IR 05000335/2020001

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Integrated Inspection Report 05000335/2020001 and 05000389/2020001 and Exercise of Enforcement Discretion
ML20126G468
Person / Time
Site: Saint Lucie  NextEra Energy icon.png
Issue date: 05/05/2020
From: Randy Musser
NRC/RGN-II/DRP/RPB3
To: Moul D
Florida Power & Light Co
References
EA-20-027 IR 2020001
Download: ML20126G468 (28)


Text

May 5, 2020

SUBJECT:

ST. LUCIE UNITS 1 & 2 - INTEGRATED INSPECTION REPORT 05000335/2020001 AND 05000389/2020001 AND EXERCISE OF ENFORCEMENT DISCRETION

Dear Mr. Moul:

On March 31, 2020, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at St. Lucie Units 1 & 2. On April 13, 2020, the NRC inspectors discussed the results of this inspection with Mr. Dan DeBoer and other members of your staff. The results of this inspection are documented in the enclosed report.

No findings or violations of more than minor significance were identified during this inspection.

This inspection documents an exercise of enforcement discretion in accordance with the NRC Enforcement Policy, Section 3.10, Reactor Violations With No Performance Deficiencies.

This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA/

Randall A. Musser, Chief Reactor Projects Branch 3 Division of Reactor Projects Docket Nos. 05000335 and 05000389 License Nos. DPR-67 and NPF-16

Enclosure:

As stated

Inspection Report

Docket Numbers: 05000335 and 05000389 License Numbers: DPR-67 and NPF-16 Report Numbers: 05000335/2020001 and 05000389/2020001 Enterprise Identifier: I-2020-001-0033 Licensee: Florida Power & Light Company Facility: St. Lucie Units 1 & 2 Location: Jensen Beach, FL 34957 Inspection Dates: January 1, 2020 to March 31, 2020 Inspectors: A. Butcavage, Reactor Inspector C. Fontana, Emergency Preparedness Inspector M. Garza, Emergency Preparedness Inspector R. Kellner, Senior Health Physicist W. Loo, Senior Health Physicist T. Morrissey, Senior Resident Inspector W. Pursley, Health Physicist J. Rivera, Health Physicist S. Roberts, Resident Inspector S. Sanchez, Senior Emergency Preparedness Inspector J. Walker, Emergency Preparedness Inspector Approved By: Randall A. Musser, Chief Reactor Projects Branch 3 Division of Reactor Projects Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at St. Lucie Units 1 & 2, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

List of Findings and Violations

No findings or violations of more than minor significance were identified.

Additional Tracking Items

Type Issue Number Title Report Section Status LER 05000335/2019-003-00 LER 2019-003-000, 71153 Closed Inoperability of Emergency Diesel Generator due to Cracked Crankshaft EDG EA-20-027 Enforcement Discretion 71153 Closed Granted for LER 2019-003-000, Inoperability of Emergency Diesel Generator due to Cracked Crankshaft

PLANT STATUS

Unit 1 began the inspection period at rated thermal power (RTP). On February 6, 2020, the unit was reduced to 92 percent RTP to troubleshoot and repair the 4B feedwater heater level control system. The unit was returned to RTP on February 7, 2020. Unit 1 operated at or near RTP for the remainder of the inspection period.

Unit 2 began the inspection period at RTP. On February 17, 2020 the unit was shutdown for a planned refueling outage. On March 18, 2020 the unit was restarted and returned to RTP on March 20, 2020. Unit 2 operated at or near RTP for the remainder of the inspection period.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed plant status activities described in IMC 2515, Appendix D, Plant Status, and conducted routine reviews using IP 71152, Problem Identification and Resolution. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

Starting on March 20, 2020, in response to the National Emergency declared by the President of the United States on the public health risks of the coronavirus (COVID-19), resident inspectors were directed to begin telework and to remotely access licensee information using available technology. During this time the resident inspectors performed periodic site visits each week during which they conducted plant status activities as described in IMC 2515, Appendix D, and observed risk significant activities when warranted. In addition, resident and regional baseline inspections were evaluated to determine if all or portions of the objectives and requirements stated in the IP could be performed remotely. If the inspections could be performed remotely, they were conducted per the applicable IP. In the cases where it was determined the objectives and requirements could not be performed remotely, management elected to reschedule the inspection to a later date.

REACTOR SAFETY

71111.01 - Adverse Weather Protection

Impending Severe Weather Sample (IP Section 03.02) (1 Sample)

(1) The inspectors evaluated licensee readiness for cold weather conditions of 40 degrees Fahrenheit in accordance with normal operating procedure 0-NOP-99.06, "Cold Weather Preparations," on January 22, 2020.

71111.04 - Equipment Alignment

Partial Walkdown Sample (IP Section 03.01) (3 Samples)

The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:

(1) Unit 2, intake cooling water (ICW) and component cooling water (CCW) systems with 2B CCW heat exchanger (HX) and 2B ICW header out of service (OOS) for maintenance, on February 19-20, 2020
(2) Unit 1, 1B startup transformer (SUT) and buses 2B4, 1B2, and 1B3 with 1A SUT OOS for maintenance, on February 24-25, 2020
(3) Unit 2, 2C auxiliary feedwater (AFW) train after being returned to service following refueling outage maintenance activities, on March 16, 2020

71111.05 - Fire Protection

Fire Area Walkdown and Inspection Sample (IP Section 03.01) (4 Samples)

The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:

(1) Unit 1, 1A and 1B electrical penetration rooms, on January 12, 2020
(2) Unit 2, CCW building, on January 28, 2020
(3) Unit 2, fuel handling building (FHB), on February 12, 2020
(4) Unit 2, reactor containment building, on March 2, 2020

Fire Brigade Drill Performance Sample (IP Section 03.02) (1 Sample)

(1) The inspectors evaluated the onsite fire brigade training and performance during two separate fire drills; an unannounced fire drill on January 10, 2020 and an announced drill on January 27, 2020. The inspectors also evaluated the licensee's self-contained breathing apparatus (SCBA) program including storage, training, expectations for use and maintenance.

