IR 05000387/2010006

IR 05000387-10-006 - 05000388-10-006; on 01/11/2010 - 01/29/2010; Susquehanna Steam Electric Station, Units 1 and 2; Identification and Resolution of Problems, Four Findings Were Identified in the Areas of Problem Identification, Problem Ev

ML100740339
Person / Time
Site:	Susquehanna
Issue date:	03/15/2010
From:	Racquel Powell Division Reactor Projects I
To:	Rausch T Susquehanna
Powell R, RI/DRP/610-337-6967
References
IR-10-006
Download: ML100740339 (36)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION

REGION I

475 ALLENDALE ROAD KING OF PRUSSIA. PENNSYLVANIA 19406-1415 March 15, 2010 Mr. Timothy Senior Vice President and Chief Nuclear Officer PPL Susquehanna, LLC 769 Salem Boulevard Berwick, PA 18603-0467 SUBJECT: SUSQUEHANNA STEAM ELECTRIC STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000387/2010006 AND 05000388/2010006

Dear Mr. Rausch:

On January 29, 2010, the U. S. Nuclear Regulatory Commission (NRC) completed an inspection at your Susquehanna Steam Electric Station Units 1 and 2. The enclosed report documents the inspection results discussed on February 18, 2010, with you and other members of your staff.

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

The inspectors concluded that although PPL Susquehanna, LLC (PPL) had, in general, developed adequate program procedures for identifying, evaluating. and resolving problems.

there are programmatic weaknesses associated with the implementation of certain aspects of PPL's corrective action program. Specifically, weaknesses were observed in the effectiveness of corrective actions for identified deficiencies; the timeliness of corrective actions; the station's actions to resolve PPL's Quality Assurance-identified findings; and the effectiveness of PPL's trending program. Also of concern were PPL's actions to resolve certain NRC findings, NRC regulatory requirement violations. and risk significant equipment problems. Prior to the inspection. you and your staff identified problems with the implementation of your corrective action program. Corrective actions to address these problems were ongoing at the time of this inspection. Based on the nature of the problems noted during the inspection, the NRC will closely monitor the implementation and effectiveness of these corrective actions.

The report documents four NRC-identified findings of very low safety significance (Green). The findings were also determined to involve violations of NRC requirements. However, because of the very low safety significance and because they were entered into your corrective action program, the NRC is treating these findings as non-cited violations (NCVs) consistent with Section VI.A.1 of the NRC Enforcement Policy. If you contest any NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 0001; with copies to the Regional Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the Susquehanna Steam Electric Station. In addition, if you disagree with the characterization of any finding in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region I and the NRC Resident Inspector at the Susquehanna Steam Electric Station. The information you provide will be considered in accordance with Inspection Manual Chapter 0305,*Operating Reactor Assessment Program."

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for publlc inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html{the Public Electronic Reading Room) .

.

Sincerely,

~/~

Raymond J. Powell, Chief Technical Support & Assessment Branch Division of Reactor Projects Docket Nos. 50-387; 50-388 License Nos. NPF-14, NPF-22

Enclosures:

Inspection Report 05000387/2010006 and 05000388/2010006 w/Attachment: Supplemental Information

REGION I==

Docket No: 50-387,50-388 License No: NPF-14, NPF-22 Report No: 05000387/2010006 and 05000388/2010006 Licensee: PPL Susquehanna, LLC Facility: Susquehanna Steam Electric Station, Units 1 and 2 Location: Berwick, Pennsylvania Dates: January 11, 2010 through January 29, 2010 Team Leader: E. DiPaolo, Team Leader, Senior Resident Inspector, DRP Inspectors: P. Finney, Senior Resident Inspector,DRP A. Rosebrook, Senior Project Engineer. DRP J. Hawkins, Project Engineer, DRP Approved by: Raymond J. Powell, Chief Technical Support & Assessment Branch Division of Reactor Projects Enclosure

SUMMARY OF FINDINGS

IR 05000387/2010006,05000388/2010006,01/11/2010 - 01/29/2010; Susquehanna Steam

Electric Station, Units 1 and 2; Identification and Resolution of Problems, four findings were identified in the areas of Problem Identification, Problem Evaluation, Corrective Actions, and Use of Operating Experience.

This NRC team inspection was performed by two senior resident inspectors and two regional inspectors. Four findings of very low safety significance (Green) were identified during this inspection and were classified as non-cited violations (NCVs). The significance of most findings is indicated by their color (Green, White, Yellow, Red) using NRC Inspection Manual Chapter (IMC) 0609, "Significance Determination Process (SDP)." Findings for which the SDP does not apply may be Green or assigned a severity level after NRC management review. The cross cutting aspect for findings is determined using IMC 0305, "Operating Reactor Assessment Program." The NRCs program for overseeing the safe operation of commerCial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process,>> Revision 4, dated December 2006.

Identification and Resolution of Problems The inspectors determined that, in general, PPL Susquehanna, LLC (PPL) identified problems and entered them into the corrective action program (CAP) at a low threshold. However, the inspectors identified one finding associated with the failure to identify a procedure inadequacy associated with a preventive maintenance implementation procedure. In addition, the inspectors identified several problems associated with ineffective trending of problems and observed that continued problems with ineffective trending of issues could lead to future failures to identify adverse conditions.

The inspectors determined that, in general, PPL adequately prioritized and evaluated issues commensurate with the safety significance of the identified problem. The inspectors identified one finding associated with this area of assessment. Specifically, although PPL identified that certain maximum safe water levels associated with emergency core cooling system areas were non-conservative, PPL inappropriately determined that the emergency operating procedure which utilizes these levels did not require a revision. Additionally, the inspectors noted issues regarding condition report (CR) classifications. Prior to the inspection, PPL identified that problems have been encountered with prioritization and the level of investigation for issues.

Corrective actions to address these licensee-identified issues were ongoing at the time of this inspection.

Based on the samples reviewed, the inspectors concluded that corrective actions for identified deficiencies and timeliness of these actions were marginally adequate with programmatic weakness noted. Most noteworthy, the weaknesses in this area of assessment were demonstrated by the station's actions to resolve PPL's Quality Assurance-identified findings.

Of the 20 findings identified by Quality Assurance since 2008. ten findings were subsequently elevated and one finding was subsequently escalated due to either recurrence of the issues or not completing corrective actions in a timely manner. Also of concern were PPL's actions to resolve certain NRC findings, NRC regulatory requirement violations, and risk significant equipment problems. The inspectors identified one finding associated with this area of assessment This issue was associated with the failure to follow corrective action procedural requirements with respect to corrective action timeliness and corrective action due date I'

I, extensions. Prior to the inspection, PPL identified problems and corrective actions in this area of assessment. PPL identified that the root cause of these problems was Senior Station Management's failure to value the CAP which resulted in ineffective implementation of the program. Corrective actions to address these licensee-identified issues were ongoing at the time of this inspection.

The inspectors determined that, in general, PPL appropriately considered industry Operating Experience (OE) information for applicability, and used the information for corrective and preventive actions to identify and prevent similar issues. In general, OE was appropriately applied and lessons learned were communicated and incorporated into plant operations.

However, the inspectors identified one finding associated an incorrect safety-relief valve testing methodology which had an aspect associated with OE application.

The inspectors concluded that self-assessments, audits, and other internal PPL assessments were generally adequate in that they were generally critical, probing, thorough, and effective in identifying issues. The audits and self-assessments were completed to a sufficient depth to identify issues that were entered into the CAP for evaluation. However, as demonstrated by the Quality Assurance example provided above, the inspectors concluded that PPL's response to the assessments and audits was, in many instances, less than adequate. With respect to PPL's trending program, several aspects were determined to be ineffective and in need of Improvement, which has been acknowledged by the licensee. Specifically, the inspectors observed that some departments have not put a priority on quarterly Responsibility Center Quarterly trend reviews as demonstrated by multiple failures to perform quarterly department trend reviews.

Based on interviews, observations of plant activities, and reviews of the CAP and the employee concerns program (ECP), the inspectors determined that, in generaf, site personnel were willing to identify and raise safety issues. All persons interviewed demonstrated an adequate knowledge of the avenues ava.ilable for raising safety concerns including CAP and ECP. The inspectors also observed that PPL appeared to be making progress with respect to safety conscious work environment (SCWE) concems; however, the inspectors identified during several interviews that site personnel remained concerned about staffing issues, knowledge transfer issues, and issues regarding CAP ineffectiveness in addressing long term concerns.

Overall, during 2009, PPL's corrective actions appear to have been effective and PPL has made adequate progress in addressing SCWE concerns as demonstrated by inspection results, allegation trend data, SCWE metrics, surveys, and the development and use of alternate processes to raise concerns. While there has not been sufficient time to make broad conclusions regarding the sustainability of PPL's corrective actions, initial trends provide indications of improvement in SCWE at the site.

