IR 05000369/2019002
| ML19213A224 | |
| Person / Time | |
|---|---|
| Site: | McGuire, Mcguire  |
| Issue date: | 08/01/2019 |
| From: | Frank Ehrhardt NRC/RGN-II, Division Reactor Projects II |
| To: | Teresa Ray Duke Energy Carolinas |
| Reeder D | |
| References | |
| IR 2019002 | |
| Download: ML19213A224 (25) | |
Text
August 1, 2019
SUBJECT:
MCGUIRE NUCLEAR STATION - INTEGRATED INSPECTION REPORT 05000369/2019002 AND 05000370/2019002
Dear Mr. Ray:
On June 30, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at McGuire Nuclear Station. On July 9, 2019, the NRC inspectors discussed the results of this inspection with Mr. E. Pigott and other members of your staff. The results of this inspection are documented in the enclosed report.
Two findings of very low safety significance (Green) are documented in this report. Both of these findings involved violations of NRC requirements. We are treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2.a of the Enforcement Policy.
If you contest the violations or significance or severity of the violations documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region II; the Director, Office of Enforcement; and the NRC Resident Inspector at McGuire.
If you disagree with a 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 U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region II; and the NRC Resident Inspector at McGuire. 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 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA/
Frank J. Ehrhardt, Chief Reactor Projects Branch 1 Division of Reactor Projects
Docket Nos. 05000369 and 05000370 License Nos. NPF-9 and NPF-17
Enclosure:
As stated
Inspection Report
Docket Numbers:
05000369 and 05000370
License Numbers:
Report Numbers:
05000369/2019002 and 05000370/2019002
Enterprise Identifier: I-2019-002-0021
Licensee:
Duke Energy Carolinas, LLC
Facility:
McGuire Nuclear Station
Location:
Huntersville, NC 28078
Inspection Dates:
April 01, 2019 to June 30, 2019
Inspectors:
G. Hutto, Senior Resident Inspector
R. Cureton, Resident Inspector
A. Butcavage, Reactor Inspector
B. Collins, Reactor Inspector
C. Dykes, Health Physicist
M. Magyar, Reactor Inspector
M. Toth, Project Engineer
Approved By:
Frank J. Ehrhardt, Chief
Reactor Projects Branch 1
Division of Reactor Projects
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at McGuire Nuclear Station 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. Findings and violations being considered in the NRCs assessment are summarized in the table below.
List of Findings and Violations
McGuire Loss of Inventory in Mode 5 Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events Green NCV 05000369/2019002-01 Open/Closed
[H.12] - Avoid Complacency 71111.20
A self-revealed Green finding and associated NCV of Technical Specification (TS) 5.4.1,
Procedures, was identified when the licensee failed to adequately implement the procedure requirements for installing a test gauge tubing for emergency core cooling system (ECCS)testing. Specifically, the licensee installed the incorrect tubing on a test connection which resulted in the loss of approximately 300 gallons of reactor coolant system (RCS) inventory while in Mode 5.
Unit 1 Over Temperature/Delta Temperature (OT/DT) Trip Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events Green NCV 05000369/2019002-02 Open/Closed
[H.11] -
Challenge the Unknown 71153 A self-revealed Green finding and associated NCV of TS 5.4.1 Procedures, was identified when the licensee failed to adequately implement procedure OP/1/A/6100/003, Controlling Procedure for Unit Operation,
4.6, Operation of Pressurizer Heaters, resulting in a Unit 1 reactor trip.
Additional Tracking Items
None.
PLANT STATUS
Unit 1 began the inspection period shutdown for a scheduled refueling outage. The unit was placed on line April 16, 2019, and power was increased to 46 percent rated thermal power (RTP) on April 17, 2019, when the 1B main feedwater pump was damaged while placing it in service. Unit 1 was maintained at 46 to 52 percent RTP while repairs to the pump were attempted. On April 25, 2019, power was reduced to approximately 13 percent RTP to successfully complete the 1B main feedwater pump repairs and on May 2, 2019, Unit 1 achieved 100 percent RTP. On May 3, 2019, Unit 1 experienced a reactor trip due to operator error. Following the trip investigation, Unit 1 was restarted on May 4, 2019, and on May 7, 2019, returned to 100 percent RTP for the remainder of the inspection period.
Unit 2 operated at or near 100 percent RTP for the entire 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.
REACTOR SAFETY
71111.01 - Adverse Weather Protection
Summer Readiness Sample (IP Section 03.01) (1 Sample)
The inspectors evaluated summer readiness of offsite and alternate alternating current (AC) power systems.
Seasonal Extreme Weather Sample (IP Section 03.02) (1 Sample)
The inspectors evaluated readiness for seasonal extreme weather conditions prior to the onset of seasonal hot temperatures for the following systems:
- (1) Unit 1 diesel generators
- (2) Control room chillers
Impending Severe Weather Sample (IP Section 03.03) (1 Sample)
The inspectors evaluated readiness for impending adverse weather conditions for a severe thunderstorm warning on April 8, 2019.
