IR 05000336/2009005

IR 05000336/2009005, 05000423/2009005; October 1, 2009 - December 31, 2009; Millstone Power Station Unit 2 and Unit 3; Operability Evaluations; Refueling and Other Outage Activities; Event Follow-up

ML100341288
Person / Time
Site:	Millstone
Issue date:	02/03/2010
From:	Diane Jackson NRC/RGN-I/DRP/PB5
To:	Heacock D Dominion Resources
References
FOIA/PA-2011-0115 IR-09-005
Download: ML100341288 (52)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION

REGION I

475 ALLENDALE ROAD

SUBJECT:

MILLSTONE POWER STATION - NRC INTEGRATED INSPECTION REPORT 05000336/2009005 AND 05000423/2009005

Dear Mr. Heacock:

On December 31, 2009, the U.s. Nuclear Regulatory Commission (NRC) completed an inspection at your Millstone Power Station Unit 2 and Unit 3. The enclosed inspection report documents the inspection results, which were discussed on January 13. 2010, with Mr. A. J. Jordan, and other members of your staff.

The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission's rules and regulations, and with the conditions of your license. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel.

This report documents one NRC-identified finding and three self-revealing findings of very low safety significance (Green). Two of these findings were determined to involve violations of NRC requirements. However, because of the very low safety significance and because they have been entered into your corrective action program, the NRC is treating these findings as non-cited violations (NCV), consistent with Section VI.A.1 of the NRC Enforcement Policy. If you contest any NCV in this report, 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 Administrat'or, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Senior Resident Inspector at Millstone. 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, 10 the Regional Administrator. Region I, and the NRC Senior Resident Inspector at Millstone. The information you provide will be considered in accordance with Inspection Manual Chapter 0305. In accordance with Title 10 of the Code of Federal Regulations (CFR) Part 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 public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of the 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, Mf.

Donald E. Jacks ,Chief Projects Branch 5 Division of Reactor Projects Docket Nos. 50-336, 50-423 License Nos. DPR-65, NPF-49 Enclosure: Inspection Report 05000336/2009005 and 05000423/2009005 w/Attachment: Supplemental Information cc w/encl: Distribution via Listserv

SUMMARY OF FINDINGS

IR 05000336/2009005, 05000423/2009005; October 1,2009 - December 31,2009; Millstone

Power Station Unit 2 and Unit 3; Operability Evaluations; Refueling and Other Outage Activities;

Event Follow-up.

The report covered a three~month period of inspection by resident and region-based inspectors.

Four Green findings, two of which were non-cited violations (NCV), were identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process (SOP}." The cross-cutting aspect was determined using IMC 0305, "Operating Reactor Assessment Program." Findings for which the SOP does not apply may be Green or be assigned a severity level after NRC management review. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649. "Reactor Oversight Process," Revision 4. dated December 2006.

Cornerstone: Initiating Events

Green.

A self-revealing, Green finding (FIN) was identified for Dominion's failure to take adequate precautions and adequately schedule maintenance on a Unit 2 motor operated disconnect (MOD) associated with the main transformer. The maintenance on the MOD disrupted a switch connection and caused increaSing conductor temperatures, which forced Dominion to perform an unplanned shutdown of the Unit 2 reactor.

Dominion has taken corrective action to modify the appropriate procedures and has entered this issue into their corrective action program (CR 351109).

This finding was more than minor because it was associated with the Equipment Performance attribute of the Initiating Events cornerstone, and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. The inspectors performed a Phase 1 screening in accordance with NRC Inspection Manual Chapter (IMC) Attachment 0609.04, "Phase 1 -Initial Screening and Characterization of Findings." The inspectors determined the finding was of very low safety significance (Green) because it did not contribute to the likelihood that mitigation equipment or functions would not be available.

