IR 05000315/2003009
| ML031970694 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 07/15/2003 |
| From: | Grant G Division Reactor Projects III |
| To: | Bakken A American Electric Power Co |
| References | |
| IR-03-009 | |
| Download: ML031970694 (22) | |
Text
uly 15, 2003
SUBJECT:
D. C. COOK NUCLEAR POWER PLANT, UNITS 1 AND 2 NRC INSPECTION REPORT 50-315/03-09 (DRP); 50-316/03-09 (DRP)
Dear Mr. Bakken:
The NRC conducted a follow-up supplemental inspection using inspection procedure 95002 Inspection For One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area at your D. C. Cook Nuclear Power Plant, Units 1 and 2 during the week of June 16, 2003. The enclosed report documents the inspection findings which were discussed on June 20, 2003, with J. Pollock and other members of your staff.
The NRC previously performed this supplemental inspection as required by the NRC Action Matrix based on plant performance for D. C. Cook Unit 2 being within the Degraded Cornerstone Column of the NRC Action Matrix due to two White findings in the Mitigating Systems Cornerstone. As stated in our inspection report dated April 15, 2003, we concluded that your evaluation of these findings was incomplete because an adequate extent of condition review for the root and contributing causes had not yet been performed. Specifically, the extent of condition reviews for maintenance procedure adequacy and condition report evaluation and closure for equipment-related issues, which were two important causes for both of the White findings, were not adequately completed. This was considered to be a significant weakness with your evaluation and resulted in both of the White findings that contributed to the Degraded Cornerstone remaining open.
Based on the results of this follow-up inspection, the inspectors determined that an adequate extent of condition review had been completed. Given the acceptable performance in addressing the incomplete extent of condition evaluation of the issues, the two White findings leading to the Degraded Cornerstone will only be considered in assessing plant performance using the NRC Action Matrix thru the end of the second quarter 2003. This supplemental 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 purpose of this inspection was to (1) provide assurance that the root and contributing causes for both White findings and for the overall performance issues which resulted in the Degraded Cornerstone are understood; (2) independently assess the extent of condition and generic implications of the White findings; and (3) provide assurance that the corrective actions to address the White findings are sufficient to prevent recurrence.
In accordance with 10 CFR 2.790 of the NRCs "Rules of Practice," a copy of this letter and its enclosures will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRCs document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Geoffrey E. Grant, Director Division of Reactor Projects Docket Nos. 50-315; 50-316 License Nos. DPR-58; DPR-74
Enclosure:
Inspection Report 50-315/03-09 (DRP); 50-316/03-09 (DRP)
w/Attachment: Supplemental Information
REGION III==
Docket Nos: 50-315; 50-316 License Nos: DPR-58; DPR-74 Report No: 50-315/03-09(DRP); 50-316/03-09(DRP)
Licensee: Indiana Michigan Power Company Facility: D. C. Cook Nuclear Power Plant, Units 1 and 2 Location: 1 Cook Place Bridgman, MI 49106 Dates: June 16 through June 20, 2003 Inspectors: L. Kozak, Project Engineer C. Brown, Resident Inspector Approved by: E. Duncan, Chief Branch 6 Division of Reactor Projects Enclosure
SUMMARY OF FINDINGS
IR 05000315-03-09 (DRP), IR 05000316-03-09 (DRP); Indiana Michigan Power Company; 06/16/03-06/20/03; D. C. Cook Nuclear Power Plant, Units 1 and 2; Supplemental Inspection -
Mitigating Systems Cornerstone.
This report covers a supplemental inspection performed by regional-based and resident inspectors. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG 1649, "Reactor Oversight Process," Revision 3, dated July 2000.
Cornerstone: Mitigating Systems
The NRC performed a follow-up supplemental inspection to assess the licensees extent of condition evaluation for the two White performance issues associated with the Degraded Cornerstone. The failure to perform an adequate extent of condition evaluation was identified during the initial supplemental inspection and was considered a significant weakness in the licensees evaluation. This resulted in the two White findings remaining open pending the licensees completion of the extent of condition evaluation and the NRCs inspection of the evaluation.
