IR 05000269/2020002
| ML20224A059 | |
| Person / Time | |
|---|---|
| Site: | Oconee  |
| Issue date: | 08/11/2020 |
| From: | Frank Ehrhardt NRC/RGN-II/DRP/RPB1 |
| To: | Burchfield J Duke Energy Carolinas |
| References | |
| IR 2020002 | |
| Download: ML20224A059 (27) | |
Text
August 11, 2020
SUBJECT:
OCONEE NUCLEAR STATION - INTEGRATED INSPECTION REPORT 05000269/2020002 AND 05000270/2020002 AND 05000287/2020002
Dear Mr. Burchfield:
On June 30, 2020, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Oconee Nuclear Station. On July 27, 2020, the NRC inspectors discussed the results of this inspection with you and other members of your staff. The results of this inspection are documented in the enclosed report.
Two findings of very low safety significance (Green) are documented in this report. Two of these findings involved violations of NRC requirements. We are treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.
If you contest the violations or the significance or severity of the violations documented in this inspection report, 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 copies to the Regional Administrator, Region II; the Director, Office of Enforcement; and the NRC Resident Inspector at Oconee Nuclear Station. 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 Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA/
Frank J. Ehrhardt, Chief Reactor Projects Branch 1 Division of Reactor Projects
Docket Nos. 05000269 and 05000270 and 05000287 License Nos. DPR-38 and DPR-47 and DPR-55
Enclosure:
As stated
Inspection Report
Docket Numbers:
05000269, 05000270 and 05000287
License Numbers:
Report Numbers:
05000269/2020002, 05000270/2020002 and 05000287/2020002
Enterprise Identifier: I-2020-002-0060
Licensee:
Duke Energy Carolinas, LLC
Facility:
Oconee Nuclear Station
Location:
Seneca, South Carolina
Inspection Dates:
April 01, 2020 to June 30, 2020
Inspectors:
J. Nadel, Senior Resident Inspector
J. Parent, Resident Inspector
A. Ruh, Resident Inspector
B. Collins, Senior Reactor Inspector
Approved By:
Frank J. Ehrhardt, Chief
Reactor Projects 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 Oconee Nuclear Station, 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 Alarm Response Guide for ES Voter Trouble Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000269,05000270,05000287/202000 2-01 Open/Closed None (NPP)71111.18 A NRC identified Green Non-cited Violation (NCV) of 10 CFR 50, Appendix B, Criterion V,
Instructions, Procedures, and Drawings, was identified when the licensee failed to maintain alarm response guides OP/1/A/6101/007, OP/2/A/6102/007, and OP/3/A/6103/007 appropriate to the circumstances.
Failure to Correct Cubicle Door Interference Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000269,05000270,05000287/202000 2-02 Open/Closed None (NPP)71152 A self-revealed Green Non-cited Violation (NCV) of 10 CFR 50, Appendix B, Criterion XVI,
Corrective Action, was identified when the licensee failed to correct a condition adverse to quality associated with a standby shutdown facility breaker cubicle door interference that impaired accessibility for in-service inspection, maintenance, and repair.
Additional Tracking Items
None.
PLANT STATUS
Unit 1 operated at or near 100 percent rated thermal power (RTP) for the entire inspection period.
Unit 2 operated at or near 100 percent RTP for the entire inspection period.
Unit 3 began the inspection period at or near 100 percent RTP. On April 10, 2020 the unit was shutdown for a scheduled refueling outage. The unit was returned to 100 percent RTP on May 11, 2020 and remained at or near 100 percent RTP for the remainder 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 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.
Starting on March 20, 2020, in response to the National Emergency declared by the President of the United States on the public health risks of the coronavirus (COVID-19), resident inspectors were directed to begin telework and to remotely access licensee information using available technology. During this time the resident inspectors performed periodic site visits each week and during that time conducted plant status activities as described in IMC 2515, Appendix D; observed risk significant activities; and completed on site portions of IPs. In addition, resident and regional baseline inspections were evaluated to determine if all or portions of the objectives and requirements stated in the IP could be performed remotely. If the inspections could be performed remotely, they were conducted per the applicable IP. In some cases, portions of an IP were completed remotely and on site. The inspections documented below met the objectives and requirements for completion of the IP.
REACTOR SAFETY
71111.01 - Adverse Weather Protection
External Flooding Sample (IP Section 03.03) (1 Sample)
- (1) The inspectors evaluated flood protection barriers, mitigation plans, procedures, and equipment are consistent with the licensees design requirements and risk analysis assumptions for coping with external flooding.
71111.04 - Equipment Alignment
Partial Walkdown Sample (IP Section 03.01) (5 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
- (1) Unit 3 low pressure injection system (B train) during reactor coolant system draindown to 80 inches on April 14, 2020
- (2) Low pressure service water train A during Unit 3 refueling outage on April 21, 2020
- (3) Low pressure service water train B during Unit 3 refueling outage on April 21, 2020
- (4) Low pressure service water train C during Unit 3 refueling outage on April 21, 2020
- (5) CT5 power alignment while CT3 was out of service due to planned maintenance during Unit 3 refueling outage, on April 23, 2020
Complete Walkdown Sample (IP Section 03.02) (1 Sample)
- (1) Unit 3 recirculated cooling water system while Unit 3 was defueled with all fuel assemblies in the spent fuel pool on April 23, 2020
71111.05 - Fire Protection
Fire Area Walkdown and Inspection Sample (IP Section 03.01) (4 Samples)
The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:
- (1) Protected area - south fire zone ESVB (Building 8084) on April 15,2020
- (2) U1 and U2 auxiliary building elevation 758', fire zones 55/55A/56, on May 14, 2020
- (3) Unit 1 auxiliary building 2nd floor hallway, fire zone 85, on June 5, 2020
- (4) Unit 2 cable room, fire zone 105, on June 5, 2020
71111.08P - Inservice Inspection Activities (PWR) PWR Inservice Inspection Activities Sample (IP Section 03.01)
The inspectors evaluated pressurized water reactor non-destructive testing by reviewing the following examinations from April 13 - 17, 2020:
(1)03.01.a - Nondestructive Examination and Welding Activities.