Enforcement action did not apply because the performance deficiency did not involve a violation of a regulatory requirement. Because this finding did not involve a violation of regulatory requirements, and has very low safety significance (Green), it has been identified as a finding (FIN). This finding had a cross-cutting aspect in the Human Performance cross-cutting area, Work Control component. because Dominion did not appropriately incorporate risk inSights and work scheduling of activities consistent with nuclear safety. H.3(a) (Section 1R20)

• GreEm. A

Green.

self-revealing non-cited violation (NCV) of Millstone Technical Specification (TS) 6.8.1(a}. "Procedures." was identified for Dominion's failure to adequately implement procedures during partial draining of the reactor coolant system (RCS) in preparation for defueling the reactor. Dominion did not properly align the reactor vessel vent path prior to partially draining the RCS as required by Dominion procedure OP w2301E, "Draining the RCS (ICCE)." Immediate corrective actions included stopping the drain down and verifying the valve alignment. Dominion entered this issue into the corrective action program (CR 351853).

This finding was more than minor because it was associated with the Human Peliormance attribute of the Initiating Events cornerstone, and affected the cornerstone objective to limit the likelihood of those events that challenge critical safety functions during shutdown operations. Specifically, the operators failed to properly position 2-RC 447 to vent to the reactor vessel during partial drain down of the reactor vessel. The inspectors determined the significance of this finding using NRC Inspection Manual Chapter 0609, Appendix "G," *Shutdown Operations Significant Determination Process."

This finding had a cross-cutting aspect in the Human Performance cross-cutting area,

Work Practices component, because Dominion failed to define and effectively communicate expectations regarding procedural compliance, and personnel follow procedures. H.4(b) (Section 1R20)

Cornerstone: Mitigating Systems

Green.

A Green, self-revealing finding (FIN) was identified for Dominion's failure to complete effective corrective actions for known degraded conditions associated with the VR-11 and VR-21 120-volt AC non~vital instrument power supplies. This condition led to a loss of annunciators and declaration of a Notification of Unusual Event (NOUE) on November 15, 2009. Dominion took immediate action to expedite the installation of an uninterruptible power supply (UPS) for VR-11 and VR-21.

This finding was more than minor because it was associated with the Procedure Quality attribute of the Mitigating Systems cornerstone and affected the cornerstone objective of ensuring capability of systems that respond to initiating events to prevent undesirable consequences. The finding was determined to be of very low safety significance (Green) because the finding did not involve a design or qualification deficiency resulting in loss of operability or functionality, did not result in a loss of system safety function, and did not screen as potentially risk significant due to external initiating events. No violation of regulatory requirements occurred, because the annunciator system is non safety related. This finding had a cross-cutting aspect in the Problem Identification and Resolution cross-cutting area, Corrective Action Program component, because Dominion did not take appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with their safety Significance and complexity. P.1(d) (Section 40A3)

Cornerstone: Barrier Integrity

Green.

The inspectors identified a Green, nonwcited violation (NCV) of Millstone Power Station Technical Specification (TS) surveillance requirement 4.3.3.8 for Dominion's failure to perform a channel calibration of the Unit 2 Inadequate Core Cooling Monitoring System (ICCMS) every 18 months. Dominion entered the issue into their corrective action program and concluded that the ICCMS was operable. Dominion performed a risk assessment of the missed surveillance in accordance with TS 4.0.3, and determined that the completion of the surveillance could be delayed up to the 18 month surveillance interval without a significant increase in risk.

This finding was more than minor because it was associated with the Procedure Quality attribute of the Barrier Integrity cornerstone. and affected the cornerstone objective of providing reasonable assurance that physical design barriers (fuel cladding) protect the public from radionuclide releases caused by accidents or events. Specifically, in 1997,

Dominion incorrectly revised surveillance procedure SP 2407A so that It no longer met the requirements of TS surveillance requirement 4.3.3.8. The inspectors determined the finding was of very low safety significance (Green) because it was associated with a fuel barrier of the Barrier Integrity cornerstone. This finding did not have a cross-cutting aspect because the performance deficiency occurred in 1997, and was not indicative of current performance. (Section 1R15)