The inspectors concluded during the follow-up supplemental inspection that the licensee had completed an adequate extent of condition evaluation. As a result, the two White findings will be closed as of the end of the second quarter 2003.
NRC-Identified
and Self-Revealed Findings No findings of significance were identified.
Licensee-Identified Violations
None
REPORT DETAILS
Inspection Scope This follow-up supplemental inspection, performed in accordance with Inspection Procedure 95002, Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area, was conducted to review the licensees extent of condition evaluation for the root and contributing causes to the two White findings that resulted in a Mitigating Systems Degraded Cornerstone. Specifically, the extent of condition evaluation included a review of maintenance procedure adequacy and a review of the evaluation and closure of equipment-related issues identified during the expanded system readiness review (ESRR) conducted during the extended outage.
The inspectors reviewed the licensees extent of condition evaluation to determine if the evaluation was thorough and properly determined the applicability of the root and contributing causes to other plant equipment issues and procedures. In addition to reviewing the licensees results regarding extent of condition, the inspectors independently sampled maintenance procedures and equipment-related issues and compared the results of the independent review to the licensees results. The inspectors also reviewed the corrective actions specified for the problems identified to verify that the corrective actions were appropriate.
The inspectors reviewed the licensees independent assessment performed by the Performance Assurance (PA) department and compared the inspectors conclusions regarding the thoroughness of the review to the conclusions of the PA assessment.
Evaluation of Inspection Requirements Inspection requirements 02.01a - d, 02.02a - c, and 02.03a - d of Inspection Procedure 95002 were completed and documented in the initial supplemental inspection report 50-315/03-04; 50-316/03-04. Inspection requirements 02.02d and 02.04 were only partially completed at that time because the licensees extent of condition evaluation was incomplete. The results of the additional inspection for these two requirements are documented below.
02.02 Root Cause and Extent of Condition Evaluation D.
Determine that the root cause evaluation included consideration of potential common cause(s) and extent of condition of the problem.
Extent of Condition Evaluation for Maintenance Procedure Adequacy The inspectors reviewed the licensees extent of condition evaluation for maintenance procedure adequacy performed under corrective action 11 of Condition Report (CR)02277047, Common Cause Investigation for Mitigating Systems Degraded Cornerstone. The action required a multi-disciplined team assessment of a statistically significant sample of safety-related maintenance procedures. The licensee selected 70 safety-related maintenance procedures for review. To ensure consistent reviews of the selected procedures, the licensee developed a matrix of items to be checked and a process of individual and team reviews. The results of each procedure review were documented on individual CRs. Of the 70 procedures reviewed, 9 (13 percent) had wrong technical data in the procedure and were placed on hold until the technical data was revised and/or validated to be correct, 43 (61 percent) were lacking technical justification or clarification, and 18 (26 percent) identified user preferences or enhancements.
After the first 95002 inspection, the licensee generated a roll-up CR to address all maintenance procedure issues (CR 03057040, Screening committee request to generate a roll-up CR for Maintenance Procedure issues identified in the 95002 inspection). The apparent cause evaluation for this CR revealed that a previous self-assessment (SA-2001-BDC-014, Procedure Programmatic Assessment), performed by a multi-disciplined team in October 2001, had found that efforts to improve the procedure program had been delayed or hampered by restart, refueling outages, and forced outages and that some of the past efforts were either ineffective or never fully implemented. The self-assessments primary recommendations included bench marking, revising program procedures, establishing a standard set of procedure software, and providing additional training for procedure writers and reviewers. The assessment also determined that procedure development, changes, and reviews were discrete activities for all personnel involved. Some organizations had budgeted time for procedure reviews but higher priority work and support activities had routinely impacted personnel availability to complete the reviews. This condition had resulted in perceived time pressure, inadequate reviews, and ultimately plant events due to inadequate procedures.
The results of the individual procedure reviews during the extent of condition evaluation revealed the following weaknesses as the cause of the technical and procedural inadequacies.