71111.04 - Equipment Alignment
Partial Walkdown (IP Section 03.01) (3 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
(1) "B" control room chiller on April 3, 2019
- (2) 1A diesel generator on May 14, 2019
- (3) 2B safety injection system on May 22, 2019
71111.04S - Equipment Alignment
Complete Walkdown (IP Section 03.02) (1 Sample)
The inspectors evaluated system configurations during a complete walkdown of the 2B train auxiliary feedwater system on June 27, 2019.
71111.05Q - Fire Protection
Quarterly Inspection (IP Section 03.01) (5 Samples)
The inspectors evaluated fire protection program implementation in the following selected areas:
- (1) Unit 1 spent fuel pool on April 25, 2019
- (2) Unit 2 spent fuel pool cooling pump room on April 25, 2019
- (3) Unit 1 767' elevation electrical penetration room on June 18, 2019
- (4) 1A diesel generator room on June 18, 2019
- (5) 1B diesel generator room on June 18, 2019
71111.06 - Flood Protection Measures
Internal Flooding (IP Section 02.02a) (1 Sample)
The inspectors evaluated internal flooding mitigation protections in the:
- (1) Unit 1 and 2 auxiliary building 695' elevation on June 17, 2019
71111.07A - Heat Sink Performance
Annual Review (IP Section 02.01) (1 Sample)
The inspectors evaluated readiness and performance of:
- (1) KC-1A component cooling water heat exchanger
===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 are appropriately monitored for degradation and that repairs and replacements were appropriately fabricated, examined, and accepted by reviewing the following activities from April 1, 2019 to June 24, 2019:
03.01.a - Nondestructive Examination and Welding Activities
- (1) Containment ASME,Section XI IWE examinations, (NRC Walk-down and Document Review)
- (2) Visual examination (VT-3), reactor vessel supports, ASME Class 1, (Reviewed)
- (3) Control rod guide tube assemblies, guide card visual inspections guide tube locations D14, F02, J13, M08 (Observed)
- (4) Liquid penetrant examination (PT), ASME Class 2, nozzle to reinforcing pads, component ID's, 1ACSHX-A-Inlet, 1ACSHX-B-Outlet (Reviewed)
- (5) Work Order 2020502, Check Valve 1NI-60 Replacement Welds (Reviewed)
- (6) McGuire Unit-1, Steam Generator Inspection Skip Year Basis (Reviewed)
03.01.b - Pressurized-Water Reactor Vessel Upper Head Penetration Examination Activities
- (1) Reactor vessel closure head, control rod drive penetrations No's. 13, 64 and 65, ASME Class 1, ultrasonic examination (Observed)
03.01.c - Pressurized-Water Reactor Boric Acid Corrosion Control Activities
- (1) Action Reports 02219841, 02224655, 02227433 (Reviewed)
- (2) NRC containment boric acid walk-down Inspection
- (3) NRC reactor vessel closure head, ASME Class 1, upper surface walk-down inspection
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance
Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01) (1 Sample)
The inspectors observed and evaluated licensed operator performance in the Control Room during Unit 1 start-up activities on April 16, 2019.
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
The inspectors observed and evaluated active simulator exam ASE-10 which involved a rod ejection requiring safety injection, and a subsequent loss of off-site power on June 12, 2019.
71111.12 - Maintenance Effectiveness
Routine Maintenance Effectiveness Inspection (IP Section 02.01) (2 Samples)
The inspectors evaluated the effectiveness of routine maintenance activities associated with the following equipment and/or safety significant functions:
- (1) Nuclear condition report (NCR) 2256190, 2EDGB negative side ground on 2B diesel generator control power breaker
71111.13 - Maintenance Risk Assessments and Emergent Work Control
Risk Assessment and Management (IP Section 03.01) (5 Samples)
The inspectors evaluated the risk assessments for the following planned and emergent work activities:
- (1) Unit 1 outage protection plan for "B" train maintenance on April 3, 2019
- (2) Unit 1 feedwater protection plan for the 1B main feedwater pump turbine rotor replacement on April 17, 2019
- (3) Unit 1 spent fuel pool cooling equipment protection plan following core off-load on April 30, 2019
- (4) Unit 1 and 2 equipment protection plan for standby shutdown facility diesel generator maintenance on May 29, 2019.
