IR 05000266/2009006
| ML091280093 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 05/08/2009 |
| From: | Michael Kunowski NRC/RGN-III/DRP/B5 |
| To: | Meter E Point Beach |
| References | |
| IR-09-006 | |
| Download: ML091280093 (35) | |
Text
May 8, 2009
SUBJECT:
POINT BEACH NUCLEAR POWER PLANT PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION 05000266/2009006; 05000301/2009006
Dear Mr. Meyer:
On March 27, 2009, the U. S. Nuclear Regulatory Commission (NRC) completed a biennial problem identification and resolution (PI&R) team inspection at your Point Beach Nuclear Power Plant, Units 1 and 2. This inspection included a review of your actions to address the two substantive cross-cutting issues discussed in the Annual Assessment Letter, dated March 4, 2009. The enclosed report documents the inspection results, which were discussed on March 27, 2009,with you and members of your staff.
The inspection examined activities conducted under your license as they relate to safety and compliance with the Commissions rules and regulations and with the conditions of your license.
The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel.
The inspectors concluded that problems were, in general, properly identified, evaluated, and resolved within the corrective action program. The inspectors also concluded that improvements have been made in prioritizing issues, reducing the backlog of corrective actions, and maintaining the schedule for actions. Finally, the inspectors concluded that the plans and actions for the substantive cross-cutting issues are appropriate to successfully address the issues; however, all the actions are not yet complete and more time will be required for the NRC to gain the necessary confidence to conclude these issues have been resolved.
The report documents three NRC-identified findings of very low safety significance (Green).
Two of these findings were determined to involve violations of NRC requirements. However, because of the very low safety significance and because the issues were entered into your corrective action program, the NRC is treating these issues as Non-Cited Violations (NCVs) in accordance with Section VI.A.1 of the NRCs Enforcement Policy.
If you contest any NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a copy to the Regional Administrator, Region III; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Point Beach.
In addition, if you disagree with the characterization of any finding 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 Regional Administrator, Region III, and the NRC Resident Inspector at Point Beach. The information you provide will be considered in accordance with Inspection Manual Chapter 0305.
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 System (PARS)
component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Website at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Michael A Kunowski, Chief
Projects Branch 5
Division of Reactor Projects
Docket Nos. 50-266; 50-301 License Nos. DPR-24; DPR-27
Enclosure:
Inspection Report 05000266/2009006; 05000301/2009006 w/Attachment: Supplemental Information cc w/encl:
M. Nazar, Senior Vice-President and Chief Nuclear Officer
A. Khanpour, Vice-President, Engineering Support M. Warner, Vice-President, Nuclear Plant Support
Licensing Manager, Point Beach Nuclear Plant
R. Hughes, Director, Licensing and Performance Improvement
M. Ross, Managing Attorney A. Fernandez, Senior Attorney T. O. Jones, Vice-President, Nuclear Operations, Mid-West Region P. Wells, Vice-President, Nuclear Safety Assessment J. Bjorseth, Plant General Manager
K. Duveneck, Town Chairman, Town of Two Creeks
Chairperson, Public Service Commission of Wisconsin
J. Kitsembel, Electric Division, Public Service Commission of Wisconsin
P. Schmidt, State Liaison Officer
SUMMARY OF FINDINGS
IR 05000266/2009006; 05000301/2009006; NextEra Energy Point Beach, LLC; on 03/09/2009 - 03/27/2009; Point Beach Nuclear Power Plant, Unit 1 and Unit 2; biennial baseline Problem Identification and Resolution inspection.
This report covers a 2-week, baseline inspection of problem identification and resolution of problems (Inspection Procedure 71152). In addition, the inspection was expanded to include an assessment of repetitive cross-cutting themes in the areas of Human Performance and Problem Identification and Resolution as discussed in the 2008 Point Beach Annual Assessment letter, dated March 4, 2009. This inspection was performed by three regional inspectors, the Point Beach resident inspector, and the Kewaunee resident inspector. Three Green findings, two of which were also Non-Cited Violations (NCVs) of NRC requirements, were identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, Significance Determination Process (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006.
Problem Identification and Resolution Based on the samples selected for review, the inspectors concluded that implementation of the corrective action program (CAP) was adequate. The inspectors noted that the licensee has a sufficiently low threshold for identifying issues and entering them in the CAP and established additional directions to ensure a lower threshold was consistently used. Prioritization of items entered in the CAP was adequate with recent improvements that have reduced the action item backlog and allowed the station to focus on higher priority items. The inspectors noted that the licensee entered operating experience into the CAP but did not always fully evaluate the information for applicability to station components. Audits and self-assessments were determined to be performed at an appropriate level to identify deficiencies. On the basis of licensee self-assessments and interviews conducted during the inspection, workers at the site expressed freedom to raise safety concerns
NRC-Identified
and Self-Revealed Findings
Cornerstone: Initiating Events
- Green.
A finding of very low safety significance was identified by the inspectors for the licensees failure to maintain control over the proper storage and placement of materials, within the risk significant areas of the outdoors protected area, that were classified as high winds/tornado hazards in accordance with station procedures PC 99, Tornado Hazards Inspection Checklist, and NP 1.9.6, Plant Cleanliness and Storage.
Specifically, these unsecured items were identified near the Unit 1 and Unit 2 main transformer lines, auxiliary transformers, and the G-03/G-04 emergency diesel generator building. Once notified, the licensee removed or secured the materials appropriately and entered the issue into its CAP. At the end of the inspection period, the licensee continued to perform a root cause evaluation and develop long-term corrective actions.
