IR 05000327/2005009

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IR 05000327-05-009 and 05000328-05-009 on 07/25/2005 - 08/12/2005, Sequoyah Nuclear Power Plant, Units 1 & 2, Problem Identification and Resolution
ML052520427
Person / Time
Site: Sequoyah  
Issue date: 09/09/2005
From: Cahill S
Reactor Projects Region 2 Branch 6
To: Singer K
Tennessee Valley Authority
References
IR-05-009
Download: ML052520427 (26)


Text

September 9, 2005

SUBJECT:

SEQUOYAH NUCLEAR POWER PLANT - NRC PROBLEM IDENTIFICATION AND RESOLUTION (PI&R) INSPECTION REPORT 05000327/2005009 AND 05000328/2005009

Dear Mr. Singer:

On August 12, 2005, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Sequoyah Nuclear Power Plant, Units 1 and 2. The enclosed inspection report documents the inspection findings, which were discussed on August 12, 2005, with Mr. R.

Douet and other members of your staff.

The inspection was an examination of activities conducted under your license as they relate to the identification and resolution of problems, and compliance with the Commissions rules and regulations and with the conditions of your operating license. Within these areas the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.

On the basis of the sample selected for review, overall the team concluded that problems were being properly identified, documented, evaluated, and corrected. However the team identified several isolated examples where corrective actions did not appear appropriate, were not accurately documented, or were not completely carried out. The team observed that the quality of Problem Evaluation Report documentation has improved since the last NRC biennial PI&R inspection. The team did observe that there continues to be some lingering technical problems with the electronic document management eCAP program, more than a year after it was placed in service.

TVA

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 (PARS) component of NRC's 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/

Stephen J. Cahill, Chief Reactor Projects Branch 6 Division of Reactor Projects Docket No.:

50-327, 50-328 License No.:

DPR-77, DPR-79

Enclosure:

Inspection Report 05000327/2005009 and 05000328/2005009 w/Attachment: Supplemental Information

REGION II==

Docket Nos:

50-327, 50-328 License Nos:

DPR-77, DPR-79 Report No:

05000327/2005009 and 05000328/2005009 Licensee:

Tennessee Valley Authority (TVA)

Facility:

Sequoyah Nuclear Plant Location:

Sequoyah Access Road Soddy-Daisy, TN 37379 Dates:

July 25, 2005 - August 12, 2005 Inspectors:

C. Julian, Team Leader M. Speck, Resident Inspector K. VanDoorn, Senior Reactor Inspector B. Holbrook, Senior Reactor Inspector J. Wiebe, Senior Reactor Inspector, RI Approved by:

S. Cahill, Chief Reactor Projects Branch 6 Division of Reactor Projects

Enclosure

SUMMARY OF FINDINGS

IR 05000327/2005009, IR 05000328/2005009; 07/25/2005 - 08/12/2005; Sequoyah Nuclear

Power Plant, Units 1 & 2; Problem Identification and Resolution.

The inspection was conducted by three Region II reactor inspectors, a resident inspector, and one Region I reactor inspector. No findings were identified during this inspection.

Identification and Resolution of Problems The team determined that the licensee was identifying plant deficiencies at an appropriately low level and effectively entering them into their corrective action program. The team also determined that the licensee was prioritizing and evaluating issues properly. The team identified several isolated examples where corrective actions did not appear appropriate, were not accurately documented, or were not completely carried out. Overall, the team found the effectiveness of corrective actions to be acceptable. The team observed that the quality of Problem Evaluation Report (PER) documentation has improved since the last NRC biennial PI&R inspection, but further improvements could be made. There continue to be lingering technical problems with the Electronic Corrective Action Program (eCAP) electronic document management program more than a year after it was placed in service. The team concluded, however, that the licensee was generally providing an effective corrective action program.

On the basis of interviews conducted during this inspection, the inspectors determined that workers at the site felt free to put safety concerns into the corrective action program. The inspectors concluded that the employee Concerns Resolution program was functioning acceptably but the inspectors observed that there was a work backlog.

REPORT DETAILS

OTHER ACTIVITIES (OA)

4OA2 Identification and Resolution of Problems

a.

Effectiveness of Problem Identification

(1) Inspection Scope The team reviewed items selected across the span of plant activities to determine if problems were being properly identified, characterized, and entered into the corrective action program for evaluation and resolution. Specifically, the team reviewed approximately 425 problem evaluation reports (PERs) from 11,080 that had been issued during the inspection review period of September 1, 2003, to June 30, 2005. The team examined PERs and work orders (WOs) associated with the Reactor Protection System, Emergency Core Cooling System, Residual Heat Removal System, Ice Condenser System, Emergency Gas Treatment System, Radiation Monitoring System, 480V and 6.9kV Shutdown Power System, and the Main Control Room, 6.9 kV Shutdown Board Room, and Electric Board Room Air Conditioning Systems. The team reviewed PERs associated with radiological protection and emergency preparedness events, problems, and deficiencies. The team reviewed operating experience resolution documents, and employee Concerns Resolution activities. The team also reviewed licensee corrective action trend reports, PER effectiveness reviews, as well as Nuclear Assurance department audits and surveillances from the review period. The team evaluated these items to determine the licensees threshold for identifying problems.

The team conducted system walkdowns to verify that observed problems were being properly identified. All members of the team also attended the licensees various Plan of the Day and Management Review Committee meetings to observe how site management implemented the initial phase of the corrective action program.

(2) Issues The team determined that the licensee was effective at identifying problems at an appropriately low threshold and entering them into the corrective action program. Only in the System Status Report for Emergency Gas Treatment System, were two instances identified where repetitive equipment problems did not result in the initiation of a PER.

However, these problems were already being addressed.