- (5) Unit 2 equipment protection plan for turbine driven auxiliary feedwater pump maintenance on June 19, 2019
71111.15 - Operability Determinations and Functionality Assessments
Operability Determination or Functionality Assessment (IP Section 02.02) (6 Samples)
The inspectors evaluated the following operability determinations and functionality assessments:
- (2) NCR 2267180, KD piping wall thinning at hanger on 1A diesel generator, on April 23, 2019
- (3) NCR 2274520, 2B RN pump requires an oil change, on June 3, 2019
- (4) NCR 2276128, Westinghouse issued NSAL 19-1, update from NSAL 14-6, on June 10, 2019
- (5) NCR 2277158, 1B containment spray pump leak, on June 20, 2019
71111.19 - Post-Maintenance Testing
Post Maintenance Test (IP Section 03.01) (6 Samples)
The inspectors evaluated the following post maintenance tests:
- (1) PT/1/A/4204/002 B, "ND Train B Valve Stroke Timing - Quarterly," following valve 1ND-14B air line replacement, on April 10, 2019
- (2) PT/1/A/4350/002 A, "Diesel Generator 1A Operability Test," following outage maintenance, on April 10, 2019
- (3) PT/0/A/4150/028, "Initial Criticality and Zero Power Physics Testing," following core alterations, on April 15, 2019
- (4) PT/0/A/4200/002, "Standby Shutdown Facility Operability Test," following jacket water temperature switch replacement, on May 7, 2019
- (5) PT/2/A/4350/002 A, "Diesel Generator 2A Operability Test," following ventilation damper preventive maintenance, on May 21, 2019
- (6) PT/0/A/4200/002, "Standby Shutdown Facility Operability Test," following fuel line flex connection replacement, on May 30, 2019
71111.20 - Refueling and Other Outage Activities
Refueling/Other Outage (IP Section 03.01) (1 Sample)
- (1) The inspectors evaluated Unit 1 refueling outage activities from April 1, 2019 to April 16, 2019.
71111.22 - Surveillance Testing
The inspectors evaluated the following surveillance tests:
Containment Isolation Valve Testing (IP Section 03.01) (1 Sample)
- (1) PT/1/A/4200/001 C, "Isolation Valve Leak Rate Test, Enclosure 13.48 Test Sheet for Penetration M-390 (RV)," on April 9, 2019
Ice Condenser Testing (IP Section 03.01) (1 Sample)
- (1) PT/0/A/4200/032, "Periodic Inspection of Ice Condenser Lower Inlet Doors," on April 14, 2019
Inservice Testing (IP Section 03.01) (1 Sample)
- (1) PT/1/A/4206/001 A, "1A NI Pump Performance Test," on April 24, 2019
RCS Leakage Detection Testing (IP Section 03.01) (1 Sample)
- (1) PT/1/A/4150/001 B, "Reactor Coolant Leakage Calculation," on June 27, 2019
Routine (IP Section 03.01) (1 Sample)
- (1) PT/2/A/4350/002 B, "Diesel Generator 2B Operability Test," on May 8, 2019
71114.06 - Drill Evaluation
Select Emergency Preparedness (EP) Drills and/or Training for Observation (IP Section
03.01)
- (1) The inspectors evaluated the EP drill conducted on May 13, 2019. The drill involved a turbine trip/reactor trip, followed by large break reactor coolant system leak and subsequent increase in containment radiation levels.
RADIATION SAFETY
71124.01 - Radiological Hazard Assessment and Exposure Controls
During facility tours, the inspectors directly observed radiological postings, dosimetry placement, container labeling, and radiological surveys for areas established within the restricted area including the independent spent fuel storage installation.
Radiological Hazard Assessment (IP Section 02.01) (1 Sample)
The inspectors evaluated radiological hazards assessments and controls. The inspectors reviewed the following:
Radiological surveys
- (1) MNS-M-20190302-3, 750 Elevation Hallways, March 2, 2019
- (2) MNS-M-20190224-1, 750 Elevation Hallways, February 23, 2019
- (3) MNS-M-20190209-1, 733 Elevation Hallways, February 9, 2019
- (4) MNS-M-20190313-1, 733 Elevation Hallways, March 13, 2019
- (5) MNS-M-20190331-19, U1 Rx Head Inspection Stating area, March 31, 2019
- (6) MNS-M-20190401-6, U1 Rx Head Inspection Staging Area, April 1, 2019
Air sample survey records
- (1) Sample ID: MN19032900016 U1 U/C Head Work, March 28, 2019
- (2) Sample ID: MN19032900025 U1 UC Operating floor, March 28, 2019
- (3) Sample ID: MN19032900021 U1 UC cavity during cavity fill, March 28, 2019
- (4) Sample ID: MN19040100043 NI 60, April 1, 2019
Instructions to Workers (IP Section 02.02) (1 Sample)
The inspectors evaluated instructions to workers including labels, radiation work permits and electronic dosimeter alarm setpoints used to access high radiation areas. Some samples included the following:
Radiation work permits (RWP), including RWPs for airborne areas as available
- (1) RWP 1349 U1 Rx Head, Auxiliary Head Adapter Building (AHA), Inspections and Repairs
- (2) RWP 1840 U1 Outage Decon Team; Reactor Cavity, Cleanup and Decon (Shallow End
& Deep End)
- (3) RWP 1951 U1 Outage: Reactor Services Deep End Activities
Electronic alarming dosimeter alarms
- (1) ED #892860, Invalid dose rate alarm, 10/1/2018
- (2) No other unexpected alarms occurred during the period of this inspection Labeling of containers
- (1) Outside RCA for outage related containers
- (2) 760 elevation near truck bay
- (3) Radwaste storage
Contamination and Radioactive Material Control (IP Section 02.03) (1 Sample)
The inspectors evaluated licensee processes for monitoring and controlling contamination and radioactive material. The inspectors verified transactions nationally tracked sources had been reported and the following sealed sources are accounted for and are intact:
- (1) Source # 0303GY, assay date August 18,1991
- (2) Source # 68283, assay date October 27, 2014
- (3) Source # AJ-9164, assay date May 5, 2017
- (4) Source KR-2750, assay date August 18, 1991
Radiological Hazards Control and Work Coverage (IP Section 02.04) (1 Sample)
The inspectors evaluated in-plant radiological conditions during facility walkdowns and observation of radiological work activities. Inspectors observed the following work activities:
Risk significant radiological work activities
- (1) Initial entry under the head, Survey #MNS-M-20190329-12, March 29, 2019
- (2) EC412266-Cut out/replace 1N1-60
- (3) Inspection of AHA nozzle at 0 degrees and 90 degrees
- (4) Control Rod Guide Card Inspections
High Radiation Area and Very High Radiation Area Controls (IP Section 02.05) (1 Sample)
The inspectors evaluated risk-significant high radiation area and very high radiation area controls, including postings and physical controls.