The finding was determined to be more than minor because if left uncorrected, the loose items would become a more significant safety concern. The inspectors evaluated the finding using the Significance Determination Process in accordance with IMC 0609,
Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, dated January 10, 2008. The finding is of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available.
Additionally, the inspectors determined that the finding had a cross-cutting aspect in the area of human performance, work practices component, because the licensee failed to ensure adequate supervisory and management oversight of the implementation and follow-through of the corrective actions from previous related issues (H.4(c)).
(Section 4OA2.1.b.(3).i)
Cornerstone: Mitigating Systems
- Green.
A finding of very low safety significance (Green) and associated NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified by the inspectors for the failure to have appropriate maintenance procedures for Mechanism Operated Cell (MOC) switches. Specifically, the licensee failed to have steps in the MOC switch preventative maintenance procedures for specific inspection and verification actions at the frequency, and with actions, recommended by causal evaluations and the vendor. The licensee entered this issue into the corrective action program and was evaluating corrective actions.
The finding was determined to be more than minor because if left uncorrected the issue would lead to a more significant safety concern. Specifically, the failure to identify degraded hardware on a MOC switch could lead to the failure of associated safety-related equipment and alarms. The issue was of very low safety significance based on a Phase 1 screening in accordance with IMC 0609, Appendix A, Significance Determination of Reactor Inspection Findings for At-Power Situations, dated January 10, 2008. This finding has a cross-cutting aspect in the area of problem identification, corrective action program component, because the licensee failed to thoroughly evaluate problems such that the resolutions addressed causes and extent of condition as necessary (P.1(c)). (Section 4OA2.1.b.(3).ii)
- Green.
A finding of very low safety significance (Green) and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified by the inspectors for the licensees failure to have appropriate maintenance procedures and work instructions in place for certain safety-related inverters.
Specifically, the licensee failed to have steps in the routine maintenance procedure (RMP) 9036 series maintenance procedures for periodic replacement of the electrolytic capacitors in the SCI-model inverters as recommended by the vendor. The licensee entered this issue into the corrective action program, scheduled replacement of the capacitors, and was further evaluating the vendor recommendation.
The finding was more than minor because, if left uncorrected, the finding would become a more safety significant concern. Not replacing the electrolytic capacitors in the SCI inverters based on the vendor recommended life could result in the failure of the inverter to perform their safety function and respond to initiating events. The issue was of very low safety significance based on a Phase 1 screening in accordance with IMC 0609,
Appendix AProperty "Inspection Manual Chapter" (as page type) with input value "NRC Inspection Manual 0609,</br></br>Appendix A" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process., ASignificance Determination of Reactor Inspection Findings for At-Power Situations,@ dated January 10, 2008. This finding had a cross-cutting aspect in the area of problem identification and resolution, corrective action program component, because the licensee failed to implement and institutionalize operating experience, including vendor recommendations, through changes to station procedures (P.2(b)).
(Section 4OA2.2.b.i).
Licensee-Identified Violations
None.
REPORT DETAILS
OTHER ACTIVITIES
4OA2 Problem Identification and Resolution
Completion of Sections
.1 through.4 constitutes one biennial sample of problem
identification and resolution as defined in Inspection Procedure 71152.
.1 Assessment of the Corrective Action Program (CAP) Effectiveness
a. Inspection Scope
The inspectors reviewed items selected across the NRCs cornerstones of safety to determine if problems were being properly identified, characterized, and entered into the CAP for timely and complete evaluation and resolution. The inspectors reviewed CAP documents generated since January 2007, when the previous NRC problem identification and resolution team inspection was conducted (Inspection Report (IR)05000266/2006015; 05000301/2006015). These documents included:
- actions requests (ARs), the generic term for items entered into the corrective action program)
- condition reports (CRs)
- corrective actions (CAs)
- condition evaluations (CEs)
- apparent cause evaluations (ACEs)
- root cause evaluations (RCEs)
- corrective actions to prevent recurrence (CAPRs)
- effectiveness reviews (EFRs)
- maintenance rule evaluations (MREs)
- procedure change requests (PCRs)
The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC documented findings as sources to select issues. Additionally, the inspectors reviewed CRs generated as a result of facility personnels performance of daily plant activities and a selection of completed RCEs, ACEs, and common cause assessments.
The inspectors performed a 5-year review of ARs associated with the air start system of the emergency diesel generators (EDGs) and also the service water (SW) pumps and performed partial system walkdowns of these systems to ensure the condition of the systems were appropriately portrayed by the CAP. Further, the inspectors reviewed CRs associated with open control room deficiencies, operator burdens, and operator workarounds to assess the level of review and appropriateness of corrective actions.
The inspectors attended a sample of the issue screening team (IST) meetings, the management review committee (MRC) meetings, and the corrective action review board (CARB) meetings.
The inspectors reviews were designed to determine whether the licensees actions were in compliance with the facilitys CAP and 10 CFR Part 50, Appendix B requirements.
Specifically, the inspectors activities were designed to determine whether licensee personnel were identifying plant issues at the proper threshold, entering issues into the stations CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. In addition, the inspectors activities were to determine whether the licensee assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed assessments, and NRC findings, including Non-Cited Violations (NCVs).
b.
Assessment
- (1) Effectiveness of Problem Identification Overall, based on the description of the CAP, the number of ARs generated by all plant departments, and the types of issues in the program, the inspectors concluded that the licensee was generally identifying issues and entering them into the CAP at an appropriate level. However, several recent issues were identified that had resulted in the licensee issuing additional direction to ensure a low threshold was consistently applied, especially for safety-related equipment.