The inspectors observed that there are lingering technical problems with the new eCAP computerized corrective action system which have not been corrected despite repeated attempts for over a year. The system is cumbersome and not everyone in the plant can initiate a PER due to the lack of computer access, passwords, and training on operating the system. The licensee also stated that they are considering implementing a process for initiating an anonymous PER. Although a paper PER initiation form can be printed, there are no paper forms readily available and no locations or drop boxes to deposit a completed form.

b.

Prioritization and Evaluation of Issues

(1) Inspection Scope The team reviewed Procedure SPP-3.1, Corrective Action Program, Revision 8, Business Practice document BP 250, Corrective Action Program Handbook, Revision 8, and various other supporting documents to determine the various licensee requirements for prioritizing and evaluating issues. The team then reviewed selected PERs to ensure that PER level classifications, operability determinations, reportability determinations, degraded and non-conforming condition determinations, cause evaluations, and selection of proper corrective actions were consistent with the significance of the problem described. The team reviewed a sample of PERs as described in paragraph a(1) above. The team also reviewed a sample of PERs associated with NRC findings, non-cited violations of regulatory requirements, and Licensee Event Reports issued during the selected review period. Specific items reviewed are listed in the attachment.
(2) Issues The team determined that PER level classifications were consistent with established procedures and that licensee audits and self-assessments generally confirmed that conclusion. The team further determined that operability, reportability, degraded or non-conforming condition determinations and cause evaluations were also consistent with SPP-3.1.

At one Management Review Committee (MRC), meeting inspectors observed that PER 86552 contained an unclear problem description of corroded sump pump isolation valves in the Essential Raw Cooling Water (ERCW) intake structure. The MRC downgraded the PER from level C to D and returned it for revision due to a mis-stated operability concern. When the PER subsequently passed through MRC again, the inspectors observed that the problem description was clearer but still incorrectly listed the valves as part of the ERCW system when they should be part of the floor drain system.

Inspectors concluded that various problems with electrical circuit breaker performance still need attention. The inspectors observed a root cause critique meeting for level B PER 80797 on continuing performance problems with various kinds of electrical circuit breakers. This PER was initiated by the Nuclear Safety Review Board pointing out the need to take a broad look at circuit breaker problems. The inspectors observed that the Sequoyah Root Cause Analysis Grading Checklist was not directly applicable to the Common Cause analysis technique used on this PER. The licensee recognized this and was considering implementing a checklist for this technique.

The inspectors observed that there had been many time extensions granted on PER actions in the past. The licensee had recently recognized this and revised procedures to require an escalating level of approval for successive extensions.

PER 78863 identified the need for multiple changes to Abnormal Operating Procedures (AOPs) for loss of offsite power discovered during an Emergency Preparedness training exercise of March 17, 2005. The actions to complete the procedure changes had been extended to September 16, 2005. The inspectors questioned if changes to important procedures, such as AOPs, should take so long to complete. Operations management indicated that the procedure change would be rescheduled for early completion.

c.

Effectiveness of Corrective Actions

(1) Inspection Scope The team reviewed the same selected sample of PERs to verify that the specified corrective actions were effective in fixing the problems described. The team also reviewed documented results of MRC effectiveness reviews for completed PERs and observed an MRC effectiveness review meeting and a Plant Health committee meeting.

Specific items reviewed are listed in the attachment.

(2) Issues Based on a review of numerous corrective action plans and their implementation, the team found, for the most part, that the licensees corrective actions were effective.

Effectiveness reviews and audits were generally of good depth and correctly identified issues similar to those raised during previous NRC inspections. However, the team did identify several corrective action deficiencies.

The Electronic Corrective Action Program (eCAP) system has problems with filing attachments to PERs. This causes the system not to be able to retrieve attachments and thus lose prompt access to documentation of corrective actions. The problem has been documented since 8/12/2004 (PER 66958) and was originally scheduled for correction 3/31/2005. Several attempts have been made to fix the problem but were not completely successful. This deficiency can cause the staff to lose confidence in the system and not provide attachments to PERs. NRC expressed similar concerns with the TVA eCAP problems in the last Watts Bar PI&R inspection report, 50-390/2005006, dated March 17, 2005.

The inspectors observed several examples of unclear, incomplete, or inaccurate documentation in PERs. There were similar comments in the last NRC Sequoyah PI&R inspection report 50-327,328/2003009, issued 10/24/03. However the inspectors noted that there had been improvements in documentation quality since the last inspection and improvement could be seen between 2003 and 2005 vintage PERs:

a. PER 71060 was written for a failure to immediately borate when a boron concentration reduction occurred following entry into Mode 6. This is related to Licensee Event Report (LER) 1-2004-002. The documentation of the corrective action taken to prevent recurrence was so general that one could not tell what procedure changes were made.

b. PER 20212 dealt with an unsuccessful attempt to start an ERCW pump for post-maintenance testing (PMT) following circuit breaker and control switch replacement.

The PER documentation did not describe the troubleshooting, repairs or resolution of the problem. The inspectors learned that actual work included visual inspection and extensive troubleshooting, work instruction revisions, a second PMT that failed, and additional technical support and troubleshooting. Finally, a replacement breaker was installed and tested successfully.

c. PER 80535, identified a problem with a Unit 1 reactor trip breaker that, when given a close signal, attempted to close then immediately opened. The Root Cause Analysis identified that two different breakers had exhibited similar failures in the same breaker cubicle during three different outages (2000, 2004, and 2005). These causes had not been definitely corrected, the PER was still open, and additional troubleshooting activities were scheduled during the 2006 spring outage. The breaker is meeting its design safety function to open and is being tested bimonthly. The inspectors noted that the review and analysis did not contain any assessment or discussion on the important operational implications of the breakers ability to close when needed. Under certain plant conditions, the reactor trip breakers must be closed before the operators can re-set the safety injection block signal and feedwater isolation signals. Engineering personnel informed the inspectors that these actions were discussed and assessed during the PER review but that the discussions were not documented.

