IR 05000331/2013007

IR 05000331-13-007, 02/11/2013 - 03/01/2013, Duane Arnold Energy Center, Problem Identification and Resolution

ML13093A262
Person / Time
Site:	Duane Arnold
Issue date:	04/02/2013
From:	Robert Orlikowski NRC/RGN-III/DRP/B1
To:	Richard Anderson NextEra Energy Duane Arnold
References
IR-13-007
Download: ML13093A262 (35)

Text

April 2, 2013

SUBJECT:

DUANE ARNOLD ENERGY CENTER PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000331/2013007

Dear Mr. Anderson:

On March 1, 2013, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution (PI&R) inspection at the Duane Arnold Energy Center.

The enclosed report documents the inspection results, which were discussed on March 1, 2013, with you and other members of your staff.

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

Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems at the Duane Arnold Energy Center was effective. Licensee identified problems were entered into the corrective action program at a low threshold. Problems were effectively prioritized and evaluated commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of problems. Lessons learned from industry operating experience were generally reviewed and applied when appropriate. Audits and self-assessments were effectively used to identify problems and appropriate actions.

One NRC-identified finding of very low safety significance (Green) was identified during this inspection. This finding was determined to involve a violation of NRC requirements. The NRC is treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2 of the Enforcement Policy. If you contest the violation or significance of the NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington DC 20555-0001; with copies to the Regional Administrator, Region III; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at The Duane Arnold Energy Center.

If you disagree with the cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region III and the NRC Resident Inspector at The Duane Arnold Energy Center.

In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this letter and its enclosure will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)

component of NRCs Agencywide Documents Access and Management System (ADAMS),

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

Sincerely,

/RA/

Robert Orlikowski, Acting Chief Branch 1 Division of Reactor Projects Docket No. 50-331 License No. DPR-49

Enclosure:

Inspection Report 05000331/2013007 w/Attachment: Supplemental Information

REGION III==

Docket No: 50-331 License No: DPR-49 Report No: 05000331/2013007 Licensee: NextEra Energy Duane Arnold, LLC Facility: Duane Arnold Energy Center Location: Palo, IA Dates: February 11 - March 1, 2013 Inspectors: C. Phillips, Project Engineer - Team Lead L. Haeg, Senior Resident Inspector Duane Arnold G. ODwyer, Reactor Engineer C. Brown, Reactor Engineer Approved by: Robert Orlikowski, Acting Chief Branch 1 Division of Reactor Projects Enclosure

SUMMARY OF FINDINGS

IR 05000331/2013007, 02/11/13 - 03/01/13; Duane Arnold Energy Center; Biennial Baseline

Inspection of the Identification and Resolution of Problems.

This team inspection was performed by three regional inspectors and the site senior resident inspector. One Green finding was identified by the inspectors. The finding was considered a non-cited violation (NCV) of NRC regulations. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609,

Significance Determination Process (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006.

Identification and Resolution of Problems Overall, the Corrective Action Program (CAP) was appropriately identifying, evaluating, and correcting issues. Issues were generally being identified at a low threshold, evaluated appropriately, and corrected in the CAP. Overall performance in prioritization and evaluation of issues was acceptable. Issues were appropriately screened by both the Issue Screening Team and the Management Review Committee and the inspectors had no concerns with those items assigned an apparent cause evaluation or root cause evaluation. Corrective actions were generally appropriate for the identified issues. Those corrective actions addressing selected NRC documented violations were also generally effective and timely. The inspectors review going back five years of the licensees efforts to address issues with 4160 and 480 volt electrical breakers did not identify any negative trends or inability by the licensee to address long term issues. However, the inspectors determined that the corrective actions for some issues had not been effective.

In general, Operating Experience (OE) was effectively utilized at the station. The inspectors observed that OE was discussed as part of the daily station and pre-job briefings. Industry OE was effectively disseminated across the various plant departments and no issues were identified during the inspectors review of licensee OE evaluations.

The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying issues and enhancement opportunities at an appropriate threshold level. The inspectors observed that CAP items had been initiated for issues identified through Nuclear Oversight (NOS) audits and self-assessments. The inspectors reviewed the self-assessment performed on the CAP and found no issues and generally agreed with the overall results and conclusions drawn.

The inspectors determined that plant staff were aware of the importance of having a strong safety-conscience work environment and expressed a willingness to raise safety issues. No one interviewed had experienced retaliation for safety issues raised or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP process.

Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable safety-conscience work environment.

NRC-Identified

and Self-Revealed Findings

Cornerstone: Barrier Integrity

Green.

