IR 05000305/2008007

IR 05000305-08-007, on 05/19/2008-06/06/2008, Kewaunee Power Station, Routine Biennial Problem Identification and Resolution Inspection

ML082001067
Person / Time
Site:	Kewaunee
Issue date:	07/18/2008
From:	Michael Kunowski NRC/RGN-III/DRP/B5
To:	Christian D Virginia Electric & Power Co (VEPCO)
References
IR-08-007
Download: ML082001067 (24)

Text

uly 18, 2008

SUBJECT:

KEWAUNEE POWER STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION 05000305/2008007

Dear Mr. Christian:

On June 6, 2008, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution team inspection at your Kewaunee Power Station. The enclosed report documents the inspection findings, which were discussed on June 6, 2008, with Mr. M. Crist and other 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.

On the basis of the samples selected for review, there were no findings of significance identified during this inspection. The team concluded that problems were properly identified, evaluated, and resolved within the corrective action program. The inspection team did identify several examples of minor documentation issues, including insufficient documentation, lack of documentation of completed actions, and missing links between corrective action documents.

The inspection team also noted that while there has been improvement in the sites trending program, the program was still in a state of transition at the time of the inspection.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure 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

Mr. system (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Michael Kunowski, Chief Projects Branch 5 Division of Reactor Projects Docket No. 50-305 License No. DPR-43 Enclosure: Inspection Report 05000305/2008007 w/Attachment: Supplemental Information cc w/encl: S. Scace, Site Vice President T. Webb, Director, Nuclear Safety and Licensing C. Funderburk, Director, Nuclear Licensing and Operations Support T. Breene, Manager, Nuclear Licensing L. Cuoco, Esq., Senior Counsel D. Zellner, Chairman, Town of Carlton J. Kitsembel, Public Service Commission of Wisconsin P. Schmidt, State Liaison Officer

M

SUMMARY OF FINDINGS

IR 05000305/20008007; 05/19/2008-06/06/2008; Kewaunee Power Station; Routine Biennial

Problem Identification and Resolution Inspection.

This inspection was conducted by the Duane Arnold Energy Center senior resident inspector and three regional inspectors. 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.

Identification and Resolution of Problems On the basis of the sample selected for review, the team concluded that implementation of the corrective action program (CAP) at Kewaunee Power Station was generally good. The licensee had a low threshold for identifying problems and entering them in the CAP. Items entered into the CAP were screened and prioritized in a timely manner using established criteria; were properly evaluated commensurate with their safety significance; and corrective actions were generally implemented in a timely manner, commensurate with the safety significance. The team noted that the licensee reviewed Operating Experience (OE) for applicability to station activities. Audits and self-assessments were determined to be performed at an appropriate level to identify deficiencies. In interviews conducted during the inspection, workers at the site expressed freedom to enter safety concerns into the CAP.

NRC-Identified

and Self-Revealed Findings No violations of significance were identified.

Licensee-Identified Violations

No violations of significance were identified.

REPORT DETAILS

4OA2 Problem Identification and Resolution

Completion of sections

.1 through .4 constitutes one biennial sample of Problem

Identification and Resolution (PI&R) as defined in Inspection Procedure 71152.

.1 Assessment of the Corrective Action Program

a. Inspection Scope

The inspectors reviewed the licensees CAP implementing procedures and attended CAP meetings to assess the implementation of the CAP by site personnel.

The inspectors reviewed risk and safety significant issues in the licensees CAP since the last NRC PI&R inspection in May 2007. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self assessment, licensee audits, OE reports, and NRC documented findings as sources to select issues.

Additionally, the inspectors reviewed condition reports (CRs) generated by facility personnel during the course of their daily plant activities. In addition, the inspectors reviewed CRs and a selection of completed investigations from the licensees various investigation methods, which included root cause, apparent cause, equipment apparent cause, and common cause evaluations.

The inspectors selected one high risk system, the auxiliary feedwater (AFW) system, to review in detail. The inspectors review was to determine whether the licensee staff were properly monitoring and evaluating the performance of this system through effective implementation of station monitoring programs.

During the reviews, the inspectors determined whether the licensee staffs actions were in compliance with the facilitys CAP and 10 CFR Part 50, Appendix B requirements.