REPORT DETAILS

Summary of Plant Status

Millstone Power Station Units 2 and 3 began the inspection period operating at 100 percent power. On October 6,2009, Unit 2 was shutdown to begin refueling outage 2R19. Unit 2

-returned to 100 percent power on November 18,2009, and remained at or near 100 percent power for the remainder of the inspection period. On December 19, 2009, the Unit 3 reactor tripped due to a damaged main generator output breaker, and remained shutdown to repair the breaker thrQugh the remainder of the inspection period,

REACTOR SAFETY

Cornerstones: Initiating Events, Mitigating Systems, and Barrier Integrity

1R01 Adverse Weather Protection

Seasonal Site Inspection

a. Inspection Scope

The inspectors reviewed the readiness of Unit 2 and Unit 3 for seasonal cold weather.

The inspectors reviewed selected equipment, instrumentation, and supporting structures to determine if they were configured in accordance with Dominion's procedures, and that adequate controls were in place to ensure functionality of the systems. The inspectors reviewed the Unit 2 and 3 Updated Final Safety Analysis Report (UFSAR)and Technical Specifications (TS), and compared the analysis with procedure requirements to ascertain that procedures were consistent with the UFSAR. The inspectors performed partial walkdowns of the Unit 2 Condensate Storage and Surge Tanks, and Refueling and Primary Water Storage Tanks. The inspectors also performed partial walkdowns of the Unit 3 Condensate Storage and Surge Tanks, Intake Structure ventilation, Main Steam Isolation Valve Building. and heat tracing for safety related systems. The walkdowns were performed to verify completion of cold weather preparations. Documents reviewed during the inspection are listed in the Attachment.

No findings of significance were identified.

1R04 Eguipment Alignment (71111.04 ~ 5 samples)

Partial System Walkdowns

a. Inspection Scope

The inspectors performed five partial system walkdowns during this inspection period.

The inspectors reviewed the documents listed in the Attachment to determine the correct system alignment. The inspectors performed a walkdown of each system to determine if the critical portions of the selected systems were correctly aligned in accordance with the procedures, and to identify any discrepancies that may have had an effect on operability. The walkdowns included selected switch and valve position checks, and verification of electrical power to critical components. Finally, the inspectors evaluated other elements, such as material condition, housekeeping. and component labeling. The fonowing systems were reviewed based on their risk significance for the given plant configuration:

• Spent fuel pool cooling system on October 15, 2009; Unit 3

• "An Service Water (SW) System while the "B" train was out of service (OOS) for planned maintenance on October 14, 2009;

• "B" Motor Driven Auxiliary Feedwater (MDAFW) Pump and the Turbine Driven Auxiliary Feedwater (TDAFW) Pump while the "A" MDAFW Pump was OOS for surveillance testing on November 9, 2009;

• "An Charging while the "6" train was OOS for surveillance testing on November 18, 2009; and

• "A" Emergency Diesel Generator (EDG) while the "6" EDG was OOS for planned maintenance on December 16,2009.

b. Findings

No findings of significance were identified.

1ROS Fire Protection (71111.050 ~ 8 samples)a. l.n.§Qection Scope The inspectors performed walkdowns of eight fire protection areas. The inspectors reviewed Dominion's fire protection program to determine the required fire protection design features, fire area boundaries, and combustible loading requirements for the selected areas. The inspectors walked down these areas to assess Dominion's control of transient combustible material and ignition sources. In addition, the inspectors evaluated the material condition and operational status of fire detection and suppression capabilities, fire barriers, and any related compensatory measures. The inspectors compared the existing conditions of the areas to the fire protection program requirements to determine if all program requirements were being met. Documents reviewed during the inspection are listed in the Attachment. The fire protection areas reviewed included:

• Containment Building Elevation -3', Zone C-1;

• Containment Building Elevation -22'-6", Zone C-1;

• Containment Building Elevation 14'-6", ZOl1e C-1;

• Containment Building Elevation 38'-6", Zone C-1;

• North Containment Recirculation Cooler Cubicle, Fire Area ESF-2;

• North Residual Heat Removal Heat Exchanger Cubicle, Fire Area ESF-3;

• East Floor Area, Fire Area ESF-4; and

• "An EDG Enclosure, Fire Area EG-3, Zone A.

b. Findings

No findings of significance were identified.