1. Ultrasonic Examination (UT)
a. 3" high pressure injection system nozzle piping welds (3-RC-211-70,- 73), ASME Class 1 (reviewed)
2. Liquid Penetrant Examination (PT)
a. 36" main steam system pipe support (3-01A-0-2401B-H18), ASME Class 2 (reviewed)
3. Radiographic Testing (RT)
a. 3" high pressure injection system pipe-to-pipe weld (3-HP-0351-60),
ASME Class 2 (reviewed, including welding documentation)
The inspectors reviewed the licensee's boric acid corrosion control program performance.
The inspectors reviewed the licensee's justification for skip-cycle approach on steam generator inservice inspection activities.
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 U3 draindown of the reactor coolant system (RCS) to 80 inches on April 14, 2020
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
- (1) The inspectors observed and evaluated crew performance evaluation segment 2001, including a simulated steam generator tube rupture, on June 10, 2020
71111.12 - Maintenance Effectiveness
Maintenance Effectiveness (IP Section 03.01) (4 Samples)
The inspectors evaluated the effectiveness of maintenance to ensure the following structures, systems, and components (SSCs) remain capable of performing their intended function:
- (1) Nuclear Condition Report (NCR) 2321306, standby shutdown facility (SSF) and failure on March 18, 2020
- (2) NCR 2326989, elevated water storage tank level dropped below 70,000 gallons on April 6, 2020
- (3) NCR 2204828, Unit 3 recirculating cooling water system and failure on April 21, 2020
'B' diesel on June 17, 2020
Quality Control (IP Section 03.02) (1 Sample)
The inspectors evaluated the effectiveness of maintenance and quality control activities to ensure the following SSC remains capable of performing its intended function:
- (1) Keowee hydro Unit 1 generator breaker ACB-1 maintenance per IP/0/A/4980/094C, ABB Type MG-6 Relay Replacement and Testing on June 24, 2020
71111.13 - Maintenance Risk Assessments and Emergent Work Control
Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)
The inspectors evaluated the accuracy and completeness of risk assessments for the following planned and emergent work activities to ensure configuration changes and appropriate work controls were addressed;
- (1) Risk assessment for April 14, 2020 during the drain down of Unit 3 RCS to 80 inches which caused the risk to go yellow due to decay heat removal
- (2) Risk assessment for April 15, 2020 with Unit 3 in lowered inventory, yellow high risk plant operating state (HRPOS)
- (3) Risk assessment for April 27, 2020 during Unit 3 elevated risk due to drain down of Unit 3 RCS to 80 inches
- (4) Risk assessment for April 27 and May 1, 2020 during Unit 2 elevated risk due to turbine building heavy lifts over main feeder busses
- (5) Risk assessment for June 16, 2020 during Units 1, 2, and 3 elevated risk due to SSF outage
71111.15 - Operability Determinations and Functionality Assessments
Operability Determination or Functionality Assessment (IP Section 03.01) (6 Samples)
The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:
- (1) Immediate determination of operability (IDO) for NCR 2323774, Unit 2 engineered safeguards voter subsystem trouble alarms
- (2) IDO for NCR 2323458, 2B high pressure injection pump vibrations above inservice test alert range during surveillance test
- (3) Engineering evaluation for NCR 2325512 regarding acceptability of localized wall thinning in 3B condenser cooling water inlet pipe
- (4) Engineering evaluation for NCR 2325972 regarding functionality of 3HP-140 with closing torque exceeding maximum allowed
- (5) IDO for NCR 02323274, OSC-2042 TACs do not address all high pressure injection (HPI) pump operational requirements
- (6) Engineering evaluation for NCR 2329396, 3CCW-PG-0434 reading high
71111.18 - Plant Modifications
Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02) (1 Sample)
The inspectors evaluated the following temporary or permanent modifications:
- (1) Design changes 90423, 77067, 77069 for replacement emergency safety features actuation system and creation of Selected Licensee Commitment 16.7.15
71111.19 - Post-Maintenance Testing
Post-Maintenance Test Sample (IP Section 03.01) (6 Samples)
The inspectors evaluated the following post maintenance test activities to verify system operability and functionality:
- (1) IP/0/A/3001/001 L, As-left diagnostic testing after lowering torque switch setting and slight overthrust of 3HP-24, Work Order (WO) 20334466-06
- (2) Torque testing of 3CF-5 following change in valve packing design and torque switch setting, WO 20357500-01
- (3) PT/1/A/0202/011, High Pressure Injection Pump Test, following routine maintenance on the 1A HPI pump on May 26, 2020
- (4) PT/0/A/0400/004, Diesel Service Water Pump Test, following installation of a new flow orifice in accordance with EC 413000 on June 17, 2020
- (5) OP/0/A/1600/010, Operation of the SSF Diesel-Generator, testing following replacement of the 'A' and 'B' SSF diesel governors and relays on June 19, 2020
- (6) ACB-1 testing per IP/0/A/4980/094C after relay replacements on June 24, 2020
71111.20 - Refueling and Other Outage Activities
Refueling/Other Outage Sample (IP Section 03.01) (1 Partial)
- (1) The inspectors evaluated refueling outage U3R30 activities from April 11, 2020 to May 9, 2020. The inspectors completed inspection procedure Sections 03.01.a through 03.01.d.1 and 03.01.e.