- Wrong personnel doing reviews (maintenance and engineering).
- Ineffective understanding of what to review and verify.
- Not self-critical enough, ok as is.
- Failure to validate technical information.
- Lack of management oversight and support.
- Insufficient information available or provided to the writer for procedure development.
- Lack of comprehensive review by the reviewer.
- Timeliness and/or priority of procedures out for review.
- Lack of timely procedure upgrades.
- Inadequate level of detail to support the least experienced user.
- Lack of vendor information.
- Ineffective or lack of notification when procedure inputs change.
To further evaluate procedural weaknesses and to determine if additional maintenance procedures needed to be placed on administrative hold, the licensee broadened the scope of review to include about 2000 open maintenance procedure change CRs using the same criteria established for condition report action (CRA) 02277047-11. An additional 23 procedures were identified that warranted being placed on administrative hold.
Based on the results of the licensees apparent cause evaluation and the results of the sample initially selected for review, the scope of the review was expanded to include all maintenance procedures. The licensee had concluded that the apparent cause for the condition of the maintenance procedures was an organizational and programmatic breakdown based on inadequate job skills, work practices, and decision making - a Nuclear Organization Programmatic Deficiency. This was supported by licensee findings that identified that there had been an acceptance of substandard information in procedures, a lack of justification for technical data, and a lack of engagement by maintenance supervision to ensure that procedure reviews utilized craft input. The corrective actions were to ensure that all procedures owned by maintenance would be reviewed against the standards established in CRA 02277047-11.
Performance Assurance (PA) staff performed an independent review of the procedures after the procedure team had completed their review and documented their recommendations in separate condition reports (PA-SR-03-0003, Degraded Cornerstone Extent of Condition Surveillance). The initial PA reviews identified numerous additional items. These PA findings were shared with the procedure review team in order to improve subsequent reviews. The inspectors noted that the number, type, and significance of additional PA findings decreased as the procedure team learned more and became more thorough in their reviews. In addition to a technical review, PA also performed a separate usability review on the procedures. A third independent review was completed on a sample of completed and released procedures as a final check, using an in-field walk down inspection technique. The results of the in-field walk down procedure reviews demonstrated that the quality of the procedures had been markedly improved.
The inspectors found the licensees extent of condition review to be thorough and self-critical and the corrective actions identified should correct the condition of the maintenance procedures. The improvements were notable after incorporating performance assurances findings as feedback. The PA independent review was thorough and intrusive and added value (as noted above). Corrective actions included nearly tripling the procedure review staff including dedicated maintenance personnel support. The licensee planned to incorporate the CRA 02277047-11 procedure review matrix into the required biennial review process for all procedures. The review group planned to review about 700 procedures in 2003 which was broken down into approximately 25 instrument procedures, 2 electrical procedures, and 8 mechanical procedures per week. The review was planned to continue through 2004 and was planned to complete in 2005. The inspectors considered this to be an aggressive schedule which will require constant attention to achieve; however, the corrective actions were well planned and supported and are achievable. The inspectors also noted that Maintenance Procedures was number 30 on the top 30 items on the stations Equipment Reliability (EQR) List. The licensee had a July 31, 2003, due date for having plans in place complete with due dates and measurement tools for all top 30 EQR items.
Extent of Condition Evaluation for Adequacy of Evaluation and Closure of Equipment-Related Issues The licensee defined the scope and evaluation criteria to determine the extent of condition in this area. The extent of condition review was to identify any missed opportunities to correct significant equipment deficiencies. The review scope included a sampling of condition reports that were potentially inappropriately backlogged or closed with no action. A backlogged condition report (CR) was defined as a CR that was initiated prior to the restart of either D. C. Cook unit following the extended shutdown that occurred between 1997 and 2000 but evaluated after restart or a CR written after restart and not completed within 130 days. Two criteria were developed to determine if a CR was inappropriately backlogged. These criteria were:
- The documented condition caused or may cause a plant transient or other initiating event.
- The documented condition posed or may pose a challenge to timely and coordinated operational response to plant transients.