1R06 Flood Protection Measures (71111.06 - 2 sa mples)

.1 Underground Power gable

a. Inspection Scope

The inspectors inspected underground cable vault 3EMH*1, which contained, in part, the 4160 volt (V) cables for the "An & "c" SW pumps. The inspectors evaluated Dominion's protection of safety-related systems from subsurface vault conditions. The inspectors performed a walkdown of the area, Interviewed the system engineer, and reviewed the insulation ratings of the 4160V cables. Documents reviewed during the inspection are listed in the Attachment.

b. Findings

No findings of significance were identified.

.2 Internal Flooding

a. Inspection Scope

The inspectors reviewed the flood protection measures for the equipment in the Unit 2 direct current (~C) Switchgear and Battery Rooms. The inspectors evaluated Dominion's protection of safety-related systems from internal flooding conditions. The inspectors performed a walkdown of the area, interviewed the system engineers, reviewed the internal flooding evaluation, and verified that the floor drain configuration remained consistent with those Indicated in the design basis and flooding documents.

Oocuments reviewed during the Inspection are listed in the Attachment.

b. Findings

No findings of significance were Identirred.

1R08 Inservice Inspection (lSI)

a. Inspection Scope

The purpose of this inspection was to assess the effectiveness of the licensee's inservice inspection program for monitoring degradation of the reactor coolant system boundary and risk significant piping system boundaries. The inspector assessed the inservice inspection activities using the criteria specified in the American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessel Code,Section XI.

One repair activity was reviewed. consisting of the reactor coolant pump seal weld. to ensure that the welding activities and applicable non-destructive examination (NDE) was performed in accordance with ASME Code requirements. the inspector reviewed for adequacy the root cause analysis for the pressure boundary leak related to the repair.

The inspector reviewed the results of the automated visual test (VT) examinations of a sample of reactor vessel head penetrations. The inspector reviewed licensee criteria for confirming visual examination quality and Instructions for resolving interference or masking issues to confirm they are consistent with 10 CFR 50.55a(g)(6)(ii)(0). The inspector reviewed the records recording the extent of inspection for each penetration nozzle including documents which resolved interference or masking issues to confirm that the extent of examination meets 10 CFR 50.55a(g)(6}(ii)(0). The inspector reviewed coverage achieved with no limitations in coverage recorded. The inspector verified that the activities were performed In accordance with the requirements of 10 CFR 50.55a(g}(6)(ii)(D), and indications and defects, if detected, were dlspositioned in accordance with 10 CFR 50.55a(g)(6)(ii)(0).

The results of a number of ultrasonic examinations were reviewed. The phased array examination of a diSSimilar metal weld was reviewed. Although the steam generators were not examined by eddy current during this outage, the inspector reviewed the engineering justification for deferring the inspection, and compared the justification with the results of the last eddy current inspection of the steam generators. The inspector verified that the basis for deferral met the NRC accepted Electric Power Research Institute (EPRI) Steam Generator management guideline recommendations.

ThE~ inspector reviewed the dissimilar weld metal program using the guidance in NRC inspection procedure 71111.08P, and Temporary Instruction ("1"1) 172. The inspector determined what deviations from EPRI's Materials Reliability Program (MRP) 139 guidelines were planned, and the basis for the deviation. The inspector reviewed the results of volumetric examinations utilizing the guidance in MRP-139 for volumetric examinations being performed during the outage. The inspector reviewed the phased array results of a number of welds to verify conformance with MRP-139, Sec. 5.1. The inspector verified conformance with the relief request for a weld overlay. The inspector verified that personnel performing the examination were qualified, and deficiencies were being appropriately dispositioned.

b. Findings

No findings of significance were identified.