71111.22 - Surveillance Testing
The inspectors evaluated the following surveillance tests:
Surveillance Tests (other) (IP Section 03.01)
===20375447 on April 6, 2020 / April 23, 2020
- (2) PT/3/A/0152/012, 3LP-22 stroke test, via WO 20260620 on April 23, 2020
- (3) PT/3/A/0601/0100 J, Emergency Power Switching Logic Functional Test on April 30, 2020
- (4) PT/1/A/0230/015, High Pressure Injection Motor Cooler Performance Test, via WO 20388258 on May 26, 2020
Inservice Testing (IP Section 03.01)===
- (2) PT/3/A/0261/010, 3C ESV Pump Test (WO# 20383388) on April 6, 2020
Containment Isolation Valve Testing (IP Section 03.01) (1 Sample)
- (1) PT/3/A/0151/019, Penetration 19 Leak Rate Test on May 2, 2020
71114.06 - Drill Evaluation
Select Emergency Preparedness Drills and/or Training for Observation (IP Section 03.01) (1 Sample)
- (1) The inspectors evaluated the emergency planning drill which included a leak from the gaseous waste decay tanks and dropped rods on May 27, 2020
Drill/Training Evolution Observation (IP Section 03.02) (1 Sample)
The inspectors evaluated:
- (1) The inspectors evaluated the emergency planning drill which included a 1T transformer lockout causing a reactor trip and a subsequent loss of coolant accident (LOCA) on June 23,
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 1 (July 1, 2019 - March 31, 2020)
- (2) Unit 2 (July 1, 2019 - March 31, 2020)
- (3) Unit 3 (July 1, 2019 - March 31, 2020)
MS08: Heat Removal Systems (IP Section 02.07) (3 Samples)
- (1) Unit 1 (July 1, 2019 - March 31, 2020)
- (2) Unit 2 (July 1, 2019 - March 31, 2020)
- (3) Unit 3 (July 1, 2019 - March 31, 2020)
MS10: Cooling Water Support Systems (IP Section 02.09) (3 Samples)
- (1) Unit 1 (April 1, 2019 - March 31, 2020)
- (2) Unit 2 (April 1, 2019 - March 31, 2020)
- (3) Unit 3 (April 1, 2019 - March 31, 2020)
BI02: RCS Leak Rate Sample (IP Section 02.11) (3 Samples)
- (1) Unit 1 (April 1, 2019 - March 31, 2020)
- (2) Unit 2 (April 1, 2019 - March 31, 2020)
- (3) Unit 3 (April 1, 2019 - March 31, 2020)
71152 - Problem Identification and Resolution
Semiannual Trend Review (IP Section 02.02) (1 Sample)
- (1) The inspectors reviewed the licensees corrective action program for potential adverse trends in the area of equipment reliability that might be indicative of a more significant safety issue.
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) NCRs 2323774,1905415, 1816606, 1806678, 1257514 regarding resolution of emergency safeguards protective system voter trouble alarm design issues
- (2) NCRs 1849742, 1851133, 1833499, 2321306 regarding resolution of OTS1-0 breaker cubicle door interference and actuation of sensitive tripping relay
71153 - Followup of Events and Notices of Enforcement Discretion Reporting (IP Section 03.05)
- (1) The inspectors reviewed the circumstances of NCR 2325879 surrounding a potential report issue involving a lowering Unit 2 borated water storage tank level due to leakage in excess of selected licensee commitment 16.6.4 limits past a low pressure injection cooler vent valve.
INSPECTION RESULTS
Inadequate Alarm Response Guide for ES Voter Trouble Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems
Green NCV 05000269,05000270,05000287/20200 02-01 Open/Closed
None (NPP)71111.18 A NRC identified Green Non-cited Violation (NCV) of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified when the licensee failed to maintain alarm response guides OP/1/A/6101/007, OP/2/A/6102/007, and OP/3/A/6103/007 appropriate to the circumstances.
Description:
At 2310 hours0.0267 days <br />0.642 hours <br />0.00382 weeks <br />8.78955e-4 months <br /> on April 3, 2020, the Unit 2 control room received a statalarm ES Odd Voter Trouble and two other alarms on the operator aid computer (OAC): ES Odd Voter 1 Hardware Fail and ES Odd Voter 1 Trouble. At 0005 on April 4, based on the instructions in alarm response guide (ARG) OP/2/A/6102/007, Alarm Response Guide 2SA-07, operators bypassed the ES voter 1 subsystem (comprised of the ES odd voter 1 and even voter 1) since all OAC alarms indicated the problem was with the voter 1 subsystem. Later, instrumentation and electrical technicians began troubleshooting odd voter 1 per IP/2/A/0315/005H, TXS Plant Protective System Cabinets ON2PPSCA0012, ON2PPSCA0013, And ON2PPSCA0017 Troubleshooting, Analysis, And Maintenance, and found that odd voter 1 appeared to be operating normally, but status lights on the odd voter 2 subrack were indicating a 15V power supply failure. Since indications existed that odd voter 2 was inoperable, which was contrary to the OAC alarms and would require actions contrary to the ARG, engineering was requested to validate the conditions against design drawings. Once odd voter 2 was confirmed to be failed, technical specification limiting condition for operation (LCO) 3.3.7, condition A was entered for four emergency safeguards protective system (ESPS) automatic actuation output logic channels being inoperable. This LCO, which has a required action completion time of one hour, was required because with odd voter 1 bypassed, and odd voter 2 in a failed state, there were no ES voters capable of automatically actuating ES equipment associated with ES channels 1, 3, 5, or 7. At 0209 hours0.00242 days <br />0.0581 hours <br />3.455688e-4 weeks <br />7.95245e-5 months <br /> operations returned ES voter subsystem 1 to service and bypassed subsystem 2 to permit exiting the LCO and to make repairs. During the 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> period of time that no odd voters were operable, even voter 2 was operable and could have actuated the minimum set of ES equipment associated with ES channels 2, 4, 6, and 8 in the event of an accident.