71111.06 - Flood Protection Measures

Inspection Activities - Internal Flooding (IP Section 03.01) (1 Sample)

The inspectors evaluated internal flooding mitigation protections in the:

(1) Unit 1 reactor auxiliary building (RAB) -0.5 foot elevation, on February 26, 2020

71111.07A - Heat Sink Performance

Annual Review (IP Section 03.01) (1 Sample)

(1) The inspectors evaluated readiness and performance of the 2B CCW HX by verifying that periodic maintenance conducted was in accordance with the Electric Power Research Institute (EPRI) HX monitoring guideline, NP-7552, on February 19, 2020.

71111.08P - Inservice Inspection Activities (PWR) PWR Inservice Inspection Activities Sample (IP Section 03.01)

The inspectors verified that the reactor coolant system boundary, steam generator tubes, reactor vessel internals, risk-significant piping system boundaries, and containment boundary were appropriately monitored for degradation and that repairs, and replacements were appropriately fabricated, examined, and accepted. The inspector reviewed the following activities on site from February 24 to February 28, 2020 and conducted an in-office document review as work was still in progress during the onsite week.

(1) 03.01.a - Nondestructive Examination and Welding Activities.
  • Ultrasonic testing (UT), Component ID, RC-141-FW-2003, Class 1 (Reviewed, Use as is, Geometry)
  • Inspection Not Scheduled this Outage.
  • Industry Operating Experience Review, Westinghouse NSAL-20-1 (Reactor Vessel Thermal Sleeve Degradation), Reviewed with Responsible Engineer 03.01.c - Pressurized-Water Reactor Boric Acid Corrosion Control Activities.
  • AR 02344816-01, Boric Acid (BA) Residue on Unit-2 Valve 3800, 2/17/20 (Reviewed)
  • AR 02345267-01, BA Residue on Unit-2 Level Transmitter LT-1105 Low Side Tubing and VLT-1105, 5 Valve Instrument Manifold, 2/19/20 (Reviewed)
  • AR 02345318-01, BA Residue Observed at Body to Bonnet Joint on Unit 2 Valve 5201, 2/19/20 (Reviewed)
  • Containment Walk-down Conducted with Boric Acid Program Owner, AR 02346139 Initiated for BA at Valve VPT-1103
  • Reviewed Reactor Lower Head Area visual examination (VT-2) Results, IAW St. Lucie Unit-2 Relief Request No. 4, Rev.1 03.01.d - Pressurized-Water Reactor Steam Generator Tube Examination Activities.
  • No Eddy Current Examinations Scheduled this Outage
  • Reviewed Condition Monitoring and Operation Assessment Summary for Cycle 25

71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance

Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)

(2 Samples)

(1) The inspectors observed and evaluated licensed operator performance in the control room during a planned power reduction and shutdown of Unit 2 to support a refueling outage, on February 16-17, 2020
(2) The inspectors observed and evaluated licensed operator performance in the control room during Unit 2 startup and power ascension activities following a refueling outage, on March 18-20, 2020.

Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)

(1) On January 21, 2020, the inspectors observed a licensed operator requalification training evaluation on the control room simulator. The simulated scenario included a loss of 2B5 480-volt (V) motor control center (MCC), loss of the 2B heater drain pump, a rapid down power, reactor coolant system (RCS) leak, a loss of coolant accident (LOCA), and a manual reactor trip. The LOCA resulted in an Alert emergency event classification which required a simulated notification to the State of Florida and the NRC.

71111.12 - Maintenance Effectiveness

Maintenance Effectiveness (IP Section 03.01) (2 Samples)

The inspectors evaluated the effectiveness of maintenance to ensure the following structures, systems, and components (SSCs) remain capable of performing their intended function, in addition a periodic evaluation was completed as allowed by procedure:

(1) AR 2336005, Unit 2, containment cooler fan HVS-1C fan tripped
(2) AR 2325531, St. Lucie Periodic evaluation required by 10 CFR 50.65(a)(3)

Quality Control (IP Section 03.02) (1 Sample)

The inspectors evaluated the effectiveness of maintenance and quality control activities to ensure the following SSC remains capable of performing its intended function:

(1) Unit 2, ICW system, system health report, dated January 14, 2020 including review and observation of ICW piping replacement per engineering change (EC) 290047

71111.13 - Maintenance Risk Assessments and Emergent Work Control

Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)

The inspectors evaluated the accuracy and completeness of risk assessments for the following planned work activities to ensure configuration changes and appropriate work controls were addressed;

(1) Unit 1 elevated risk with 1A charging pump, HCV-08-2A (1A steam generator (SG)atmospheric dump valve) and HVE-6A (shield building exhaust fan) OOS for planned maintenance, on January 8, 2020
(2) Unit 2 elevated risk with 2A ICW train OOS for planned maintenance, on February 4, 2020
(3) Unit 2 Yellow shutdown safety assessment (SSA) with the RCS in a lowered inventory condition to support reactor head removal on, February 19-20, 2020
(4) Unit 1 elevated risk with the 1A SUT OOS for planned maintenance, on February 24-25, 2020
(5) Unit 2 Yellow SSA with the RCS in a lowered inventory condition to support reactor head installation, on March 9, 2020

71111.15 - Operability Determinations and Functionality Assessments

Operability Determination or Functionality Assessment (IP Section 03.01) (6 Samples)

The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:

(1) AR 2341950, Pitting identified on ICW piping to 1B CCW HX, on January 24, 2020
(2) AR 2342170, Several Unit 1 refueling outage work orders (WOs) for environmentally qualified transmitter replacement have steps that may not have been completed, on January 29, 2020
(3) AR 2343492, Unit 1, 1B main steam isolation valve (MSIV) direct current (DC)ground, on February 5, 2020
(4) AR 2342351, Unit 1, 1B AFW discharge flow transmitter leakage, on February 3, 2020
(5) AR 2347673, Unit 1, 1B emergency diesel generator (EDG) lockout relay failure, on March 11, 2020
(6) AR 2348808, Unit 1, CCW HX 1B flow transmitter fire damage, on March 17, 2020