1R11 LicEmsed Operator Regualification Program

.1 Resident Inspector Quarterly Review (71111.11 Q - 2 samples)

a. Inspection Scope

The inspectors observed simulator-based licensed operator requalification training for Unit 2 on December 4,2009, and for Unit 3 on November 19, 2009. The inspectors evaluated crew performance in the areas of clarity and formality of communications; ability to take timely actions; prioritization, interpretation, and verification of alarms; procedure use; control board manipulations; oversight and direction from supervisors; and command and control. Crew performance in these areas was compared to Dominion management expectations and guidelines as presented in procedure OP-MP*

100-1000, "Millstone Operations Guidance and Reference Document." The inspectors compared simulator configurations with actual control board configurations. The inspectors also observed Dominion evaluators discuss identified weaknesses with the crew and individual crew members, as appropriate. Documents reviewed during the inspection are listed in the Attachment.

b. Findings

No findings of significance were identified.

.2 Biennial Licensed Operator Regualification (71111.11 B-1 sample)

a. Inspection Scope

The following inspection activities were performed using NRC NUREG 1021, Revision 9, "Operator Licensing Examination Standards for Power Reactors," NRC inspection procedure 71111.11, "Licensed Operator Requalification Program," and 10 CFR 55.

A review was performed of recent operating history documentation found in the inspection reports, Dominion's corrective action program, and the most recent NRC plant issues matrix (PIM) . The inspectors also reviewed specific events from Dominion's corrective action program which indicated possible training deficiencies to verify that they had been appropriately addressed.

The three written examinations from 2008 and selected operating tests from the 2009 annual examination were reviewed for content, quality, and excessive overlap to ensure that these exams met the criteria established in the Examination Standards and 10 CFR 55.59.

On October 9,2009, the results of the annual operating tests for 2009 were reviewed to determine if pass/fail rates were consistent with the guidance of NUREG-1 021, Revision 9, *Operator Licensing Examination Standards for Power Reactors," and NRC Manual Chapter 0609, Appendix I, "Operator Requalification Human Performance Significance Determination Process (SDP)." The review verified the following:

• Crew pass rates were greater than 80%. (Pass rate was 100%);

• Individual pass rates on the dynamic simulator test were greater than 80%, (Pass rate was 100%);

• Individual pass rates on the job performance measures of the operating examination were greater than 80%, (Pass rate was 96.5%);

• Individual pass rates on the written examination (2008) were greater than 80%,

(Pass rate was 95.9%);

• More than 75% of the individuals passed all portions of the 2009 operating examination, (Pass rate was 96.5%);

• Crew pass rates were greater than 80%, (Pass rate was 100%);

• Individual pass rates on the dynamic simulator test were greater than 80%, (Pass rate was 100%);

• Individual pass rates on the job performance measures of the operating examination were greater than 80%, (Pass rate was 95.0%);

• Individual pass rates on the written examination (2008) were greater than 80°10, (Pass rate was 95.4%); and

• More than 75% of the individuals passed all portions of the 2009 operating examination, (Pass rate was 95.0%).

Observations were made of the Unit 3 dynamic simulator examinations and job performance measures (JPM) administered during the week of August 31,2009 for Operations Crew E and Administrative Crew E. These observations included facility evaluations of crew and individual performance during the dynamic simulator examinations and individual performance of JPMs.

The: remediation plans for several Unit 2 and Unit 3 failures were reviewed to assess the effectiveness of the remedial training. Eight Unit 3 Dominion reactivations were reviewed to ensure that Dominion conditions and applicable program requirements were mel. Five reactor operator records were checked to verify the maintenance of an active license.

Simulator performance and fidelity were reviewed for conformance to the reference plant control room. Selected simulator deficiency reports were reviewed to assess Dominion prioritization and timeliness of resolution. Simulator testing records were reviewed to verify that scheduled tests were performed.