Two criteria were also developed to determine if a CR was inappropriately closed with no action. These criteria were:
- Condition reports closed an item to another process that failed to resolve the issue and could have allowed or led to the degradation of equipment that could have had an adverse impact on nuclear safety or reliable plant operation.
- Condition reports closed with no correction and without documented technically appropriate justification that could have allowed or led to the degradation of equipment that could have had an adverse impact on nuclear safety or reliable plant operation.
The licensee developed several different categories of CRs to review. These categories included CRs evaluated for maintenance rule functional failures prior to October 2001; backlogged category 4 CRs written between October 1997, and December 2000, for selected safety systems; backlogged CRs written between October 1997, and December 2000, for several important nonsafety-related systems; category 3 CRs closed to no action; and recently closed CRs. The majority of the CRs reviewed were category 4 CRs that were potentially backlogged. In all, the licensee reviewed 3161 CRs to determine if CRs that were inappropriately backlogged or closed to no action represented missed opportunities to correct significant equipment deficiencies.
The licensees evaluation of the 3161 CRs concluded that 2 CRs were inappropriately backlogged and 10 CRs were inappropriately closed to no action. New CRs were written to address these inappropriate actions. As the overall number was very low, the conclusion of the extent of condition review was that there was no significant trend or programmatic breakdown. Performance Assurance (PA) completed a surveillance activity to independently review the extent of condition results and identified 2 additional instances of CRs that were inappropriately backlogged. Performance Assurance concluded that the extent of condition was adequately performed.
The inspectors reviewed the extent of condition assessment and concluded that the review was adequate and that the results were reasonable given the scope and criteria applied. The inspectors noted that the definition of a category 4 CR was a condition adverse to quality that has minimal impact on plant or personnel safety. Given this definition, it was not expected that many conditions meeting the criteria defined for the review would be identified in a population of mainly category 4 CRs. However, the purpose of the review was to find situations similar to what had been identified in the essential service water (ESW) silt intrusion root cause evaluation. That evaluation determined that several category 4 CRs were inappropriately backlogged or closed with no action. If these CRs had received additional evaluation and corrective action, the failed ESW strainer basket may have been discovered prior to the silt intrusion event in August 2001.
The inspectors reviewed the 12 CRs identified by the line organization and the 2 CRs identified by PA during the extent of condition review. The majority of the conditions affected nonsafety-related equipment. Several of the conditions had resulted in repeat issues that were currently being addressed or were recently addressed by the licensee.
The inspectors concluded that none of the conditions identified affected the operability or availability of important plant equipment and that the likelihood of these issues causing a reactor transient was low. Overall, the issues identified were not significant.
Although the overall conclusion of the review did not identify any significant problems, the licensee generated a corrective action to enhance the guidance in the corrective action process to contain a category for equipment failure analysis that required some cause identification at the category 4 level. The intent of this action was to further ensure that equipment conditions and issues that appeared to be low-level were evaluated and corrected prior to becoming larger problems. The inspectors concluded that the licensees proposed action would improve the evaluation and resolution of equipment-related issues that are determined to be category 4 CRs.
02.04 Independent Review of Extent of Condition Extent of Condition Evaluation for Maintenance Procedure Adequacy The inspectors performed an independent review of three maintenance procedures that had been completely through the licensees review and/or revision procedure. The inspectors review identified a number of items for the licensee to evaluate. However, all of the items were considered to be clarifications, human factors improvements, or enhancements. The inspectors did not find any technical errors during the independent review. The results were as follows:
1) 12-MHP-5021-019-003, Essential Service Water Strainer Maintenance, Revision 7b, Change 0. The inspectors found that the procedure had been revised six times since February 2003. An example of one of the inspectors observations was that the procedure contained a potential to measure basket height without the basket top hat installed due to the wording and placement of a Note. The licensee documented the inspectors observations in CR 03171023.
2) 12-MHP-5021-032-018, Emergency Diesel Engine Fuel Injector Maintenance, Revision 6, Change 0. The most significant observation was changing the person verifying the absence of fuel leaks from a supervisor to a mechanic and not giving specific directions on how to find fuel leaks in an oily environment. The licensee documented the inspectors observations in CR 03171016.