71111.18 - Plant Modifications

Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02)

(1 Sample)

The inspectors evaluated the following temporary or permanent modifications:

(1) EC 290047, 2B and 2C ICW pump discharge cross-tie pipe replacement

71111.19 - Post-Maintenance Testing

Post-Maintenance Test Sample (IP Section 03.01) (7 Samples)

The inspectors evaluated the following post maintenance test activities to verify system operability and functionality:

(1) Unit 1, WO 40608294, HVE-6A shield building exhaust fan D-23 damper motor replacement, on January 9, 2020
(2) Unit 2, WO 40591838, 2C AFW pump, MV-08-13 linkage lube, on February 6, 2020
(3) Unit 1, WO 40702578, replace 1B AFW flow transmitter valves, on February 11, 2020
(4) Unit 2, WO 40628302, Solenoid valve, V5201, pressurizer surge line sample containment isolation valve inspection, on March 9, 2020
(5) Unit 2, WO 40628585, MV-08-03 (AFW 2C trip and throttle valve) inspect and overhaul actuator, on March 12, 2020
(6) Unit 2, WO 40646288, Overhaul HCV-09-1B, main feedwater isolation valve (MFIV),actuator, on March 19, 2020
(7) Unit 2, WO 40548423, 2A ICW pump overhaul, on March 30, 2020

71111.20 - Refueling and Other Outage Activities

Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)

(1) The inspectors evaluated the Unit 2 refueling outage (SL 2-25) activities from February 17, 2020 through March 19, 2020

71111.22 - Surveillance Testing

The inspectors evaluated the following surveillance tests:

Surveillance Tests (other) (IP Section 03.01)

(1) Unit 2, 2-OSP-59.01A, "2A Emergency Diesel Generator Monthly Surveillance," (fast start), on January 6, 2020
(2) Unit 2, 2-SMM-08.08, "Main Stream Safety Valve Setpoint Surveillance Using Furmanite Trevitest Mark VIII Equipment," on February 16, 2020
(3) Unit 2, 2-OSP-03.17, "Stroke Testing of the SIT Discharge and SI Loop Check

Valves," on February 24, 2020 Inservice Testing (IP Section 03.01) (1 Sample)

(1) Unit 1, 1-OSP-03.05A, "1A High Pressure Safety Injection Code Run," on March 25, 2020

Containment Isolation Valve Testing (IP Section 03.01) (1 Sample)

(1) Unit 2, 2-OSP-68.02, "Local Leak Rate Test," (Penetration 48A, hydrogen sampling to analyzer 2A), on February 24, 2020

FLEX Testing (IP Section 03.02) (1 Sample)

(1) 0-OSP-83.04A (B)(C), "Periodic Testing of the Flex 480V DG" A, (B) and (C), on January 9, 2020.

71114.01 - Exercise Evaluation

Inspection Review (IP Section 02.01-02.11) (1 Sample)

(1) The inspectors evaluated the biennial emergency plan exercise during the week of January 13, 2020. The simulated scenario began with a report from the field that a diesel fuel oil truck accidently caused damage to the Unit 2 diesel fuel oil building, thus meeting the criteria for declaration of an Alert. Subsequently, a steam generator (SG) tube rupture from an earlier simulated loose part occurred (leading to a rapid downpower), along with a trip of the 2A heater drain pump and the 2B SG main steam safety valve failing open. This met the conditions for declaring a Site Area Emergency. When radiation levels reached a prescribed threshold from the loose part impacting the fuel clad, conditions for a General Emergency were met, and the Offsite Response Organizations were able to demonstrate their ability to implement emergency actions.

71114.04 - Emergency Action Level and Emergency Plan Changes

Inspection Review (IP Section 02.01-02.03) (1 Sample)

(1) The inspectors evaluated submitted Emergency Action Level, Emergency Plan, and Emergency Plan Implementing Procedure changes during the week of January 13, 2020. This evaluation does not constitute NRC approval.

71114.06 - Drill Evaluation

Drill/Training Evolution Observation (IP Section 03.02) (1 Sample)

The inspectors evaluated:

(1) On January 21, 2020, the inspectors observed a licensed operator requalification training evaluation on the control room simulator

71114.08 - Exercise Evaluation Scenario Review

Inspection Review (IP Section 02.01 - 02.04) (1 Sample)

(1) The inspectors reviewed and evaluated in-office, the proposed scenario for the biennial emergency plan exercise at least 30 days prior to the day of the exercise.

RADIATION SAFETY

71124.01 - Radiological Hazard Assessment and Exposure Controls

Radiological Hazard Assessment (IP Section 03.01) (1 Sample)

(1) The inspectors evaluated how the licensee identifies the magnitude and extent of radiation levels and the concentrations and quantities of radioactive materials and how the licensee assesses radiological hazards

Instructions to Workers (IP Section 03.02) (1 Sample)

(1) The inspectors evaluated radiological protection-related instructions to plant workers

Contamination and Radioactive Material Control (IP Section 03.03) (2 Samples)

The inspectors evaluated licensee processes for monitoring and controlling contamination and radioactive material.

(1) The inspectors observed workers exiting the radiological control area during the Unit 2 (U2) refueling outage.
(2) The inspectors observed licensee surveys of potentially contaminated material leaving the reactor containment building during the U2 refueling outage.

Radiological Hazards Control and Work Coverage (IP Section 03.04) (4 Samples)

The inspectors evaluated in-plant radiological conditions during facility walkdowns and observation of radiological work activities.

(1) The inspectors evaluated the U2 spent fuel pool ion exchanger inspection under Radiation Work Permit (RWP) 20-0119, a Locked High Radiation Area (LHRA) entry.
(2) The inspectors evaluated the reactor water storage tank diving activities to perform tank inspection under RWP 20-2535, a LHRA entry.
(3) The inspectors evaluated U2 incore detectors removal under RWP 20-3118.
(4) The inspectors evaluated U2 reactor head removal under RWP 20-3008, a LHRA entry with alpha level II controls.