NRC inspectors observed several examples of corrective actions that do not appear appropriate or had not been completely executed:

a. PER 24617 dealt with a turbine building sump discharge effluent radiation monitor RM-90-212 being found during surveillance to have its trip point set too high by a factor of 100. PER action 24617-003 directed Chemistry to include this occurrence in the Annual Effluent Report to the NRC due to the radiation monitor being inoperable for greater than 30 days as required by Technical Specification 6.8.4.f.1 and Offsite Dose Calculation Manual (ODCM) 1.1.1. However the Action Taken description states, Evaluation of setpoint error and corresponding releases indicated that no ODCM violations occurred. Monitor was determined NOT to be inoperable for greater than 30 days based on evaluation. Monitor was inoperable for approximately 2 days during functional evaluation.

The ODCM requires reporting an inoperability of greater than 30 days or a failure to take grab samples during the inoperablility (ODCM deviation). The Action Taken states that an evaluation found that the monitor was only inop for two days but did not include an explanation of the basis for reaching that conclusion. The licensee could not locate any other documentation that indicated why the issue was not reportable. The licensee initiated PER 87449 promptly to investigate this matter and to take corrective action.

b. B Level PER 77234 concerns a Unit 2 reactor trip caused by maintenance workers inadvertently tripping two circuit breakers by dropping a panel cover. Action Description 77234-023 directs issue a Site-Wide Briefing to reinforce managements expectations for incorporating tribal knowledge into procedures using this event as an example of where incorporating tribal knowledge could have prevented a plant event. The Action Taken just re-states the Action Description and the Action Attachment File Name states Bulletin-PentaGen-Industrial Safety Performance 051905. The inspectors reviewed the attached Bulletin and found that it dealt with accident prevention and did not address management expectations for incorporating tribal knowledge into procedures.

Therefore the directed action was not accomplished. The licensee initiated PER 87502 to correct this issue.

c. PER 31322, was initiated to address an operating experience issue from Browns Ferry that identified a problem with General Electric HFA relay coil spools that were subject to aging with portions breaking off and potentially keeping the relay from performing its safety function. The closed PER did not document how the work was completed or its current status. In response to inspectors questions about the current work status, the licensee identified that Action Item 8 had been closed even though nine compartments on shutdown board 1B-B had not been inspected. Also, Action Item 10, to initiate WOs to replace any HFA relay whose coil spool was not made of Tefzel or initiate preventive maintenance items to periodically inspect non-Tefzel coil spools, was closed with work not completed. The licensee initiated PER 87474 to correct these problems.

d. PER 66228, identified a problem with a Unit 2 6.9kV breaker indicating light for RHR pump 2B. The indicating light being extinguished meant that contacts on the control switch were open and the RHR pump breaker would not close on demand. The PER indicated that the lack of light indication for the breaker did not draw operators attention to the fact that there was a problem. The inspectors noted that a previous PER, 27270, dated October 2003, was to review operating experience from Browns Ferry that stressed the importance of understanding breaker light indications, breaker switch positions, and the interrelationship with respect to breaker operability. One action for PER 27270 was to revise breaker inspection procedures to verify switch position, but the PER took no action on communicating the importance of breaker light indications. The operating experience information was not communicated to plant staff which could have prevented the event described in PER 66228.

e. PER 76030, dated February 2005, identified that the high-power trip setpoints for both units were changed in midsummer 2004 and some alarm response procedures were not updated. PER 62131, dated May 2004, identified the same apparent problem.

One action for PER 62131 was to evaluate for possible procedure/simulator impacts and revise accordingly. The PER closure documentation contained no attachment that could be used to verify that the action was completed correctly. The PER was closed in August 2004, with apparently some actions not completed.

f. PER 21094, identified a problem with missing records associated with licensed operator reactivation prior to assuming duties. A PER action was to review licensee procedures and make revisions necessary to correct the problem. The action was closed stating that the records were left in an empty office and lost but that procedures in place were adequate and no revisions were needed.

The problem occurred due to not following the procedures for the control of the documents but no further action was taken to prevent recurrence.

The inspectors did not identify any more than minor equipment performance issues from the above described deficiencies.

d.

Assessment of Safety-Conscious Work Environment

(1) Inspection Scope The team reviewed numerous audits, assessments, PERs, WOs, and other corrective action documents and held discussions with numerous personnel at various levels in the organization to assess if a work environment existed that was conducive to the identification of nuclear safety issues. Inspectors also examined the licensees employee Concerns Resolution Program records and discussed the program with the implementer to determine if issues affecting nuclear safety were being appropriately addressed.
(2) Issues The team determined that workers at the site felt free to raise safety concerns.

Personnel stated that they do not hesitate to raise nuclear safety issues to their management without fear of retaliation by their management. The wide spectrum of PER documented issues supported this conclusion. The team had no indication during this inspection of individuals being inhibited from identifying problems using the corrective action process.

Inspectors concluded that the Concerns Resolution Program was functioning acceptably, but that there was a backlog of work to be done in the program. There were no technical safety issues identified that were lingering without attention in the program.

The inspectors reviewed the last two Nuclear Assurance (NA) assessments of the CAP program performance. The management organization is appropriately responding to NA by initiating PERs and taking corrective actions.