The inspectors identified a finding of very low safety significance (Green) and associated Non-Cited Violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions,

Procedures, and Drawings, for two examples of the failure to follow procedures associated to the troubleshooting and repair of RIS4131A Refuel Floor Exhaust Radiation Monitor. The licensee initiated WO 40190702-01, RIS4131A Refuel Floor Exhaust Rad Mon Upscale and Group 3, to troubleshoot and repair the power supplies.

The licensee was still evaluating planned corrective actions for the failure to follow the work order instructions.

The performance deficiency was determined to be more than minor because it was associated with the Barrier Integrity Cornerstone attribute of providing reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Specifically, RIS4131A failing to operate in conjunction with a single additional failure (RIS4131B) could allow the release of radioactive contamination due to preventing an automatic secondary containment isolation (Group 3). The finding screened as having very low safety significance (Green) because the inspectors answered Yes to question C.1 of IMC 0609, Appendix A, Exhibit 3. The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting aspect of Human Performance, having Work Control components that support long-term equipment reliability by performing maintenance that is more preventive than reactive. [H.3.(b)]

(Section 40A2.1.b.(3))

Licensee-Identified Violations

No violations of significance were identified.

REPORT DETAILS

4OA2 Problem Identification and Resolution

The activities documented in Sections

.1 through .4 constituted one biennial sample of

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

.1 Assessment of the Corrective Action Program (CAP) Effectiveness

a. Inspection Scope

The inspectors reviewed the licensees CAP implementing procedures and attended selected CAP program 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 biennial PI&R inspection in April 2011. The items selected ensured an adequate review of issues across the NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC-documented findings as sources to select issues. Additionally, the inspectors reviewed CAP items generated as a result of facility personnel performance in daily plant activities. The inspectors also reviewed CAP items and a selection of completed investigations from the licensees various investigation methods, including root, apparent, and common cause evaluations. The inspectors also observed the loading of hydrogen tanks to verify corrective actions associated with an Alert classification that occurred because of a fire while loading hydrogen in May 2011.

The inspectors performed a more extensive review of the safety-related 480 and 4160 VAC electrical breakers. This review consisted of a five year search of related issues identified in the CAP and discussions with appropriate licensee staff to assess the licensees efforts in addressing identified concerns.

The inspectors attended meetings of the Issue Screening Team (IST), Management Review Committee (MRC), and department Corrective Action Review Boards (CARBs)to observe how issues were being screened and evaluated and to obtain insights into the licensees oversight of the CAP program. The inspectors interviewed members of the licensees staff.

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

Specifically, the inspectors evaluated 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 assessed whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also reviewed the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and NRC findings, including Non-Cited Violations (NCVs).

b. Assessment

(1) Effectiveness of Problem Identification Issues were generally being identified at a low threshold, evaluated appropriately, and corrected in the CAP. Workers were familiar with the CAP and felt comfortable raising concerns. This was evident by the large number of CAP items generated annually; which were reasonably distributed across the various departments. A shared, computerized database was used for creating individual reports and for subsequent management of the processes of issue evaluation and response. These processes included determining the issues significance, addressing such matters as regulatory compliance and reporting, and assigning any actions deemed necessary or appropriate.

Observations Condition Report (CR) Quality The inspectors noted that there were several examples of Condition Reports (CR) where the documentation was insufficient to determine exactly what the problem was.

Although the IST and MRC typically sent these types of CRs back for more information it had the potential to be an error trap in that the problem may not be sufficiently described.

Reduction in the Number of CRs The inspectors noted that the licensee initiated CR 1842365 that stated that the number of CRs generated by the Operations Department was 9 percent lower in an outage year (2012) from the previous non-outage year (2011). The licensee documented that it appeared to correlate to the about 10 percent reduction in the number of Senior Reactor Operators (SROs) over the last year. The licensee also documented in the 3rd and 4th Quarter Operations Performance Assessment Report that in some cases, Radioactive Waste Operators (RWOs) were not generating CRs for system or process issues until they become significant plant problems and that RWOs did not see the value in writing CRs. The inspectors interviewed an RWO based on the comments in the Operations Performance Assessment Report. The RWO stated that the comment was not true.

The RWO stated that CRs were being written for equipment problems but there was no response to the CR until they became significant plant problems. The licensee captured these issues in CR 1842365.