High Radiation Area and Very High Radiation Area Controls (IP Section 03.05) (2 Samples)

The inspectors evaluated licensee controls of the following High Radiation Areas and Very High Radiation Areas:

(1) The inspectors evaluated controls of the U1 Fuel Handling Building Heat Exchanger Filter & Pump Room, a LHRA.
(2) The inspectors evaluated controls of the U2 Waste Hold-Up Tank Room, a LHRA.

Radiation Worker Performance and Radiation Protection Technician Proficiency (IP Section 03.06) (1 Sample)

(1) The inspectors evaluated radiation worker and radiation protection technician performance as it pertains to radiation protection requirements.

71124.06 - Radioactive Gaseous and Liquid Effluent Treatment

Walk Downs and Observations (IP Section 02.01) (1 Sample)

The inspectors walked down the following gaseous and liquid radioactive effluent monitoring and filtered ventilation systems to assess the material condition and verify proper alignment according to plant design:

(1)

  • RE-6627, Liquid Radwaste Discharge Process Monitor
  • U1-RSC-26-1, Unit 1 Plant Vent Low Range Radiation Monitor
  • U1-RT-6648, Gaseous Radwaste Process Monitor Calibration and Testing Program (Process & Effluent Monitors) (IP Section 02.02) (1 Sample)

The inspectors reviewed gaseous and liquid effluent monitor instrument calibrations or tests by reviewing information not limited to but including alarm set points, periodicity, National Institute of Standards and Traceability for sources used.

(1)

  • RE-6627, Liquid Radwaste Discharge Process Monitor (Work Order Packages

===40471192 01, July 6, 2017; and 40581278 01, March 13, 2019)

  • RM-26-12, Fuel Handling Building Vent Stack Radiation Monitor (Work Order Packages 40428188 01, September 14, 2016; and 40556491 01, May 8, 2018)
  • U1-RT-6648, Gaseous Radwaste Process Monitor (Work Order Packages 40521892 01, February 28, 2018; and 40620662 01, December 9, 2019)

Sampling and Analysis (IP Section 02.03) ===

The inspectors reviewed radioactive effluent sampling and analysis activities:

(1) Radioactive Effluent Sampling and Analysis Activities
  • Unit 1 Plant and Fuel Building Vent Skids Weekly Sample and Analysis, January 28, 2020
  • Unit 2 Plant Vent A/B PIG and Fuel Building Skids Weekly Sample and Analysis, January 28, 2020 Effluent Discharges None were available for review during this inspection period.

Instrumentation and Equipment (IP Section 02.04) (1 Sample)

The inspectors reviewed flow rates for effluent stack and related vent flow and surveillances.

Inspectors also reviewed maintenance and methodologies for one or two high-range effluent monitors (or other effluent/process monitor) relied on in emergency operating procedures for decision making.

(1)

  • 1-OSP-25.04, Filter Testing Unit 1, Rev. No. 0 (1-HVE-7A, August 14, 2019; and 1-HVE-6A, November 10, 2019)
  • 2-OSP-25.04, Filter Testing Unit 1, Rev. No. 0 (2-HVE-6B, January 30, 2020; and 2-HVE-7B, January 30, 2020)
  • RM-26-14, Unit 2 Plant Vent Stack Radiation Monitor (Work Order Packages

40514601 01, February 21, 2018; and 40619243 01, October 24, 2019) Dose Calculations (IP Section 02.05)

The inspectors reviewed required annual reports for changes, release permits and the offsite dose calculation manual for changes and results.

(1) Liquid and Gaseous Discharge Permits
  • Gas Permit Post-Release Data, Permit Numbers: G-19-459-C, Unit 1 Plant Vent, December 31, 2019; and G-19-460-C, Unit 1 Fuel Handling Building, December 31, 2019
  • None were available for review during this inspection.

71124.07 - Radiological Environmental Monitoring Program

Site Inspection (IP Section 02.01) (1 Sample)

The inspectors performed walkdowns of sampling stations, thermoluminescent locations and meteorological instrumentation. Inspectors also performed observations of preparation and collections of different environmental sample types. Inspectors reviewed sampling results and maintenance, calibration, quality control and ground water records.

(1) The inspectors reviewed the following:

Walkdowns, Calibrations, and Maintenance Record Review

  • H34 - Onsite at Meteorological Tower - Air (Particulate and Iodine Sampler) and Direct Radiation thermoluminescent dosimeter (TLD)
  • H14 - Onsite Near South Property Line - Air (Particulate and Iodine Sampler) and Direct Radiation (TLD)
  • H33 - Onsite North of Intake Canal, West of Dunes - Air (Particulate and Iodine Sampler)
  • SE1 - South of Cooling Canal - Direct Radiation (TLD)

Environmental Sample Collections and Preparation Observation

  • H-15 Atlantic Ocean vicinity of public beaches east side Route AIA - Surface Water (ocean)

Licensee Actions in Response to Missed Sample, Inoperable Sampler, Lost TLD or Anomalous Measurement

  • AR 02245961: Sample Pump at REMP Location H-14 Found OOS
  • AR 02262572: TLD Missing at Port Saint Lucie REMP Program Monitoring Location WSW-10
  • AR 02283308 Loss of Power at REMP Program Monitoring Location H-30 Sampling Program for the Potential of Licensed Material Entering Groundwater
  • Unit 1 & 2 Fuel handling building spent fuel pool
  • Unit 1 Waste monitor tanks A & B
  • Site storm drain system

Groundwater Protection Initiative (GPI) Implementation (IP Section 02.02) (1 Sample)

(1) The inspectors reviewed the licensees continuing implementation of the voluntary Nuclear Energy Institute (NEI) Ground Water Protection Initiative.

71124.08 - Radioactive Solid Waste Processing and Radioactive Material Handling, Storage,

and Transportation

Radioactive Material Storage (IP Section 02.01)

The inspectors evaluated radioactive material storage areas for compliance with postings, labels, radiological controls and physical controls during plant walk downs. Inspectors also evaluated the material condition of several containers of radioactive materials for signs of degradation.