Observations
Although the overall assessment was that the threshold for identifying issues was appropriate, inconsistencies were identified, especially when individuals considered the condition to be a housekeeping issue or not a safety issue. The inspectors also noted that some plant personnel may not be entering issues into the CAP due to their lack of confidence in the system. This lack of confidence was highlighted in the results of the 2008 safety culture survey. One recent improvement, however, was that initiators of CRs were getting feedback on those CRs, giving them more confidence in the process and willingness to use it for all issues.
One example of this threshold inconsistency was an instance where insulation was removed from the residual heat removal (RHR) heat exchangers during the refueling outage and never reinstalled. This issue was verbally discussed several times by auxiliary operators (AOs) with their supervision but no action was taken. The AOs considered this a housekeeping issue not worthy of a CAP, not realizing the removed insulation could affect the heat load in the auxiliary building, resulting in a safety issue.
This issue was not entered into the CAP until it was identified by the resident inspectors.
Another example was oil leakage found on the 1P-11B component cooling water (CCW)pump which was entered into the CAP on January 5, 2009. However, oil leaks on this pump were noted in operator logs and oil-add sheets on December 30, 2008, January 1, 2009, and January 3, 2009. Both issues were subsequently entered in the CAP and corrected. Also, during walkdown of the G-01 and G-02 emergency diesel generator (EDG) air start systems, the inspectors noted that a paperclip was used to secure the mercury switch for a starting air compressor motor. In this case, the switch had just been repaired and accepted the week prior to the NRC inspection. The use of the paperclip to secure the switch, for which the vendor recommended lockwire, was subsequently determined by the licensee to be unacceptable. AR 01146017, Use of Paperclips as Securing Devices, was written and actions taken to ensure that all these switches were secured with lockwire.
The inspectors noted that the licensee had recently issued directives that any abnormal condition found on safety-related equipment should be entered in the CAP. Interviews with licensee operations personnel confirmed this new threshold had been communicated.
- (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors concluded that issue resolutions established and monitored through the issue screening team and the management review board were correctly assigned significance and priority in accordance with station procedures. The inspectors noted the licensee recently reduced the open CAP issues backlog through a reprioritization effort that allowed higher risk issues to become more visible and addressed quicker.
Efforts to further reduce the backlog were ongoing.
Observations The inspectors reviewed a recent process change to classify issues into either a condition adverse to quality (CAQ) or a non-condition adverse to quality (NCAQ) to be consistent with other NextEra plants. AR 01141302, Differences in Classification Between the MRC and IST was written on December 18, 2008, to address the resident inspectors observations of a negative trend. Of concern was the threshold of the IST when certain issues were classified as low-level NCAQs but the MRC subsequently reclassified the issues as CAQs. However, since resolution and documentation of CAQ and NCAQ issues were handled the same, the inspectors concluded the even if the category assigned was not correct there would be no effect on how the issue was addressed.
Findings No findings of significance were identified.
- (3) Effectiveness of Corrective Actions The inspectors concluded that the corrective action program was generally effective in addressing identified issues. A CAP improvement initiative, rolled out in the fourth quarter of 2008, has been effective in eliminating missed due dates and more control on extension requests. However, the inspectors identified several issues where corrective actions were not fully effective.
Observations The inspectors reviewed evaluations and corrective actions for a negative trend of human performance errors in the operation department. The inspectors noted that ACEs throughout 2007 and early 2008 failed to correct the recurring human performance errors and similar issues continued. The inspectors found ACE quality improved during the first half of 2008 and that the number of operations human performance errors in the second half of 2008 was reduced to one, indicating an improving trend and that the corrective actions were now effective.
The following findings were considered the most significant examples where corrective actions were not effective.
Findings i.
Failure to Adequately Control High Winds/Tornado Hazards
Introduction:
The inspectors identified a finding of very low safety significance for the licensees failure to maintain control over the proper storage and placement of materials, within the risk significant areas of the outdoors protected area, that were classified as high winds/tornado hazards in accordance with station procedures PC 99, Tornado Hazards Inspection Checklist and NP 1.9.6, Plant Cleanliness and Storage.
Description:
As part of the review of corrective actions related to the problem identification and resolution (PI&R) cross-cutting theme, the inspectors selected the high winds/tornado hazards issue to perform a detailed follow-up of the effectiveness of the licensees corrective actions. As noted in the licensees RCE 01131240-01, NRC Crosscut PI&R Aspect P.1(d), three high winds/tornado hazards related NRC Green findings had been identified at Point Beach since 2006, all with the cross-cutting aspect of P.1(d) for inadequate corrective actions. On March 18, 2009, the inspectors performed a walkdown of the risk significant outdoors areas within the protected area to assess the effectiveness of the licensees ability to prevent and correct high winds/tornado hazard material issues.
This detailed walkdown was conducted in the risk significant areas of the Unit 1 and Unit 2 main transformers under their respective 345-kilovolt lines, near the Unit 1 and Unit 2 auxiliary transformers, in and around the switchyard, around the G-03 and G-04 EDG building, and in the outdoors protected area in general. At Point Beach, the loss of offsite power (LOOP) initiating event was found to be among the leading contributors to overall plant risk, according to licensee risk document, PRA 11.0, Internal Events Quantification Notebook. The structures, systems, and components in these areas would have been likely to cause a LOOP if impacted by a high wind missile. The inspectors used inspection procedure 71111.01, Adverse Weather, and licensee procedures PC 99 and NP 1.9.6 as guidelines for this walkdown. The focus of these procedures, as they pertained to high winds/tornado missile hazards, was to minimize the risk of causing a LOOP as a direct result of uncontrolled loose materials coming into contact with vulnerable plant equipment.