Inspectors reviewed the engineering changes (EC) that replaced the engineered safety features actuation system (ESFAS) to understand why the ARG contained the non-conservative actions that caused the above event. Ultimately, ARG writers failed to consider that certain hardware failures (e.g. a voter power supply failure) would not activate the OAC alarms associated with the failed voter and instead that only the redundant voters OAC alarm would show as activated. This failure mode was reasonably within the licensees ability to foresee and the event should have been prevented based on information in the systems failure modes and effects analysis (FMEA) and corrective action program.
In the FMEA, OM 201.N-0028.004, Oconee Nuclear Station RPS/ESFAS Controls Upgrade Failure Modes and Effects
Analysis.
Attachment 4, Section 1.11.3 described that the voter trouble statalarm would activate in the event of loss of voter subrack power and the OAC alarms were not listed as a method of failure detection. Additionally, section 1.0.17 described that the OAC would fail to alarm as a result of a power supply failure.
Additionally, between January and June of 2011, the licensee discovered and attempted to resolve several different design issues associated with the voter trouble statalarm during EC implementation on Unit 1. NCRs 1816606 and 1806678 identified that there was no easy means to determine which voter subsystem was causing a trouble statalarm because the system was designed such that the redundant voters (e.g. odd 1 and odd 2) shared a single statalarm. In response, the ARG was drafted to monitor OAC alarms to determine which voter subsystem was failed since the OAC alarms were setup to monitor all four voters individually. Engineers documented that this would be inadequate in some circumstances because hardware failure signals originating from one voter would result in activation of a hardware failure signal in the redundant voter and still hamper diagnosis. The NCR concluded regarding the draft ARG: not ALL scenarios are covered by it and that additional evaluation of this problem was necessary. This additional evaluation was closed to a vendor design change that enabled each voters manual bypass switch to disable its input to the statalarm so the alarm could be cleared and remain available to monitor the remaining voter.
This design change did not address the original problem statement of how to diagnose the alarm in the event of a hardware failure signal. Instead, it only provided a means to clear the alarm after a diagnosis and decision of which voter to bypass had been made. A proper diagnosis required examination of the equipment cabinets for indications of failure; however, the ARG was approved and maintained with instructions for operators to take initial action based strictly on OAC alarms. The ARG did include steps for instrumentation and electrical troubleshooting procedures to aid in alarm diagnosis, but these steps would only be performed if the previous steps (such as OAC alarm reviews) yielded inconclusive results. This alarm response methodology was incorrect for hardware failure events such as the April 3, 2020 voter power supply failure since the OAC would yield false conclusive indications. The inspectors added value by discovering the past NCR corrective action gaps discussed above and therefore this violation is characterized as NRC identified.
Corrective Actions: The licensee revised the ARGs to require more intrusive troubleshooting before taking actions to bypass an ES voter.
Corrective Action References: NCR 2323774
Performance Assessment:
Performance Deficiency: The failure to assure the accuracy and correctness of information in ARGs OP/1/A/6101/007, OP/2/A/6102/007, and OP/3/A/6103/007 per NSD 110, Technical Review and Control, Revision 11, was a performance deficiency. Specifically, for certain equipment failures that would activate the ES even or odd voter trouble alarm, the procedures directed operators to take non-conservative actions due to incorrect instructions.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Procedure Quality attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, following the ARG caused the inoperability of both Unit 2 odd ES voters which prevented the capability to automatically actuate odd channel ES components.
Significance: The inspectors assessed the significance of the finding using Appendix A, The Significance Determination Process (SDP) for Findings At-Power. A detailed risk evaluation was required because the degraded condition represented a loss of the PRA function of four of eight channels of ESPS automatic actuation output logic for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />, which was greater than the technical specification required action completion time of 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. A regional Senior Reactor Analyst (SRA) conducted a detailed risk assessment in accordance with the guidance of NRC Inspection Manual Chapter 0609 Appendix A, The Significance Determination Process for Reactors at Power. The SRA used Oconee Unit 1, 2, and 3 SPAR model version 8.60 date 5/13/19 and SAPHIRE 8 version 8.2.1. The analyst assumed that equipment on channels 1, 3, 5, and 7 of ESFAS would not receive an automatic start signal on a valid request due to the performance deficiency. Affected equipment includes high pressure injection pumps A and B, low pressure injection pumps A and B, low pressure service water pumps A and C, and the Unit 1 Keowee hydro unit. Channels 2, 4, 6, and 8 are unaffected and the performance deficiency does not impact the operators ability to manually start affected equipment as directed by procedure thus credit for recovery is applied. Exposure time was two hours. The dominate accident sequence was a stuck open primary relief valve with failure of decay heat removal and high pressure recirculation functions. Applying credit for recovery, plant risk was less than 1 E-8 which corresponds to a finding of very low safety significance (Green).
Cross-Cutting Aspect: Not Present Performance. No cross cutting aspect was assigned to this finding because the inspectors determined the finding did not reflect present licensee performance.