CR Not Properly Classified The licensee allowed some items to be tracked outside of the CAP database due to the minor nature of the issues. These items included, but were not limited to, minor procedural changes, Routine Work Tracking (RWT) items, and training program improvements. The inspectors reviewed some of these items and verified that they were of low enough significance to not warrant inclusion in the CAP. The inspectors also noted that these items were routinely reviewed during MRC meetings.

The inspectors identified that RWT 01851946 was incorrectly designated as a condition not adverse to quality (NCAQ) vice a condition adverse to quality (CAQ) during an observation of the MRC meeting on February 13, 2013. The RWT documented that the licensee had previously identified that Engineering Change (EC) 274627, Primary Containment Coating, Revision 0, had failed to properly require the correction of calculations CAL-M98-002, Post-LOCA [Loss of Coolant Accident] Debris Generation for ECCS [Emergency Core Cooling System] Strainers, Revision 1; and PCPP 2.1, Long-Term Strategy for Primary Containment, to include the details of a new torus coating. Calculations CAL-M98-002 and PCPP 2.1 were required to have the torus coating specification and associated analysis corrected to reflect the replacement of the Carbozinc 11 coating with the new Carboguard 6250N coating for the wetted portions of the interior of the torus. The inspectors determined that the fact that the calculations of record were incorrect was a CAQ. The inspectors identified that the licensee procedures, listed below, stated that a CR was for tracking a CAQ and an RWT was for tracking a NCAQ.

Licensee procedure PI-AA-204, Condition Identification and Screening Process, Revision 18, Section 2, Terms and Definitions, defined a CAQ as any deficiency that has potential to affect nuclear safety functionality of safety related to structures, systems and components (SSCs), or any programmatic or operational aspects associated with nuclear safety. Licensee procedure PI-AA-204, Attachment 3, Guidance on the Classification of Condition Reports, gave as an example of a Severity Level 3 CAQ the condition of Errors in a safety related work package. The inspectors concluded that the existing error that required correction in a safety-related calculation was the same as the Errors in a safety related work package example and fit the definition of a CAQ.

The inspectors were concerned that the RWT process did not have controls, i.e.,

tracking, completion and timeliness requirements to ensure that the changes to the safety-related documents were actually made. The inspectors determined that since the debris-generation portion of calculation CAL-M98-002 was incorrect and the calculation was a quality document, then the incorrect calculation was a CAQ and the correction was required by their procedures to be tracked by a CR vice an RWT.

The inspectors determined that the failure to follow procedure PI-AA-204 and to define the incorrect safety-related calculation as a CAQ was an NRC-identified performance deficiency. The inspectors determined that the performance deficiency was minor because under the current conditions there were no safety consequences associated with the incorrect documents.

Engineering Change 274627 was implemented during Refueling Outage (RFO) 23 (during November and December of 2012) when the existing Carbozinc 11 coating was removed and the Carboguard 6250N coating was installed. The licensee had previously determined Carboguard 6250N was an acceptable coating for these portions of the torus in EC 274627 prior to the installation of the new coating. The licensee documented the performance deficiency of the improper RWT designation as CR 01851946 on February 27, 2013. The recommended action of the CR was to convert the RWT to a CR.

Trending Trending of issues had improved since the 2011 PI&R inspection. The licensees pre-inspection self-assessment stated that, The trending program is performing as designed and is effective. The inspectors concurred with the licensees assessment; however, the inspectors identified an area for improvement in trending. In 2009, the licensee began assigning Nuclear Safety Culture Aspects to selected issues in order to identify potential adverse trends in human performance. In 2011, the PI&R team noted that while useful, the effort was of limited value as these Aspects were only assigned to NRC findings and not to licensee self-identified or near miss events. Given that NRC findings constituted only a small subset of the total issues in the CAP, this resulted in a low probability of identifying an adverse trend at a precursor stage. The licensee documented this issue in 2011 as CAP 1646247. The inspectors verified that the licensee had assigned a Nuclear Safety Culture Aspect to every Apparent Cause Evaluation (ACE) and Root Cause Evaluation (RCE) performed in 2012. However, the inspectors could find no objective evidence that the information was used in any way.

There were no trend CRs or common cause evaluations performed based on the information provided from the assigned Nuclear Safety Culture Aspects. The licensee documented this issue in CR 1852016, Use of Safety Culture Aspects in RCEs and ACEs.

The inspectors also identified a potential trend developing where some Health Physics (HP) Technicians in the Radiation Protection (RP) Department were not generating CRs when issues were first identified. For example, there were two RP department clock resets in January 2013 for CRs not being generated when issues warranting a CR were first discovered. The example was associated with missed radiological surveys, and the second was the failure to perform self-contained breathing apparatus (SCBA)/breathing air testing. The inspectors considered these failures to document issues in the CAP as multiple examples of a licensee-identified performance deficiency for failing to follow procedure PI-AA-204, Condition Identification and Screening Process, Revision 19.