Radiation Worker Performance and Radiation Protection Technician Proficiency (IP Section 02.06) (1 Sample)
The inspectors evaluated radiation worker awareness and performance and radiation protection technician proficiency.
OTHER ACTIVITIES - BASELINE
===71151 - Performance Indicator Verification
The inspectors verified licensee performance indicators submittals listed below:
MS05: Safety System Functional Failures (SSFFs) (IP Section 02.04)===
- (1) Unit 1 (April 1, 2018 - March 31, 2019)
- (2) Unit 2 (April 1, 2018 - March 31, 2019)
MS06: Emergency AC Power Systems (IP Section 02.05) (2 Samples)
- (1) Unit 1 (April 1, 2018 - March 31, 2019)
- (2) Unit 2 (April 1, 2018 - March 31, 2019)
MS07: High Pressure Injection Systems (IP Section 02.06) (2 Samples)
- (1) Unit 1 (April 1, 2018 - March 31, 2019)
- (2) Unit 2 (April 1, 2018 - March 31, 2019)
OR01: Occupational Exposure Control Effectiveness (IP Section 02.15) (1 Sample)
- (1) Unit 1 and 2 (October 1, 2018 - February 28, 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) NCR 2264663, Unit 1 AP-10 entry for reactor coolant system leakage.
Semiannual Trend Review (IP Section 02.02) (1 Sample)
The inspectors reviewed the licensees corrective action program for potential adverse trends in the area of human performance that might be indicative of a more significant safety issue.
71153 - Followup of Events and Notices of Enforcement Discretion Event Followup (IP Section 03.01)
The inspectors evaluated the Unit 1 reactor trip and licensees response on May 3,
OTHER ACTIVITIES
- TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL
71003 - Post-Approval Site Inspection for License Renewal Post-Approval Site Inspection for License Renewal
The inspectors observed and reviewed the implementation of the following license renewal activities (listed by aging management program) from April 1 - 5, 2019:
- (1) 18.2.6, Inservice Inspection Program
- (2) 18.2.10, Flow-Accelerated Corrosion Program a) 1C3 feedwater heater shell
- (3) 18.2.12, Galvanic Susceptibility Program a) two containment ventilation cooling water system valves (1RV-482, 1RV-485)
- (4) 18.2.21.1, Condenser Circulating Water System Internal Coating Inspection
- (5) 18.2.24, Selective Leaching Inspection Program a) fire protection system jockey pump 1A strainer b) fire protection system main fire pump A c) three fire protection system valves (1RF-11, 1RF-444, 1RF-446)
INSPECTION RESULTS
McGuire Loss of Inventory in Mode 5 Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events
Green NCV 05000369/2019002-01 Open/Closed
[H.12] - Avoid Complacency 71111.20
A self-revealed Green finding and associated NCV of TS 5.4.1, Procedures, was identified when the licensee failed to adequately implement the procedure requirements for installing a test gauge tubing for ECCS testing. Specifically, the licensee installed the incorrect tubing on a test connection which resulted in the loss of approximately 300 gallons of reactor coolant system (RCS) inventory while in Mode 5.
Description:
On March 25, 2019, Unit 1 entered abnormal procedure AP-10 Case 2, "RCS Leakage Less Than the Capacity of Both Charging Pumps," when charging flow became erratic and volume control tank level began to slowly decrease. The licensee determined that the cause of the leak was a failed instrument test line that had been installed on the "A" train charging line. The instrument test line was installed for ECCS testing that was scheduled for later that day. Operators isolated the leak and exited the AP. No other equipment was affected. The operators estimated that approximately 300 gallons of inventory was lost due to the leak. At the time, the unit was in Mode 5 with both trains of decay heat removal in service and pressurizer level was at approximately 50 inches. Procedure PT/1/A/4209/012A, 1A NV Pump Head Curve Performance Test, specified that Flukecal high pressure tubing or equivalent shall be used when installing the high and low pressure connections to the temporary flow test gauge. Contrary to this procedural requirement, operators used low pressure (150 psig rated) tubing for the low pressure connection. As a result, when seal injection to the reactor coolant pumps was secured as part of the outage plant condition sequence, the resulting pressure surge in the charging discharge line caused the low pressure tubing to fail.