Cornerstone: Mitigating Systems

• ~. The inspectors identified a Green NCV of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," for PPL's failure to provide an adequate procedure to address and prevent multiple critical component preventive maintenance (PM) items from expiring without timely engineering justification. The inspectors determined this procedural inadequacy was a performance deficiency that was within PPL's ability to foresee and correct, and has contributed to programmatic deficiencies associated with the PM program. PPL entered this issue into the CAP for resolution as CR 1229194.

This finding is more than minor because it is similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," examples 3.j and 3.k in that significant programmatic deficiencies were identified that could lead to a more significant safety concern if left uncorrected. Additionally, the inspectors determined that this issue was more than minor because it affected the procedure quality attribute of the Mitigating Systems cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The inspectors determined this finding was not a design qualification deficiency resulting in a loss of functionality or operability, did not represent an actual loss of safety function of a system or train of eqUipment, and was not potentially risk-significant due to a seismic, fire, flooding, or severe weather initiating event. Therefore, the finding is considered to be of very low safety significance.

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because PPL failed to identify the issues associated with the PM implementation procedure completely, accurately, and in a timely manner [P.1.(a>>). [Section 40A2.1.c(1>>)

• ~. The inspectors identified a Green NCVof 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," for PPL's failure to correct a condition adverse to quality associated with non-conservative maximum safe water levels in Table 10 of Emergency Operating Procedure EO-000-104. "Secondary Containment Contro!." Although some of the values in Table 10 were recognized as non-conservative, PPl determined that a change to the procedure was not necessary. PPL entered this issue into the CAP as CR 1229012 and revised the procedure on February 11, 2010.

The finding was determined to be more than minor because it was similar to IMC 0612,

"Power Reactor Inspection Reports,n Appendix E, "Examples of Minor Issues," example 4.d because PPL failed to take prompt corrective action for a condition adverse to quality and the condition could contribute to safety-related eqUipment unavailability. The inspectors assessed the finding to be of very low safety significance because it did not involve the loss or degradation of equipment or function specifically designed to mitigate a flooding initiating event and did not involve the total loss of any safety function that contributes to external event initiated core damage accident sequences.

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program. because the problem was not thoroughly evaluated such that the resolution addressed the cause and extent of condition [P.1.(c)J.

Specifically, although the values of Table 10 were recognized as non-conservative, PPl determined that a change to EO-000-104 was not necessary. [Section 40A2.1.c(2)]

• ~. The inspectors identified a Green NCV of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," for PPL's recurring failure to implement corrective action program procedural requirements. Specifically, Procedure NDAP-QA-0702. "Action Request and Condition Report Process," Revision 25, states, in part. that all condition report (CR) action items shall be completed by the due date specified in the CR evaluation and action plan. If an action item cannot be completed by the specified due date, the action item due date may be revised by following a specified extension process. Contrary to these procedural requirements, PPL has consistently failed to implement the procedural requirements as demonstrated by sampling audits performed between January 2009 and May 2009, and by observed examples during the inspection. PPL entered this issue into the CAP as CR 1224714.

This finding is more than minor because it was similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," example 3.j in that it represents a significant programmatic deficiency that could lead to worse errors if uncorrected. If left uncorrected this issue would have the potential to lead to a more significant safety concern because not following an established process for extending due dates (including assessment of the impact on equipment and the identification of necessary compensatory actions) may lead to inoperable, nonfunctional, or degraded equipment. This finding was determined to be of very low safety significance because it was not a design or qualification deficiency, did not represent a loss of system safety function, did not represent a loss of safety function of a single train for greater than its TS allowed outage time, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event.

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because PPL did not implement appropriate corrective actions, in a timely manner, to address repetitive non-compliance with procedural requirements [P. 1(d)]. [Section 40A2.1.c(3)]

Green.

The inspectors identified a Green NCVof 10 CFR 50 Appendix B Criterion XI,

"Test Contro!," for PPL's failure to appropriately implement American Society of Mechanical Engineers (ASME) Code for Operation and Maintenance of Nuclear Power Plants (OM Code) Interpretation 01-18. In 2005, PPL changed their in-service test (1ST)program for testing Class I Safety Relief Valves (SRVs) to adopt the "Installation" to "Test" methodology when calculating test periodicity. ASME OM Code Interpretation 01 18, identified that the Code requires the owner to use the "Test" to "Test" methodology.

As a result of the Incorrect methodology being used, a total of 12 SRVs exceeded the six year test periodicity. Of these 12 valves, four are currently installed in Unit 1.

Additionally, two of the valves, when removed and tested in March 2009, failed to meet the ASME and Technical SpeCification limits. PPL has entered this issue into their CAP, has initiated action to revise their 1ST program to make it consistent with the ASME OM Code, and has submitted or prepared Relief Requests for all currently installed valves which have or will exceed the 6 year test interval before the next refueling outage.

The fact that PPL's 1ST testing program for Class I SRVs was not consistent with the underlying ASME OM code requirements is a performance deficiency which was reasonable within PPL's ability to foresee and prevent. The finding affects the equipment performance attribute of the Mitigating Systems cornerstone and the corresponding cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (Le.,

core damage). The finding is also Similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," example 1.c in that a missed surveillance is more than minor if, when tested, the eqUipment fails its test acceptance criteria as two SRVs did in this case. This finding was determined to be of very low safety significance because it was not a design or qualification deficiency, did not represent a loss of system safety function, did not represent a loss of safety function of a single train for greater than the TS allowed outage time, and did not screen as potentially risk signiffcant due to a seismic, flooding, or severe weather initiating event.

This finding has a cross cutting aspect in the area of OE because PPL failed to collect, evaluate, and communicate OE in a timely manner P.2(a). Specifically, PPL failed to identify that ASME OM Code Interpretation 01-18 had been issued in 2003 and failed to evaluate relevant OE. [Section 40A2.2.c(1)]

REPORT DETAILS

OTHER ACTIVITIES (OA)

40A2 Problem Identification and Resolution (71152B)

.1 Assessment of the Corrective Action Program Effectiveness

a.

Insgection Scope The inspectors reviewed the procedures that describe PPL's CAP at the Susquehanna Steam Electric Station (Susquehanna). PPL used a single-point entry system and identified problems by the initiation of an Action Request (AR) using the PIMS computer program, The AR would then be sub-classified depending on the information provided; for example, as maintenance work order (WO) for a WO, as a condition report (CR) for a CR, etc. ARs were sub-classified as CRs for conditions adverse to quality (CAO). such as plant equipment deficiencies, industrial or radiological safety concerns. or other significant issues. The CRs were subsequently screened for operability and re porta bility, categorized by significance from 1 (the highest level of significance) to 3 (the lowest), assigned a level of evaluation, and issued for resolution, To assess the effectiveness of the CAP at Susquehanna, the inspectors reviewed performance in three primary areas: problem identification; prioritization and evaluation; and corrective action implementation. The inspectors compared performance in these three areas to the requirements and standards contained in 10 CFR Part 50. Appendix B, Criterion XVI and PPL procedure, NDAP-OA-0702, "Action Request and Condition Report Process," Revision 25, The scope of the inspectors' review for each of these areas at Susquehanna is described below. The CRs, procedures, and other documents reviewed for the inspection are listed in the Attachment.

Effectiveness of Problem Identification .

The inspectors reviewed a sample of plan of the day (POD) meeting packages and meeting minutes for a sample of corrective action review board (CARB), Susquehanna Review Committee, and maintenance rule expert panel meetings. The inspectors also attended a CARB meeting and a number of POD, management review committee (MRC), and CR screening meetings. The inspectors evaluated whether identified issues discussed at these meetings were entered into the CAP for evaluation and corrective action as appropriate.

The inspectors reviewed the condition of several risk significant systems as determined by the Susquehanna Probabilistic Risk Assessment model. These systems included the high pressure coolant injection (HPCI) system, the SRV and automatic depressurization system (ADS), and the emergency service water (ESW) system. The inspectors reviewed system health reports and a sample of completed preventative and corrective maintenance WOs. The inspectors also completed a field walkdown of the accessible portions of these systems. The inspectors evaluated whether conditions adverse to quality identified through this review were entered into the CAP as appropriate.

The inspectors reviewed the results of PPL periodic equipment and human performance trend analyses for major site functional groups {I.e., Operations, Engineering, Maintenance, Radiation Protection, Emergency Preparedness, Chemistry, Security, and Corrective Action and Assessment) and system health reports for risk significant systems. The inspectors determined whether identified trends were entered into the CAP for further evaluation and corrective action as appropriate.

The inspectors also determined whether issues identified through internal self assessments and audits and the OE program were entered into the CAP for evaluation and corrective action as appropriate.

Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the evaluation and prioritization for a sample of CRs issued since the last NRC problem identification and resolution inspection that was performed in January 2008. The inspectors considered risk insights from the station's risk analysis and ensured that the selected CRs were appropriately distributed across the seven cornerstones of safety and the emergency preparedness, engineering, maintenance, operations, physical security, and radiation safety functional areas. Inspectors' samples in this area were focused on the HPCI system, the SRV and ADS system, and the ESW system, but were not limited to them.

The inspectors also observed seven daily CR screening meetings during the onsite weeks. During these meetings PPL personnel reviewed new CRs for prioritization and assignment. The issues and CRs reviewed encompassed the full range of evaluations, including root cause analyses (RCA), apparent cause evaluations, correct condition, and closure. CRs that were assigned lower levels of significance that did not include formal cause evaluations were also reviewed by the inspectors to ensure they were appropriately classified. The inspectors' review included the appropriateness of the assigned significance, the scope and depth of the causal analysis, and the timeliness of resolution. The inspectors assessed whether the evaluations identified likely causes and developed appropriate corrective actions (CAs) to address the identified causes.

Further, the inspectors reviewed equipment operability determinations, reportability assessments, and extent-of-condition reviews for selected problems to verify these processes adequately addressed equipment operability, reporting of issues to the NRC, and the extent of problems. The inspectors also observed seven MRC meetings during which PPL managers reviewed prior-day screened results, operating experience screening, and other corrective action program items.

Effectiveness of Corrective Actions The inspectors verified completion of CAs for a sample of CRs and WOs issued since the last NRC problem identification and resolution inspection that was performed in January 2008. The inspectors considered risk insights from the station's risk analysis and ensured that the selected CAs were appropriately distributed across the seven cornerstones of safety and the emergency preparedness, engineering, maintenance, operations, physical security, and radiation safety functional areas. Inspectors'samples in this area were focused on the HPCI system, the SRV and ADS system, and the ESW system, but were not limited to them. CAs were verified to have been completed through documentation review and field walkdowns, when appropriate. The inspectors also reviewed a sample of corrective actions for CRs greater than two years old. The inspectors selected these items based on risk significance, and determined whether appropriate interim actions were in place and that the basis for not completing the specified CAs was appropriately documented and well supported.

The inspectors reviewed CRs for adverse trends and repetitive problems to determine whether CAs were effective in addressing the broader issues. The inspectors reviewed PPL's timeliness in implementing CAs and effectiveness in precluding recurrence for significant conditions adverse to quality. The inspectors also reviewed a sample of CRs associated with selected NCVs, and licensee event reports to determine whether PPL personnel properly evaluated and resolved these issues. In addition, the corrective action review was expanded to five years to evaluate PPL's actions related to the HPCI system, the SRV and ADS system, and the ESW system.

b. Assessment Effectiveness of Problem Identification Based on the selected samples, plant walkdowns. and interviews of site personnel in multiple functional areas, the inspectors determined that PPL identified problems and entered them into the corrective action program at a low threshold. For example, PPL generated over 4900 and 5100 CRs in 2008 and 2009, respectively. During walkdowns of the plant and control room, the inspectors did not identify any notable discrepancies that were not already identified by PPL.

The inspectors assessed that PPL's implementation of this aspect of the CAP was effective. However, the inspectors identified one finding associated with failure to identify a procedure inadequacy associated with PM implementation procedure, NDAP QA-0524, qEquipment Reliability and Station Health Process," Revision 6. The inspectors determined that this procedure was not specific enough to assist PPL in precluding the amount of PMs that were deferred and/or expired. Despite numerous CRs and the performance of a self-assessment associated with programmatic deficiencies in the PM program {Le., the high quantity of deferred or expired PMs), PPL's investigations did not identify or address the inadequacy of the PM procedure. This issue is discussed in further detail in section 40A2.1.c(1).

In addition, the inspectors identified several problems associated with ineffective trending of problems as discussed in "Self-Assessments and Audits" In section 40A2.3.

The inspectors observed that continued problems with ineffective trending of issues could lead to future failures to identify adverse conditions.

Effectiveness of Prioritization and Evaluation of Issues The Inspectors determined that, in general, PPL adequately prioritized and evaluated issues commensurate with the safety significance of the identified problem. CRs were screened for operability and reportability, categorized by significance, and assigned to a department for evaluation and resolution. The various CR screening and management review groups considered human performance issues, radiological safety concerns, repetitiveness, adverse trends, and potential impact on the SCWE during the conduct of reviews. The inspectors assessed that PPL's implementation of this aspect of the CAP was adequate; however, some weaknesses were noted.

The inspectors identified one finding associated with this area of assessment. Although PPL identified that some maximum safe water levels associated with emergency core cooling system areas were non-conservative, PPL inappropriately determined that the emergency operating procedure which utilizes these levels did not require a revision.

The inspectors determined that the non-conservative water levels constituted a condition adverse to quality because operators could base their decision on the non-conservative value during an emergency. This could potentially result in adverse emergency equipment availability, reliability, and capability. This issue is discussed in further detail in Section 40A2.1.c(2).

During the inspection, the inspectors noted some weakness in this area of assessment.

Several of the issues overlap with the assessment area of effective corrective actions.

Weaknesses observed and/or identified by the inspectors are as follows:

• Energy Control Process (i.e., tagout) events have recurred. In 2009, eight significant events occurred despite the performance of multiple root cause evaluations.

• Corrective actions to prevent recurrence for a radiation protection "as low as reasonably achievable" (A LARA) NRC finding (FIN) identified in 2007 (FIN 05000388/2007003-03) did not prevent a similar occurrence in 2009. This resulted in another ALARA finding (FIN 05000388/2009004-04).

• Corrective actions for a 2006 root cause evaluation related to a Unit 1 HPCI system steam stop valve failure, rendering the HPCI system inoperable, were ineffective in preventing ari additional similar failure. The failure to prevent the recurrence of the valve's failure, a significant condition adverse to quality, was the subject of NCV 050000387/2009004-03. See NRC Inspection Report 05000387; 388/2009001, dated November 13, 2009, for additional details.

• During Screening Committee observations, the inspectors identified examples of ARs/CRs being incorrectly classified. The result of a CR being incorrectly classified impacts the priority of evaluations assigned and priority of the action plan to fix the issue. The inspectors noted that NDAP-QA-0702, UAction Request and Condition Report Process," contained significant guidance on CR significance level assignments. However, the inspectors noted that the procedure contained minimal guidance on assigning the evaluation type. Examples include:

1) CR 1222679 was classified as a "correct," however. the inspector noted that the author of the CR requested an "evaluation" of the issue identified.

PPL wrote CR 1223881 to document the incorrect evaluation type.

2) CR 1222961 was written to document that the spent fuel criticality radiation monitor had failed downscale. The Screening Committee determined that this condition was "not a condition adverse to quality."

The inspectors noted that the equipment was required to be operable per the Technical Requirements Manual. Because a limiting condition for operation was entered due to the instrument failing downscale. the CR should have been classified as a "condition adverse to quality." PPL generated CR 1223881 to document incorrect classification.

3) CR 1121250 was classified as "correct" and was associated with a safety related battery calculation discrepancy. The inspectors questioned whether the CR should have been classified as "evaluate" because NDAP-QA-0702 contained a requirement to perform the minimum of an "evaluation" if a CR identified a deficiency on a significant system (e.g.,

station battery). PPL agreed that the guidance NDAP-QA-0702 needed enhancement and generated CR 1223841 to evaluate revising procedure guidance with respect to assignment types.

The inspectors independently evaluated deficiencies, not previously dis positioned in NRC inspection reports, noted above for potential significance per the guidance in IMC 0612, Appendix B, "Issue Screening," and Appendix E, "Examples of Minor Issues," and detennined the issues to be of minor significance. Minor violations of NRC requirements are not subject to enforcement action in accordance with the NRC Enforcemen't Policy.

However, these minor violations and observations support the inspectors' overall assessment that PPL's performance was adequate with weaknesses noted in the area of problem evaluation.

Prior to the inspection, PPL identified that problems have been encountered with prioritization and the level of investigation of issues. As a result, CR 1188912 identified corrective actions to provide an improved definition of "a condition adverse to quality" and "a Significant condition adverse to qualityn in applicable procedures. PPL has also identified problems with the adequacy of root cause analysis training. In addition, PPL identified that procedural requirements with respect to identifying corrective actions also required improvement. This is because PPL identified that corrective actions developed from causal analysis of events have not been sufficient to prevent similar events or problems. PPL also identified also that effectiveness reviews have not been performance~based. Corrective actions to address these licensee-identified issues were ongoing at the time of this inspection (CR 1102142).