Procedure PI-AA-204 stated, in part, that the stations CAP database SHALL be used to document and track Conditions Adverse to Quality (CAQ). Attachment 3 of PI-AA-204 provided guidance on the types of items that warrant a condition report and the applicable significance levels. Section 14, Radiation Protection, of Attachment 3 of PI-AA-204 lists, in part, Administrative/minor errors in paperwork or reports (radiological program), as an issue representing a significance level 3 CAQ. The inspectors determined that the performance deficiency was minor because it did not adversely affect the Occupational Radiation Safety Cornerstone objective (i.e. the issues were eventually identified, entered into the CAP, and resulted in no radiation safety consequences). The licensee had generated CR 01838349 and was in the process of reviewing these issues for common cause to determine corrective actions.

(2) Effectiveness of Prioritization and Evaluation of Issues The inspectors determined that the overall performance in prioritization and evaluation of issues was effective. The inspectors observed that the majority of issues identified were of low-level and were either closed to trend or at a level appropriate for a condition evaluation. Issues were being appropriately screened by both the IST and MRC and the inspectors had no concerns with those items assigned an ACE or RCE. There were no items in the operations, engineering, or maintenance backlogs that were risk-significant, individually or collectively. The inspectors also identified no issues during the review of the Operational Decision Making Issue (ODMI) process.

Observations Most issues screened in the CAP were closed to a work request or to another CAP report. Generally, both the parent and daughter documents had the necessary statements to document the interrelationship.

However, the inspectors noted while reviewing ACE 01840678, NRC Potential Green Non-Cited Violation Respiratory Program, that the extent of condition stated, in part, that discussions with members of the Chemistry and PI group indicate that similar scheduling and tracking tools are in use in other departments as well, and that the activities controlled by these tools may be at risk. The inspectors identified that the licensee did not generate a new CR or a CA to investigate this concern. The inspectors considered this an NRC-identified performance deficiency for failing to follow procedure PI-AA-100-1007, Apparent Cause Evaluation, Revision 6, which stated, in part, that Once the Extent of Condition has been quantified, corrective actions to resolve identified areas of vulnerability are required to be included in the corrective action plan for the original condition. The inspectors determined that the performance deficiency was minor because it did not represent a safety concern. The licensee generated CR 01851574 to further investigate the extent of condition.

Findings No findings were identified.

(3) Effectiveness of Corrective Actions Corrective actions were generally appropriate for the identified issues. Those corrective actions addressing selected NRC documented violations were also generally effective and timely. The inspectors review going back five years of the licensees efforts to address issues with 4160 and 480 VAC electrical breakers did not identify any negative trends or the inability by the licensee to address long term issues. However, the inspectors determined that the corrective actions for some issues had not been effective.

Observations Human Performance The licensee generated RCE 01748776, NRC Cross-Cutting Human Performance H.1.a Issue, to address a trend in a series of human performance events associated with decision making/systematic process issues. The licensee had concluded that the corrective actions associated with the RCE were effective. However, the inspectors concluded that the corrective actions have not been effective in the long run. The basis for this conclusion was that although the licensee completed the RCE in May 2012, and there were no additional findings identified with an H.1.(a) cross-cutting aspect in 2012, there were recent examples identified where the aspect of H.1.(a) appeared to be a contributing cause.

The event that was reported in LER 2012-006 was an example of the above. On November 27, 2012, during start up from a recent refueling outage, Local Power Range Monitor (LPRM)32-25A was identified as providing a 'zero' input signal to its associated Average Power Range Monitors (APRMs) C and D. At that time it was believed that there was a blown fuse in LPRM 32-25A's circuit card and therefore, the LPRM was considered operable. On December 1, 2012, while operating at 71% power, a different operating crew reviewed the condition and bypassed LPRM 32-25A. After bypassing LPRM 32- 25A, indicated reactor power on APRMs C and D increased approximately 4%. At this time, the LPRM was determined to be inoperable. Since the inoperable LPRM was providing inputs to APRMs C and D, Technical Specification (TS)

Surveillance Requirement (SR) 3.3.1.1.2 which requires verification of the difference between the APRM channels and calculated power to be within 2% of rated thermal power every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, was not met. Therefore, this event resulted in a condition prohibited by TS. A root cause evaluation was in progress to determine the cause and corrective actions for this event and a supplemental report was expected to be issued by March 29, 2013. The resident inspectors were following up on this event and the results of that inspection will be documented in NRC Inspection Report 05000331/2013002. The licensee captured this issue in CR 01851409.