During the March 18 walkdown, the inspectors identified a number of items within these areas, including a stack of pallets, a lightweight and unsecured plywood picnic table (with a chain for securing it to a solid foundation, but the chain was not secured),a number of unsecured wooden planks, and a sea-van storage container that contained loose materials (with its open doors attempting to be held closed with an elastic rubber cord). The inspectors noted that the licensee had performed a PC 99 inspection two days prior and identified no such items. The inspectors also noted that a number of these identified materials were located in high-to-moderate pedestrian-traffic areas, such that it would have been expected that, with the number of plant personnel walking past the same items, someone with the proper training (which was one of the corrective actions from the previous event) and appropriate level of sensitivity could have identified these materials and wrote a CR.
The inspectors reviewed and assessed the corrective actions taken from the most recent high winds/tornado hazard related NRC finding in 2008, and determined that the corrective actions may have prevented this recurrence if the actions from 2008 were actually sustained, and if appropriate levels of accountability and oversight were maintained. The inspectors also found that the corrective actions associated with the previous findings were primarily focused on increasing the level of detection of loose items, as opposed to preventing the items from being placed there. At the time of this report, the licensee continued to perform an RCE (AR 01146388) that captured the inspectors concerns.
Analysis:
The inspectors determined that the licensees ineffective control of the storage and placement of materials, which were classified as high winds/tornado missile hazards in accordance with station procedures PC 99 and NP 1.9.6, within the risk significant areas of the outdoors protected area was a performance deficiency.
Using IMC 0612, Appendix B, Issue Disposition Screening, dated December 4, 2008, the inspectors determined that the finding was more than minor because if left uncorrected, the loose items would become a more significant safety concern. The inspectors evaluated the finding using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, tables 3b and 4a for the Initiating Events Cornerstone, dated January 10, 2008. The finding is of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. Additionally, the inspectors determined that the finding had a cross-cutting aspect in the area of human performance, work practices, because the licensee failed to ensure adequate supervisory and management oversight of the implementation and follow-through of the corrective actions from previous related issues (H.4(c)).
Enforcement:
No violations of NRC requirements were identified because the failure to maintain the protected area adequately free of tornado hazards was not an activity affecting quality, subject to 10 CFR Part 50, Appendix B; nor did the issue involve a procedure or activity subject to a license conditions or the TSs. The licensee included this finding in its CAP as AR 01146388 and the licensee continued to perform an RCE and develop long-term corrective actions. No violation of regulatory requirements occurred (FIN 05000266/2009006-01; 05000301/2009006-01).
ii. Failure to Adequately Input Mechanism Operated Cell (MOC) Switch Failure Evaluations and Recommendations into Maintenance Procedures
Introduction:
The Inspectors identified an NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, having very low safety significance (Green)for the failure to ensure preventative maintenance procedures were appropriate for maintenance and inspection of safety-related MOC switches. Specifically, the licensee failed to incorporate into its routine maintenance procedure (RMP) 9370 series maintenance procedure, information and recommendations from its causal evaluations and from the vendor following previous MOC switch failures.
Description:
The inspectors reviewed licensee actions for five MOC switch failures (MOC switches are electro-mechanical devices located in 4160-volt breaker cubicles).
The first event occurred in June 2001, when the safety injection (SI) pump 1P-15A was started for a surveillance and the pump operation indicator light lit and went out shortly thereafter. Upon inspection, the associated MOC switch pantograph mounting hardware was found in the bottom of cubicle 1A52-59. Subsequent inspections identified galled threads on the mounting bolting. The licensee initiated action to remount the pantograph using spare hardware and inserted steps into RMP 9370 to visually inspect the MOC switches and ensure the MOC switch hardware was snug. This procedure change was implemented in RMP 9370, revision 4, dated May 11, 2005.
The second event was discovered during refueling outage, U2R25, in April 2002, when the MOC switch pantograph hardware associated with the 2P-1B reactor coolant pump breaker was noted to be loose. Subsequent inspection of the mounting plate found that the bolt hole was stripped. To correct this condition, action was taken to drill and re-tap the damaged bolt hole. No equipment failure was associated with this event and subsequent inspection of 10 percent of the total population of MOC switches did not identify any additional MOC switch hardware or mounting plate degradation. No additional actions were taken since the procedure change to RMP 9370 was still in the change process.
The third event took place in October 2005 during removal of a breaker for maintenance and test. A mounting bolt for the MOC switch pantograph assembly associated with the 1P-15A SI pump motor breaker was found on the bottom of cubicle 1A52-59.
Subsequent inspection identified the bolt hole in the pantograph mounting plate was stripped. Actions to correct the mounting plate hardware issue included replacing the defective plate with a spare from another cubicle. No failure was associated with this event and no additional corrective actions were taken other than the immediate repairs mentioned.
The fourth event occurred on July 17, 2007, during a post-maintenance test (PMT) on 2P-15A SI pump breaker following a breaker swap. When the pump was started, the associated safeguards monitoring panel indicating light lit but then went out unexpectedly. Upon investigation, maintenance personnel identified that some of the MOC switch mounting hardware had become dislodged, which allowed the repositioning of the mounting plate which led to the false, un-lit indication for the pump. Subsequent inspection of the mounting hardware noted obvious degradation of threads on both the pantograph mounting plate and the bolting. An ACE concluded that the untimely implementation of previous corrective actions was one of the factors that led to the failure. In addition, a failure analysis report generated by a contractor stated hardware degradation as a result of high impact load forces contributed to the apparent cause.
The licensee took immediate action and replaced the failed hardware. The licensee performed walkdowns as well as modified work standards to shorten the inspection frequency to three years. However, this was a visual inspection that could not identify if the bolting or mounting plate threads were degraded and did not include checks to see if the bolting was tight. The only consequence of this event was a small increase in the planned time spent in the action condition for Technical Specification (TS) 3.5.2.A.1 for having one train of emergency core cooling system (ECCS) inoperable.