Effectiveness of Corrective Actions Based on the sample reviewed, the inspectors concluded that corrective actions for identified deficiencies and timeliness of these actions were marginally adeq uate with programmatic weakness noted. Weaknesses in PPL's resolution of degraded conditions, documentation of actions, and completion of identified corrective actions were also noted. The inspectors Identified one finding associated with this area of assessment. This issue was associated with the failure to follow the corrective action procedural requirements of NDAP-QA-0702, "Action Request and Condition Report Process," with respect to corrective action timeliness and corrective action due date extensions. The inspectors detennined that corrective actions associated with this issue only increased the visibility of overdue CR action items and would not, by themselves.

correct the condition. This issue is discussed in further detail in Section 40A2.1.c(3).

Most noteworthy, the weaknesses in this area of assessment were demonstrated by the station's actions to resolve PPL's Quality Assurancewidentified findings. Of the 20 findings identified by the Quality Assurance group since 2008, ten findings were elevated and one finding was escalated due to either recurrence of the issues or not completing corrective actions in a timely manner. See Section 40A2.3 of this report for additional details regarding Quality Assurance-identified findings. Also of concern were PPL's actions to resolve certain NRC findings, NRC regulatory requirement violations, and risk significant eqUipment problems. Example include:

• NRC Inspection Report 05000387; 388/2009005, dated January 28,2009, documented a licensee-identified violation of 10 CFR Part 50, Appendix 8, Criterion VII, "Identification and Control of Materials, Parts and Components," associated with a non-safety-related 480 volt breaker installed in a safety-related breaker cubicle.

Corrective actions to resolve this issue included verifying breaker serial numbers in WOs that perform breaker swaps. These actions were completed in March 2009 as documented in CR 1101415. In April 2009 a similar event occurred when a breaker was removed to perform a PM. The removed breaker was inadvertently reinstalled into the breaker cubicle instead of a temporary maintenance breaker. The apparent cause for the second event was that "work instructions did not require that the serial number of the breaker being installed be verified" as documented in CR 1136568.

• NRC Inspection Report 05000387; 388/2009004, dated November 13, 2009, identified an NCV of 10 CFR Part 50, Appendix B, "Corrective Action," associated with repeat failures of the Unit 1 HPCl system turbine stop valve. Although PPL appropriately identified several causes following the 2006 valve failure, adequate corrective actions to address the causes were not implemented. This resulted in a repeat failure of the valve on August 18, 2009. In both cases, the failure of the stop valve rendered this single train system inoperable.

• CR 784890 was written to address a pinhole leak on the ESW system down stream of UC" emergency diesel generator (EDG). The cause of the pinhole leak was determined to be cavitation corrosion caused by the heavily throttled butterfly valves downstream of the EDG throttle valves. The inspectors found that there have been several repeat events of this issue and in each case the cause was determined to be the throttling of the butterfly valves. Several repeat events from 2006 through 2009 have occurred with actions leading to evaluating the replacementof the butterfly valves. The replacement of the butterfly valves with more appropriate throttle valves has not occurred.

• The inspectors observed several CRs where the due date for planned corrective actions would not support the need date for an associated activity. For example, CR 1225187 was to perform an evaluation of the proper Limiting Condition for Operation to be entered for a planned surveillance test; the due date was scheduled after the next planned performance of the test. CR 1113128 was to revise a HPCI maintenance procedure with a due date of October 2010; the next planned maintenance using the procedure was March 2010. CR 1169263 identified an incorrect wiring configuration for a recently replaced HVAC temperature indication controller. The action to correct the maintenance instructions was due in May 2010 but the next temperature indication controller was scheduled for replacement in February 2010.

The inspectors independently evaluated the deficiencies, not previously dispositioned in NRC inspection reports, noted above for potential significance per the guidance in IMC 0612, Appendix B "Issue Screening" and Appendix E, ~Examples of Minor Issues," and determined the issues to be of minor Significance. Minor violations of NRC requirements are not subject to enforcement action in accordance with the NRC Enforcement Policy.

However, these minor violations and observations support the inspectors' overall assessment that PPL's performance was marginally adequate with weaknesses noted in the area of timely and effective corrective actions.

Prior to the inspection, PPL identified problems and corrective actions in this area of assessment. PPL identified that the root cause of this issue was that Senior Station Management failed to value the CAP resulting in ineffective implementation of the program (CR 1194033 and CR 1222762). The most significant planned actions were noted as follows:

(1) establishing the CAP as a core business activity (including incorporating the CAP into a site focus area in strategic planning, providing adequate resources, etc.);

(2) increasing Senior Management engagement in the CAP; (3)establishing a Performance Improvement Manager position to emphasize the importance of the CAP and provide focused CAP health reporting responsibility; (4)adding additional CAP program personnel resources and expanding their responsibilities; {5} escalating the approval requirement for corrective action due date extensions;

(6) adding additional resources to CAP program implementation and monitoring including the temporary addition of industry experienced peers to review screening, causal analysis, corrective action and closure activities of the CAP; and (7)establishing performance indicators to monitor CAP quality, timeliness, and overall program health.

c. Findings

(1) Inadequate Preventive Maintenance Implementation Procedure Leading to Programmatic Deficiencies in the PM Program

Introduction:

The inspectors identified a Green NCV of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," for PPL's failure to provide an adequate procedure for ensuring equipment reliability through PM. Specifically, PPL's procedure covering PM implementation as described in NDAP-QA-0524, "Equipment Reliability and Station Health Process," Revision 6, failed to prevent multiple critical component PMs from expiring without timely engineering justification.

Description:

On January 15,2010, inspectors reviewed the PM history associated with all safety-related 4kV breakers. During the review the inspectors noted that the Unit 1

'B' Reactor Building {RB} chiller 4kV breaker {cubicle 1A20203} PM had expired on December 31 r 2009 and that no CR had been written documenting the expiration. The inspectors identified that this PM was originally scheduled for November 5,2009, and the system engineer had provided engineerlng justification to defer completion of this PM until December 31, 2009. The inspectors noted that this was within the 25 percent grace period for the four year breaker PM frequency, since the PM had last been performed on November 5, 2004. However, the inspectors discovered that the PM was not completed in the additional time allowed by engineering; instead it was scheduled for June 1, 2010, six months after the expiration date.

The inspectors reviewed the PM implementation process, PM procedures, and interviewed the responsible PPL department managers (Station Engineering, Work Management, and Maintenance) to determine whether adequate procedures and processes existed that should have prevented the PM from expiring. The inspectors identified that the PM implementation procedure, NDAP-QA-0524, "Equipment Reliability and Station Health Process," Revision 6, stated "the standard is to perform the full scope of the [PM] prior to the due date. Approval for partial performance or waivers must be obtained from the [PM] owner via [CR]." The inspectors determined that this procedure did not provide adequate procedural guidance or standards to assist PPL in scheduling PM work in a timely manner, minimizing the amount of deferred PMs, and preventing expired PMs on safety-related components. As a result, PMs were frequently scheduled well into the 25 percent grace period which contributed to the number of expired PMs due to the subsequent rescheduling of the PMs for a variety of reasons.

In order to evaluate the extent of deficiencies in the PM process, the inspectors reviewed PPL internal performance indicators for the previous two years regarding PM deferrals and expirations. The inspectors noted that PPL assigns criticality codes to components based on the consequence of component failure, with 1 being the most critical and 6 being the least. Criticality Code 1 and 2 components are components whose failure can lead to TS down powers or shutdowns, immediate down powers or shutdowns, or loss of safety significant maintenance rule functions. At the time of this inspection, there were more than 17 PMs classified as criticality code 1 or 2 that were either deferred or had expired due to the ineffective PM process.

The inspectors reviewed PPL's most recent self-assessment of the PM process, in which PPL identified the causes of the PM process deficiencies to be:

(1) significantly reduced available resources in Electrical Maintenance, Mechanical Maintenance, and Instrumentation & Controls;

(2) failure of PPL management to address the insufficient resources, and;

(3) eroded standards for implementation of PM activities. The inspectors identified that PPL did not address the inadequacy of the PM procedure in any of the 13 corrective actions implemented by the self-assessment or any other CR corrective actions. After the inspectors raised their observations regarding the PM procedure to PPL management, CR 1229194 was written to ensure the deficiency was captured and appropriate corrective actions were added to the Station Excellence Plan.

Analysis:

The inspectors determined that failing to provide an adequate procedure for ensuring equipment reliability through PM implementation is a performance deficiency that was within PPL's ability to foresee and correct which contributed to programmatic deficiencies associated with the PM program. This finding is more than minor because it is similar to examples 3.j. and 3.k. in IMC 0612, Appendix E, where significant programmatic deficiencies were identified that could lead to a more significant safety concern if left uncorrected. This finding also affects the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the finding using Phase 1, "Initial Screening and Characterization" worksheet in Attachment 4 to IMC 0609, "Significance Determination Process." The inspectors determined this finding was not a design qualification deficiency resulting in a loss of functionality or operability, did not represent an actual loss of safety function of a system or train of equipment, and was not potentially risk-significant due to a seismic, fire, flooding, or severe weather initiating event. Therefore, the 'finding is considered to be of very low safety significance (Green).