Specifically, the inspectors determined if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the stations CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff 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 investigations, and NRC findings, including non-cited violations.

b. Assessment

(1) Effectiveness of Problem Identification Based on the information reviewed, the inspectors concluded that the threshold for initiating CRs was appropriate and well below the plant procedural requirements. The inspectors concluded that the program was effective at identifying issues.

Findings No findings of significance were identified.

Observations Weakness in Initiating Condition Reports (CRs) to Address Problem Identification Issues The inspectors reviewed several CRs generated to document issues where corrective actions (CAs) were either closed inappropriately or did not adequately address the issue documented in the original CR. In all instances, the deficiencies recognized by the station were corrected. While the licensee appropriately addressed specific issues, CRs were not always written to address the program issues related to why the issues were inappropriately closed or why inadequate CAs were implemented.

An example of this was CA 13151, which was written to address a violation issued during the last PI&R inspection. NRC Inspection Report 05000305/2007008 documented a non-cited violation (NCV) (05000305/2007008-01) for failing to follow the sites cause evaluation procedure, with six examples where Root Cause Evaluations (RCEs) or Apparent Cause Evaluations (ACEs) did not follow the procedure. This CA corrected the deficiencies in the six RCEs or ACEs, but failed to address the deficiency of why the station did not follow the procedures. After reviewing the actions taken in CA 13151, station personnel recognized that the CA was deficient in that it did not address the stations failure to use the cause evaluation procedure. Condition report 23235 was generated to document the lack of adequacy in CA 13151. A new CA (20174) was generated to address the lack of procedure use that resulted in the non-cited violation. However, while CR 23235 addressed the deficiency in CA 13151, it did not address why CA 13151 was written such that it only fixed the specific problems, and did not address the more basic cause of the problem.

In-Depth Review of the AFW System The inspectors considered risk insights from the NRCs and licensees risk analyses to select a risk-significant component for a vertical slice and chose to review the AFW.

For the selected risk-significant system, the inspectors reviewed the system health reports, a sample of work requests and engineering documents, and plant log entries.

When performing the vertical slice on the AFW system, it was observed that there were several CRs written that showed that there was a low threshold for the identification of equipment deficiencies. The housekeeping and cleanliness of AFW rooms were generally good, enhancing the ability of personnel to easily identify equipment deficiencies and monitor equipment for worsening conditions.

(2) Effectiveness of Prioritization and Evaluation of Issues Inspectors reviewed the classification of CRs for resolution ranging from 1, for the most significant, to 4, the least significant. Inspectors also attended the Condition Review Trending (CRT) meetings to observe the management review of CR classification. All CRs were assigned appropriate prioritization and evaluation levels.

Findings No findings of significance were identified.

Observations Trending Program The inspectors reviewed Kewaunee Power Stations trending program, as well as trend reports from the previous four quarters. The inspectors were informed of a recent change to the CAP that involved tracking and trending cross-cutting issues. The licensee had compared its CAP cause codes with the cross-cutting aspects provided in NRC Inspection Manual Chapter 0305. When there were differences between the NRCs safety culture aspects and its CAP cause codes, the licensee generated new cause codes. The licensee then went back two months and evaluated all condition reports against the CAP cause codes, new and old. The results were then plotted to identify negative trends. While the program has just started, the inspectors concluded that the new initiative had the potential to identify negative trends in performance earlier than waiting for the performance deficiencies to result in significant equipment degradation.

The inspection team did not identify any discrepancies in the sites trending program.

However, Kewaunee Power Stations trending program was in a state of transition at the time of the inspection. The site had recently hired a new trending program coordinator, and while some improvements had been initiated already, there were still outstanding actions in Kewaunees CAP Change Management Transition Plan.

(3) Effectiveness of Corrective Actions In general, the licensees corrective actions for the samples reviewed were appropriate, and appeared to have been effective. The inspectors determined that the timeliness of issue resolution had improved since the last biennial PI&R Inspection. Interviews with licensee staff indicated that there has been a significant increase in management attention to the identification and timely resolution of issues. In addition, staff interviews indicated that the development and staffing of the Department Corrective Action Coordinator (DCAC) position has been very beneficial to each organizations implementation of the CAP.

Findings No findings of significance were identified.