The fifth event occurred on March 15, 2009, during the PI&R inspection. The control room received a G-02 EDG trip or lockout alarm while performing procedure TS-82, EDG Routine Testing after the G-02 output breaker, 2A-05, was closed. In response to the alarm, the licensee identified hardware associated with the MOC switch on the cubicle floor. The licensees subsequent operability determination concluded this failure would not have impacted the ability of the diesel generator to perform its safety function.
The licensee initiated AR 2246127 and was in the process of conducting an ACE to evaluate the circumstances of the event at the conclusion of the inspection.
The inspectors reviewed causal evaluations, procedure revisions, work standards, and recommendations associated with the MOC switches failures to determine if steps were appropriately incorporated that would identify loose and degraded hardware as found in previous failures. The inspectors found recommendations from causal evaluations to inspect mounting bolting and mounting panel threading. In addition, the licensee requested the manufacturer provide recommendations to prevent further failures. The manufacturer responded with an e-mail from a senior engineer who recommended, among other actions, the use of thread locker and types of lock washers to use for hardware replacements. The inspectors noted, however, that no formal documentation was found that showed the licensees evaluation for selecting or omitting actions recommended in the e-mail. The e-mail and the licensees casual evaluations indicated that the licensee was aware of threading issues but had not addressed them appropriately.
The licensee RMP series maintenance procedures were revised to include periodic visual inspections of the MOC switches. The inspections did not require disassembly of the switch to check for degradation of the mounting bolting or mounting plates as existed in previous failures. The inspections did not require the licensee to check the tightness of the mounting hardware. The licensee evaluation of the period chosen to perform the inspections did not properly consider service factors and installation practices to inspect the MOC switches prior to predicted failure.
Subsequent to the latest failure, the licensee approved a design change that would reduce the impact force on MOC switch hardware and effectively eliminate the major thread degradation mechanism identified.
Failure of the MOC switches affected the reliability of the associated safety-related equipment. Although in some cases the equipment would have maintained its safety-related function, additional or more significant failures could negatively impact their reliability or capability.
Analysis:
The inspectors determined that the failure to include steps and requirements to assess the tightness and condition of the mounting hardware and threads in the MOC switch maintenance procedure was a performance deficiency. The inspectors further determined that the issue was within the licensees ability to foresee and correct, and that it could have been prevented because the conclusions of the causal evaluations and vendor recommendations from previous failures discussed bolting degradation due to service conditions. The inspectors determined the event was more than minor in accordance with IMC 0612, Appendix B, Issue Disposition Screening, dated December 4, 2008, because the finding was associated with the Mitigating Systems Cornerstone attribute of procedure quality and adversely affected the cornerstone objective of ensuring capability of systems that respond to initiating events. Specifically, the failure to ensure that degraded hardware conditions would be identified and corrected by procedures, with the currently installed design, could have affected the operability of safety-related equipment during an event or a design basis accident.
The inspectors screened the finding using IMC 0609, Significance Determination Process, Attachment 0609.04, for the Mitigating Systems Cornerstone, dated January 10, 2008. The inspectors determined that the finding was of very low safety significance (Green) because the finding did not involve a design or qualification deficiency, there was no actual loss of safety function, no single train loss of safety function greater for greater than the TS allowed outage time, and no risk due to external events.
The contributing cause of the finding was related to the cross-cutting area of problem identification and resolution, corrective action program, because the licensee failed to thoroughly evaluate problems such that the resolution addresses causes and extent of condition as necessary (P.1(c)).
Enforcement:
Title 10 CFR Part 50, Appendix B, Criterion V, Instructions Procedures, and Drawings, requires in part, that activities affecting quality be prescribed by documented instructions procedures, or drawings of a type appropriate to the circumstances and be accomplished in accordance with these instructions procedures or drawings.
Contrary to the above, as of March 27, 2009, licensees procedure RMP 9370 was not appropriate to the circumstances. Specifically, the procedure failed to include steps to ensure MOC switch mounting hardware and mounting plate threads were not degraded nor were inspections required to be performed at frequencies appropriate to the service of the MOC switch. The licensee has entered the most recent failure into its CAP as AR 1146127. Because the violation was not willful, was of very low safety significance and was entered into the licensees corrective action program, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000266/2009006-02; 05000301/2009006-02).
.2 Assessment of the Use of Operating Experience (OE)
a. Inspection Scope
The inspectors reviewed the licensees implementation of its OE program. Specifically, the inspectors reviewed implementing procedures and dissemination of OE information.
In addition, the inspectors reviewed completed evaluations of OE issues and events identified through NRC generic communications, reports made under 10 CFR Part 21, and external and internal OE.
The inspectors review was to determine whether the licensee effectively integrated OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensees program was sufficient to prevent occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed whether corrective actions, as a result of OE experience, were identified, and effectively and timely implemented.
b.
Assessment The inspectors concluded that operating experience was appropriately entered into the corrective action system. However, several evaluations were identified by the inspectors that did not address all the vendor recommendation or in some cases did not take appropriate corrective actions to implement vendor recommendations. This resulted in missed opportunities to preclude potential equipment degradation or failure.
