EHC Leakage Has Degraded Further
2/20/2018
247636
Blocked Quill Oil Passage Causes Turbine Trip and RX
05/09/2019
249933
Adverse Trend in Equipment Performance Since D3R25
05/17/2019
270769
Trend in Maintenance Work Planning Deficiencies
08/09/2019
Procedures
Equipment Classification
System Vulnerability Review Process
and 10
Maintenance Planning
and 26
MA-AA-716-010-
1015
Operational Critical Component Work (OPCCW) Process
0, 5, and 6
Work Orders
01081964
Turbine Front Standard Mechanical Inspect/Maint
11/11/2013
01799328
Stem/Insp Overhaul Intern Overhaul ACT for FW Reg B
11/01/2018
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
04606118
3B EHC Discharge Pipe Leaking at Tee to Accumulator
Rack
10/29/2018