Observations Follow-up of Issues from Supplemental Inspection 95002 Report 05000305/2007011 During the supplemental inspection 95002, Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area, completed on December 19, 2007, the inspectors concluded that the corrective actions appeared adequate to address the Yellow finding associated with the failure to evaluate and repair a fuel oil leak on the 1A Emergency Diesel Generator and the White performance indicator for unplanned scrams per 7000 critical hours. The inspectors also noted that while the corrective actions appeared adequate, many of them had not been completed at the time the 95002 inspection was completed. As part of the PI&R Inspection, the inspectors reviewed the status of those corrective actions to ensure that they were being completed as planned. The inspectors determined that the corrective actions associated with the findings inspected in the 95002 supplemental inspection were being completed as scheduled with minimal due date extensions.

The inspectors also reviewed the status of commitments as outlined in Dominion Energy Kewaunee, Inc. Letter Serial Number 08-0114, Follow-up Commitments Related to the NRC Supplemental Inspection Pursuant to Inspection Procedure 95002. There was one minor discrepancy noted between the due dates stated in the letter and the due dates listed in the respective tracking assignments of Kewaunees Condition Reporting System (CRS). It was determined that the licensee had not changed the due dates in CRS to match those of letter 08-0114. The licensee initiated CR 100641 to track this discrepancy, and a corrective action was initiated to correct the due dates in CRS to match the dates in the commitment letter. No other discrepancies were identified by the inspectors, and all other commitments were found to be either completed or on schedule for completion by their stated due dates.

Corrective Action Program Documentation In general, the documentation generated through the CAP did not appear to be generated with the thought that they should be stand alone documents. In most cases, questions generated by the inspectors regarding CAP documents stemmed from their inability to identify all relevant information and successfully integrate the information into a coherent assessment of the issue or corrective action.

The inspectors also identified cases where the final CAs did not match the issue(s) or the original CAs. While CAs can be changed, the differences between the original actions and the final actions need to be addressed and documented to ensure the final actions appropriately address the concerns. The following items serve as examples to some of the issues identified by the inspectors.

a.

RCE 2007-039, Substantive Crosscutting Issue in the Area of Human Performance.

CA 26633 was generated to address the concern of Standards and Policies were not well communicated to existing workers... The closure for the corrective action only addressed newly badged workers, thus setting up discrepancy between the defined issue and the corrective action. Additional review by the inspector identified that five additional corrective actions had been generated to address the communications issue; however, this was not documented as part of the closure for CA 26633. While the issues had been satisfactorily addressed, a significant amount of effort was necessary to understand the closure activity.

While the issues had been satisfactorily addressed, a significant amount of effort was necessary to understand the closure activity.

b.

CR 20723, NOD IDs No CAP Written for Adverse Trend of Department Clock Resets, September 24, 2007.

In reading the corrective actions, the inspector could not identify any information that supported the licensees conclusion that no additional corrective actions were necessary. Discussions with the licensee identified that most of the deficiencies had been grouped in one area and therefore the corrective action appropriately targeted that area. While the inspector agreed with the licensees overall conclusion, the documentation provided as part of the CR and CA did not support the documented conclusion.

c.

CR 13238, CA 29984 Closed Without Completing the Action June 7, 2007.

The inspectors identified that although the licensees staff had not performed a search of the previous corrective action programs tracking system (t-track) in looking for additional examples of corrective actions closed without completing the actions. The actions taken were appropriate, overall. Pending integration of the previous CAP data base into the new system, additional actions should be considered to ensure appropriate system searches are accomplished.

d.

CR 26711, 2007 95002 NRC Insp - Potential Adverse Trend for Identification of Leaks, December 10, 2007.

Condition report was evaluated through ACE 000864. That apparent cause stated that

...the station failed to recognize that the threshold for identification and documentation of leaks was not in alignment with industry standards... The licensee had generated a number of corrective actions to address the threshold for leak identification; however, there were no corrective actions to address the ...failed to recognize... aspect of the issue. This is a case where the licensees staff failed to verify the corrective actions against the cause(s). If the verification had been properly performed, the delta between the cause and the corrective actions would likely have been identified.

The inspectors noted that the licensee was taking actions, stemming from other assessments, to address the ...failed to recognize... aspect of the concern; however, the actions were not included in the resolution of CR 26711.

e.

CA 21419, Perform FME Training, with hands on Laboratory Exercises (Operations), November 16, 2007.

This CA was generated based on the results of ACE 662 that addressed foreign material exclusion (FME) issues at the site. The CAs description was Develop and perform FME Training with hands on laboratory exercises to demonstrate knowledge and skills for FME controls. This training shall cover all the different risk levels. Training will be provided to Operations, Radiation Protection, Outage & Planning, Nuclear Security Services, and Chemistry. However, CA 21419 only addressed operations personnel.