4OA6 Meetings

Exit Meeting Summary

On August 12, 2005, the inspectors presented the inspection results to Mr. R. Douet and other members of his staff, who acknowledged the findings. The inspectors asked the licensee whether any of the material examined during the inspection should be considered proprietary. No proprietary information was identified.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

SUPPLEMENTAL INFORMATION

PARTIAL LIST OF PERSONS CONTACTED

Licensee personnel

T. Cornelius, Emergency Preparedness
T. Cosby, Maintenance Support Manager
R. Douet, Site Vice President
M. Gillman, Operations Manager
J. Hamilton, Site Support Manager
Z. Kitts, Licensing Engineer
D. Kulisek, Plant Manager
B. Marks, Manager, Emergency Services
J. McGuire, Program Manager, Nuclear Assurance
R. Newby, Concerns Resolution Manager
P. Pace, Licensing and Industry Affairs Manager
M. Palmer, Outage and Scheduling Manager
K. Parker, Maintenance and Modifications Manager
R. Richie, Chemical/Environmental Manager
R. Rogers, Engineering Manager
P. Sawyer, Radiation Protection Manager
J. Smith, Site Licensing Supervisor

J. Thomas Design Engineering Manager

K. Whittenburg, Communications Consultant

NRC personnel

S. Cahill, Branch Chief, Region II
S. Freeman, Senior Resident Inspector, Sequoyah

LIST OF DOCUMENTS REVIEWED

PERs Initiated as a Result of this Inspection

86775 Tin Whiskers, clarify attachment to PER 81118

87474 - HFA relays

87449 - Effluent report

87502 - Unit 2 trip

87672 - EGTS recurrence issues

85151 - OPS re-activation of licensing documentation

87933 - Inadequate documentation for PER 70987

Selected Problem Evaluation Reports (PERs)

86945 Grid disturbance resulting in electrical power swings on both Units

15702 Problem concerning logging EDGE unavailability time

25083 Unexpected results during molded case breaker testing

27050 Visual inspection of an HFA relay problem

27673 Root causes of PER 02-0125591 and 02-010111 were graded as 78%

31869 Unit 2 tripped

33629 PER incorrectly closed

2131 Annunciator response procedures not revised

63941 Procedure deficiency for jumper removal

65735 Molded case circuit breaker aging problem

228 Organization and management decisions - Siemens breakers

67963 PER effectiveness review

70383 CAP timeliness and quality

70384 PER quality not meeting goals

70385 Extent of condition and similar events

2939 Review of PER closure during the U1C13 outage

76030 Setpoint change to high power trips

79197 PER closure problems

298 PER closure problems

86522 ERCW sump valves are rusted

80518 Unit 1 reactor trip

80733 Maintenance and mods adverse trend on CAP performance

80797 NSRB issued PER to review breaker programs

85145 PER classification problems

85620 Organizational trust, response to Self Assessment SQN-SIT-05-006

85622 Questioning attitude, response to Self Assessment SQN-SIT-05-006

01192 Actions taken have been ineffective to address CAP weaknesses

27168 Local leak rate test failures

27976 Raw Cooling Water Booster Pump failures

31540 Poor scheduling lead to challenges to defense in depth

68805 Tolerance for degraded equipment conditions

81669 Divider Barrier Seal cut

81686 Local leak rate test failures

83084 Outage clearance problems

PERs Reviewed associated with NRC Identified Items

20373 1B centrifugal charging pump tagged out of service when ERCW 1B header was

tagged, NCV 2003/006-05

20585 Work week manager failed to update PSA color, NCV 2003/006-05

21094 Problem with licensed operator reactivation paperwork, NCV 2003/006-03

2355 PORV block valves on both units were closed with EWR and no risk assessment, NCV

2003/006-04

24833 Draindown of Unit 2 RCS to the midloop condition, NCV 2003/006-06

26422 Unit 1 generator tripped while performing main turbine overspeed test, NCV 2003/006-

63941 Jumper left in circuit following maintenance, LIV 2004-03

64477 Failure of Unit 2 LCP protection set 4 rack 13, Eagle 21 malfunction, NCV 2004/004-001

218 Unexpected loss of VCT level on Unit 1, NCV 2004/004-003

2-013504 Wrong oil added to 2A-A ERCW strainer, LIV 2003-06

2-013637 Wrong oil placed in 2A-A ERCW strainer, LIV 2003-06

03-011298 Wrong oil added to 2A-S TDAFW pump, LIV 2003-06

03-009567 Wrong oil in DG 1A2 Engine, LIV 2003-06

61626 BB Electric Board Room chiller trip due to unauthorized work, NCV 2004/003-001

60182 NRC identified improper storage of ISFSI components on pad, NCV 2004/009-001

66902 Missed opportunity to identify cracks on aux bldg crane, NCV 2004/009-002

20732 & 20588 Inservice Inspection procedure did not adequately address gaps and

clearances for supports, NCV 2003/006-02

224 & 27268, RWST level instruments failed high due to freezing, NCV 2003/006-08 and

LER 2-2003-002

PERs Reviewed Associated With LERs

234 U2 Reactor trip when breakers inadvertently tripped, LER 2-2005-001

80518 U1 Reactor trip on Auto Stop Oil failure, LER 1-2005-001

71060 U1 boron low in Mode 6, LER 1-2004-002

33325 & 33278 Reactor Trip inadvertent main transformer sudden pressure relay operation,

LER 1-2004-001

Audits, Self-Assessment

Nuclear Assurance Assessment Report NA-CH-03-001, Corrective Action Program

Nuclear Assurance Assessment NA-CH-04-003, TVAN Corrective Action Program

Nuclear Assurance Quarterly Oversight Report-August 21 through December31, 2004, and

Annual Assessment of Quality Assurance Program Implementation Effectiveness

Nuclear Assurance Quarterly Oversight Report - January 1 through April 19, 2005

Nuclear Assurance Oversight Report for the Period of January 1, 2005 through March 31, 2005,

NA-SQ-05-03

Nuclear Assurance TVAN-Wide-Audit Report NO. SA0304

Self-Assessment, SQN-SIT-03-006, Corrective Action Program

Self-Assessment, SQN-SIT-05-007, Corrective Action Program - Focused on NRC Module

71152

Self-Assessment Final Report, SQN-OPS-04-001, Corrective Action Program Effectiveness in

Operations

Nuclear Assurance-Oversight Report for Period August 21, 2004 through December 31, 2004,