Observations During review of issues in the corrective action program, the inspectors found instances where vendor recommendations were not incorporated into plant procedures or evaluations had been performed to not incorporate these recommendationsP. The first example involved operating experience from another plant that discussed motor starter failures due to mechanical interlock binding. The vendor also issued a technical bulletin containing recommended actions for this issue. The licensee evaluation of the OE, however, did not address some of the actions the vendor recommended nor did the licensee contact the vendor to verify it did not have to perform all the actions. The inspectors concluded this was a minor issue since the plant had not yet experienced binding of these interlocks. The second issue, discussed previously in this report, was related to vendor recommendations for inspection of MOC switches that were not incorporated into the maintenance inspection procedures. Subsequent failure of bolts on a MOC switch may have been prevented by using those recommendations. The last issue is discussed below.
Findings
i.
Inverter Maintenance Procedures Did Not Include Steps for Capacitor Replacement
Introduction:
The inspectors identified an NCV of 10 CFR Part 50, Appendix B, Criterion V, AInstructions, Procedures, and Drawings,@ having very low safety significance (Green) involving the licensees failure to have appropriate maintenance procedures and work instructions in place for safety-related inverters. Specifically, the RMP 9036 series maintenance procedures did not contain steps for periodic replacement of the electrolytic capacitors in the SCI-model inverters as recommended by the vendor.
Description:
On May 28, 2008, during pre-charging of the capacitors on the DY-0C white channel swing instrument inverter, following maintenance that replaced eight capacitors, an unexpected transfer of the power supply of the 2DY-03 white channel instrument inverter from its safety-related supply to its non-safety-related backup power supply occurred. Additionally, there were unexpected annunciator alarms. The licensees subsequent troubleshooting identified that one of the eight replaced capacitors had an unexpected ground path present. The grounded case of this capacitor was found to be in contact with a mounting bolt internal to the DY-0C inverter.
Upon review of RMP 9045-1, DY-0C White Channel Instrument Bus Static Inverter Maintenance Procedure, and associated work package instructions, the licensee determined that no instructions existed to direct maintenance staff to check for DC grounds following maintenance or prior to attempting system restoration. As a corrective action, the licensee revised the RMP 9045 series maintenance procedures for Elgar inverters and the RMP 9036 series maintenance procedures for the SCI inverters and added steps to check for grounds (the licensee has inverters from two different manufacturers).
During a review of the revised procedures to ensure adequate steps were incorporated to prevent recurrence of the 2008 event, the inspectors identified that the maintenance procedures for the SCI and Elgar inverters did not match with respect to the replacement of the capacitors. The Elgar inverters specified capacitor replacement every six years per the RMP 9045 series procedures. The SCI inverters, however, did not have any requirements listed in the RMP 9036 series procedures to replace the capacitors. After an inquiry from the inspectors, the licensee reviewed the vendor technical manual for the SCI inverters and identified that the vendor recommended the capacitors be replaced every 10 years. Review of the work order history for all six SCI inverters (DY-0A, DY-0B, 1DY-01, 1DY-02, 2DY-01 and 2DY-02) found that the capacitors have never been changed out since inverters were originally installed in the 1990s. Additionally, no evaluation was found to justify not replacing the capacitors per the vendor recommendations.
Analysis:
The inspectors determined that the failure to include steps and requirements to replace the electrolytic capacitors in the inverter maintenance procedures was a performance deficiency. This deficiency resulted in the capacitors in the SCI inverters exceeding the vendor recommended service life. The inspectors further determined that the issue was within the licensee's ability to foresee and correct, and that it could have been prevented, because the licensee revised these procedures to add steps checking for electrical grounds after capacitor replacement as a corrective action from the 2008 event. The inspectors determined that the performance deficiency was more than minor in accordance with IMC 0612, Appendix B, AIssue Disposition Screening,@ dated December 4, 2008, because the finding was associated with the Mitigating Systems Cornerstone attribute of procedure quality and adversely affected the cornerstone objective of ensuring capability of systems that respond to initiating events. Specifically, the failure to ensure the replacement of capacitors prior to exceeding the vendor recommended service life could have affected the operability of safety-related equipments during an event or a design basis accident.
The inspectors screened the finding using IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Tables 3b and 4a for the Mitigating Systems Cornerstone, dated January 10, 2008. The inspectors determined that the finding was of very low safety significance (Green) because the finding did not involve a design or qualification deficiency, there was no actual loss of safety function, no single train loss of safety function for greater than the TS allowed outage time, and no risk due to external events.
A contributing cause of the finding was related to the cross-cutting area of problem identification and resolution, corrective action program component, because the licensee failed to implement and institutionalize Operating Experience, including vendor recommendations, through changes to station procedures (P.2(b)).
Enforcement:
Title 10 CFR Part 50, Appendix B, Criterion V, AInstructions, Procedures, and Drawings,@ requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures and drawings.
Contrary to the above, as of March 12, 2009, the licensee=s RMP 9036 series procedures failed to include steps to ensure periodic replacement of the electrolytic capacitors in the SCI inverters as recommended by the vendor.
The licensee entered the finding into its CAP as AR 01146020. Because this violation was not willful, was of very low safety significance and was entered into the licensee=s corrective action program, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000266/2009006-03; 05000301/2009006-03).
.3 Assessment of Self-Assessments and Audits
a. Inspection Scope
The inspectors reviewed recent self-assessments of the CAP, quality assurance short-term narrow focus reviews, and quarterly Department Roll-Up Meetings for the security and corrective action process areas. The purpose of the inspectors review was to determine if the licensees self-assessment program was functioning to identify issues and to enter those problems into the CAP for appropriate prioritization, evaluation, and correction.
b.
Assessment The inspectors concluded that, overall, the licensees use of self-assessments and audits was appropriate for the identification, evaluation, and correction of issues. The programs for self-assessments and audits were scheduled and included a broad cross-section of performance areas. Procedures for performing assessments were in place and implemented providing guidance and consistency. For the audits and assessments reviewed, observations were documented and for deficiencies that were identified, ARs were written and evaluated to address the deficiencies. Overall, self-assessments were adequately performed.