Component Mispositionings The 2011 PI&R report stated that there was a negative trend in component mispositionings. The number of mispositionings in 2012 did not show a significant improvement from those in 2011, and the inspectors identified that the number of component mispositionings in 2013 extrapolated out also did not show significant improvement in the number of component mispositionings. This indicated that the actions to correct the trend may have been ineffective. The licensee was in the process of taking new and additional corrective actions to reduce the number of mispositionings as part of a common cause evaluation performed under CR 01778036. Based on a discussion with the Operations Director and review of the common cause evaluation and ongoing or planned corrective actions, the licensees current efforts appeared reasonable to reduce the number of component mispositionings and turn the ongoing negative trend.

Refuel Floor Rad Monitor Multiple Failures The inspectors also identified several issues associated with numerous momentary failures of the RIS4131A Refuel Floor Exhaust Radiation Monitor. When reviewing CR 01815175, RIS4131A Refuel Floor Exhaust Rad Monitor Upscale and Group 3 Isolation, dated October 20, 2012, the inspectors noted that the reading had failed high for about 10 minutes before returning to normal readings. The high reading had caused a Group 3 isolation signal.

The inspectors noted that another spurious high reading and Group 3 isolation occurred on December 20, 2012, which was documented in CR 01834215, Annunciator 1C03A (A-1) Fuel Pool Exhaust RIS-4131A/B HI-HI. Further investigation determined that the licensee had repaired the radiation monitor power supplies after the first spurious Hi-Hi alarm under WO 40190702, RIS4131A Refuel Floor Exhaust Rad Mon Upscale, on December 6, 2012, but had not replaced the radiation detector or the electrolytic capacitors. Following the second upscale spike and Group 3 isolation, the licensee replaced the detector and the capacitors and successfully calibrated the instrument.

The inspectors were not aware of any more spikes of the radiation monitor since the December 2012 repairs were completed.

The licensee performed a Critical Equipment Failure Evaluation (CEFE) following the second Group 3 isolation event in December 2012. The inspectors reviewed this evaluation and had the following observations:

In Section 2 of the CEFE, the licensee stated that preventive maintenance (PM) task PMID 19459-01 replaced the aluminum electrolytic capacitors in the power supply E/S-4131A of the Refuel Floor Exhaust Radiation Monitor every 10 years. There was no current history on this task, because a replacement power supply was installed on April 25, 2002, per WO 01309926. This task should have replaced the electrolytic capacitors or verified that the capacitors would not exceed their service life before the next scheduled PM task.

The licensee also stated within the CEFE that PM task PMID 22335-01 required the refurbishment of the detector in the Refuel Floor Exhaust Radiation Monitor every 10 years. This PM task also included the replacement of the electrolytic capacitors or the verification that the capacitors would not exceed their service life before the next scheduled PM task, and was performed on November 18, 2005, per WO 01265555.

The licensee stated in the CEFE that they could not verify that the electrolytic capacitors had either actually been replaced or checked to ensure that the service life would extend to the next scheduled replacement without exceeding the maximum recommended lifetime of 10 years (including shelf-life) in either of the two above work orders.

Electrolytic capacitor failure after 10 years was a widely known industry issue. Prior to the refuel floor radiation monitor failure in December 2012, the next capacitor replacement had been scheduled for March 25, 2013 per WO 40110471.

In the CEFE, the licensee concluded that the direct cause of the failure of the RIS4131A Refuel Floor Exhaust Radiation Monitor was Component Aging. Inspection of the capacitors in the power supply E/S-4131A per WO 40190702 in December 2012, showed date codes indicating that the oldest capacitors were 12.37 years old and had been in service for 10.75 years. When the electrolytic capacitors were replaced in December 2012, it was clear from measurements taken they had reached the end of their service life.

The inspectors concluded that all of the off-scale events had been equipment failures and that capacitor degradation had been indicated from the first occurrence. The licensees corrective actions to address these equipment spikes were ineffective over a very long period of time. The inspectors also observed that if the PM to replace the electrolytic capacitors had an 8-year periodicity instead of a 10-year periodicity then the capacitors would be replaced before exceeding a 10-year service life, even if the PM was performed in the 25 percent grace period.