NA-SQ-05-01

Nuclear Assurance Assessment - NA-SQ-04-02

CRP-LIA-04-001, 2004 Operating Experience Program Self-Assessment

OIG Audit Report 2004-036F, Concerns Resolution Program-TVA Nuclear 2004

OIG Audit Report 2004-036F, Concerns Resolution Program-Sequoyah Nuclear Plant 2004

Sequoyah response to Nuclear Assurance Assessment NA-CH-04-003

Self Assessment SQN-SIT-05-006, Evaluation of SQN Nuclear Safety Culture

PERs Reviewed for System 099, Reactor Protection System

17029 Unit 2 bypass RTB failed during testing

19974 Unit 1 inaccurate work document

20404 Unit 2 feedwater regulating valve did not respond as expected during a test

20734 Unit 2 RTB problem

24747 Unit 2 entered AOP, due to Eagle 21 malfunction

25088 Reactor trip and feedwater isolation signal generated during testing

25427 Spare RTB tripped during testing

25444 Unit 2 trip breaker contact alignment problem

27381 Missed a procedure step during testing

27717 Unit 2 circuit board failure

33629 PER 25088 closed in error and new PER generated

34368 Eagle 21 failure

60449 Unit 2 TSP failure

60452 Unit 2 TSP alarm

60456 Unit 2 protective set IV TSP failure

64396 Unit 2 LCP card failure

64477 Unit 2 LCP card failure

69045 New EPT board failure

69367 Unit 1 universal board failure

70900 A reactor trip breaker would not close

70711 Unit 2 TSP card failures

70741 Unit 1 TSP failure in rack 1-R-7

71617 Unit 2 protective set 3 trouble flashing

71845 Unit 2 wrong circuit board installed

2765 Unit 2 protective set 3 LCP failure

2771 Unit 2 protective set 3 lockup

80113 Question concerning LCO during WO process

80535 A reactor trip breaker opens

80555 Switch left in wrong position during work

80683 Reactor trip breaker failure to latch

Work Orders Reviewed for System 099

98-4568 Reactor trip bypass breaker repair

99-3192 RTB problem

00-1462 RTB solenoid sticking

00-1924 RTB damage found

00-9854 RTB has missing parts

01-7600 Modify RPB control relay

01-9478 Repair RTB latch

2-3927 Replace RTB arc suppressor

03-4021 RTB has low trip force

03-19348 Work on a breaker 52H switch

04-72378 Repair Unit 2 Eagle 21 malfunction

04-782116 Unit 2 eagle 21 malfunction

04-782150 Repair TSP failure

04-782797 Install Unit 2 circuit board

04-783480 Unit 2 LCP failure

PERs Reviewed for System 201, Low Voltage Power

25639 Board transfer problem

26135 During racking a shutdown board breaker, charging motor would not stop running

27538 Review of arc flash requirements and time to operate breakers per EOPs

33759 Damaged flood barrier around electrical board

60871 Arc flash tool concern

294 A breaker failed an overload test

2706 2B 480v ERCW MCC alternate feeder breaker not functional

63737 480v shutdown board loading

67779 Energized drop cord

67793 Methods to track Technical Specification 3.8.3.1 and 3.8.3.3 entries

68985 Breaker failure

68987 Missed functional failure and potential for others

69465 Inspection identified a damaged breaker

69817 Fan labeling and noun name problems

265 Possible PCB residue

71165 Problem determining operability of offsite power

71328 Foreign material in a breaker compartment

2696 Water coming in through conduit

75566 Incorrect breaker labeling

76066 Breakers exceeded an inspection extension date

77476 Shutdown board 1A2A load swing

81675 CRDM breaker 2B tripped

Work Orders Reviewed for System 201

00-1924 Perform inspection of a breaker

00-2017 Inspect breaker for damage

00-2144 A breaker tripped free on closing

00-2444 Inspect the breaker to determine cause of failure

00-9482 Remove parts from spare RTB and install on Unit 2 spare RTB

00-9854 Breaker damage found during inspection-repair

01-7600 Modify DB-50 breaker

01-9478 Replace breaker catch mechanism

PERs reviewed for System 202, Medium Voltage Power

1786 Problem with transformer sprinkler light indications

6132 Problem with transformer sprinkler light indications

220 Problem with transformer sprinkler light indications

19987 Review the ability to wave end device testing following maintenance

212 ERCW pump motor tripout alarm

2002 Problem with transformer sprinkler light indications

2700 Received motor tripout on pump P-B ERCW

24587 Annunciator setpoint problem

24704 Lighting board transfer switch problem

25017 6.9kv shutdown breaker racking problem

25108 Increased number of reportable safety system actuations

25636 6.9kv breaker trip

26036 Control wire strands not under a set screw

26037 Breaker not meeting response time

26624 Spare breaker acceptance criteria failure

27059 Problem with transformer fire protection light indications

34116 ERCW MB pump trip

60198 Missing part on a shutdown board breaker

60199 Siemens breaker problems

64539 Fuse clip problem

65059 Unit 2 ERCW MCC breaker fail to close

65164 Shutdown board breaker for ERCW P-B failed to close

65825 1B-B containment spray pump breaker failure

71149 Unit 1 start bus failed to transfer

71485 Unit 1 containment spray breaker problem

71724 Breaker problems

2085 Unit 1 shutdown board 1A-A test breaker failure

74489 Relay target amp setting different from setting sheet

78029 6.9 kv common board loss of control power