Corrective Actions: Operations personnel identified and isolated the source of the leak. Coaching was provided to all individuals involved based on human performance behaviors exhibited. Lessons learned were communicated to all operations shifts.
Corrective Action References: NCR 2264663, Loss of reactor coolant system inventory due to incorrect use of low pressure test gauge tubing.
Performance Assessment:
Performance Deficiency: The licensees failure to adequately implement procedure PT/1/A/4209/012A, resulting in a loss of RCS inventory, was a violation of TS 5.4 and a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the human performance attribute of the initiating events cornerstone and adversely affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the loss of inventory in Mode 5, if left uncorrected, would challenge the shutdown cooling safety function.
Significance: The inspectors assessed the significance using IMC 0609, Appendix G, Shutdown Operations, dated May 9, 2014. The finding was determined to be of very low safety significance (GREEN) based on the screening criteria in Attachment 1, Exhibit 2.
Specifically, the loss of inventory would not result in the method of decay heat removal to fail if left unmitigated for a 24-hour period.
Cross-Cutting Aspect: The inspectors determined the finding had a cross cutting aspect of avoid complacency [H.12], in the human performance area, because the technicians did not adequately plan for the possibility of mistakes by implementing the appropriate error reduction tools.
Enforcement:
Violation: Technical Specification 5.4.1, Procedures, required that procedures shall be established, implemented and maintained covering the applicable procedures recommended in Regulatory Guide 1.33. Regulatory Guide 1.33, Appendix A, Section 8, Procedures for Control of Measuring and Test Equipment and for Surveillance Tests, Procedures, and Calibrations, required procedures for surveillance tests. Surveillance test procedure PT/1/A/4209/012A, 1A NV Pump Head Curve Performance Test, required the use of high pressure Flukecal tubing when installing the high and low pressure connections to the temporary flow test gauges specified for the test.
Contrary to the above, on March 25, 2019, the licensee failed to adequately implement surveillance procedure PT/1/A/4209/012A. Specifically, operators used low pressure (150 psig rated) tubing for the low pressure connection to the temporary flow test gauge for the charging pump head curve test. This resulted in the failure of the tubing and a loss of 300 gallons of RCS inventory.
Enforcement Action: This violation is being treated as an NCV, consistent with Section 2.3.2 of the Enforcement Policy.
Unit 1 Over Temperature/Delta Temperature (OT/DT) Trip Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events
Green NCV 05000369/2019002-02 Open/Closed
[H.11] -
Challenge the Unknown 71153 A self-revealed Green finding and associated NCV of TS 5.4.1 Procedures, was identified when the licensee failed to adequately implement procedure OP/1/A/6100/003, Controlling Procedure for Unit Operation, Enclosure 4.6, Operation of Pressurizer Heaters, resulting in a Unit 1 reactor trip.
Description:
On May 3, 2019, Unit 1 reactor tripped from 100 percent power due to a human performance error. Operators were performing OP/1/A/6100/003, Controlling Procedure for Unit Operation, Enclosure 4.6, Operation of Pressurizer Heaters, to place pressurizer heaters in their normal alignment following a recent refueling outage. The procedure directs the operators to adjust the pressurizer master controller in manual until the C pressurizer heaters began cycling and the pressurizer spray valves close. The operators mental model of the controller was that they needed to depress the up pushbutton arrow to increase pressure to achieve the desired result. In reality, the up arrow increased the input error to the controller, which tells the controller that pressure is too high. As the up arrow was depressed, the operators did not initially observe the expected result of the C heaters cycling, and at this point should have stopped to assess their actions. Instead, the operators continued depressing the up arrow until the pressurizer spray valves opened, resulting in a rapid decrease in reactor coolant system pressure. This pressure decrease caused the OT/DT set point in the reactor protection system to be exceeded and an automatic reactor trip actuated as designed. The operators manually closed the pressurizer spray valves to stop the pressure decrease, and performed the actions of procedure, E-0, Reactor trip/Safety Injection, to stabilize the plant in Mode 3. There were no complications involved with the reactor trip.
Corrective Actions:
- The operators involved were removed from standing watch
- Post-trip fitness-for-duty testing was performed
- Reactor trip investigation was performed
Corrective Action References: NCR 2271181, Unit 1 Reactor Trip
Performance Assessment:
Performance Deficiency: The failure to follow procedure OP/1/A/6100/003, Controlling Procedure for Unit Operation, Enclosure 4.6, Operation of Pressurizer Heaters, resulting in a Unit 1 reactor trip, was a violation of TS 5.4 and a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the human performance attribute of the initiating events cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the performance deficiency resulted in a Unit 1 reactor trip.
Significance: The inspectors assessed the significance of the finding using IMC 0609 Appendix A, The Significance Determination Process for Findings at Power, dated June 19, 2012. The finding was screened as Green because the reactor trip was uncomplicated and there was no loss of mitigating equipment used to transition the plant to a stable condition following the reactor trip.
Cross-Cutting Aspect: None The inspectors determined the finding had a cross cutting aspect of challenge the unknown [H.11] in the human performance area because the operators did not stop when faced with uncertain conditions. Specifically, the operators continued to depress the up arrow on the pressurizer master controller after they did not get the expected response initially.