A sample of records for requ8lification training attendance, program feedback, reporting, and six operator medical reports were reviewed for compliance with Dominion conditions, including NRC regulations. Two reactor operators were interviewed to assess the operator's perspectives regarding training quality, incorporation of feedback, simulator performance, and examination difficulty.

b. Findings

No findings of significance were identified.

1R12 Maintenance Effectiveness (71111.12Q.1 sample)

a. Inspection Scope

The inspectors reviewed Dominion's evaluation of degraded conditions, involving safety~

related structures, systems and components for maintenance effectiveness during this inspection period for the Unit 2 Enclosure Building Filtration System (EBFS). The inspectors reviewed Dominion's implementation of the "Maintenance Rule,"

10 CFR 50.65. The inspectors reviewed Dominion's ability to identify and address common cause failures, the applicable maintenance rule scoping document for each system, the current classification of these systems in accordance with 10 CFR 50.65 paragraph (a)(1) or (a}{2), and the adequacy of the performance criteria and goals established for each system, as appropriate. The inspectors also reviewed recent system health reports, condition reports (CR), apparent cause determinations, functional failure determinations, operating logs, and discussed system performance with the responsible system engineer. Documents reviewed during the inspection are listed in the Attachment.

b. Findings

No findings of significance were identified.

'I

R13 Maintenance Risk Assessments and Emergent Work Control

a. Inspection Scope

ThE~ inspectors evaluated online risk management for emergent and planned activities.

The~ inspectors reviewed maintenance risk evaluations, work schedules, and control room logs to determine if concurrent planned and emergent maintenance or surveillance activities adversely affected the plant risk already incurred with OOS components. The inspectors evaluated whether Dominion took the necessary steps to control work activities, minimize the probability of initiating events, and maintain the functional capability of mitigating systems. The inspectors assessed Dominion's risk management actions during plant walkdowns. Documents reviewed during the inspection are listed in the Attachment. The inspectors reviewed the conduct and adequacy of risk assessments for the following maintenance and testing activities:

• Shutdown risk assessment (Orange) during RCS drain down into reduced inventory operations for defueling on October 10, 2009;

• Shutdown risk assessment (Orange) during north bus outage on October 16, 2009;

• Shutdown risk assessment (Orange) during RCS drain down into reduced inventory operations and SI-306 valve repairs on October 26, 2009; and

• On-line risk assessment (Green) during maintenance on the "B" EDG and "B" Safety Injection pump on December 17,2009.

b. Findings

No findings ~f significance were identified.

1R15 Operability Evaluations

a. Inspection Scope

The inspectors reviewed seven operability determinations {OD. The inspectors evaluated the ODs against the guidance contained in NRC Regulatory Issue Summary 2005-20, Revision to Guidance Formerly Contained in NRC Generic Letter 91-18, "Information to Licensees Regarding Two NRC Inspection Manual Sections on Resolution of Degraded and Nonconforming Conditions and on Operability." The inspectors also discussed the conditions with operators, system engineers, and design engineers. Documents reviewed during the inspection are listed in the Attachment.

The inspectors reviewed seven operability determinations (00). The inspectors evaluated the ODs against the guidance contained in NRC Regulatory Issue Summary 2005"20, Revision to Guidance Formerly Contained in NRC Generic Letter 91-18, "Information to Licensees Regarding Two NRC Inspection Manual Sections on Resolution of Degraded and Nonconforming Conditions and on Operability." The inspectors also discussed the conditions with operators, system engineers, and design engineers. Documents reviewed during the inspection are listed in the Attachment. The inspectors reviewed the adequacy of the following evaluations of degraded or non-conforming conditions:

• Operational decision making (ODM) for CR 350860, "Generator Hydrogen Seal Failed Megger Test;"

• CR354434 dispositioning of a 5/8 inch bolt found in the reactor vessel;

• Condition Report Engineering Disposition (CRED) for CRs 355509 and 355455 for unrecoverable debris in fuel assemblies Y12. Y15, and Y35;