Enforcement:
Violation: 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Additionally, site procedure NSD 110 required personnel to assure the accuracy and correctness of information when preparing or revising procedures. Contrary to above, beginning in 2011, ARGs OP/1/A/6101/007, OP/2/A/6102/007, and OP/3/A/6103/007 were not maintained appropriate to the circumstances because they were prepared and revised with incorrect information. Specifically, for certain equipment failures that would activate the ES even or odd voter trouble alarm, the procedures directed operators to take non-conservative actions due to incorrect instructions.
Enforcement Action: This violation is being treated as an non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Failure to Correct Cubicle Door Interference Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems
Green NCV 05000269,05000270,05000287/20200 02-02 Open/Closed
None (NPP)71152 A self-revealed Green Non-cited Violation (NCV) of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, was identified when the licensee failed to correct a condition adverse to quality associated with a standby shutdown facility breaker cubicle door interference that impaired accessibility for in-service inspection, maintenance, and repair.
Description:
Between December 2012 and May 2013, multiple problems were discovered and addressed during the installation of a new breaker in the standby shutdown facility for the protected service water system modification. Maintenance personnel initially identified interference between the newly installed OTS1-0 breakers cubicle door, the adjacent breakers door hinges and with newly fabricated metal deck flooring. WO 2049924-39 adjusted the door to clear the interference with the adjacent breakers door hinges, but the door still dragged against the decking. Later in December, NCR 1837741 documented that a broken plug weld was found on a vertical angle bar structural support on the inside of the cubicle door. In March 2013, NCR 1849742 identified problems with the metal decking being distorted and creating a trip hazard. WO 2049924-76 executed repairs to broken welds that were found on the upper hinge and vertical angle bar support by installing bolts through the door at both repair locations. Subsequently, NCR 1851133 identified that the door was still being obstructed by the decking and prevented the ability to open the cubicle door far enough to remove the breaker.
In April 2013 maintenance attempted to remove the breaker, but the interference caused an electrical bus lockout when a sensitive door-mounted 94AR tripping relay was actuated due to jarring of the door against the decking. NCR 1833499 described the effort to overcome the interference as requiring two people: one pushing and one pulling in order to get the door to the necessary fully open position. As a corrective action, the metal decking was flattened, leveled, plumbed, and accepted by maintenance and engineering in May 2013. The repair flattened the decking by bolting a large piece of aluminum bar stock under one end of the decking. This repair addressed the trip hazard, but it failed to resolve the other identified problem of not being able to fully open the cubicles door over other portions of the decking.
Since May 2013, all routine maintenance work was able to be completed with the flattened decking because the work did not require opening the door beyond the point of interference (around 90 degrees open). On March 18, 2020, a first-time preventive maintenance task was scheduled that required the breaker to be removed from the cubicle to allow the breaker to be inspected. The work crew anticipated the potential for interference with the decking based on past experience with this door and other similar plant breakers. During the pre-job brief the crew planned to mitigate the risk of actuating the 94AR relay by making use of clearance in the door hinges by carefully lifting the door over the area of interference. When the work was executed, interference with the decking was encountered and the crew applied slight upward pressure on the door. This action caused the door to spring free, the relay to actuate and an electrical lockout of the OTS1 switchgear. The lockout caused the SSF to become inoperable until the lockout was reset later that day. The licensees investigation of the issue concluded that there was no human performance issue by the work crew and that the cause was ineffective corrective action of the original problem from 2013. The corrective action assigned was to modify or replace the decking.
Corrective Actions: The licensee developed plans to eliminate the interference with the metal decking and to update maintenance instructions to require blocking the 94AR relays for OTS1-0 and B7T-01 prior to manipulating the cubicle door.
Corrective Action References: NCR 2321306
Performance Assessment:
Performance Deficiency: The failure to correct a condition adverse to quality associated with a standby shutdown facility breaker cubicle door interference that impaired accessibility for in-service inspection, maintenance, and repair was a performance deficiency. Specifically, past attempts to correct the condition failed to eliminate the interference.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Equipment Performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to correct the condition adverse to quality resulted in a lockout of the OTS1 switchgear and caused the standby shutdown facility to be inoperable.
Significance: The inspectors assessed the significance of the finding using Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Using exhibit 2, Mitigating Systems Screening Questions, inspectors determined the finding was of very low safety significance (Green) because the 11.7 hour8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> duration that the SSF was inoperable did not represent a loss of a probabilistic risk assessment function a single train system for greater than its technical specification allowed outage time.
Cross-Cutting Aspect: Not Present Performance. No cross cutting aspect was assigned to this finding because the inspectors determined the finding did not reflect present licensee performance.
Enforcement:
Violation: 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires, in part, that conditions adverse to quality be promptly identified and corrected. Contrary to the above, since May 2013, an identified deficient condition associated with the OTS1-0 cubicle door interfering with metal decking and impairing accessibility for in-service inspection, maintenance, and repair was not corrected. Specifically, past attempts to correct the condition failed to eliminate the interference until it resulted in an equipment failure.
Enforcement Action: This violation is being treated as an non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
- On July 27, 2020, the inspectors presented the integrated inspection results to J. Ed Burchfield and other members of the licensee staff.