Enforcement:
Violation: Technical Specification 5.4.1, Procedures, requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide (RG) 1.33, Revision 2, Appendix A, dated February 1978. Regulatory Guide 1.33 Appendix A, Section 2, General Plant Operating, Procedures, requires procedures for power operation. Licensee procedure OP/1/A/6100/003, Controlling Procedure for Unit Operation, is the plant procedure for power operation.
Contrary to the above, on May 3, 2019, the licensee failed to adequately implement procedure OP/1/A/6100/003, Controlling Procedure for Unit Operation, during alignment of pressurizer heaters. Specifically, the operators incorrectly manipulated the pressurizer master controller, which resulted in a reactor trip.
Enforcement Action: This violation is being treated as an NCV, consistent with Section 2.3.2 of the Enforcement Policy.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
- On July 9, 2019, the inspectors presented the integrated inspection results to Ed Pigott and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
71003
Drawings
3NC3021 Sheets
and 4a
Consolidated Safety Relief Valve (1RV-482)
Rev. 1
DS C93356
Crosby Pressure Relief Valve (1RV-485)
Rev. D1
MCFD-1604-
03.00
Flow Diagram of Containment Ventilation Cooling Water
System (RV)
Rev. 16
Miscellaneous
Lopez
Sonic Systems International, Inc. Vision Acuity Record
2/19/2019
UT-IIL (Lopez)
Sonic Systems International, Inc. Certificate of Qualification
2/21/2019
NDE Reports
5546
Metallurgy Report: RF Jockey Pump Strainer Inspection
January 23,
2017
5594
Metallurgy Report: A Main Fire Pump Selective Leaching
Inspection
November
27, 2018
5646A
Metallurgy Report: MNS 1 - Selective Leaching Inspection
of RF Valves
May 22,
2017
5646C
Metallurgy Report: MNS 1 - Selective Leaching Inspection
of 1RF-1165
August 6,
2018
Procedures
AD-EG-NGO-
0110
Conduct of the Nuclear Metallurgy Laboratory and Central
Receiving and Dedication Facility Dedication Laboratory
Rev. 3
MET-004
LEEB Hardness Testing Using the Equotip Hardness Tester
Rev. 2
MNS-LR-013
MNS License Renewal Flow-Accelerated Corrosion (FAC)
Program Aging Management Program Implementation Plan
Rev. 0
MNS-LR-041
Galvanic Susceptibility Inspection Implementation Plan
Rev. 1
MP/0/B/7700/103
Flow Accelerated Corrosion Component Inspection
Rev. 006
NDE-NE-ALL-
6401
Ultrasonic Thickness Measurement
Rev. 001
PT/0/B/4700/063
Periodic Inspection of Service Water Piping for Corrosion
Induced Thinning
Rev. 006
Work Orders
WO20161426 29
Perform Inspection on Flange Face of 1RV-485
04/01/19
WO20258551 01
PM-1CMHX0028-1C3 Feedwater Heater Shell UT
04/03/19
Calculations
DPC-1381.06-00-
0001
Catawba, McGuire & Oconee Degraded Grid Voltage
Setpoints for Real Time Contingency
Miscellaneous
Action register update summary reports for summer
readiness between April - June, 2019
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
CSD-EG-ALL-
2000.1
Nuclear Switchyard Interface Agreement
CSD-EG-ALL-
2000.2
Nuclear Switchyard Operating Guidelines
Procedures
PT/0/B/4700/039
Warm Weather Equipment Checkout
AD-WC-ALL-0230
Seasonal Readiness
Drawings
MCFD-2562-
03.00
Flow Diagram of Safety Injection System
MCFD-1618-
01.00
Flow Diagram of Control Area Chilled Water System
Procedures
OP/1/A/6350/002
Diesel Generator
Drawings
MCFD-2592-
01.00
Flow Diagram of Auxiliary Feedwater System (CA)
MCFD-2592-
01.01
Flow Diagram of Auxiliary Feedwater System (CA)
Procedures
OP/2/A/6250/002
4.8, Valve and Power Supply Checklist
71111.05Q Drawings
MFSD-022
Auxiliary Building 767 Level Electrical Penetration Room
AD-EG-ALL-1520
Transient Combustible Control
MFSD-005
Unit 1 1A Diesel Generator Room
MFSD-006
Unit 1 1B Diesel Generator Room
MFSD-021
Unit 2 Spent Fuel pool Cooling Pump Room
Procedures
MCC-1435.00-00-
0059
NFPA 805 - Appendix R Safe Shutdown Deterministic
Analysis
MCS-1465.00-00-
0008
Design Basis Specification for Fire Protection
MCS-1465.00-00-
22
Appendix R Safe Shutdown Analysis
Corrective Action
Documents
Resulting from
Inspection
NRC Identified Loose Grating (Free to Fall) on Platform
above PRT, Adjacent to Unit-1 In-core Room Entrance