CA 21419, without further action, was closed to CA 23169 that required operations to generate a request to the Training department for evaluation and training for FME.

CA 23169 was closed without further action to CA 21427 that required organizations to have sufficient staff trained to perform FME activities. Operations closed CA 21427 by stating that it already had nine individuals certified as FME monitors; however, there was no mention of how or if the training received by the nine individuals met the actions of CA 021419, nor was there any mention as to when the individuals had been trained.

Discussions with the licensee and review of documentation identified that the nine individuals had received training in response to CA 21427. In addition, the training received by the operations personnel was in excess of the training being requested in the original CA. Again, however, none of the detail provided to the inspectors has been included in any of the CAs mentioned above. Without the additional information it would not have been possible to determine that the licensee had successfully completed the original corrective action.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The inspectors reviewed the licensees implementation of the facilitys OE program.

Specifically, the inspectors reviewed Kewaunees OE program procedures, attended daily CRT meetings, OE Screening Board, and Significant Information Focus Team meetings. The inspectors also observed the screening and use of OE information, reviewed completed evaluations of OE issues and events, and reviewed monthly/weekly assessments of the OE performance indicators. The inspectors review was to determine whether the licensee was effectively integrating OE 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 future occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and effectively and timely implemented.

b. Assessment In general, OE was being evaluated and incorporated into station processes and procedures, although this effect has not been very timely based on the stations OE performance indicators and an assessment of the OE program. Based on the assessment, the licensee performed ACE 657, which determined the cause to be the lack of priority management assigned to OE evaluations and actions. As part of the corrective actions, evaluations were now included as part of the CAP process where significance levels were assigned to evaluations and corrective actions. Also, additional performance indicators were established to allow management to track by department overdue evaluations and corrective actions. The station has seen some improvement in timeliness since implementing the corrective actions for the assessment finding, but was still not meeting the timeliness metric for overdue items.

The inspectors did not identify any significant concerns with the sample of evaluations reviewed for OE, nor with the proposed or implemented corrective actions. The inspectors noted that the licensee performed and documented OE reviews for RCEs, ACEs, and Maintenance Rule (a)(1) determinations.

The inspectors observed the weekly OE Screening Board meeting that conducted the initial OE review to determine if the OE was applicable to the site such that an evaluation was necessary. The OE was screened to assess whether the components/systems were the same or similar to those at Kewaunee, and also for generic aspects, such as human performance, management, or generic component issues that may also be applied to Kewaunee. The generic aspect portion was part of the corrective action of RCE 718, where it was determined that OE was not adequately assessed in a manner aimed at improving plant processes and procedures. For OE that was screened out of the evaluation process, the Screening Board also made recommendations to send the OE to relevant staff for information. The Significant Information Focus meeting was a weekly call with the four Dominion sites and corporate to discuss items that were potentially generic to all stations such that corporate would conduct a review to determine if there would be actions for all fleet sites. The inspectors did not identify any OE inappropriately screened out of the evaluation process. The CRT meeting, which performed the initial screening of internal CRs, was also used to identify issues from CRs to be sent to the nuclear industry as OE. The inspectors, who observed several CRT meetings during the course of the inspection, did not identify any missed opportunities for the station to identify OE during the course of the CRT meetings.

Findings No findings of significance were identified.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors assessed the licensee staffs ability to identify and enter issues into the CAP, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits. The inspectors reviewed seven self-assessments in a number of areas.

b. Assessment In general, the assessments appeared thorough and identified a number of issues that needed to be assessed by site personnel. The licensee identified corrective actions to address the issues, however, since the majority of assessments reviewed were performed within the last year, implementation of these actions were not yet complete at the time of the inspection.

One issue identified by the inspectors was the lack of a tracking mechanism for issues identified in the As-Low-As-Is-Reasonably-Achievable (ALARA) Improvement Plan. In 2007, an industry evaluation identified weaknesses in implementation of the site ALARA program (CR 18761). The licensees action was to develop a performance improvement plan; however, the actions identified in the plan were not being formally tracked as required by the corrective action program for a Category 2 significance CR. The licensee initiated CR 100478 to address this issue.

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 the reviews of the facilitys employee concern program implementing procedures, discussions with coordinators of the employee concern program (ECP), interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from two previous safety culture surveys.