(1) The inspectors toured the following areas:
  • Low level waste building
  • Dry storage building
  • Radiological control area (RCA) Yard Sealand Storage Area The inspectors performed a container check (e.g., swelling, leakage and deformation)of multiple containers in the above locations.

Radioactive Waste System Walkdown (IP Section 02.02) (1 Sample)

The inspectors evaluated liquid and solid radioactive waste processing systems and processes during plant walkdowns for alignment with licensing descriptions, material condition, administrative and physical controls. Inspectors also evaluated changes to the systems, waste stream mixing methodologies and process control program descriptions.

(1) Liquid or Solid Radioactive Waste Processing Systems Accessible portions of the following:
  • Unit 2 Solids pretreatment tank (NOT in service)
  • Unit 2 Boron Management System (NOT in service)
  • Unit 2 Liquid waste system
  • Filter transport cask Radioactive Waste Resin and/or Sludge Discharges Processes Accessible portions of the following:
  • Unit 2 Spent Resin Processing/Transfer Area

Waste Characterization and Classification (IP Section 02.03) (1 Sample)

The inspectors evaluated the radioactive waste characterization and classification for the following waste streams:

(1)

  • Dry Active Waste (DAW), Revision Date 05/28/2019
  • DTS Waste Water Processing Skid Composite, Revision Date 08/22/2018

Shipment Preparation (IP Section 02.04) (1 Sample)

The inspectors evaluated the radioactive material shipment preparation processes by reviewing procedures, training and qualification records of licensee shipping staff, and discussion with licensee staff.

(1) Note: No radioactive material shipments were available for observation.

Shipping Records (IP Section 02.05) (1 Sample)

The inspectors evaluated the following non-excepted package shipment records:

(1) Radioactive Waste Shipment Number PSL 2018-060 Radioactive Waste Shipment Number PSL 2018-098 Radioactive Waste Shipment Number PSL 2018-117 Radioactive Waste Shipment Number PSL 2019-002 Radioactive Waste Shipment Number PSL 2019-003 Radioactive Waste Shipment Number PSL 2019-015 Radioactive Waste Shipment Number PSL 2020-016

OTHER ACTIVITIES - BASELINE

===71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:

EP01: Drill/Exercise Performance (IP Section 02.12) ===

(1) EP01: Drill & Exercise Performance for the period October 1, 2018, through

===September 30, 2019.

EP02: ERO Drill Participation (IP Section 02.13) (1 Sample)===

(1) EP02: Emergency Response Organization Drill Participation for the period October 1, 2018, through September 30, 2019.

EP03: Alert & Notification System Reliability (IP Section 02.14) (1 Sample)

(1) EP03: Alert & Notification System Reliability for the period October 1, 2018, through September 30, 2019.

IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) (2 Samples)

(1) Unit 1, January 1, 2019 through December 31, 2019
(2) Unit 2, January 1, 2019 through December 31, 2019 IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)

(2 Samples)

(1) Unit 1, January 1, 2019 through December 31, 2019
(2) Unit 2, January 1, 2019 through December 31, 2019

IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03) (2 Samples)

(1) Unit 1, January 1, 2019 through December 31, 2019
(2) Unit 2, January 1, 2019 through December 31, 2019

OR01: Occupational Exposure Control Effectiveness Sample (IP Section 02.15) (1 Sample)

(1) October 2019 to January 2020 PR01: Radiological Effluent Technical Specifications/Offsite Dose Calculation Manual Radiological Effluent Occurrences (RETS/ODCM) Radiological Effluent Occurrences Sample (IP Section 02.16) (1 Sample)
(1) October 2019 to December 2019

71152 - Problem Identification and Resolution

Annual Follow-up of Selected Issues (IP Section 02.03) (1 Sample)

The inspectors reviewed the licensees implementation of its corrective action program related to the following issues:

(1) AR 2345359, Violation of Work Hours Controls Process

71153 - Followup of Events and Notices of Enforcement Discretion Event Report (IP Section 03.02)

The inspectors evaluated the following licensee event reports (LERs):

(1) LER 05000335/2019-003-00, "Inoperability of Emergency Diesel Generator due to Cracked Crankshaft," (Agency Document and Management System (ADAMS)

Accession No.: ML19301D252). The NRC exercised enforcement discretion in Enforcement Action (EA)-20-027, in accordance with Section 3.10 of the Enforcement Policy because the violation was not associated with a licensee performance deficiency. Specifically, the violation was not attributable to an equipment failure that was avoidable by reasonable license quality assurance measures or management controls and therefore inspectors concluded that there was no performance deficiency associated with inoperability of the 1B EDG. The 1B EDG 1B2 crank shaft was replaced and the EDG was returned to an operable condition. This enforcement discretion will not be considered in the assessment process or the NRCs Action Matrix. This LER is closed.

INSPECTION RESULTS

Enforcement Enforcement Action EA-20-027: Enforcement Discretion 71153 Discretion Granted for LER 2019-003-000, Inoperability of Emergency Diesel Generator due to Cracked Crankshaft

Description:

On July 15, 2019, during routine monthly surveillance testing of the 1B emergency diesel generator (EDG), the EDG tripped due to high jacket water temperature.

The licensees investigation determined that the 1B2 engine crankshaft tapered end that connects to the radiator fan idler pulley shaft had sheared. The crankshaft tapered end can also be referred as a power take off (PTO) for the EDG engine. The 1B2 engine crankshaft was replaced and the EDG was returned to service on July 28, 2019. An independent forensic investigation determined that the crankshaft tapered end failure was caused by fatigue. The licensee reviewed historical records and found that in 1988 and again in 1991, the 1B2 fan idler pulley shaft that was connected to the crank shaft tapered end sheared due to fatigue failure induced by high vibrations. The licensee determined that it was likely during the 1988 to 1991 timeframe that the initial flaw developed in the crankshaft tapered end, however an independent forensic investigation was unable to conclusively estimate the timeline for the fracture propagation. Corrective actions implemented after the 1991 event included an engineering change to replace the torsional isolator coupling with a less stiff torsional isolator and stiffening of the base supports. The 1B EDG has operated with nominal vibration since implementation of those corrective actions.