78171 A Siemens breaker failed receipt inspection

78968 Spare breaker has missing parts

81618 6.9kv bus bolts over torqued

2016 Unit 2 6.9 kv breaker trip

2999 Breaker B-026 discrepancies found during shop inspection

84070 Diesel generator cable to shutdown bus exceeded test requirements

85306 Bus 1A 6.9kv normal feeder breaker trip coil problem

Work Orders Reviewed for System 202

2-968 ERCW pump breaker and hand switch replacement

2-5453 ERCW pump breaker and hand switch replacement

2-5817 Problem with transformer sprinkler light indications

2-14218 Check problem with transformer sprinkler light indications

2-32078 Check problem with transformer sprinkler light indications

03-14877 Troubleshoot transformer sprinkler light indications

03-22002 Check problem with transformer sprinkler light indications

04-770593 ERCW pump breaker problem

04-771281 Troubleshoot lighting board switch problem

04-774689 Repair breaker missing parts

04-780278 Swap Unit 1 6.9 kv breaker on shutdown board 1A-A

04-782385 Investigate Unit 1 containment spray breaker trip

05-770340 Replace defective lugs and missing retainers

05-772819 Work on control power converter

05-774663 Investigate breaker trip

PERs Reviewed for System 63, Safety Injection System

23817 U2C12 containment debris

81304 U2C13 containment debris

81555 Debris in U2 SG#4 enclosure

20584 U2C12 debris inside polar crane wall

31497 Worker signed on to only 1 of 2 necessary clearances to replace U2 RWST heaters

268 RWST level enclosure deficiencies

31517 inadvertent water transfer from U1 RWST to U2 RWST

83459 SI pump reliefs leaking

23110 1BB SI pump failed Section XI test

75483 Boric acid on SI pump seal areas

70762 Borated water leak 1-VLV-63-557

27978 Borated water leak 1-VLV-62-720

244 Borated water leak 2-FCV-63-152

20916 Borated water leak 2-VLV-63-615

20674 U2 forced outage leakage exam observations

20569 Borated water leak 2-FCV-63-26

34063 Borated water leak1-FCV-63-157

71038 Borated water leak 1-VLV-63-553

31880 Borated water leak 2-FCV-63-25

70761 Borated water leak 1-FCV-63-70

69773 Borated water leak 2-FCV-63-48

85481 Injection valve packing leakage

2645 Injection valve packing leakage

63984 Injection valve packing leakage

2738 Injection valve packing leakage

34063 Injection valve packing leakage

28067 Injection valve packing leakage

20689 Injection valve packing leakage

252 Borated water leak work order problems

231 Grinnell valve stem nuts loose

2716 Repeat maintenance of mechanical seals

77826 Solenoid valves having abnormally high usage

73869 Numerous areas of missing insulation

71445 Containment sump flow isolation valve would not open

2135 2B Pen room cooler low flow

PERs Reviewed for System 74, Residual Heat Removal System

21077 Borated water leak 2-FCV-74-24

31321 Borated water leak 2-VLV-74-531

74809 Borated water leak Various Valves

74493 Borated water leak Various Valves

20571 Pre-RHR outage borated water leak

20159 Output of temp monitor unstable

84378 ECCS pump room floor clogged weep holes

31417 Failed to enter LCO on both RHR pumps

24872 RCS temp increased above 285 degrees after RHR placed in service

17056 RHR heat-up rate exceeded 100 degrees

20487 RHR operating procedure question

21148 Failed to enter LCO when placing RHR in service

20546 U2C12 ice condenser debris

27960 U2 debris found inside polar crane wall

68650 Low ERCW flow in 2A RHR pump room cooler

2604 2A RHR pump abnormal noise

27603 Section of Unit 2 penetration room flooded

27625 Water flowing from 2A RHR heat exchanger room floor drain

71004 Design temperature limit changed

71522 Valve manipulations caused contamination outside posted area

PERs Reviewed for System 311, Control Building HVAC System

21010 MCR chiller operability delayed

84079 A Shutdown Board Room chiller compressor tripped

61083 1A 480V Board Room chiller tripped/lost freon

68950 B Shutdown Board Room chiller failed to restart

71484 A Shutdown Board Room chiller TCV failed

73841 B Shutdown Board Room tripped/TCV failed

68613 Shutdown Board Room AHU fan motors failed

263 2A 480V Board Room AHU fan vibration

71838 B Shutdown Board Room inoperable

69078 Six MR functional failures on SDBR chillers

280 Wrong fuses in B SDBR chiller control panel

69780 PM revisions without System Engineering review

77888 A Electric Board Room chiller vibrations

2115 Low flow on B CREVS

69777 B MCR oil TCV failure

70358 B MCR chiller high pressure oil hangers

70135 B MCR chiller tripped

19740 B MCR chiller maintenance extended six times

235 B MCR chiller maintenance extended

74332 Maintenance not performed in assigned frequency

76159 B MCR chiller AHU dampers bound

27878 MCR unnecessary LCO/MR time

252 Installation of ground on MCR chiller control system

63168 Incorrect train identification

64547 Ground wires not installed in chiller mod

63102 Transformer leads for chiller control panel mod are mislabeled

63094 Clearance tag on incorrect valve

61460 Communications problem with digital controller

71435 Chiller terminals not identified

65752 Post testing maintenance deficiencies

65037 Work order not performed as scheduled