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because PPL failed to identify the issues associated with the PM implementation procedure completely, accurately, and in a timely manner [P.1 (a)].

Enforcement:

10 CFR Part 50, Appendix S, Criterion V, Wlnstructions, Procedures, and Drawings," requires, in part, that activities affecting quality shall be prescribed by documented procedures and shall be accomplished with these procedures. Contrary to the above, PPL's PM implementation procedure, as described in NDAP-QA-0524, "Equipment Reliability and Station Health Process," Revision 6, failed to address and prevent multiple critical component PMs from expiring without timely engineering justification. The inspectors determined that this procedure was not specific enough to assist PPl in precluding the amount of PMs that were deferred andlor expired.

Specifically, the inspectors determined that this procedure did not provide adequate procedural guidance or standards to assist PPL in scheduling PM work in a timely manner, minimizing the amount of deferred PMs, and preventing expired PMs on safety related components. Because this issue is of very low safety significance (Green) and PPl entered this issue into their CAP as CR 1229194, this finding is being treated as an NCV consistent with the NRC Enforcement Policy. (NCV 05000387,388/2010006*01, Inadequate PM Implementation Procedure leading to Programmatic Deficiencies in the PM Program)

(2) Failure to Correct Non-conservative Maximum Safe Water Levels.

Introduction:

The inspectors identified a Green NCVof 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," for PPL's failure to correct non-conservative maximum safe water levels in the secondary containment control emergency operating procedure.

Description:

The inspectors reviewed CR 1072113, which performed an operating experience review generated for the identification of non-conservative values for the maximum safe operating levels in an emergency operating procedure (EOP) for secondary containment control at another facility. The maximum safe operating level is the water level in reactor building emergency core cooling system (ECCS) areas where operation below these levels would not affect the operability or functionality of ECCS equipment located in the space.

PPL performed an evaluation and conducted plant walkdowns to verify maximum safe water levels in ECCS areas. The maximum safe water levels for Susquehanna are located in Table 10 of EOP EO-000-104, "Secondary Containment Control Procedure."

PPL discovered that some Susquehanna maximum safe water levels for flooding in ECCS areas were incorrect and non-conservative. PPL found that the levels specified in Table 10 were non-conservative for the Unit 2 HPCI system area, the Units 1 and 2 reactor core isolation cooling (RCIC) system areas, and the Units 1 and 2 residual heat removal system areas. Although the correct maximum safe water level errors were on the range of one to two inches, the inspectors determined that the condition constituted a condition adverse to quality because the existing Table 10 values were non conservative (i.e., actual maximum safe water levels were lower than the Table 10 values).

As a result of discovering the non-conservative values in Table 10 to EO-OOO-104, PPL generated CR 1191940 to correct the condition. CR 1191940 evaluated the differences between the maximum safe water levels and the Table 10 values and determined that a change to Table 10 was not required. PPL determined that the maximum safe water levels determined during plant walkdowns were in "good" agreement with incorrect levels. PPL concluded "Given the fact that these water levels can not be readily measured in practice, since the room would really not be accessible at these maximum flood levels, the maximum safe operating levels included in the existing EO procedure are not considered to be non-conservative." As a result, PPL only revised the Plant Specific Technical Guidelines to clarify that the maximum safe water levels identified in Table 10 of EO-OOO-104 are approximate values.

The inspectors determined that the actions taken by PPL to resolve the differences between measured maximum safe water levels and the Table 10 values were inappropriate. First, the Plant Specific Technical Guidelines was a basis document for Susquehanna EOP deviations to the Boiling Water Reactor Owner's Group Emergency Procedure Guidelines. The inspectors noted that the Plant Specific Technical Guidelines would not be readily available for consultation during an emergency. Instead, operators experiencing a flooding event would follow the instructions of EO-000-104 and base their decisions on the non-conservative values in Table 10 of the procedure.

Second, EO-000-104 directs specific actions to be taken before any reactor building area water level reaches the maximum safe level. However, the evaluation of CR 1191940 identified that the actions in EO-000-104 to measure area water levels can not be readily practiced. This is because room access through the room doors could be restricted at maximum safe water levels. As a result, PPL has trained operators to assume that water level has reached the maximum safe level if an area cannot be accessed. The inspectors acknowledged such scenarios, but determined that PPL's conclusion did not consider

(1) times when there may be other routes available to access the rooms to determine water levels (e.g., access plug removal during system outages and/or refueling outage) or, in some cases, viewing water levels through accessible upper levels of the room; and

(2) the potential for the non-conservative values to cascade into future room or system design modifications (such as a water level detection system). PPL corrected the procedure on February 11, 2010.

Analysis:

The failure to correct a condition adverse to quality associated with non-conservative maximum safe water levels in Table 10 of Emergency Operating Procedure EO-OOO-104, "Secondary Containment Control," was a performance deficiency. The finding was determined to be more than minor because it was similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," example 4.d because PPL failed to take prompt corrective action for a condition adverse to quality and the condition could contribute to safety-related equipment unavailability. The inspectors assessed the finding to be of very low safety significance (Green) because it did not involve the loss or degradation of equipment or function specifically designed to mitigate a flooding initiating event and did not involve the total loss of any safety function that contributes to external event initiated core damage accident sequences.

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the problem was not thoroughly evaluated such that the resolution addressed the cause and extent of condition [P.1.(c)].

Specifically, although the values of Table 10 were recognized as incorrect, PPL determined that a change to EO-OOO-1 04 was not necessary.

Enforcement:

10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures shall be established to assure that conditions adverse to quality, such as deficienCies, are promptly identified and corrected. Contrary to this requirement, PPL identified that some values for maximum safe water level contained in Table 10, .

"Reactor Building Water Level," of Emergency Operating Procedure EO-OOO-104, "Secondary Containment Control," Revision 5, were in error and non-conservative, representing a condition adverse to quality, and failed to correct the condition. The non conservative values for maximum safe water level applied to the Units 1 and 2 residual heat removal areas, the Units 1 and 2 RCIC areas, and the Unit 2 HPCI area. PPL corrected the procedure on February 11, 2010. Because the finding is of very low safety significance and has been entered int.o Exel.on's c.orrective acti.on program as CR 1229012, this vi.olati.on is being treated as a n.on-cited vi.olati.on, consistent with the NRC Enf.orcement P.olicy. (NCV 05000387, 388/2010006-02, Failure tQ CQrrect N.on cQnservative Maximum Safe Water Levels)

(3) Failure t.o F.oll.ow C.onditi.on Rep.ort Pr.ocess f.or Overdue Acti.ons Intr.oducti.on: The inspect.ors identified a Green NCV.of 10 CFR Part 50, Appendix B, Criteri.on V, "Instructi.ons, Pr.ocedures, and Drawings," f.or PPL's recurring failure t.o implement c.orrective acti.on pr.ogram pr.ocedural requirements.

Descripti.on: During sampling audits perf.ormed during the m.onths .of January thr.ough May 2009, the stati.on's C.orrective Acti.on and Assessment group f.ound that appr.oximately 20 percent .of CR "c.orrect c.onditi.on" and "prevent recurrence~ acti.on items were late, and the pr.ocess f.or due date extensi.ons was n.ot f.oll.owed. Pr.ocedure NDAP QA-0702, "Acti.on Request and C.onditi.on Rep.ort Pr.ocess," contained the requirements regarding timeliness .of CR acti.on items. Step 8.2.1 .of the pr.ocedure states "All CR acti.on items shall be c.ompleted by the due date specified in the CR evaluati.on and acti.on plan. If the CR acti.on item cann.ot be c.ompleted by the specified due date, the acti.on item due date may be extended as described herein." The standard is zer.o

.overdue CR acti.on items. The pr.ocedure pr.ovides a pr.ocess f.or extensi.ons, which requires the d.ocumentati.on.of:

(1) the reas.on f.or extensi.on;

(2) the c.ompensat.ory acti.ons taken;

(3) the impact .on equipment and/.or pers.onnel safety;

(4) the Impact .on existing c.ompensat.ory acti.ons; and

(5) any acti.ons due t.o n.ot meeting the due date.

The inspect.ors perf.ormed a review .of the acti.ons taken by PPL t.o address the issue.

The inspect.ors f.ound that the CRs generated as a result.of the m.onthly audits were assigned an evaluati.on class .of "cl.osure" (Le., n.o evaluati.on .of the issue necessary).