The inspectors reviewed the LER, the independent forensic report, the licensee's failure investigation worksheet (AR 2321166), and the corrective actions associated with the 1988 and 1991 events to determine whether a performance deficiency was associated with the 2019 EDG failure. Although the 2019 LER discussed that, individual fracture origins are consistent with cracks induced by a bending load, most likely due to misalignment of the PTO shaft sometime during the history of the machine, the inspectors determined that there was insufficient evidence to state that this was a performance deficiency because;

(1) the licensee determined that the fan idler pulley shaft connected to the crank shaft tapered end was properly aligned at the time of the failure; and
(2) the independent forensic review did not conclusively support that the failure was a result of misalignment.

The inspectors concluded that this failure was not reasonably foreseeable and preventable by the licensee and subsequently, the Technical Specification (TS) violation was not a result of a clearly defined and identifiable performance deficiency, therefore this event will be appropriately addressed using traditional enforcement under the NRCs Enforcement Policy.

The LER documented that the latent failure of the 1B EDG existed for 28 days since the last successful surveillance of the EDG on June 17, 2019 which exceeded the TS 3.8.1.1, Action b, allowed outage time of 14 days.

The NRC Enforcement Policy, Section 6, Violation Examples stated, in part, that when an enforcement case scenario very nearly achieves all or some of the criteria set forth in an example, the case should be considered to be at the severity level of that example. For this event, the TS violation closely matched example 6.1.c.1 for a Severity Level (SL) III violation for the licensees failure to shut down the reactor or follow actions required by TS when a Limited Condition for Operation was not met (i.e. noncompliance with 10 CFR 50.36(c)(2)(i)).

The NRC did not complete a detailed risk assessment of this event. This decision was based on not having an underlining performance deficiency associated with the event, the ability to use enforcement discretion for violations without a performance deficiency and having an applicable SL III violation example in the NRC Enforcement Policy. The SL III example approximately bounded the upper severity level of the event. Not performing a detailed risk assessment was considered an efficient use of NRC resources. The NRC Enforcement Policy allows for the use of risk information to alter the severity levels of traditional violations, which was not required for this specific traditional enforcement case.

Corrective Actions: The 1B2 engine crankshaft was replaced. The 1B1 engine crankshaft tapered end was inspected and no deficiencies were found. The 1B EDG was returned to service on July 28, 2019. Additional extent of condition inspections were being assessed for other potentially affected EDG engines.

Corrective Action References: ARs 2321166 and 2332786

Enforcement:

Violation: TS 3.8.1, AC Sources - Operating, required, in part, that two diesel generators capable of supplying the onsite Class 1E power shall be operable in Modes 1, 2, 3, and 4.

TS 3.8.1, Action b, required, in part, that if one diesel generator is inoperable, then restore the diesel generator to operable status within 14 days or be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in hot shutdown within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />.

Contrary to the above, from June 17 through July 15, 2019, the 1B EDG was determined to be inoperable due to a crank shaft tapered end crack that would have resulted in the failure of the EDG upon the next demanded start of the EDG. The EDG was not returned to operable status within 14 days and was not placed in hot standby within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />.

Basis for Discretion: The NRC exercised enforcement discretion in Enforcement Action (EA)-

20-027, in accordance with Section 3.10 of the Enforcement Policy, (ADAMS Accession No.:

ML19352E921), because the violation was not associated with a licensee performance deficiency. Specifically, the violation was not attributable to an equipment failure that was avoidable by reasonable licensee quality assurance measures or management controls.

Therefore, inspectors concluded that there was no performance deficiency associated with the 1B EDG crank shaft tapered end failure. The 1B EDG 1B2 crank shaft was replaced and the EDG was returned to an operable condition. This enforcement discretion will not be considered in the assessment process or the NRCs Action Matrix.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

  • On April 13, 2020, the resident inspectors presented the integrated inspection results to Mr. Dan DeBoer, Site Director, and other members of the licensee staff.
  • On January 16, 2020, the inspectors presented the Emergency Preparedness Exercise inspection results to Mr. Dan DeBoer, Site Director, and other members of the licensee staff.
  • On January 30, 2020, the inspectors presented the Radiation Protection inspection results to Mr. Dan DeBoer, Site Director, and other members of the licensee staff.
  • On February 28, 2020, the inspectors presented the Inservice inspection results to Mr. Dan DeBoer, Site Director, and other members of the licensee staff.
  • On February 28, 2020, the inspectors presented the Radiation Protection inspection results to Mr. Dan DeBoer, Site Director, and other members of the licensee staff.

DOCUMENTS REVIEWED

Inspection Type Designation Description or Title Revision or

Procedure Date

71111.08P Corrective Action A/R 02343401 2A, Intake Cooling Water (ICW), Header Leak 2/3/20

Documents AR-02347269 Light Rust , Chipped and flaking Paint on Containment 3/5/20

Liner

Corrective Action AR-02346431 Corroded Deck Plate in Front of Unit 2 "A" Train Eaton 2/27/20

Documents Strainers

Resulting from CR-02346139 VPT-1103 Boric Acid Leak at Bonnet Nut 2/26/20

Inspection

Drawings 10162D14 ASME Class 1, Swing Check Valve Rev.1

2998-G-493 FP&L ST Lucie Plant, Unit-2, Reactor Building, Rev. 6

Containment Vessel Support, Plan and Sections, Grid K-

2, Joint filler

2998-G-496 Sht. 1 Reactor Bldg Interior Base Concrete Sections Rev. 7

2998-G-496-501 FP&L St. Lucie Plant, Unit-2, Reactor Bldg. Interior Base Rev. 7

Concrete Sections - Masonry, Sht. 1

Engineering EC 294340 U2 Intake Cooling Water (ICW) 2A Elbow Replacement Rev. 0

Changes EC 294347 U2-Intake Cooling Water (ICW), Piping Replacement 2B Rev. 1

and 2C, ICW Pump Discharge Piping to Cross-tie

EC-294143 Unit-2, Replacement of V3526 and V3527 Rev. 2

Engineering AIM 180110340-2Q- Condition Monitoring and Operational Assessment for the Rev. 1