The inspectors interviewed approximately 34 individuals from various departments to assess their willingness to raise nuclear safety issues. The individuals were selected to provide a distribution across the various departments at the site. The sample was made up of licensee staff level individuals only. In addition to assessing individuals willingness to raise nuclear safety issues, the interviews also addressed the changes in the CAP over the past year to year and a half.

• Knowledge and understanding of the program;

• Effectiveness and efficiency of the program;

• Willingness to use program;

• Managements support of the program;

• Feedback on issues raised; and

• Ease of input to the system.

b. Assessment Personnel Interviews All interviewees indicated that they would raise safety issues and were comfortable doing so. Further, they were encouraged by all levels of management to input issues into the CAP. All individuals knew that in addition to the CAP they could raise issues to their management, the ECP, or the NRC. None of the individuals interviewed indicated they had been retaliated against for raising issues nor were they aware of anyone who had been retaliated against.

Only a couple of individuals had direct experience with the ECP. They indicated that their issues had been fairly reviewed and would have no problem going back to the ECP if necessary.

All individuals indicated there had been a significant positive shift in the implementation of the CAP over the past year to year and a half. Management is much more supportive of the program and emphasized its use on a regular basis. The program is addressing issues in a more timely manner and individuals are notified when the issues they raised have been addressed.

Based on the interview results, the inspectors determined that the conditions at the Kewaunee Power Station were conducive to identifying issues. Further, no negative issues relating to safety conscious work environment were raised by individuals interviewed by the inspectors.

Findings No significant findings were identified.

Safety Culture Self-Assessment SAR-000310 (KPS-SA-07-61), October 19, 2007 In reviewing the corrective actions taken against the planned corrective actions, the inspectors identified that there was a mismatch in some cases without any explanation for the differences.

In discussing the various issues with the licensee, the inspectors learned that this self-assessment had been performed by individuals not familiar with Kewaunees process for performing and documenting self-assessments. As a result, following completion of the self-assessment, the Vice President, Director Organizational Effectiveness, Director Safety and Licensing, and the Supervisor Human Performance reviewed the self-assessment. Following their review, the group developed corrective actions to address the identified concerns. None of this detail was provided in the original package.

Again, the licensees failure to view CAP documents as stand-alone documents resulted in a document where listed corrective actions and corrective actions taken were not consistent.

Findings No significant findings were identified.

4OA3 Follow-Up of Events and Notices of Enforcement Discretion

.1 (Closed) Licensee Event Report (LER) 05000305/2006013-00: Reactor Trip from

Nuclear Instrumentation Low Range-High Flux Trip Caused by Blind Relay Contact On November 11, 2006, Kewaunee Power Station personnel were performing a planned shutdown to investigate abnormal temperature and vibration indications on the number nine turbine bearing. With reactor power at approximately 10 percent, a spurious reactor protection system actuation occurred. The cause of the reactor trip was determined to be a blind contact failure (i.e., the relay appeared to be closed mechanically but there was no electrical continuity) of relay NC41P-XB associated with power range nuclear instrumentation low range-high flux trip for power range channel N-41. As the reactor protection system permissive P-10 cleared at approximately 10 percent reactor power, the reactor tripped since the two-of-out-four reactor trip signal logic was made up by nuclear instrumentation power range channels N-41 and N-42 (Note: The P-10 permissive interlock, when enabled, permits the operator to manually block the intermediate power range nuclear instrument high flux trips to prevent inadvertent reactor trips during startup). Following the trip, the NC41P-XB relay was checked and contacts were found to be mechanically closed but electrically open. The cause of the reactor trip was the low current application in which the relays were used, which led to contact oxidation and tarnish. Corrective actions included:

(1) revising test procedures to check for blind failures in permissive logic matrices; and

(2) modifying the system to enable testing contacts that are normally de-energized (open) to mechanically wipe the contact surface to remove oxidation layers. Documents reviewed as part of this inspection are listed in the Attachment. This LER is closed.

This inspection constitutes one sample as defined in Inspection Procedure 71153-05.