F.oll.owing the May 2009 audit, an acti.on item was generated t.o create a perf.ormance indicat.or t.o m.onit.or f.or acti.on items that were .overdue and had n.ot been pr.operly extended. After experiencing c.ontinued pr.oblems with .overdue acti.on/n.on-extended acti.on items. the Empl.oyee C.oncerns Oversight C.ommittee directed the MRC t.o determine specific acti.ons t.o ensure the stati.on standard f.or zer.o .overdue items was achieved and sustained. CR 1183423 was generated.on N.ovember 27.2009, t.o address these c.oncerns. Alth.ough acti.ons were taken .or planned in CR 1183423, the inspect.ors n.oted that the acti.ons w.ould .only result in increased visibility of .overdue acti.ons, and w.ould n.ot prevent future .overdue acti.on items. The acti.ons included a plan f.or daily review.of .overdue CR acti.on items at the MRC meeting and a revisi.on t.o the performance indict.or that m.onitored overdue acti.ons. The change t.o the perf.ormance indicat.or revised the green thresh.old fr.om five .overdue/n.on-extended acti.on items t.o zer.o, c.onsistent with the standard established in NDAP-QA-0702, "Acti.on Request and C.onditi.on Rep.ort Pr.ocess," for zer.o .overdue CR acti.on items.

The inspect.ors determined that these acti.ons .only increased the visibility .of .overdue CR acti.on items and w.ould n.ot, by themselves, c.orrect the c.onditi.on. During the inspection, the inspect.ors .observed several MRC meetings where late CR acti.on items were reviewed. For example, .on January 12 and again .on January 25, three overdue items were reviewed at each MRC meeting. Alth.ough .overdue CR acti.on items were n.ot reviewed at the MRC.on January 27, the inspectors noted that there were f.our .overdue CR acti.on items. Based.on the recurrence .of .overdue/n.on-extended CR acti.on items, the inspectors c.oncluded that PPL's actions t.o c.orrect the failure t.o f.oll.ow NDAP-QA Encl.osure 0702 requirements with respect to timeliness of CR action items or processing extensions to the due dates were ineffective.

Anal'lsis; The performance deficiency associated with this issue is that PPL consistently failed to implement corrective action program procedural requirements with respect to the timeliness of CR action items and the processing of extensions to due dates. This finding is more than minor because it was similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," example 3.j in that it represents a significant programmatic deficiency that could lead to worse errors jf uncorrected. If left uncorrected this issue would have the potential to lead to a more significant safety concern because not following an established process for extending due dates (including assessment of the impact on equipment and the identification of necessary compensatory actions) could lead to Inoperable, nonfunctional or degraded equipment. This finding was evaluated in accordance with NRC IMC 0609, Attachment 4, "Phase 1 - Initial Screening and Characterization of Finding," and determined to be of very low safety significance because it was not a design or qualification deficiency, did not represent a loss of system safety function, did not represent a loss of safety function of a single train for greater than its TS allowed outage time, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event.

This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because PPL did not implement appropriate corrective actions, in a timely manner, to address repetitive non-compliance with procedural requirements P.1(d).

Enforcement:

10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality shall be prescribed by documented procedures and shall be accomplished with these procedures. Procedure NDAP-QA-0702, "Action Request and Condition Report Process," Revision 25 is a procedure affecting quality. Step 8.2.1 requires that all CR action items shall be completed by the due date specified in the CR evaluation and action plan. Step 8.2.1 also states that if the CR action item cannot be completed by the specified due date, the action item due date may be extended. Contrary to the above. PPL has not followed the requirements of Step 8.2.1 as demonstrated by sampling audits performed between January 2009 and May 2009, where approximately 20 percent of CR action items were late and the process for due date extensions was not fOllowed. In addition, during the inspection there were three overdue CR action items on both January 12 and January 25, and four overdue CR action items on January 27. Because this finding is of very low safety signiffcance and has been entered into PPL's CAP (CR 1224714). this violation is being treated as a Non¥Cited Violation (NCV), consistent with the NRC Enforcement Policy. (NCV 05000387,388/2010006-03, Failure to Follow Condition Report Process for Overdue Actions)

.2 Asse.ssment of the Use of Operating Experience (OE)

a. Inspection Scope

The inspectors selected a sample of industry OE issues to confirm that PPL evaluated the OE information for applicability to Susquehanna and took appropriate actions when warranted. The inspectors reviewed OE documents to determine whether PPL appropriately considered the underlying problems associated with the issues for resolution via their CAP. The inspectors also observed plant activities to determine if industry OE was considered during the performance of routine and infrequently performed activities. A list of the documents reviewed is included in the Attachment.

b.

Assessment The inspectors determined that, in general, PPL appropriately considered industry OE information for applicability, and used the information for corrective and preventive actions to identify and prevent similar issues. OE was typically appropriately applied and lessons learned were communicated and incorporated into plant operations. However, the inspectors identified one finding associated with an incorrect safety~relief valve testing methodology which had an aspect associated with OE application.

c. Findings

(1) Failure to Test Reactor Vessel Safety Relief Valves In Accordance With ASME Code

Introduction:

The inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion XI, "Test ContrOl," for PPL's failure to appropriately implement ASME Code for Operation and Maintenance of Nuclear Power Plants (OM Code) Interpretation 01-18.

As a result, a total of 12 SRVs exceeded the six-year test periodicity.

Description:

Susquehanna is committed to the 1998 Edition of the ASME OM Code through the 2000 Addenda. ASME OM Code Mandatory Appendix I Section 1-1330 requires that Class I SRVs be tested every five years and acceptance criteria for this test must be +/- 3 percent of the valve nameplate set pressure. In 2001, ASME received a request to interpret the Code as to whether the five year periodicity was from "Test" to "Test" or from "Installation" to "Test." In 2003, ASME issued ASME OM Code Interpretation 01-18 which clarified that the Class I SRV testing requirement was "Test" to "Test" and that no grace period was permitted. This interpretation was also included in the ASME OM Code 2004 Edition published the following year in Section 1-1320 of Mandatory Appendix I.

In 2004, Susquehanna developed engineering work request (EWR) 486485, which evaluated changing the 1ST program to a six year testing periodicity to account for the two year refueling cycles at both Susquehanna Units. This evaluation adopted the

-Installation" to "Test" Methodology when calculating the time between SRV tests. When an SRV is removed for testing it is sent to the vendor's facility and tested "as found."

The valve is then overhauled at the vendor and required PMs are performed. At the completion of the maintenance, the valve is "as left" tested to ensure the valve lifts at +/

1 percent of the nameplate set pressure. The valve is then returned to the licensee and is typically installed in the next refueling outage (RFO). An SRV can be used in either unit. EWR 486485 established that PPL intended to only count the time between installation of the valve in the unit to the next "as found" test for test periodicity purposes.

However, the ASME OM Code Interpretation 01-18 clarified the requirement was "Test" to "Test" or the "as left" test to the next "as found" test. The difference between the two methodologies results in approximately 10 to 12 months of additional time between tests when using the "Instal/ation" to "Test" methodology. When revising their program, PPL did not identify that their new methodology was not consistent with the current ASME OM Code Interpretation.

PPL submitted Relief Request (RR)-02 to change the SRV test periodicity from five to six years; however, this relief request did not request a change in the testing methodology.

The NRC granted RR-02 in 2005 and PPL implemented the 1ST program change for their next RFO.

In 2007, industry OE was issued which identified the test methodology issue. PPL received the OE but failed to conduct a review of this OE. This was a significant missed opportunity to identify and correct this issue at Susquehanna. Similar OE was again issued in 2009. PPl received the 2009 OE and identified on November 18, 2009, that four valves currently installed in Unit 1 were at or beyond their six year test frequency when applying the proper methodology. One valve was counted as a missed surveillance and the licensee entered SRO 3.0.3 and conducted a safety evaluation to establish operability until the next RFO. A verbal one time relief request (RR-07) was requested and granted for the two valves which had not yet passed their six year periodicity. The remaining valve was declared inoperable until RR-08 was submitted in December 2009 and granted by the NRC in January 2010. Since the Technical Specifications require 14 of the 16 SRVs to be operable and RR-07 was granted before two of the valves went out of periodicity, the Technical Specifications requirements were always met and no loss of safety function resulted.

During the PI&R inspection, the inspectors reviewed RR-07 and RR-08 and discovered that in addition to the four valves currently installed in Unit 1, there were five valves in Unit 2 that would exceed their six year periodicity in August 2010 (before the next Unit 2 RFO). The inspectors also identified that an additional eight valves had exceeded their six year testing periodicity. These eight valves were tested in 2007, 2008, and 2009. Of this population of eight valves, two of the valves (N63790-00-0019 and N63790-00- '

0020) failed their "as found" tests in 2009. Valve N63790-00-0019 tested at -3.35 percent deviation and N63790-00-0020 tested at -3.32 percent deviation, both greater than the +/- 3 percent deviation for set pressure (AS ME and Technical Specification limits). The licensee's review of the 2009 SRV failures (CR 1159523) identified the cause as set pOint drift. The licensee did not identify that the valves had gone seven years between testing. Therefore, if the cause were set point drift, it is reasonable to assume the valves went out of tolerance during this final year beyond the six year test periodicity. Since PPL failed to identify the additional population of valves that had gone beyond their testing periodicity and failed to identify this potential cause for the failure, the NRC added value to PPL's evaluation and this finding is being treated as NRC identified in accordance with IMC 0612 guidance.