• ODM for CR352045. "B" Reactor Coolant Pump (RCP) electrical penetration M2SWX-A2-T1 failed locallaak rate test (LLRT) administrative limit;

• Engineering information record Document No. 51-9126147-00 which evaluates the effects of the thimble tubes being cut 1 ~ inches shorter than designed;

• Channel "S" Wide Range Logarithmic Nuclear Instrument OOS for reactor startup; and

• CR359570 seven core exit thermocouples reading outside tolerance.

b. Findings

Introduction:

The inspectors identified a Green, non-cited violation (NCV) of Millstone Power Station Technical Specification (TS) surveillance requirement 4.3.3.8 for Dorninion's failure to perform a channel calibration of the Unit 2 Inadequate Core Cooling Monitoring System (ICCMS) every 18 months.

Description:

On November 15, 2009. condition report (CR) 358117 was submitted as a result of one of the retests for the incore thimble replacement modification. The CR identified that seven of the core exit thermocouples (CET) indicated 12 degrees higher than cold leg temperature (Tcold) while at hot zero power. These seven CETs also indicated 12 degrees higher than Tcold prior to the modification. The inspectors reviewed the most recent surveillance performed and TS; interviewed the system engineer; and questioned whether the channel calibration required by the TS had been performed. After review, Dominion concluded that the required channel calibration for the ICCMS, which includes the CETs, reactor vessel coolant level indication, and reactor coolant system subcooled/superheat monitor, had not been adequately performed since 1997.

The apparent cause evaluation determined that surveillance procedure SP 2407 A was revised in 1997 to support new equipment that was installed under modification DCR M2**96-077, "Replacement Inadequate Core Cooling Monitoring System (ICCMS)." The surveillance was approved in accordance with existing Millstone procedures. The new ICeMS system has input cards and an analog to digital (AID) card that must be adjusted separately. The personnel involved with the procedure revision incorrectly assumed that adjusting the Digital and Analog Loopback and Calibration card, which adjusts the AID card, was all that was required for the calibration.

Dominion concluded that the seven individual CETs were inoperable, but the overall CET system remained operable since the number of remaining operable CETs per quadrant was greater than the TS required minimum. Dominion also concluded that the realr;tor vessel coolant level indication and reactor coolant system subcooled/superheat monitor were operable. Dominion entered the issue into their corrective action program (CR 359247), and performed a risk assessment of the missed surveillance in accordance with TS 4.0.3, which determined that completion of the surveillance could be delayed up to the 18 month surveillance interval without a significant increase in risk.

The! inspectors reviewed the risk assessment and verified that there was no unacceptable increase in risk.

Analysis:

The inspectors determined that Dominion's failure to provide an adequate calibration procedure for the ICCMS was a performance deficiency. The cause was reasonably within Dominion's ability to foresee and correct, and should have been prevented. Traditional Enforcement did not apply, as the issue did not have actual or potential safety consequence, had no willful aspects, nor did it impact the NRC's ability to perform its regulatory function.

A review of NRC Inspection Manual Chapter 0612, Appendix E, "Minor Examples,"

revealed that no minor examples applied to this finding. This finding was more than minor because it was associated wi,th the Procedure Quality attribute of the Barrier Integrity cornerstone, and affected the cornerstone's objective of providing reasonable assurance that physical design barriers (fuel cladding) protect the public from radionuclide releases caused by accidents or events. Specifically, in 1997, Dominion incorrectly revised surveillance procedure SP 2407A, which caused them to no longer meHt the requirements of TS surveillance requirement 4.3.3.8 to perform a channel calibration of the Unit 2 ICCMS every 18 months.

Thl3 inspectors performed a Phase 1 screening in accordance with NRC Inspection Manual Chapter (IMC) Attachment 0609.04, "Phase 1 - Initial Screening and Characterization of Findings." The inspectors determined the finding was of very low safety significance (Green) because it was associated with a fuel barrier of the Barrier Integrity cornerstone. This finding did not have a cross*cutting aspect because the performance deficiency occurred in 1997, and was not indicative of current performance.