4/2/2019
NRC identified Oil Stain on Containment Vessel Wall (ASME
IWE Surface) in Unit 1 Pipe Chase
4/2/2019
Drawings
108D843
Reactor Vessel Support Hardware Assembly
4/13/1972
MC-1042-05.00
Reactor Building Containment Vessel Base Liner Plate Test
Channel Layout
11/18/2015
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
MC-1414-04.20-
Piping Layout Plan, ND System, Reactor Building
Rev.12
MC-ISIC2-1042-
22
Reactor Building -Unit-1 Steel Containment Vessel In-
service Inspection Areas Plan of Base Liner Plate Inspection
Port Location References
2/1/2015
Engineering
Evaluations
1EOC26 Skipped
Inspection Cycle
McGuire Unit-1 Steam Generator 1EOC26 Skip Inspection
Outage Review
3/9/2019
Boric Acid Corrosion Evaluation
08/30/2018
Boric Acid Corrosion Evaluation
08/30/2018
Boric Acid Corrosion Evaluation
10/02/2018
Miscellaneous
- 9295066 -
000
McGuire Unit 1, RVCH Penetration Coverage Assessment
for Spring 2019 (1EOC26) Outage
2/20/2019
Form NIS-2A
Owners Certificate of Conformance, Repair Replacement
Plan WO 20240502
6/6/2019
Employee 18992
Certification Record, Method Visual, VT-1, 2 and 3, Limited
to Spring 2019 Guide Card Examinations at McGuire Station
2/11/2019
Employee ID
18992
Certification Record, Method Visual, VT-1, 2, 3
Expires
1/27/21
Employee ID
33915
Certification Record, Method Visual, VT-1, 2, 3
8/9/2020
Employee ID
40001
Certification Record, Method Visual, VT-1, 2,3
Expirees
7/10/2020
Employee ID
88547
Certification Record, Method Visual, VT-1, 2, 3
Expires
8/8/2020
Employee ID No.
15601
Certification Record, Method Visual, VT-1 and 3, Limited to
Spring 2019 Guide Card Examinations at McGuire Station
3/24/2019
NDE Reports
Observed On Site, Control Rod Guide Tube, Screen Shots
6/28/19
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Guide Tube
Locations D14,
FO2, J13, M08
of Results Summary for Limiting Locations, During In-
Progress Work, Site Observations
Doc. ID. 180-
296414-000
Reactor Vessel Closure Head Penetration Ultrasonic
Examination
5/24/2019
PT-19-002,
Summary No. M1-
2000
Liquid Penetrant Examination (PT) of Nozzle to Reinforcing
Pads/Channel, Component ID. 1ACSHX-A-Inlet
3/26/19
PT-19-002,
Summary No. M1-
2001
Liquid Penetrant Examination (PT) of Nozzle to Reinforcing
Pads/Channel, Component ID. 1ACSHX-B-Outlet
3/26/19
Report No. 40350 Liquid Penetrant Examination Report, ID No. NI1F636
4/9/19
Report No. 40350
Liquid Penetrant Examination Report, ID No. NI1F106
4/9/19
VT-17-100,
Summary No.
M1.B4.10.0001
Visual Examination for Boric Acid (VT-2), Reactor Pressure
Vessel Closure Head Outer Surface
10/2/17
VT-19-058,
Summary No. M1-
07568
Reactor Vessel "C" Hot Leg Support
3/27/2019
VT-19-061,
Summary No. M1-
07567
Reactor Vessel "B" Cold Leg Support
3/30/2019
VT-19-062,
Summary No. M1-
07569
Reactor Vessel "D" Cold Leg Support
3/30/2019
VT-19-063,
Summary No. M1-
07562
Reactor Vessel "A" Hot Leg Support
3/30/2019
Procedures
54-ISl-604-014
Automated Ultrasonic Examination of Open Tube Reactor
Pressure Vessel
Closure Head Penetrations
2/19/19
AD-EG-ALL-1604
NDE Level III Oversight of Complex Nondestructive
Examinations
9/20/2017
AD-EG-PWR-
Boric Acid Corrosion Control Program Implementation
Rev. 2
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
1611
MP/0/A/7700/080
Inspection Assessment and Cleanup of Boric Acid on Plant
Materials
Rev. 22
NDE-NE-ALL-
7101
Nuclear fleet NDE Special Process Procedure, VT-1 Visual
Examination
6/15/2017
NDE-NE-ALL-
201
Nuclear Fleet NDE Special Process Procedure, VT-2 Visual
Examination
9/14/2017
NDE-NE-ALL-
7302
Nuclear Fleet NDE Special Process Procedure, VT-3 Visual
Examination of Component Supports
6/15/2017
Self-Assessments AR #01985576,
Type SAST,
Assignment 03
General Office/Corporate, Acid Corrosion Control Program -
Implementation Procedure Effectiveness
7/27/2016
G-ENG-SA-15-01
General Corporate Office, Augmented In-service Inspection,
Incorporating McGuire Operating Experience at Oconee and
Robinson Sites
6/11/2015
Work Orders
VT-19-003
Visual Examination of Pipe Hanger Support or Restraint
(VT-3) Summary No. M1-07562, Reactor Vessel "A" Hot Leg