Evaluations 3 St. Lucie Unit 2 Steam Generators Based on Eddy

Current Examination End of Cycle 23, September 2018

SIA, File No.: St. Lucie, Code Case N-513-4 Evaluation of Leaking ICW Rev. 0

2000146.301 Elbow

Miscellaneous Welder ID Number Welder Qualification for WPS-103 1/23/20

TXF013B, N366750

LMT-SOP-46 Personnel Certification Statements:

T. Coburn,
M. Landis, 1/14/20
D. Popp, R. Leidenfrost

PVE-1 Certification of Visual Acuity and Color Vision; T. Coburn 8/16/19

PVE-1 Certification of Visual Acuity and Color Vision ; M. Landis 1/24/20

PVE-1 Certification of Visual Acuity and Color Vision, D. Popp 6/13/19

PVE-1 Certification of Visual Acuity and Color Vision; R. 9/14/19

Leidenfrost

Inspection Type Designation Description or Title Revision or

Procedure Date

SPEC-C-034 Protective Coatings for Service Level I Applications Inside Rev. 9

the Reactor Containment Building

SS-COC-SL-20-001 Certificate of Conformance Valves, SN SC1912-0001, 1/30/20

SC1912-0002; and Valve Disc's SC1912-0003, SC1912-

0004

St Lucie Operator, Teleconference with NRR Verbal approval of FPL 2/10/20

Narrative Log Request, per PSL Licensing Letter L-2020-025 Dated Feb

7, 2020

St. Lucie Plant Unit System Leakage Test of Reactor Pressure Vessel Bottom 5/31/15

No. 2, Relief Head, and Class 1 and 2 Piping in Covered Trenches

Request No. 4,

Revision 1

STD-W-002 General Welding Standard for Safety Related Piping Rev. 14

Weld Traveler Single Weld Traveler , Weld 02000, Work Order 2/10/20

2000-021505 40585622-07

Welder ID Number Welder Qualification for WPS-103 2/20/20

N368391

NDE Reports PSL2-UT-20-006 UT Examination, RC-141-FW-2003, Elbow to Pipe, 3/3/20

Summary No SL2-069750

PSL2-UT-20-009 UT Examination, RC-141-FW-902, Pipe to Elbow, 2/27/20

Summary No SL2-069900

PSL2-UT-20-010 UT Examination, SI-191-FW-1, Valve V3526 to Pipe, 2/27/20

Summary No SL2-081900

PSL2-UT-20-011 UT Examination, SI-191-FW-2001, Valve V3527 to Pipe, 2/27/20

Summary No SL2-080750

PSL2-UT-20-012 UT Examination, SI-191-FW-2000, Pipe to Valve V3527, 2/27/20

Summary No SL2-080850

PSL2-UT-20-013 UT Examination, SI-181-FW-14, Pipe to Valve, V-3526 2/27/20

Weld , Summary No. SL2-415000

PSL2-VT-20-057 Visual examination of IWE Surfaces, Summary No. SL2- 3/5/20

2171

PSL2-VT-20-068 Visual Examination of Moisture Barrier, Annulus Side, 0- 3/5/20

Degrees

Weld No. 02000 PT Final on ID and OD of Tee to Flange Weld, WO 2/17/20

Inspection Type Designation Description or Title Revision or

Procedure Date

40585622-07

Weld Traveler ID Radiographic Inspection Report, Part No. SI-191/Joint 2/21/20

2001-009579 02000

WO 40628084-02 Reactor Bottom Head Area, VT-2 Inspection, IAW NDE- 3/2/20

4.2

Procedures ER-AP-116-1000 NEXTera, Nuclear Fleet Administrative Procedure, Boric Rev. 4

Acid Corrosion Control Program

NDE 5.4 NDE Manual Examination Procedure, Ultrasonic Rev. 23

Examination of Austenitic Piping Welds

WPS-103 Welding Procedure Specification Rev. 5

Self- AR 2262124-01 Self Level 1 Core Business Assessment Report, Fleet 6/20/18

Assessments Assessment Assessment of St Lucie BACC Program

AR 2341291 Self NRC Plant St Lucie Unit 2, Reactor Vessel Head & Steam 1/24/20

Assessment Generator Examinations

Work Orders WO 40628038-04 SL2-25 Annulus Emergent Coatings Walk-down, As- Rev. 4

Found Coatings Report

WO 40708565-01 U2: RCB - Light Rust, Chipped/Flaking Paint on 3/6/20

Containment Liner

71124.01 Corrective Action AR 02334690 Job Coverage Survey Not Documented 11/07/2019

Documents AR 02340770 Compensatory Sample Action Exceeded 01/10/2020

AR 02345766 Worker Contamination Event 02/24/2020

Corrective Action AR 02346475 ED Dose Rate Setpoints for Outage Activities Are High 02/28/2020

Documents

Resulting from

Inspection

Miscellaneous Air Sample Data ICI Cold End Cutting 02/23/2020

Summary Sheet,

Sample No. 202-

0185

Air Sample Data U2 RWT Open Manway 02/25/2020

Summary Sheet,

Sample No. 202-

28

Air Sample Data U2 RCB 62' A-Side 02/21/2020

Inspection Type Designation Description or Title Revision or

Procedure Date

Summary Sheet,

Sample No. 202-112

Procedures HPP-30 Personnel Monitoring Rev. 62

HPP-4 Scheduling of Health Physics Activities Rev 62

NISP-RP-005 Access Controls for High Radiation Areas Rev. 1

RP-SL-103-2006 Radiation Protection Outage Activities Rev. 13

Radiation PSL-M-20180412-7 U1 RAB Boric Acid Pre-Concentrator Filters 04/12/2018

Surveys PSL-M-20200221-11 U2 RCB Upper Reactor Cavity 02/21/2020

PSL-M-20200225-13 U2 ICI Removal 02/24/2020

PSL-M-20200225-36 U2 Reactor Water Storage Tank 02/25/2020

PSL-M-20200226-19 U2 RCB Top of Pressurizer 02/26/2020

Self- AR - L2A 2334740 St. Lucie SL1-29 Radiation Worker Practices and ALARA 11/01/2019

Assessments Review

71124.06 Miscellaneous Attachment 4, Sampling Unit 1 Eberline Skid, CY-SL-104- 01/28/2020

1011, Unit 1 Gaseous Effluent Grab Sample, Rev. No. 10

2, Sampling Unit 1 Mirion Fuel Building Vent 01/28/2020

Sample Skid, CY-SL-104-1011, Unit 1 Gaseous Effluent

Grab Sample, Rev. No. 10

Procedures C-200 Offsite Dose Calculation Manual (ODCM) Current Rev.