209 Chiller equipment failure during PMT

24594 Chiller electrical compartment missing covers

20192 Chiller oil cooler outlet temp high

68880 Clams in electric board room chiller

PERs Reviewed for System 313, Auxiliary Building HVAC System

67713 A Electric Board Room chiller freon leak

65727 BB Shutdown Board Room TCV failure

27995 480V Board Room supply fan 1A-2B high vibrations

64375 Shutdown Board Room 1BB AHU motor bearing functional failure

28393 Replace MCR A chiller oil cooler TCV

60826 Vital Bat Rm IV pressure greater than MCR

25392 High vibrations on 480V Board Room 2B-B AHU

77086 No alarm response procedures for digital chiller control mod

73354 Evaluate need for alarm response procedures

78475 2B 480V Board Room chiller tripped

77994 2B 480V Board Room chiller tripped

77314 2B 480V Board Room chiller inop

16383 Results of PER 981237 Effectiveness Review

69078 Trend PER for Shutdown Board Room chiller failures

67983 Safety related chiller resets

2864 Board jumper problem on chiller control upgrade

65198 Some CRDM A/C units have wrong bearings

66597 1B CRDM Air A/C unit compressors failed

20538 125 Volt Battery Room fan bad bearing

20342 Improper scheduling of preventive maintenance

61003 Water leaking from valve vault room to Aux Building

21061 Electric Board Room chiller freon leak

67964 Electric Board Room freon leak

21001 Shutdown Board Room chiller freon leak

25712 Auxiliary Building chiller tripped twice

20897 Shutdown Board Room chiller would not start

26777 480V Board Room chiller freon leak

PERs Reviewed for System 61, Ice Condenser System

17042/32518/71284/82389 Baskets weighed less than the minimum analytical limit

20546/21301/72053/72903/83064 Debris left in ice bed

20446 Condenser back draft damper found closed

20518 Ice basket damage was identified

20542 Condenser back draft damper annunciator came in and cleared

20630 Condenser back draft damper found closed

24195 Ice bed temperature switches in alarm

25087 Condenser back draft damper alarm

208 Check valve leak rate failure

25331 Glycol chiller disconnect switch found open

25463 Air handling defrost timers found improperly set

25608 Preventive maintenance scheduled after environmental qualification due date

25638 Glycol system valve stroke time greater than acceptable

27360 Glycol valves did not perform as required

29453 Floor monitoring cables not adequate for long term use

60749 Condenser back draft damper alarm

67190 Insulation degradation and corrosion

69493 Unplanned LCO for valve that would not stroke

69739 Glycol expansion tank low-low low level alarm

70871 Two Ice Condenser door seals have small tears

71380 Basket vertical ligaments broken

71441 Five baskets found heavy

71498 Boron from ice melt leaking through ceiling

71682 Ice bed temperature detectors damaged

236 Ice machine glycol cylinders excessive leakage

2626 Floor monitoring system alteration not properly documented

75098 Testing changes not adequately reviewed

2536 Borax solution does not meet acceptance criteria

2408 Craft not following procedure for packing ice

2409 Five baskets requiring servicing missed

2575 Yellow plastic used in Ice Condenser posed debris risk

269 Inlet door with incorrect hinge pin

PERs Reviewed for System 65, Emergency Gas Treatment System

00-007785 Annulus vacuum system recurrent damper problems

2-013522 Hole found in EGTS fan flexible discharge duct

03-010200 Problems with Unit 1 annulus fan dampers and annulus vacuum fan

03-010357 Unit 2 annulus vacuum fan indicating switch problem

03-010996 Duct access panel found unlatched

03-013356 Debris found in flow element

03-014018 Elapsed time meter failed

25191 Tear in EGTS ductwork

03-010769/04-000447/24360 Annulus pressure control degraded

03-011493/33963 Annulus vacuum fan flow switch problems

03-008880 Annulus vacuum fan suction dampers leaking air

234 Inappropriate use of 10 minute hold time for functional evaluation

PERs Reviewed for System 90, Radiation Monitors

233 Alarm 1-RA-400B Shield Bldg. Vent malfunction

245 Alarm 1-RA-400B Shield Bldg. Vent malfunction

03-15959 Alarm 1-RA-400B Shield Bldg. Vent malfunction

24617 0-RM-90-212A setpoint found at 7.40e+04 instead of 7.40e+2

26052 Maintenance Rule functional failure of 2-RM-90-400A, Shield Building Exhaust

70654 Minimum required sample flow rate could not be achieved

76916 Particulate filter not installed in 1-RM-90-400 as required

2707 During PMTs it was discovered that the suction isolation valve was closed

77446 During lifting clearance it was discovered that the suction valve was closed

84902 Maintenance Rule functional failure of 1-RM-90-400, Shield Building Exhaust

19759 Unplanned entry into ODCM 1.1.2 Action 42

20566 Rad Monitors 0-RA-134B and 141B inoperable and ODCM 1.1.1 action 32 entered

20925 Alarm 1-RA-400B Shield Bldg. Vent malfunction

21316 Shield Bldg Ventilation monitor sample pump trip

291 0-RM-90-126 declared inoperable due to rad monitor pump tripping

25543 Alarm 1-RA-400B Shield Bldg. Vent malfunction

26307 Alarm 1-RA-400B Shield Bldg. Vent malfunction

66167 2-RM-90-106 failed causing unplanned entry into LCOs 3.3.3.1 and 3.4.6.1.