Support
3/30/2019
EC 412266, 1NI-60: REPLACE 10" CHECK VALVE
6/3/2019
71111.11Q Procedures
SOMP 01-07
Control Room Oversight
AD-OP-ALL-1000
Conduct of Operations
NSD 509
Site Standards in Support of Operational Focus
OMP 4.3
Use of Emergency and Abnormal Procedures and FLEX
Support Guidelines
Miscellaneous
Duke Equipment Reliability Maintenance Rule Database
Procedures
AD-EG-ALL-1204
Single Point Vulnerability Identification, Elimination and
Mitigation
AD-EG-ALL-1206
Equipment Reliability Classification
AD-EG-ALL-1209
System, Component, and Program Health Reports and
Notebooks
AD-EG-ALL-1210
AD-EG-ALL-1211
System Performance Monitoring and Trending
AD-OP-ALL-0201
Protected Equipment
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
NSD-213
Risk Management Process
NSD-415
Operational Risk Management (Modes 1-3) per 10 CFR 50.65(a)(4)
OMP 13-7
Operational Control of Protected Equipment
SOMP 02-02
Operations Roles in the Risk Management Process
AD-OP-ALL-0102
Operability Decision Making
AD-OP-ALL-0105
Operability Determinations and Functionality Assessment
AD-EG-ALL-1155
Post Modification Testing
IP/0/A/2001/004 H Removal and Installation of Station Circuit Breakers
MP/0/A/7300/007
Rotating Equipment Inspection and Vibration Measuring
NSD-408
Testing
PT/1/A/4350/002
A
Diesel Generator 1A Operability Test
PT/2/A/4208/001
B
2B NS Performance Test
PT/2/A/4350/002
A
Diesel Generator 2A Operability Test
OP/1/A/6100/003
Controlling Procedure for Unit Operation
PT/0/A/4150/028
Initial Criticality and Zero Power Physics Testing
PT/0/A/4150/047
1/M Monitoring During Startup
PT/1/A/4600/003F Containment Cleanliness and ECCS Operability Inspection
AD-EG-ALL-1202
Preventive Maintenance and Surveillance Testing
Administration
AD-EG-ALL-1720
In-service Testing (IST) Program Implementation
AD-WC-ALL-0250
Work Implementation and Completion
RP/0/A/5700/000
Classification of Emergency
RP/0/A/5700/002
Alert
RP/0/A/5700/003
Site Area Emergency
RP/0/A/5700/004
General Emergency
RP/0/A/5800/010
NRC Immediate Notification Requirements
RP/0/B/5700/029
Notification to Offsite Agencies from the Control Room
ALARA Plans
M1R26 RVCH meteorology, penetration volumetrics, & AHA
UT's
Revision 0
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
EC412266-Cut out/replace 1N1-60
Revision 0
Inspection of AHA nozzles at 0 degrees and 90 degrees
Revision 1
Corrective Action
Documents
237056
Miscellaneous
AD-RP-ALL-2019
TEDE-ALARA Evaluation Worksheet RWP 1298 Task 6
03/28/2019
AD-RP-ALL-2019
TEDE-ALARA Evaluation Worksheet RWP 1840 Task 4
03/31/19
Dose Rate Alarms Dose Rate Alarm table from 10/1/2018 to 2/11/2019
HP/0/B/1004/034
Radioactive Sources, Enclosure 5.2 Inventory and Leak Test December
2018
Confirmation
2019 Annual Inventory Reconciliation Confirmation
01/23/2019
Sample
MN19032900018
U1 U/C Head work I/S, RWP 1298
03/28/2019
Sample
MN19032900019
U1 U/C operating floor, RWP 1728
03/28/2019
Procedures
AD-RP-ALL-0005
Access Controls for High and Locked High Radiation Areas
Revision 0
RPMP 7-1
Radiological Key Control
Revision 015
Radiation
Surveys
HP/1/B/1006/045
- ISFSI* Radiation Protection Controls for Loading Spent
Fuel Assemblies Into NAC-Magnastor Dry Storage Casks
05/28/18 -
06/03/18
MNS-M-
20190323-32
U1-Rx Head area Initial Entry
03/23/2019
MNS-M-
20190331-19;
MNS-M-
20190401-6
U1 Rx Head Inspection Staging Area
03/31/2019;
04-01-2019
MNS-M-
20190401-17
Cut out of 1NI-60 Survey
03/37/2019
MNS-M-
20190401-30
Room 817 Mechanical Pen Room
04/01/2019
MNS-M-
20190402-B
1NI-60 Survey of Work Are Post Cut out
04/01/2019
Radiation Work
Permits (RWPs)
RWP #1349
U1 Rx Bldg:Emergent Work-Reactor Head Auxiliary Head
Adapter (AHA)
Revision 1
71151
Procedures
AD-LS-ALL-0004
NRC Performance Indicators and Monthly Operating Report
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
AD-PI-ALL-0100
Corrective Action Program
AD-LS-ALL-0006
Notification/Reportability Evaluation
AD-PI-ALL-0100
Corrective Action Program
AD-PI-ALL-0104
Prompt Investigation Response Team
AD-PI-ALL-0105
Effectiveness Reviews
PT/0/A/4700/045
Reactor Trip Investigation