- On April 16, 2020, the inspectors presented the Oconee U3 ISI Inspection Exit Meeting inspection results to Mr. Ed Burchfield, Site Vice President and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Calculations
OSC-2240
Verification of SSF Sump System Parameters
Corrective Action
Documents
1753624, 1747483, 2272266, 2329909
Drawings
O-447A
Piping Layout SSF Plans Sections & Details at El. 754-0
O-447C
Piping Layout SSF Auxiliary Service Water Piping Plan,
Sections & Details
OM 111-0220.001
PLFBCGH Hinged Flood Barrier
D0D
OM 111-0266.001
CG11HA
D0G
Procedures
AP/0/A/1700/047
External Flood Mitigation
FG/0/A/1900/005
Initial Assessment and FLEX Equipment Staging
MP/0/A/1400/033
Flood Door - SSF Building - Presray - Semi-Annual and 5
Year - Preventive Maintenance and Repair
PT//0/A/0400/019
SSF Sump Pump Discharge Check Valve Test
Corrective Action
Documents
2169391
Drawings
OFD-100A-3.1
Flow Diagram of Reactor Coolant System
OFD-102A-3.1
Flow Diagram of Low Pressure Injection System (Borated
Water Supply and LPI Pump Suction)
OFD-102A-3.2
Flow Diagram of Low Pressure Injection System (LPI Pump
Discharge)
OFD-102A-3.3
Flow Diagram of Low Pressure Injection System (Core
Flood)
OFD-124B-3.1
Flow Diagram of Low Pressure Service Water System
(Auxiliary Building Services)
OFD-125A-3.1
Flow Diagram of Recirculated Cooling Water System (Pump
and Heat Exchangers)
OFD-125A-3.2
Flow Diagram of Recirculated Cooling Water System
(Turbine Building Loads)
OFD-125A-3.3
Flow Diagram of Recirculated Cooling Water System
(Turbine Building Loads)
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
OFD-125A-3.4
Flow Diagram of Recirculated Cooling Water System
(Auxiliary Building Loads)
OFD-125A-3.5
Flow Diagram of Recirculated Cooling Water System (Misc.
Loads)
OFD-125A-3.6
Flow Diagram of Recirculated Cooling Water System
(Turbine Building Loads)
Procedures
OP/3/A/1103/011
Draining and Nitrogen Purging RCS
097
OP/3/A/1104/006
SF Cooling System
099
OP/3/A/1104/009
RCW System
035
Work Orders
20334172
Calculations
OSC-9659
Oconee Nuclear Safety Capability Assessment for Units 1, 2
and 3
Fire Plans
CSD-ONS-PFP-
Pre-Fire Plan for U1 Auxiliary Building Elevation 783
CSD-ONS-PFP-
Pre-Fire Plan for U2 Auxiliary Building Elevation 809
Procedures
AP/0/A/1700/043
Fire Brigade Response Procedure
AP/1/A/1700/050
Challenging Plant Fire
AP/2/A/1700/050
Challenging Plant Fire
Calibration
Records
689151
Standards Laboratory Instrument Certification: IR
Thermometer (G503097)
7/1/19
Corrective Action
Documents
CR02280288
07/03/2019
CR02301162
Boron Leak Identified on 3B LPI Pump Casing and Bolting
11/06/2019
Miscellaneous
Duke Energy Certificate of Method Qualification: UT II-N
(May)
1/28/20
Record of Welder Performance Qualification Test (Murison)
09/26/2008
Sonic Systems International, Inc. Certificate of Qualification:
UT II-PDI (Harmon)
20.01.14
Sonic Systems International, Inc. Vision Acuity Record
(Harmon)
09/06/2019
Duke Energy Certificate of Method Qualification: UT II-N
2/20/2020
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
(Jensen)
Visual Acuity Record (Jensen)
6/12/20
Visual Acuity Record (May)
01/28/2020
Visual Acuity Record (Ransom)
8/29/19
Duke Energy Certificate of Method Qualification: UT II-N
(May)
9/12/2017
Duke Energy Certificate of Method Qualification: PT II-N
(May)
9/6/2017
171796
Duke Energy Corporation Weld Record (3-HP-0351-60)
10/29/19
19D05K
Magnaflux Spotcheck Penetrant SKL-SP2
04/12/2019
19K12K
Magnaflux Spotcheck Developer SKD-S2
10/18/2019
GT000808-04
Welding Procedure Specification
L-110D
Procedure Qualification Record
January 3,
1991
Procedure Qualification Record
9/12/74
L-148C
Procedure Qualification Record
4/13/88
NDE Reports
6080
Metallurgy File: ONS O3R30 Reactor Vessel Head Deposit
Samples
April 20,
20
PT-20-008
Liquid Penetrant Examination Record (3-01A-0-2401B-H18)
4/16/2020
UT-20-075
UT Calibration/Examination Record (3-PDB2-47)
4/15/2020
UT-20-106
UT Calibration/Examination Record (3RC-211-73)
4/13/2020
VE-20-012
Ultrasonic Examination Record (3RC-211-70)
4/14/20
Procedures
AD-EG-PWR-
1611
Boric Acid Corrosion Control Program - Implementation
MP/0/A/1800/132
Inspection, Assessment, and Cleanup of Boric Acid on Plant
Materials
010
MP/0/A08140/001
QA and Non-QA Welding
010
NDE-NE-ALL-
6304
Utilization of EPRI-DMW-PA-1 Procedure for Manual
Phased Array Ultrasonic Examination of Dissimilar Metal
000
PD-EG-PWR-
1611
Boric Acid Corrosion Control Program
71111.11Q Procedures
OP/0/A/1102/026
Operations IPTE Pre-Job Briefings
031
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
OP/3/A/1102/001
Controlling Procedure for Unit Startup
279
OP/3/A/1103/011