PPL has entered this issue into their CAP, has initiated action to revise their 1ST program to make it consistent with the ASME OM Code, and has submitted or prepared Relief Requests for all currently installed valves which have or will exceed the six year test interval before the next refueling outage.

Analysis:

The fact that PPL's 1ST testing program for Class I SRVs was not consistent with the underlying ASME OM code requirements is a performance deficiency which was reasonably within PPL's ability to foresee and prevent. The finding affects the equipment performance attribute of the Mitigating Systems cornerstone and the corresponding cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (Le.,

core damage). The finding is also similar to IMC 0612, "Power Reactor Inspection Reports," Appendix E. "Examples of Minor Issues,* example 1.c in that a missed surveillance is more than minor if, when tested, the equipment fails its test acceptance criteria as two SRVs did in this case. The inspectors assessed this finding in accordance with IMC 0609, Attachment 4, "Phase 1 - Initial Screening and Characterization of Findings." This finding was determined to be of very low safety significance because it was not a design or qualification deficiency, did not represent a loss of system safety function, did not represent a loss of safety function of a single train for greater than its TS allowed outage time, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event.

This finding was assigned a cross-cutting aspect in the area of Operating Experience because PPL failed to collect. evaluate, and communicate OE in a timely manner.

Specifically, PPL failed to identify that ASME OM Code Interpretation 01~18 had been issued in 2003 and also failed to evaluate 2007 industry OE [P.2.(a)].

Enforcement:

10 CFR 50.55a, "Codes and Standards" states, in part that 'Throughout the service life of a boiling or pressurized water cooled nuclear power facility, pumps and valves which are classified as ASME Code Class 1, Class 2, and Class 3 must meet the inservice testing requirements set forth in the ASME OM Code and addenda that become effective subsequent to that 120 month intervaL" Susquehanna committed to the 1998 Edition through the 2000 Addendum of the ASME OM Code. Section 1-1330 of Mandatory Appendix I of the 1998 ASME OM Code states, in part, Class I SRVs shall be tested every five years, ASME OM Code Interpretation 01-18 clarified this test periodicity shall be "Test" to "Test." Relief Request RR-02 granted PPL relief from the ASME Code requirement and increased the test interval from five years to six years. 10 CFR 50, Appendix B ,Criterion XI, "Test Control," states, in part, that a test program shall be established to test SSC's and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. Contrary to the above, from 2005 until November 2009, PPL's 1ST Program was not in accordance with the reqUirements of the underlying ASME Code requirements which resulted in at least two SRV failing to meet the test acceptance criteria. Since this finding is of very low safety significance and has been entered into PPL's CAP (CR 1181478), this violation is being treated as an NCV, consistent with the NRC Enforcement Policy. (NCV 05000387, 388/2010006-04, Failure to Test Reactor Vessel Safety Relief Valves in Accordance with ASME Code)

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors reviewed a sample of audits, including the most recent audit of the CAP, departmental self-assessments, Quality Assurance audits and assessments, and assessments performed by independent organizations. These reviews were performed to determine if problems identified through these assessments were entered into the CAP, when appropriate, and whether CAs were initiated to address identified deficiencies. The effectiveness of the audits and assessments was evaluated by comparing audit and assessment results against self-revealing and NRC-identified observations made during the inspection. A list of documents reviewed is included in the to this report.

b.

Assessment The inspectors concluded that self-assessments, audits, and other internal PPL assessments were generally adequate in that they were generally critical, probing, thorough, and effective in identifying issues. The inspectors observed that these audits and self-assessments were completed in a methodical manner by personnel knowledgeable in the subject: The audits and self-assessments were completed to a sufficient depth to identify issues that were entered into the CAP for evaluation.

However, the inspectors concluded that PPL's response to the assessments and audits was, in many instances, less than adequate. For example, the inspectors determined that PPL's site Quality Assurance organization has been effective in identifying issues during the performance of audits and assessments. For example, since 2008, 20 findings were identified. However, station response to the findings has required Quality Assurance to appropriately elevate 10 of the findings and escalate 1 finding. The Quality Assurance organization elevates a finding to formally provide line management with an opportunity to take action to correct a problem. If an elevated finding is not being adequately addressed, Quality Assurance could escalate the finding. This action brings the issue to the attention of progressively more senior levels of management. The inspectors noted that Quality Assurance elevated or escalated the findings due to either:

(1) not completing corrective actions in a timely manner or

(2) recurrence of the issues.

Of particular note, PPL's Quality Assurance identified findings regarding trending and the self-assessment program not contributing to improving plant performance. The inspectors noted that both of these findings had to be elevated due to overdue corrective actions by the station. At the time of the inspection corrective actions remained incomplete.

With respect to PPL's trending program, several aspects were determined to be ineffective and in need of improvement. These observations were acknowledged by the licensee. Specifically, the inspectors observed that some departments have not put a priority on quarterly Responsibility Center Quarterly trend reviews as demonstrated by the failure to perform quarterly department trend reviews. For example, from the third quarter 2008 through the third quarter 2009 (five quarters). Maintenance, Health Physics and Work Management have only performed 2 of 5 Responsibility Center (Le.,

Department) Quarterly Trend Reports.

Prior to the inspection, PPL identified problems and corrective actions in this area. PPL identified that performance improvement tools such as self-assessments, benchmarking, and trending are not used collectively to drive performance improvement. This included the determination that:

(1) station level CAP trending analysis is not consistently performed and results provide limited value and

(2) functional unit quarterly CAP trending analysis and reporting is not being conSistently performed by all functional units.

In addition. PPL determined that internal oversight groups have frequently identified problems with the CAP, but have not effectively ensured that management's response was appropriate. Corrective actions were planned at the time of the inspection (CRs 1194026. 1222764, and 1222767).

c. Findings

No findings of significance were identified.

.4 Assessment of Safety Conscious Work Environment

a. Background On January 28, 2009, the NRC issued a Potential Chilling Effect Letter advising PPL of concerns related to the SCWE at Susquehanna and requested PPL to provide:

(1) a description of PPL's current action plans to address existing SCWE concerns to preclude a chilled work environment at Susquehanna;

(2) PPL plans for further evaluating the health of the SCWE at Susquehanna; and

(3) the metrics PPL intended to monitor to determine the effectiveness of their actions and ensure a SCWE at the Susquehanna site (ML090280115). Also, on January 28,2009, the NRC issued Susquehanna Steam Electric Station - NRC Integrated Inspection Report 05000387; 388/2008005 (ML090230434) which described the SCWE concerns at PPL and provided additional background.

PPL completed their RCA of the work environment issues in May 2009. The NRC reviewed the RCA, as documented in NRC Integrated Inspection Report 05000387; 388/2009003 (ML092230158), and conducted a review of PPL's progress in implementing corrective actions in the third quarter of 2009, as documented in NRC Integrated Inspection Report 05000387; 388/2009004 (ML093170275). During the fourth quarter of 2009, the NRC reviewed the results of an independent third party safety culture survey performed by an independent third party vendor, as documented in NRC Inspection Report 05000387; 388/2009005 (ML100321652).

b. Inspection Scope

The inspectors reviewed the SCWE at Susquehanna through conduct of the following activities:

• During interviews with staff personnel, the inspectors questioned individuals regarding: their willingness to raise safety concerns, their knowledge of the avenues available for raising safety concerns, the effectiveness of actions taken by management to foster a SCWE at the site, and their knowledge of individuals who had experienced a negative reaction for raising a safety concern.

• The inspectors reviewed implementation of the site employee concerns program (ECP). The inspectors compared the number and type of issues documented in the Susquehanna ECP between September 2007 to January 2010 to the number and type of issues documented as Susquehanna NRC allegations for that same period.

The inspectors reviewed the site procedure for conducting ECP investigations and reviewed a sample of ECP files to assess the program's effectiveness at addressing potential safety issues. The inspectors also reviewed how the program handled two ongoing ECP investigations.

• The inspectors conducted interviews of various groups across the site including both bargaining unit and management personnel in order to assess SCWE. The inspectors interviewed groups from Electrical Maintenance, I&C Maintenance, Chemistry, and Quality Assurance. The results of these group interviews were compared with other group interview results conducted during a third quarter 2009 problem identification and resolution inspection sample.

• The inspectors observed a plant management meeting where PPL management received a debrief from the independent third party vendor concerning the results of their SCWE survey issued on December 15, 2009. The inspectors also attended employee All Hands meetings conducted on January 15, 2010, during which PPL management discussed the Susquehanna Vision. Goals, and Improvement Plans.