Findings No findings of significance were identified.
.4 Assessment of Safety Conscious Work Environment
a. Inspection Scope
The inspectors assessed the licensees safety conscious work environment through discussions with the Employee Concerns Program (ECP) coordinator, interviews with 13 individuals from various departments, and review of the licensees 2008 Safety Conscious Work Environment (SCWE) survey.
b.
Assessment Willingness to Raise Safety Issues All of the individuals interviewed indicated they would not hesitate to raise a safety issue.
Their preference for raising concerns was through their supervisor and management, including identifying the issue in the CAP. If not satisfied, then the individuals would seek further resolution through the ECP. All individuals expressed the willingness to go to the NRC to resolve the issues if needed.
All individuals expressed that they had raised issued through their management and used the CAP and in most cases, the issue was addressed. Most interviewees stated they used or knew of someone who used the ECP process to address concerns.
Several interviewees knew of a recent issue identified to the NRC when a supervisor responded inappropriately to an AOs safety concern. Licensee senior managers had not been aware of the incident until informed by the resident inspectors. Senior management immediately took appropriate, aggressive action that satisfied the concerns the interviewees may have had.
The inspectors also asked questions about the climate at the plant for raising safety concerns. Most interviewees expressed that improvement had occurred in this area, especially with respect to senior management promoting the need to raise all issues.
However, the inspectors noted several recent events, such as a production over safety concern in the 2008 spring refueling outage and as part of the Extended Power Uprate project and a recent event (same as discussed in the preceding paragraph) concerning the response of some supervisors when concerns over safety issues were raised during work on the SW system, that indicated continued attention was required by plant management to maintain an environment where safety issues were readily identified.
Employee Concerns Program All interviewees were aware of the ECP. Most stated the ECP manager was visible and periodically attended department and group meetings. They also stated their department supervisors and management discussed the ECP at meetings. Overall, the majority of the individuals interviewed had no personal experience with the ECP, although many had positive impressions of the program. Several individuals stated the current manager was trustworthy and well known to the plant and therefore they thought the program was more effective than in the past.
The current ECP manager was relatively new to the program and made a point of attending department meeting and plant employee meetings to discuss ECP. The manager also noted that all Point Beach ECP issues were recently reviewed by NextEra corporate ECP personnel and, as a result, many non-nuclear safety concerns were turned over to Human Resources. This reduced the number of ECP concerns at Point Beach, although it was noted that Point Beach still had the most ECP issues of the NextEra fleet. The inspectors observations aligned with the results of the Point Beach 2008 safety culture survey which rated ECP as effective.
Retaliation When asked if there have been any instances where individuals experienced retaliation or other negative reaction for raising safety issues, no one interviewed was aware of any recent issues.
Safety Culture Survey The sites latest safety culture survey, which was conducted in July-August 2008, showed little improvement from the previous survey, conduced in 2006. The licensee submitted the results of the survey and associated actions to the NRC on December 22, 2008, as committed in confirmatory order EA-06-178. The overall nuclear safety culture was rated as an area in need of attention and had remained relatively steady since 2006. Actions to address the survey results were being tracked in AR 01141463, NRC Submittal - 2008 Safety Culture Survey Results.
The safety culture results were discussed during the interviews and all interviewees indicated the results were communicated to them. Many of the individuals indicated that improvements have been made which they thought would make the survey results better if taken again now. Some of the improvements discussed were additional staff, a more positive environment to raise issues that was supported by senior management, and the improvements to the CAP that have resulted in more confidence in the program.
c. Findings
No findings of significance were identified.
.5 Assessment of Substantive Cross-Cutting Issue (SCCI) P.1(d) Actions
a. Inspection Scope
As discussed in the March 4, 2009, Point Beach annual assessment letter, the licensee was informed that an SCCI in the area of PI&R would remain open for a third consecutive assessment period. Specifically, the cross-cutting theme was identified in the P.1(d) aspect of the CAP component which states, The licensee takes appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with their safety significance and complexity. The NRC further noted in the assessment letter that several long-term corrective actions were scheduled for completion in the first half of 2009, and that the effectiveness of those actions had not yet been assessed. As a result, the licensee was informed that the NRC would further assess Point Beachs actions regarding this cross-cutting aspect during the 2009 biennial PI&R inspection.
The inspectors reviewed RCE 01131240-01, NRC Crosscut PI&R Aspect P.1(d),revision 3, to assess the adequacy of the licensees efforts and progress in evaluating and correcting the P.1(d) SCCI. The inspectors also performed a review of the corrective actions associated with a selection of previously identified NRC findings, which contributed to the establishment of the SCCI, to assess the adequacy and effectiveness of those corrective actions.
b.
Assessment The inspectors determined that the issue was evaluated using a systematic method to identify root and contributing causes. The licensees RCE was conducted using the combination of a common cause/common factors assessment and why-staircase analysis to make a determination of the root cause for the common factors. The inspectors found the evaluation methods to be acceptable.
The root cause of the SCCI was found to be that station management had not provided the training, focus, accountability, and oversight necessary to effectively implement the CAP. The contributing causes included such deficiencies as management and supervisions level of knowledge in causal evaluation elements, limited personnel resources, inadequate understanding of identified problems, non-specific corrective actions to address the declining trend in P.1(d) findings prior to the establishment of the SCCI, and ineffective evaluation and corrective actions for longstanding issues. The inspectors concluded that the RCE was conducted to a level of detail commensurate with the significance of the problem.