.2 (Closed) LER 05000305/2007001-01: Reactor Trip During Turbine Trip Mechanism

Testing On January 12, 2007, the turbine and reactor tripped while plant personnel were performing a turbine mechanical trip test. Additional reactor coolant system cool down occurred during the transient when valve MS-201B1, Reheat Steam to moisture separator reheater (MSR) B1, failed to close. Operators took action to close MS-201B1 and restore average coolant temperature to 547 degrees F. The additional cool down resulted in letdown isolation on low pressurizer level. Feedwater isolated and AFW initiated, as designed, due to low-low level in the steam generators.

The cause of the transient was the loss of auto stop oil pressure to the turbine interface steam valve that resulted in a turbine-reactor trip. Although foreign material was found on the valve seating surface, this was identified as a probably cause and no root cause could be determined. Since no root cause was identified for the trip, no root cause corrective actions existed. To address the foreign material issue, Kewaunee Power Station implemented a Change Management Plan that included procedure enhancements to the foreign material and supplemental personnel process procedures, as well as improvements to training and qualification requirements related to foreign material control at the station. Documents reviewed as part of this inspection are listed in the Attachment.

Maintenance was performed to shorten the stroke of MS-201B1 during the forced outage. After comparing the air operated valve diagnostic testing of MS-201A1 and MS-201B1, a determination was made to declare the issue an Operator Work Around and procedure changes were made to address the possibility of MS-201B1 not closing on future trips. This LER is closed.

This inspection constitutes one sample as defined in Inspection Procedure 71153-05.

.3 (Closed) LER 05000305/2007004-00: Reactor Trip During Quarterly Nuclear

Instrumentation Calibration Procedure On February 27, 2007, the reactor tripped while plant personnel were performing a quarterly channel calibration on nuclear instrument channel N-43. Additional Reactor Coolant System cool down occurred during the transient when valve MS-201B1, Reheat Steam to MSR B1, failed to close. Operators took action to close MS-201B1 and restore average coolant temperature to 547 degrees F. The additional cool down resulted in letdown isolation on low pressurizer level. Feedwater isolated and AFW initiated, as designed, due to low-low level in the steam generators.

The cause of the event was a failure of a Westinghouse BF66 relay contact in the reactor protection system trip matrix associated with nuclear instrumentation. The most probably root cause has been determined to be blind contact relay failures due to a combination of relay contact sulfidation caused by poor circuit design, manufacturing defects in some installed relays, and installation practices from the original installation 30 years ago being inconsistent with current standards and practices. Corrective actions to address the root cause included replacing 88 reactor protection system trip matrix relays, inspection and preventative maintenance was performed in both reactor trip breakers and both bypass breakers, and MS-201B1 was rebuilt. Documents reviewed as part of this inspection are listed in the Attachment.

Because the root cause of the reactor trip on February 27, 2007, and the root cause of the reactor trip on November 11, 2006, were both due to blind relay failures, NRC inspection report 05000305/2007011 identified and documented a non-cited violation (05000305/2007011-05) for Kewaunee Power Stations failure to perform an adequate extent of condition review of BF-66 Relays due to their potential for blind relay failures.

The inspectors did not identify any additional findings while reviewing this LER. This LER is closed.

This inspection constitutes one sample as defined in Inspection Procedure 71153-05.

4OA6 Management Meetings

.1 Exit Meeting Summary

On June 6, 2008, the inspectors presented the inspection results to Mr. Crist, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee:

M. Crist, Plant Manager

P. Blasioli, Director, Organizational Effectiveness

R. Adams, Health Physicist

L. Armstrong, Site Engineering Director

M. Bernsdorf, Chemistry

M. Wilson, Director, Safety and Licensing Manager

T. Breene, Manager Licensing

S. Scace, Site Vice-President

W. Henry, Maintenance Manager

B. Lembeck, Radiation Protection Supervisor

J. Ruttar, Operations Manager

D. Shannon, Health Physics Operations Supervisor

R. Steinhardt, Site Maintenance Rule Coordinator

C. Tiernan, Corporate Maintenance Rule Coordinator

S. Wood, Emergency Preparedness Manager

Nuclear Regulatory Commission

G. Shear, Deputy Director, Division of Reactor Projects

M. Kunowski, Chief, Division of Reactor Projects, Branch 5

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Closed

05000305/2006013-00 LER Reactor Trip from Nuclear Instrumentation Low Range-High Flux Trip Caused by Blind Relay Contact

05000305/2007001-01 LER Reactor Trip During Turbine Trip Mechanism Testing

05000305/2007004-00 LER Reactor Trip During Quarterly Nuclear Instrumentation Calibration Procedure Attachment