Findings Failure to Follow Procedures Affecting Quality

Introduction:

The inspectors identified a finding of very low safety significance (Green)and associated Non-Cited Violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for two examples of the failure to follow procedures associated to the troubleshooting and repair of the RIS4131A Refuel Floor Exhaust Radiation Monitor.

Description:

The inspectors noted that upward spikes of the RIS4131A Refuel Floor Exhaust Radiation Monitor resulted in two recent Group 3 isolations that were reported to the NRC. The first occurred on October 20, 2012, and was documented in CR 01815175, RIS4131A Refuel Floor Exhaust RAD Monitor Upscale and Group 3 Isolation. The second occurred on December 20, 2012, and was documented in CR 01834215, Annunciator 1C03A (A-1) Fuel Pool Exhaust RIS-4131A/B HI-HI. The inspectors determined that the licensee had repaired the refuel floor exhaust radiation monitor power supplies after the first spurious Hi-Hi alarm under WO 40190702, RIS4131A Refuel Floor Exhaust Rad Mon Upscale, on December 6, 2012, but had neither replaced the radiation detector nor the electrolytic capacitors. Following the second upscale spike and Group 3 isolation, the licensee replaced the detector and successfully calibrated the instrument. There has not been another spurious Group 3 isolation attributed to this detector since the replacement of the radiation detector and capacitors.

The inspectors identified that the RIS4131A Refuel Floor Exhaust Radiation Monitor had been experiencing momentary down scale failures since 2007. Nine different CRs had been initiated noting momentary down-scale failures that lasted several minutes each.

Eight of these CRs had been closed to WO 01331784, Troubleshoot and Repair RIS4131A Radiation Monitor. This WO had instructions to replace the electrolytic capacitors and the radiation detector, the same work that eventually repaired the RIS4131A Refuel Floor Exhaust Radiation Monitor. However, a work planner cancelled WO 01331784 in 2010 without justification despite numerous references within the WO prohibiting cancellation. There had been numerous opportunities between 2007 and 2010 when the WO could have been accomplished since the work could have been performed either on-line or when shut down.

The inspectors concluded that the licensee failed to recognize that closing WO 01331784-01 without completing the work or justification was a failure to track corrective actions to completion as required by procedure PI-AA-205, Condition Evaluation and Corrective Action, Section 4.10, Completion of Corrective Actions. Specifically, Step 10 required that all open corrective actions be tracked to completion and that the plant WOs were the only other system that could be used for tracking corrective actions.

The requirement to track the corrective actions does not stop if a CR is closed to a work order in accordance with PI-AA-205.

This requirement was not well understood by the licensee as evidenced by the answer to PI&R Inspection Question 22, Discuss why no actions were taken out of CR 1825422, Corrective Action Work Request Cancelled without Justification. The licensee responded that CRs 01825411 and 01825422 had been initiated. Condition Report 01825411 was initiated to provide coaching to planners (this was done). Condition Report 01825422 was written to investigate why barriers broke down to allow a WO that was a corrective action to be closed. The licensee stated there was no assignment from this CR [01825422] since the CAP process does not require CA tracking for work orders. The inspectors determined this answer was incorrect as PI-AA-205 did require the work order system to track corrective actions, as shown above.

The inspectors reviewed WO 40190702-01 that was used to troubleshoot and repair the RIS4131A Refuel Floor Exhaust Radiation Monitor after the first Group 3 isolation in October 2012. The inspectors noted that the instructions included using the manufacturers Area Radiation Monitor (ARM) Power Supplies Calibration, Section A, 1, Calibration Data Sheet and a Support/Refute Matrix. The technicians were to record the as-found and as-left voltage and ripple voltage measurements on the power supplies that were electrically loaded per the manufacturers instructions.

These measurements were also required to be entered on the Support/Refute Matrix as part of the troubleshooting decision making process. The inspectors noted that the technicians did not electrically load, measure, and record the as-found and as-left DC voltages and AC ripple voltages of the ARM power supplies on the Calibration Data Sheet and on the Support/Refute Matrix. The inspectors saw that the technicians had noted that the measurements were taken unloaded; however, no supervisor or manager had challenged the incorrect work. Additionally, no conclusions were documented on the Support/Refute Matrix.

The Support/Refute Matrix was attached to the CEFE for CR 01815175-02 which was performed after the second Group 3 isolation in December 2012. The CEFE contained clear statements that the voltage measurements had not been taken per the vendor manual instructions to load the power supplies. Again, there was no evidence that this failure to follow the work order instructions had been challenged. The inspectors had doubts about the accuracy of the troubleshooting and repair efforts but did note that the equipment had passed STP 3.3.6.1-21, Refuel Floor Exhaust Duct Radiation Monitor Channel Calibration, Revision 11, before being declared operable.