The corrective actions were clearly described and were entered into the licensees tracking system. The corrective actions to prevent recurrence, developed in the RCE, were determined to appropriately address the many aspects of the root cause, and if properly implemented and sustained, would prevent recurrence. As a result of one of the CAPRs, a CAP performance improvement dashboard was created to monitor sitewide CAP performance. Inspectors noted a marked improvement in overall CAP performance in the most recent dashboard data when compared to the data from when the dashboard was first implemented in October 2008.
The inspectors noted that one CAPR associated with the implementation of a new causal evaluator/approver certification training course had yet to be completed.
Additionally, the licensees effectiveness review of the corrective actions of this RCE was due to be completed by the end of 2009. Lastly, the licensee had implemented a number of other CAP improvement initiatives that affect this SCCI. Therefore, applicability of this SCCI to Point Beach will continue to be assessed through conduct of the NRC baseline inspections until sufficient additional confidence is obtained that the actions have been effective and sustained.
.6 Assessment of Substantive Cross-Cutting Issue H.2(c)
a. Inspection Scope
As discussed in the March 4, 2009, Point Beach annual assessment letter, the licensee was informed that an SCCI in the area of Human Performance would remain open for a fourth consecutive assessment period. Specifically, the cross-cutting theme was identified in the H.2(c) aspect of the Resources component, which states, The licensee ensures that personnel, equipment, procedures, and other resources are available and adequate to assure nuclear safety. Specifically, those necessary for complete, accurate and up-to-date design documentation, procedures, and work packages, and correct labeling of components. The NRC further noted in the assessment letter that several long-term corrective actions were scheduled for completion in the first half of 2009, and that the effectiveness of those actions had not yet been assessed. As a result, the licensee was informed that the NRC would assess Point Beachs actions regarding this SCCI during the 2009 biennial PI&R inspection.
The inspectors reviewed RCE 01131171-01, Significant Cross-Cutting Issue Aspect H.2c Accurate Documentation, revision 1, to assess the adequacy of the licensees efforts and progress in evaluating and correcting the H.2(c) SCCI. The inspectors also performed a follow-up review of the corrective actions associated with a selection of previously identified NRC findings, which contributed to the establishment of the SCCI, to assess the adequacy and effectiveness of those corrective actions.
b.
Assessment The inspectors determined that the issue was evaluated using a systematic method to identify root and contributing causes. The licensees RCE was conducted using the combination of a common cause/common factors assessment and why-staircase analysis to make a determination of the root cause for the common factors. The inspectors found the evaluation methods to be acceptable.
The root cause of the SCCI was found to be that the detail and rigor, primarily in the maintenance procedures, for the installation, overhaul and refurbishment of safety significant plant equipment, was not sufficient to compensate for the loss of experience and skill the plant experienced through retirement and attrition. The licensee further added that station management, primarily in the maintenance department, had not effectively communicated the expectations or provided the resources, training, and accountability necessary to ensure quality documentation was maintained. The contributing causes included: a less than adequate level of guidance for reviewing and revising procedures; a less than adequate ownership of the Vendor Technical Information Program; and differing definitions of skill of the craft led to various levels of detail in station procedures. The inspectors determined that the RCE was conducted to a level of detail commensurate with the significance of the problem.
The corrective actions were clearly described and were entered into the CAP. The inspectors noted, however, that the single corrective action to prevent recurrence appeared to be narrowly focused because it only addressed the maintenance procedures. The maintenance department was responsible for the largest share of the findings that contributed to the SSCI, but up to half of the total findings that contributed to SSCI were from other departments. Overall, it appeared that the cumulative corrective actions for the root and contributing causes would appropriately address the many aspects of the root cause, and if properly implemented and sustained, prevent recurrence.
The licensees effectiveness review of the corrective actions of this RCE was due to be completed by the end of 2009. Therefore, applicability of this SCCI to Point Beach will continue to be assessed through conduct of the NRC baseline inspections until sufficient additional confidence is obtained that the actions have been effective and sustained.
4OA6 Management Meetings
Exit Meeting Summary
On March 27, the inspectors presented the inspection results to Mr. Meyer and other members of the licensees staff. The licensees staff acknowledged the issues presented. The inspectors confirmed that none of the potential report inputs discussed was considered proprietary.
ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
L. Meyer
Site Vice-President
J. Costedio
Regulatory Affairs Manager
F. Flentje
Regulatory Affairs Supervisor
B. Castiglia
Performance Improvement Manager
R. Farrell
Radiation Protection Manager
R. Harrsch
Operations Manager
D. Lauterbur
Training Manager
D. Tomaszewski
Engineering Director
L. Hawki
Program Engineering Manager
J. Henrickson
Employee Concerns Manager
A. Mitchell
Design Engineering Manager
T. Vehec
Maintenance Manager
S. Pfaff
Corrective Action Program Supervisor
B. Scherwinski
Regulatory Affairs
C. Ford
Maintenance Programs Department Supervisor
C. Hill
Operations Assistant Manager-Work Management
G. Vickery
Work Management Manager
B. Leonhardt
Operations Unit Supervisor
S. Cassidy
Communications Manager
M. Fencl
Security Manager
S. Ruesch
Nuclear Oversight Manager
J. Golding
Emergency Diesel Generator System Engineer
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened and Closed
- 05000301/2009006-01 FIN Failure to Adequately Control High Winds/Tornado Hazards (Section 4OA2.1.b.(3).i)
- 05000301/2009006-02 NCV Failure to Adequately Input MOC Switch Failure Evaluations and Recommendations into Maintenance Procedures (Section 4OA2.1.b.(3).ii)
- 05000301/2009006-03 NCV Inverter Maintenance Procedures Did Not Include Steps for Capacitor Replacement (Section 4OA2.2.b.i)