Work Orders Reviewed for System 90

WO 04-772209 Take ambient temperature data on 1-RE-090-0400A power supply

WO 04-772210 Take ambient temperature data on 1-RE-090-0400A power supply

PERs Reviewed for Emergency Preparedness Issues

33682 Improvement items identified during the March 23, 2004 Orange Team REP drill

20576 The radio for REP communications located in the RADCON lab is not working

21057 HP Radio in the RadCon Lab had to be turned all the way up to be audible

205 Repeat problem with EPIP procedure revisions

03-010688 Problem with EPIP procedure revisions

236 Continued failure to repair REP radio

03-015918 REP Radio in RadCon Lab

25802 Issues identified during the 10/17/03 REP drill

26306 Issue identified during actual ALERT on 8/28/2003

220 Trend PER for Pager tests

61309 Set points on Post Accident Radiation Monitors are higher than the EAL values

78915 Chem Lab is without vital power in Loss of Offsite Pwr

Work Orders Reviewed for Emergency Preparedness Issues

TPS WO #03-046437-000-001 REP radio in RadCon lab malfunction

Exercise Evaluations Reviewed

REP Drill on 8/18/2004

Graded Exercise on 6/23/2004

Off-Year REP Exercise on 3/16/2005

PERs Reviewed for Radiation Control Issues

279 RadWorkers not following radiological controls during U2C12 outage

03-16521 Workers entered U-2 690' pipe chase on wrong RWP

244 Individual exited gatehouse and went home with Electronic Dosimeter

64393 Person crossed a Radiography Boundary during the initial set up phase

64734 Contaminated nylon sling found in the Service Bldg clean tool room

65650 Trend PER for not signing out on RWPs and not reporting dose rate alarms

68353 Worker failed to sign out on his RWP

71635 Employee received both a dose and a dose rate alarm and failed to exit area

71595 Worker exceeded his RWP dose limit

71524 Worker received dose rate alarm and failed to notice upon exiting the RCA

2323 Pallet of chain hoists with purple paint on the loading dock by the Laborer Shop.

74749 Worker received a dose rate alarm on his Electronic Dosimeter

75039 Possible trend of inappropriate release of material from the RCA

75400 Trend PER for radworker performance during outage

80415 Discovery of purple-painted tools in unauthorized areas of the plant

81947 Worker failed to notice dose alarm and leave the area

2833 Unexpected dose rates in the Unit 2 Annulus during fuel transfer

2998 Individual received 5 electronic dosimeter alarms and did not immediately report

83091 Individual was on the wrong RWP and received a dose rate alarm. He failed to notify

radiation protection of this alarm

211 Individual was on wrong RWP, received dose rate alarm and did not immediately notify

RadCon

PERs Reviewed For Operating Experience

25619 Generic operating experience review for inaccurate work documents

25625 Review Westinghouse Technical Bulletin 99-05, R1, Breaker Minimum Trip Force and

Seismic Enhancements

25865 Generic review of WBN PER

26602 Generic review of operating experience for logic power supply

270 Generic review of BFN PER breaker light indications

280 Review of General Electric Technical Information Letter 1378-1

31532 Generic review of NRC EN 40364

2154 Review of operating experience OE-18349, HFA relay cracking

63333 Review of operating experience OE-40804

65735 Review Westinghouse Technical Bulletin (TB-04-13) molded case circuit breakers

68143 Review Westinghouse Technical Bulletin TB-04-17, Tyco relay issues

69552 Generic Review of BFN PER

70310 Review of Westinghouse Info Gram, IG-04-6, RTB test pushbutton problems

70386 Generic review of WBN and BFN PERs

75417 Generic review of operating experience OE-19727

77817 Generic review of operating experience, labeling problems

274 Review of Watts Bar White finding for silting in raw water systems

Procedures, Instructions, Guidance Documents, and Operating Manuals

SPP-3.1, Corrective Action Program, Rev. 8

SPP-1.6, TVAN Self-Assessment Program, Rev. 12

SPP-7.1, On Line Work Management, Rev. 6

SPP-6.0 Maintenance and Modification, Rev. 2

SPP-6.1 Work Order Process Initiation, Rev. 4

SPP-6.6 Maintenance Rule Performance Indicator Monitoring, Trending, and

Reporting - 10 CFR 50.65, Rev. 8

SPP-7.0 Work Management, Rev. 1

SPP-9.0, Engineering, Rev. 3

BP 250 Corrective Action Program Handbook, Rev. 8

TI-4, Maintenance Rule Performance Indicator Monitoring, Trending, and Reporting - 10 CFR 50.65, Rev. 17

0-TI-SXX-000-001.0, Conduct of System Engineering

0-TI-SBR-000-001.1, Breaker Testing and Maintenance Program

0-TI-OPS-000-063.0, Sensitive Equipment Control

MMDP-1, Maintenance Management System, Rev. 8

NEDP-12, System Component Health, Equipment failure Trending, Rev. 5

NADP-3, Managing the Operating Experience Program, Rev. 6

NEDP-20, Conduct of the Engineering Organization, Rev. 6

Miscellaneous Documents Reviewed

CAP Self-Assessment SQN-SIT-05-007, list of PERs

CAP Top Ten Problem List and Actions

Checklist for proper PER closure

HFA Relay Action Plan for Inspection and Repair

System Status Report, System 099, Reactor Protection System

System Health Report Card, System 099, Year 2005

System Status Report, System 201, Low Voltage Power, July 19, 2005

System Health Report Card, System 201, Year 2005

System Status Report, System 202, Medium Voltage Power, July 19, 2005

System Health Report Card, System 202, Year 2005

System Health Report Cards and Status Report for System 65, Emergency Gas Treatment

System Health Report Cards and Status Report for System 61, Ice Condenser

Meeting Minutes for PER coordinator meetings dated April 19, 2005 and July 21, 2005

Technical evaluation for molded case circuit breakers (PER 65735)

Effectiveness Review for PER 32427

Lesson plan, OPL273C0507, Welcome to Requal

Operations Standing Order 04-008, Control of Equipment Dogging Devices

Triennial Audit Schedule, 2005-2007

Westinghouse Technical Bulletin, TB-04-17 (Tyco Relay Issue)

Transmission Information Notice 04-008, possible PCB on relays

Radiation Monitoring System Status Report dated July 1, 2005

Safety Injection Systems Health Report

Residual Heat Removal Systems Health Report

Air Conditioning and Chillers System Health Report

Preventable Functional Failure Data for Systems 63 (SI) and 74 (RHR)

Integrated Quarterly Trend Reports (2004-2005)

LIST OF ACRONYMS

AOP

Abnormal Operating Procedure

CAP

Corrective Action Program

ERCW

Essential Raw Cooling Water

LER

Licensee Event Report

MRC

Management Review Committee

NA

Nuclear Assurance

NRC

Nuclear Regulatory Commission

ODCM

Offsite Dose Calculation Manual

PER

Problem Evaluation Report

PI&R

Problem Identification and Resolution

PMT

Post Maintenance Testing

Rev.

Revision

SPP

Standard Programs and Processes

TI

Technical Instruction

TS

Technical Specification

TVA

Tennessee Valley Authority

UFSAR

Updated Final Safety Analysis Report

WO

Work Order