Draining and Nitrogen Purging RCS
097
OP/3/A/1105/019
Control Rod Drive System
2
PT/0/A/0711/001
Zero Power Physics Test
074
PT/0/A/1103/020
Power Maneuvering Predictions
26
PT/3/A/0600/001
B
Instrument Surveillance Prior to Mode Change
2
PT/3/A/0600/030
NI Overlap
001
Calculations
OSC-5085
Seismic Analysis of New Floor Mounted Enclosures and
Modifications to Existing Floor Mounted Enclosures
OSC-5085-ICC-
28
Door hinge modification on OTS1 Switchgear enclosure
March 6,
2013
Corrective Action
Documents
23330, 2204828, 2326415, 2321306, 2335524
Drawings
OEE-616-02
Elementary Diagram SSF 4160V Switchgear OTS1 Unit 0
Feeder Breaker
OFD-133A-2.5
Flow Diagram of Condenser Circulation Water System (SSF
Aux. Service)
Engineering
Changes
91876
SSF 4.16kV Alternate Power Feed from PSW
Miscellaneous
MRule Manager software
SystemIQ software
Material Issue Ticket 41168800
AD-EG-ALL-1210
OM 302.A-
0097.002
Qualification Report for Duke Oconee Medium Voltage
Substation
D08
Procedures
IP/0/A/4980/094C
ABB Type MG-6 Relay Replacement and Testing
Work Orders
20389606
Calculations
OSC-11805
Generic Load Drop Analysis for Turbine Building Operating
Floor Lifts
OSC-11847
Oconee Low Pressure Turbine Replacement Heavy Lift Risk
Evaluation
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Corrective Action
Documents
27188
Miscellaneous
Outage Control Center Outage Status nightshift package
dated April 27, 2020
Standing Instruction 20-04, Rev. 3 - Low Pressure Turbine
Replacement Heavy Lift Mitigation Requirements
Elevated Risk Activity Plan for SSF Annual Outage 2020
May 20,
20
Outage Control Center Outage Status dayshift package
April 14,
20
Procedures
EP/1/A/1800/001
0Q
Unit 1 EOP Enclosures 5.41-5.46
OP/3/A/1103/011
Draining and Nitrogen Purging RCS
097
Calculations
OSC-0632
Reanalysis of the Condenser Cooling Water Pipe for
Seismic Conditions
OSC-0681
Condenser Cooling Water Pipe Design
OSC-10403
License Renewal Calculation - CCW System Internal
Coating Inspections Program
OSC-10411
License Renewal Calculation - Service Water Piping
Corrosion Program
OSC-11241
Low Frequency Electromagnetic Technique Inspection
Report
OSC-5599
Generic Letter 89-10 Calculation for Unit 3 Gate and Globe
Valves
OSC-7184
Generic Letter 89-10 Calculation for Units 1, 2, 3 Gate and
Globe Valves at Oconee
OSC-7380
CCW Intake and Discharge Piping Units 1, 2 and 3; 5 Year
Civil/Coating Inspection Report
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Corrective Action
Documents
1784715, 2202906, 2323274, 2323642, 2328102, 2328141,
29396, 1928935, 2152176
Drawings
ONTC-3-HP-140
Generic Letter 89-10 Test Acceptance Criteria
OSC-2042
HPI Pump Motor Upper Bearing Cooling Report
010
OSC-4171
SSF ASW Design Inputs Calculation
038
OSC-7561
Differential Pressure Calculations for Valves FDW-0315 and
FDW-0316
000
OSC-8176
GL 89-10 Review for Valves CCW-268 and CCW-287
Miscellaneous
OM 253.
0117.001
I/B - PSW DMV 1463 - Technical Manual for 6 Inch
Modulating Bolted Bonnet Solenoid Operated Valve Model
000
OSS-0254.00-00-
2003
Engineered Safety Features Actuation Systems Design
Basis Specification
Procedures
OP/2/A/6102/007
Alarm Response Guide 2SA-07
PT/2/A/0230/015
High Pressure Injection Motor Cooler Performance Test
047
Work Orders
20333945, 1876646
Calculations
OSC-3348
RPS/ES Failure Modes and Effects Analysis Summary
Calculation
Corrective Action
Documents
257514
Engineering
Changes
AREVA ECP 131-9159730-000
107004
Unit 1 RPS/ES Hardware Enhancement
77067
Unit 2 ESFAS Replacement Modification
77069
Unit 3 ESFAS Replacement Modification
90423
Unit 1 ESFAS Replacement Modification
Miscellaneous
OM 201.N-0020-
001
ONS Units 1, 2 and 3 RPS/ESFAS Controls Upgrade
Maintenance and User Manual Volume 1
OM 201.N-
20.008
ONS Units 1, 2 and 3 RPS/ES Control Upgrade and User
Manual Volume 4, Hardware Book 1 of 3
D09
OM 201.N-
24.005
Oconee Nuclear Station Unit 1 RPS/ESFAS Controls
Upgrade Software Design Description
D17
OSS-0254.00-00-
2003
Engineered Safety Features Actuation Systems Design
Basis Specification
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Calculations
OSC-5599
Generic Letter 89-10 Calculation for Unit 3 Gate and Globe
Valves
Corrective Action
Documents
25810, 2325897
Drawings
Valve Packing Datasheet: 3-CF-0005
KEE-114
Elementary Diagram Generator Control ACB-1 Control
Circuit
OM 245-2387.001
Seismic / Weak Link Report for 1,2,3HP-24 & 25, 6 Powell
Model 3023 300 Gate Valve with Motor Operator
ONTC-3-HP-024
Generic Letter 89-10 Test Acceptance Criteria
Engineering
Changes
409984
411450
3GWD-12 EV, 1/3CF-5,6 EV: Spring Pack Change
Miscellaneous
OSS-0254.00-00-
28
Design Basis Spec for the Low Pressure Injection and Core