Analysis:

The inspectors determined that two examples of the failure to follow a procedure was a performance deficiency. The finding was determined to be more than minor because the finding was associated with the Barrier Integrity Cornerstone attribute of SSC and Barrier Performance and affected the cornerstone objective of providing reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Specifically, RIS4131A Refuel Floor Exhaust Radiation Monitor failing to operate in conjunction with a single additional failure (RIS4131B) could allow the release of radioactive contamination due to preventing automatic secondary containment isolation (Group 3).

The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Initial Characterization of Findings. The finding screened as very low safety significance (Green) because the inspectors answered Yes to question C.1 of IMC 0609, Appendix A, Exhibit 3.

The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting aspect of Human Performance, having Work Control components that support long-term equipment reliability by performing maintenance that is more preventive than reactive.

Specifically, the licensee closed eight CRs to a single work order and then erroneously cancelled the WO without accomplishing the work or justifying the cancellation. In addition, the licensee failed to correctly perform troubleshooting per WO instructions.

These reasons caused the licensee to fail to schedule and accomplish corrective maintenance on the RIS4131A Refuel Floor Exhaust Radiation Monitor power supplies and detector before the component eventually momentarily failed high, resulting in two Group 3 isolations. H.1(a)

Enforcement:

Title 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented procedures of a type appropriate to the circumstances and be accomplished in accordance with these procedures.

The licensee established PI-AA-205, Condition Evaluation and Correction, Revision 19, as the implementing procedure for completing corrective actions to conditions adverse to quality. Procedure PI-AA-205, Step 4.10.B stated: Corrective Actions (Non-RIS 2005-20) resulting from an Engineering CR evaluation may be closed to a WO only if the WO contains the specified corrective actions, references the CR number, and states that it can NOT be cancelled unless in accordance with PI-AA-205.

The licensee also established Work Order (WO) 40190702-01, RIS4131A Refuel Floor Exhaust Rad Monitor Upscale and Group 3, as the implementing instruction for troubleshooting and repairing the RIS4131A Refuel Floor Exhaust Radiation Monitor power supplies, an activity affecting quality. Work Order 40190702-01 included using the manufacturers ARM Power Supplies Calibration, Section A, Attachment 1, Calibration Data Sheet and a Support/Refute Matrix. The Calibration Data Sheet required the technicians to record the as-found and as-left DC voltage and AC ripple voltage measurements of the electrically-loaded power supplies, per the manufacturers instructions. These measurements were also required to be entered on the Support/Refute Matrix as part of the troubleshooting decision making process.

Contrary to the above, on October, 19, 2011, the licensee failed to follow PI-AA-205, Condition Evaluation and Corrective Action, Revision 19, when a work planner cancelled WO 01331784, Troubleshoot and Repair the Power Supplies and Replace the Detector, which clearly stated do not cancel without checking the referenced CRs or justifying the cancellation per PI-AA-205 requirements.

And on December 6, 2012, the licensee failed to follow WO 40190702-01, RIS4131A Refuel Floor Exhaust Rad Monitor Upscale and Group 3, requirements and manufacturers instructions when troubleshooting and repairing the RIS4131A Refuel Floor Exhaust Radiation Monitor power supplies. Specifically, the technicians did not electrically load, measure, and record the as-found and as-left DC voltages and AC ripple voltages of the ARM power supplies on the Calibration Data Sheet and on the Support/Refute Matrix.

The licensee took the following immediate corrective actions: initiated WO 40190702-01, RIS4131A Refuel Floor Exhaust Rad Mon Upscale and Group 3, to troubleshoot and repair the power supplies.

The licensee was still evaluating planned corrective actions for the failure to follow the work order instructions. However, the inspectors determined that the continued non-compliance does not present an immediate safety concern because the system passed STP 3.3.6.1-21 before being declared operable.

These issues were two examples of the licensee failing to accomplish activities affecting quality in accordance with documented procedures or instructions. Since both examples affected the same component, they were treated as one violation of 10 CFR 50, Appendix B, Criterion V.

Because this violation was of very low safety significance and it was entered into the licensees corrective action program as CR 01825422, Corrective Action Work Order Cancelled Without Justification, dated November 20, 2012, and CR 01852027, NRC Finding - Fuel Pool Rad Monitor Failures, dated February 27, 2013, this violation is being treated as an NCV, consistent with Section 2.3.2 of the NRC Enforcement Policy (NCV 05000331/2013007-01, Fuel Pool Radiation Monitor Corrective Actions).