• With the support of the Agency Allegation Advisor, the inspectors reviewed the results of PPL's SCWE metrics. Specifically, metrics from March through October 2009 were reviewed for trends and were evaluated to assess the effectiveness of PPL's actions to ensure a SCWE at the site.

c.

Assessment Team Observations Based on interviews. observations of plant activities, and reviews of the CAP and the ECP, the inspectors determined tha~ in general, site personnel were willing to identify and raise safety issues. All persons interviewed demonstrated an adequate knowledge of the avenues available for raising safety concerns including CAP and ECP.

Following the review of ECP, the inspectors determined that improvements have been made in this area. Over the last 2 years, the ECP program has underwent several key personnel and programmatic changes, including the hiring of a new onsite ECP representative. PPL issued several focused communications informing the plant of the changes and promoting new alternative methods to raise a concern anonymously. As a result, site personnel appear to be more willing to use the ECP program as evidenced by a closer alignment in the number of ECP cases and NRC allegations.

The inspectors observed that PPL appeared to be making progress with respect to SCWE; however, the inspectors identified during several interviews that site personnel remained concerned about staffing issues, knowledge transfer issues, and issues regarding CAP ineffectiveness in addressing long term concerns.

SCWE Metrics Reviews Although PPL initially developed 24 SCWE metrics, PPL adjusted the number to 19 by October 2009. The inspectors determined that the reduction in the number of metrics did not constitute a loss of effectiveness in evaluating SCWE, but rather reflected learnings and adjustments as more information became available.

Regarding the five pillars of SCWE, metrics associated with:

• The Willingness to Raise Concerns Using Normal Problem Resolution Processes remained relatively constant with CRs continuing to be written at low thresholds. In addition, the inspectors noted an increase in the use of anonymous and external reporting processes from March through October 2009.

• Management Effectiveness at Resolving Concerns using Normal Problem Resolution Processes showed improvement in the number of backlogged and overdue corrective actions to prevent recurrence.

• The Effectiveness of the Alternate Resolution Processes remained relatively constant.

• Management Effectiveness at Detecting and Preventing Retaliation showed a decreasing trend in the number of harassment, intimidation, retaliation, and discrimination related issues raised by Susquehanna personnel.

• The General Work Environment (GWE) indicated generally improving trends. The one exception was the Operator Aggregate Index which measured the number of open control room deficiencies, operator workarounds/challenges, limiting conditions of operations, and operability determinations. PPL noted the negative trend and is developing a recovery plan to address the issues associated with the index.

Overall, SCWE metrics have shown improvement for the period between March and October 2009. PPL has continued to revise the SCWE metrics as more information, evaluations, and analyses have been completed. When positive trends have not been sustained, PPL has developed recovery plans to address the underlying issues. Current focus areas include CR timeliness, the age of open CRs, and issues associated with the Operator Aggregate Index.

Conclusion:

Overall, during 2009, PPL's corrective actions appear to have been effective and PPL has made reasonable progress in addreSSing SCWE concerns as demonstrated by inspection results, allegation trend data, SCWE metrics, surveys, and the development and use of alternate processes to raise concerns. While there has not been sufficient time to make broad conclusions regarding the sustainability of PPL's corrective actions, initial trends provide indications of improvement in SCWE at the site.

d. Findings

No findings of significance were identified.

40A3 Event Followup (71153 - 1 Sample)

(Closed) License Event Report (LER) 05000388/2009-001-00. Multiple Test Failures of Main Steam Safety Relief Valves During the Susquehanna Unit 2 14th Refueling and Inspection Outage, three Main Steam SRVs failed to meet the setpoint criteria of +/- 3 percent set forth in Technical Specification 3.4.3. All three SRVs actuated at a setpoint less than the -3 percent criteria. The cause of the lower actuation was attributed to setpoint drift. This event was determined to be a Common Cause Inoperability of Independent Trains or Channels and reportable under 10 CFR 50. 73(aX2){vii). The SRVs remained functional and the Technical Specification required number of SRVs

(12) during that fuel cycle remained operable. There were no actual adverse consequences as a result of this event. The NRC resident inspectors had previously identified a Green NCV for failure to evaluate the cause of the SRVs as required by the ASME code. Also, an SUV NCV was issued to PPL for failing to properly report this event as required by 10 CFR 50.73 within 60 days. These violations were documented in sections 1R12 and 1R20 respectively, of NRC inspection report 05000387; 388/2009003.

The inspectors reviewed this LER and the PPL CRs associated with this issue including all associated corrective actions. While reviewing this LER the inspectors identified an additional performance deficiency related to improper control of the ASME required SRV testing resulting in an improper testing frequency of the SRV since 2005. This extended testing frequency was a contributing cause to the SRV test failures discussed in this LER, but the licensee did not identify this cause in their evaluation. This resulted in a Green NCV documented in Section 40A2.2 of this report. This LER is closed.

40A6 Meetings. Including Exit On January 29,2009, the inspectors presented the inspection results to Mr. J. Helsel, Susquehanna Plant Manager, and other members of the Susquehanna staff. The inspectors confirmed that proprietary information was reviewed by inspectors and returned to the licensee during the course of the inspection, but the content of this report includes no proprietary information.

On February 18, 2009, the inspectors re-exited and presented the results of inspection to Mr. T. Rausch, Senior Vice President and Chief Nuclear Officer, and other members of the Susquehanna staff.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

T. Rausch, Senior Vice President and Chief Nuclear Officer

J. Helsel, Plant Manager

B. O'Rourke, Senior Engineer, Nuclear Regulatory Affairs

J. Scopelliti, Community Relations/Corporate Communications

P. Brady, Supervisor, Electrical and I&C Design Engineering

l. Yupco, Executive Technical Assistant to Chief Nuclear Officer

R. Smith, General Manager-Programs

B. Cooper, Senior Engineer, Corrective Action and Assessment

l. West, Supervisor, Corrective Action and Assessment

J. Seek, Manager, Quality Assurance

T. DeBortoli, Senior Assessor, Quality Assurance

A. Peimonteso, Supervisor, Station Engineering

D. D'Angelo, Manager, Station Engineering

A. Fitch, Manager, Nuclear Training

M. Schwiker, Manager, Outage and Work Management

R. Kessler, Supervisor, Radiation Operations and Health Physics

M. Rochester, Special Project Coordinator, Nuclear RegUlatory Affairs

J. Petrilla, Supervisor, Nuclear Regulatory Affairs

D. Crispell, Employee Concerns

R. Schechterly, Operating Experience Coordinator, Corrective Action and Assessment

l. Caspersen, Control Room Supervisor, Operations

T. IlIiadis, Manager, Operations

J. Tucker, Manager, Maintenance

M. Palmer, Project Manager, General Work Environment

M. Crowthers, Manager, Nuclear Regulatory Affairs

R. Hoffert, Representative, Employee Concerns Program

l. Frace, Maintenance Production Foreman, Nuclear Field Services

W. Morrissey, Manager Electrical Maintenance

S. Muntzenberger, Senior Engineer Mechanical Maintenance

P. Phillips, Senior Engineer Program and Components

V. Vincek, Project Manager, Performance Improvement

G. Machalick, Senior Program and Components Engineer

F. Negvesky, Senior Electricall&C Systems Engineer

R. Bogar, Systems Engineer

l. Caspersen, Unit Supervisor

D. D'Angelo, Manager, Station Engineering

R. Lengel, Senior Emergency Planning Coordinator

P. McGlynn, Work Management Project Manager, Work Control Systems

W. Morrissey, Manager Electrical Maintenance

F. O'Neill, Manager Mechanical Maintenance

A. Piemontese, Supervising Engineer, Station Engineering

S. Richard, Maintenance Production Foreman, Nuclear Field Services

W. Steltz, Maintenance Production Foreman, Nuclear Field Services

D. Stokes. Senior Chemist

G. Treven, Supervisor Electrical I&C Systems

J. Tucker, Vice President Nuclear Operations Management

M. Yackoski, Senior Program and Components Engineer

A. Zito, Work Week Manager, Work Control Systems

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

None

Opened and Closed

05000387, 388/2010006-01 NCV Inadequate PM Implementation Procedure Leading to Programmatic Deficiencies in the PM Program [Section 40A2.1.c{ 1)J

05000387, 388/2010006-02 NCV Failure to Correct Non-conservative Maximum Safe Water Levels [Section 40A2.1.c(2)]

05000387, 388/2010006-03 NCV Failure to Follow Condition Report Process for Overdue Actions {Section 40A2.1.c(3)]

05000387, 388/2010006-04 NCV Failure to Test Reactor Vessel Safety Relief Valves in Accordance with ASME Code

[Section 40A2.2.c(1)]

Closed

05000388/200900100 LER Multiple Test Failures of Main Steam Safety Relief Valves (40A3)

Discussed

None