Flood System (LPI)
Procedures
OP/0/A/1600/010
Operation of the SSF Diesel-Generator
096
PT/0/A/0400/011
SSF Diesel Generator Test
015
PT/0/A/0600/021
Standby Shutdown Facility Diesel-Generator Operation
016
PT/1/A/0202/011
High Pressure Injection Pump Test
104
Work Orders
295946, 20295955, 20295956, 20327685, 20299762,
299763, 20386069
Corrective Action
Documents
26176, 2326415, 2328602, 2326987, 2329314, 2326415,
26655, 2327878, 2327111, 2327349, 2327952
Drawings
OFD-100A-3.1
Flow Diagram of Reactor Coolant System
OFD-101A-3.1
Flow Diagram of High Pressure Injection System (Letdown
Section)
OFD-106A-3.1
Flow Diagram of Coolant Treatment System (RC Bleed
Holdup Tanks)
OFD-109A-3.1
Flow Diagram of Purification Demineralizers
OFD-109A-3.2
Flow Diagram of Deborating Demineralizers
Miscellaneous
AD-MN-ALL-0002
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
AD-OP-ALL-0106
Conduct of Infrequently Performed Tests or Evolutions
AD-OP-ALL-0203
Reactivity Management
OPS-3-20-LP-
3LP-8 PAK LK-
1042
5/4/20
Procedures
AP/3/A/1700/035
Loss of SFP Cooling and/or Level
OP/0/A/1102/026
Operations IPTE Pre-Job Briefings
031
OP/0/A/1108/001
Curves and General Information
115
OP/0/A/1108/001
A
Reactor Core and SFP Loss of Cooling Heatup Tables
007
OP/3/A/1102/001
Controlling Procedure for Unit Startup
279
OP/3/A/1102/010
Controlling Procedure for Unit Shutdown
250
OP/3/A/1103/004
A
RCS Boration
25
OP/3/A/1103/011
Draining and Nitrogen Purging RCS
097
OP/3/A/1104/006
SF Cooling System
099
OP/3/A/1104/009
RCW System
035
OP/3/A/1105/019
Control Rod Drive System
2
OP/3/A/1107/018
Removal and Restoration of Motor Control Centers
PT/0/A/0711/001
Zero Power Physics Test
074
PT/0/A/1103/020
Power Maneuvering Predictions
26
PT/3/A/0115/012
Unborated Water Source Isolation Verification
005
PT/3/A/0600/001
B
Instrument Surveillance Prior to Mode Change
2
PT/3/A/0600/030
NI Overlap
001
TE-MN-ALL-0002
Foreign Material Exclusion Level and Controls Screening
Work Orders
20171869
Corrective Action
Documents
24709
Drawings
OFD-116A-3.1
Flow Diagram of Reactor Building Purge System
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Miscellaneous
PT/3/A/0150/034
Leak Rate History Record and Reactor Building Leak Rate
Verification
May 6, 2020
PT/3/A/0151/019
Penetration 19 Leak Rate Test
May 3, 2020
PT/3/A/0151/019
Penetration 19 Leak Rate Test
April 10,
20
Procedures
PT/1/A/0230/015
High Pressure Injection Motor Cooler Performance Test
051
PT/2/A/0152/009
Feedwater System Valve Stroke Test
019
PT/3/A/0152/012
Low Pressure Injection System Valve Stroke Test
043
Work Orders
20334840, 20260620, 20375447, 20388258
Miscellaneous
AD-EP-ALL-0106
Activation and Operation of the Operations Support Center
AD-EP-ONS-0106 ONS Site Specific OSC Support
000
AD-OP-ALL-1000
Conduct of Operations
EP/1/A/1800/001
Immediate Manual Actions and Subsequent Actions
003
FAD-ON-EP-EAL-
EALMATRIX
Oconee Nuclear Station Classification of Emergency
001
ONS 20-02 EMPE Oconee Practice Drill
June 23,
20
RP/0/A/1000/001
Emergency Classification
006
71151
Miscellaneous
Oconee Unit 1, 2, 3, cooling water support systems
Unavailability data from April 1, 2019 to March 31, 2020
Review of cooling water support systems log entries in
eSOMS from April 1, 2019 - March 31, 2020
AD-PI-ALL-0700
Performance Indicators
Regulatory Assessment Performance Indicator Guideline
Corrective Action
Documents
21306, 1833299
Drawings
O-0320-Z-007-A
SSF Electrical Equipment Seismic Mounting Plans, Section
& Details
OM 302.A-
25.002
SSF 4.16kV Switchgear OTS1 Unit 0 Layout Drawing
D6
Miscellaneous
OM 1201.N-
24.005
Oconee Nuclear Station Unit 2 RPS/ESFAS Controls
Upgrade Software Design Description
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
OM 1201.N-
25.011
Oconee Nuclear Station Unit 2 RPS/ESFAS Controls
Upgrade Test Phase V&V Activity Summary Report
OM 1201.N-
28.004
Oconee Nuclear Station Unit 2 RPS/ESFAS Controls
Upgrade Failure Modes and Effects Analysis
OM 201.N-
22.002
Oconee Nuclear Station, Units 1, 2 and 3 RPS/ESFAS
Controls Upgrade Hardware Design Solutions
D26
OM 201.N-
28.004
Oconee Nuclear Station RPS/ESFAS Controls Upgrade
Failure Modes and Effects Analysis
Procedures
NSD-703
Administrative Instructions for Technical Procedures
OP/1/A/6102/007
Alarm Response Guide 1SA-07
OP/2/A/1105/014
Control Room Instrumentation Operation and Information
OP/2/A/6102/007
Alarm Response Guide 2SA-07
PT/1/A/0600/001
Periodic Instrument Surveillance
2
Work Orders
2049924, 20384707
Drawings
OFD-102A-2.2
Flow Diagram Low Pressure Injection System
Miscellaneous
Reportability Evaluation Worksheet for NCR 2325879
PT-2-A-0203-004
Low Pressure Injection System Leakage
2