.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 implementing OE program procedures, observed daily meetings for the use of OE information, and reviewed completed evaluations of OE issues and events. The intent was to determine if the licensee was effectively integrating OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensees program was sufficient to prevent 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 implemented effectively and in a timely manner.

b. Assessment In general, OE was effectively utilized at the station. The inspectors observed that OE was discussed as part of the daily station and pre-job briefings. Industry OE was effectively disseminated across the various plant departments and no issues were identified during the inspectors review of licensee OE evaluations. During interviews, several licensee personnel commented favorably on the use of OE in their daily activities.

The inspectors noted that station procedures required, in particular, that most formal OE-related items entered into the CAP were required to be screened and evaluated for applicability at the station within 60 days. Further, OE evaluations for items applicable at the station were to be evaluated and closed with corrective actions within 90 days. The inspectors did not identify any instances where these OE review requirements were not met. Generally, OE that was applicable to the station was thoroughly evaluated and actions were taken to address any issues that resulted from the evaluations in a timely manner.

Findings No findings 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 program, prioritize and evaluate issues, and implement effective corrective actions through efforts from departmental assessments and audits. The inspectors reviewed Nuclear Oversight (NOS) audits, departmental self-assessments, and departmental performance assessment reports. The inspectors interviewed an NOS audit lead.

b. Assessment The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying issues and enhancement opportunities at an appropriate threshold level. The audits and self-assessments were completed by personnel knowledgeable in the subject area, and the NOS audits were thorough and critical. The department self-assessments were acceptable but were not of the same level of quality as the NOS audits. The inspectors observed that CAP items had been initiated for issues identified through the NOS audits and self-assessments. The inspectors reviewed the self-assessment performed on the CAP and found no issues and generally agreed with the overall results and conclusions drawn.

Findings No findings were identified.

.4 Assessment of Safety-Conscious Work Environment

a. Inspection Scope

The inspectors assessed the licensees safety-conscious work environment (SCWE)through the reviews of the facilitys employee concerns program (ECP) implementing procedures, discussions with ECP coordinators, interviews with personnel from various departments, and reviews of issue reports. The inspectors did not review the results of the latest licensee safety culture survey because it was performed prior to the last PI&R inspection conducted in 2011 and was reviewed then. The inspectors reviewed a number of anonymous CRs written for the last two years.

b. Assessment The inspectors determined that plant staff were aware of the importance of having a strong SCWE and expressed a willingness to raise safety issues. No one interviewed had experienced retaliation for safety issues raised or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP process.

These results were similar with the findings of the licensees safety culture surveys performed in 2010. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable SCWE.

Observations The contributing cause in RCE 01748776, Trend NRC Findings in H.1.A, stated that licensee management perceived that, in general, licensee personnel felt that the risks associated with not meeting the requirements of an administrative procedure are not perceived as being as severe as the risks associated with not meeting the requirements of technical procedures or failing to meet a deadline. This appeared to the inspectors to demonstrate a focus on production over safety by licensee personnel. The inspectors questioned the above statement in the RCE and determined that it was anecdotal in nature and there was no objective evidence to support the statement.

The inspectors determined that the ECP process was being effectively implemented.

The inspectors noted that the licensee had appropriately investigated and taken constructive actions to address potential cases of harassment and intimidation for raising issues.

Findings No findings were identified.

4OA6 Management Meetings

.1 Exit Meeting Summary

On March 1, 2013, the inspectors presented the inspection results to Mr. Anderson 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.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

R. Anderson, Site Vice President

D. Brigl, Employee Concerns Manager

T. Byrne, Licensing Director, Acting

M. Davis, Emergency Preparedness Manager

J. Dubois, Program Engineering Manager

P. Hansen, Performance Improvement Manager

R. Harter, Work Management Director

G. Hawkins, System Engineering Manager

K. Kleinheinz, Engineering Director

R. Murrell, Licensing Engineer

B. Porter, Radiation Protection Manager

G. Pry, Plant General Manager

R. Wheaton, Maintenance Director

G. Young, Nuclear Oversight Manager

Nuclear Regulatory Commission

C. Lipa, Chief, Branch 1, Division of Nuclear Materials Safety

R. Murray, Resident Inspector

LIST OF ITEMS

Opened/Closed

05000331/2013007-01 NCV Fuel Pool Radiation Monitor Corrective Actions (Section 40A2.1.b.(3))

Attachment