No. 50

CY-SL-102-0104, Processing Aerated Liquid Wastes Rev. No. 12

Processing Aerated

Liquid Wastes, Rev.

No. 12

CY-SL-104-0112 Determination of Process Radiation Monitor Setpoints Rev. No. 10

CY-SL-104-1010 Sampling and Analysis of Unit 1 Containment Atmosphere Rev. No. 6

Using Local Grab Sample

CY-SL-104-1011 Unit 1 Gaseous Effluent Grab Sample Rev. No. 10

71124.07 Calibration Serial #8907728 REMP Location H-34 Gas Meter Calibration 11/22/2019

Records Serial #8907729 REMP Location H-33 Gas Meter Calibration 11/22/2019

Serial #8907736 REMP Location H-14 Gas Meter Calibration 12/02/2019

Work Order Calibration of Meteorological Tower 12/04/2019

40646042

Corrective Action AR#02262569 Air Sampler PUMP Failure at REMP Location H14 01/23/2018

Inspection Type Designation Description or Title Revision or

Procedure Date

Documents AR#02262572 TLD Missing at PSL REMP Program Monitoring Location 04/15/2018

WSW-10

AR#02275046 Review of the PSL REMP report for Quarter 2 05/01/2018

Miscellaneous Joint Frequency Distributions for St Lucie Upper 10/01/2019

Meteorological Tower, 1st, 2nd and 3rd Quarters of 2019

2017 AREOR Annual Radiological Environmental Operating Report for 04/19/2018

Calendar Year 2017

2018 AREOR Annual Radiological Environmental Operating Report for 04/11/2019

Calendar Year 2018

Procedures ADM-02.04 St. Lucie Ground Water Protection Program Revision 6

C-200 Offsite Dose Calculation Manual Revision 53

CY-SL-100-0002, Chemistry Department Groundwater Protection Program Revision 5

CHEMISTRY

DEPARTMENT

GROUNDWATER

PROTECTION

PROGRAM, Rev 5

QP-A Radiological Environmental Monitoring Program Revision 6

Self- AR #: 02189420 STATE OF FLORIDA BRC REMP PROGRAM SOUTH 07/07/2018

Assessments REGION BIENNIAL ASSESSMENT

Audit Report # PSL St Lucie Nuclear Assurance Audit of Chemistry, Effluents 12/31/2018

18-007 and Environmental Monitoring

71124.08 Calculations 2018 St Lucie DTS Waste Water SKID Composite 08/22/2018

10CFR61 Analysis

2019 St. Lucie Dry Active Waste 10CFR61 Analysis 05/28/2019

Engineering EnergySolutions Cask Book for Model 14/210 & 14-215H Revision 20

Evaluations Cask [Including Engineering Reports ER-99-011

Conformance of EnergySolutions 14-215H Cask with

Specifications for DOT 7A, Type A Packagings, Rev. 4,

Inspection Type Designation Description or Title Revision or

Procedure Date

and ER-99-028 Conformance of EnergySolutions 14-215H

Cask with Specifications for Industrial Packaging Type 1

and Type 2, Rev. 5]

Miscellaneous St. Lucie Site Map of Radiologically Controlled Areas and undated

Radioactive Material Areas inside the St. Lucie Protected

Area Boundary

St. Lucie Site Map of Category 2 radioactive material undated

locations inside the St. Lucie Protected area Boundary

Training/Qualification Radioactive Shipping Training for Qualified Shippers various

Certificates

Procedures St Lucie Plant Process Control Program Revision

Administrative 28C

Procedure 0520025

St Lucie Plant Health Classification of Radioactive Waste Material for Land Revision 16

Physics Procedure Disposal

HP-47

Radiation PSL-M-20150402-7 1A2 RCP Impeller in Cask 04/02/2015

Surveys PSL-M-20190108-5 Shipping Survey ESUU300583 01/08/2019

PSL-M-20190108-7 Shipping Survey ESUU300461, 01/08/2019

PSL-M-20200131-5 Low Level Radwaste Building 01/31/2020

PSL-M-20200212-9 1-HPS-407 Outgoing DAW Sealands20-016 02/12/2020

Work Orders 40619950-01 Level Indication for Unit 1 SRT (Spent Resin Tank) Revision 0

40619950-02 Level Indication for Unit 2 SRT (Spent Resin Tank) Revision 0

71151 Miscellaneous Gas Permit Post- Unit 2 Plant Vent 12/31/2019

Release Data,

Permit Number: G-

19-461-C

Gas Permit Post- Unit 2 Fuel Handling Building 12/31/2019

Release Data,

Permit Number: G-

19-462-C

PID 112914 Exposure Investigation Report SRD Rate Alarm (AR 11/05/2019

[Individuals Plant 02334580)

Identification

Inspection Type Designation Description or Title Revision or

Procedure Date

Number]

Unit 1 Liquid A Waste Monitor 12/13/2019

Release Permit

Number: L-19-109-B

Procedures ADM-25.02 NRC Performance Indicators Rev. No. 39

71153 Corrective Action NCR 1-163 1B1 EDG Idler Pulley Shaft Found Sheared 10/21/1991

Documents PWO 3282 1988 Event attached to NCR 1-163 1988

Miscellaneous 19-0149-TR-001 Imperia Engineering Partners Report, 1B Diesel Shaft Rev. 0,

Forensic Investigation August 2019

26