3) 12-MHP-5021-001-175, Pressurizer Power Operated Relief Valve and Actuator Maintenance, Revision 3, Change 1. The most significant observation was removing a thread locking compound and replacing it with a gasket sealant on an air operator shaft stuffing box. The licensee researched the procedure change and determined that the removal of the thread locking compound and addition of the gasket sealant were two separate and unrelated changes. However, the change documentation indicated that the two changes were related. The licensee documented the inspectors observations in CR 03171019.
Extent of Condition Evaluation for Adequacy of Evaluation and Closure of Equipment-Related Issues The inspectors reviewed 33 CRs to independently verify the conclusions of the licensees extent of condition. Some of the CRs were included in the scope of the licensees review and some were not. The inspectors did not identify any inappropriately backlogged or closed CRs that would clearly result in the plant effects used in the criteria established by the licensee. That is, none of the issues described in the CRs reviewed represented significant plant deficiencies.
Overall, after reviewing the licensees results and sampling CRs to independently review, the inspectors concluded that the results of the licensees evaluation were appropriate. The inspectors further noted that the extent of condition evaluation was not a review of corrective action implementation or effectiveness, nor was it a review of the current backlog of CRs. Therefore, the results do not reflect on current or past corrective action program implementation with respect to adequacy of corrective actions.
03 Disposition of Open Items (Closed) Violation 50-316-02-02-04(DRP): "Failure to Take Prompt Corrective Action to Prevent Repetitive Failure of the Unit 2 Turbine Driven Auxiliary Feedwater Pump." The licensee completed an adequate evaluation of this finding individually and the degraded cornerstone. Appropriate corrective actions were taken. This violation is closed.
(Closed) Violation 50-315-01-17-01; 50-316-01-17-01(DRP): Essential Service Water Strainer Maintenance Instructions Not Appropriate to the Circumstances. The licensee completed an adequate evaluation of this finding individually and the degraded cornerstone. Appropriate corrective actions were taken. This violation is closed.
(Closed) Licensee Event Report (LER) 50-316-01-03-00 (DRP): Degraded ESW Flow.
This LER describes the event that resulted in the White finding. This LER is closed.
(Closed) LER 50-316-01-03-01 (DRP): Degraded ESW Flow Renders Both Unit 2 Emergency Diesel Generators Inoperable. This LER was an update to the original LER that describes the ESW silt intrusion event which resulted in the White Finding. This LER is closed.
04 Management Meetings
Exit Meeting Summary
The inspection results were presented to Mr. J. Pollock and other members of licensee management at the conclusion of the inspection on June 20, 2003. The licensee acknowledged the findings presented. The inspectors confirmed that proprietary information was not provided or examined during the inspection.
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
- C. Coleman, System Engineering
- P. Cowan, System Engineering Manager
- R. Crane, Operations
- M. Finissi, Plant Manager
- J. Gebbie, Plant Engineering, Assistant Director
- P. Gember, Work Control Manager
- J. Giuffre, Maintenance Manager
- B. Kovarik, Performance Assurance
- D. Naughton, System Engineering
- J. Pollock, Site Vice President
- M. Scarpello, Regulatory Affairs
- L. Weber, Performance Assurance Manager
- D. White, Work Control
NRC
- B. Kemker, Senior Resident Inspector
- I. Netzel, Resident Inspector
Attachment
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
None
Closed
50-316-02-02-04 VIO Failure to Take Prompt Corrective Action to Prevent Repetitive Failure of the Unit 2 Turbine Driven Auxiliary Feedwater Pump.
50-315-01-17-01; 50-316-01-17-01 VIO Essential Service Water Strainer Maintenance Instructions Not Appropriate to the Circumstances.
50-316-01-03-00 LER Degraded ESW Flow.
50-316-01-03-01 LER Degraded ESW Flow Renders Both Unit 2 Emergency Diesel Generators Inoperable.
Discussed
None Attachment