Enforcement:

Millstone Power Station TS surveillance requirement 4.3.3.8 requires that a channel calibration of the ICCMS be performed every 18 months. Contrary to the above, from 1997 until December 2009, Dominion did not perform an adequate channel calibration of the ICCMS. Following discovery of the inadequate channel calibration, Dominion performed an overall assessment, including a risk assessment that concluded there was not a significant increase in risk by delaying completion of the surveillance until the procedure could be performed during the next refueling outage. Because this violation is of very low safety significance (Green). and has been entered into Dominion's corrective action program (CR 359247), this violation is being treated as an NCV, consistent with the NRC Enforcement Policy. (NCV 0500033612009005-01, TS Surveillance Channel Calibration of ICCMS Not Performed)

1R18 Plant Modifications

a. Inspection Scope

To assess the adequacy of the modifications, the inspectors performed walkdowns of selected plant systems and components, Interviewed plant staff, and reviewed applicable documents, including procedures, calculations, modification packages, engineering evaluations, drawings, corrective action program documents, the UFSAR, and TS. Design assumptions were reviewed to verify that they were technically appropriate and consistent with the UFSAR. For each modification, the 10 CFR 50.59 sCrE3enings or safety evaluations were reviewed. The inspectors also verified that procedures, calculations, and the UFSAR were properly updated with revised design information. In addition, the inspectors verified that the as-built configuration was accurately reflected in the design documentation, and that post-modification testing was adequate to ensure the structures, systems, and components would function properly.

Documents reviewed during the inspection are listed in the Attachment.

• Temporary modification to open 2-RW-27 in Mode 1 allowing for purification of the Refueling Water Storage Tank (RWST) via the spent fuel pool purification system;

and

• Permanent modification to install variable frequency drive units on the circulating water pumps.

b. Findings

No findings of significance were identified.

R19 Post-Maintenance Testing

a. Inspection Scope

The inspectors reviewed post-maintenance test (PMT) activities to determine whether the PMT adequately demonstrated that the safetYwrelated function of the equipment was satisfied, given the scope of the work specified, and that operability of the system was restored. In addition, the inspectors evaluated the applicable test acceptance criteria to evaluate consistency with the associated design and licensing bases, as well as TS requirements. The inspectors also evaluated whether conditions adverse to quality were entered into the corrective action program for resolution. Documents reviewed during the inspection are listed in the Attachment. The following maintenance activities and PMTs were evaluated:

• Automated Work Order (AWO) 53102300705 following Letdown Regenerative Heat Exchanger Outlet Temperature Loop (TI-221) testing and repair on November 11, 2009;

• AWO 53102302188 following Pressurizer Proportional Heater Controller testing and*

repair on November 12, 2009;

• AWO 53102221324 following RCP vibration monitoring system testing and repair on November 16, 2009;

• AWO 53102258097 following 2-SW-97A "B" circulating water pump cross-tie valve testing and repair on November 22, 2009;

• AWO 53M20808798 following the "B" heater drain pump testing and repair on iDecember 2, 2009;

• SP 3646A.1, "EDG "A" Operability Test," Revision 18 following maintenance on the jacket water and electrical systems on December 1,2009;

• SPROC OPS09-3~007, lave ReductionNalve Wide Open Test (ICCE)," Revision 000-01 as a result of the stretch power uprate on December 2, 2009; and

• SP 3630A.6-002. "Reactor Plant Component Cooling Water Pump 3CCP*P1 C Group "An Test," Revision 012 following pump bearing replacement on December 16,2009.

b. Findings

No findings of significance were identified.

1R20 Refueling and Other Outage Activitie§

Millstone Unit 2 Refueling Outage (2R19)

a. Inspection Scope

Dominion began refueling outage 2R19 on October 6, 2009, and completed the outage on November 18, 2009. The inspectors evaluated the outage plan and outage activities to determine if Dominion had considered risk, developed risk reduction and plant configuration control methods, considered mitigation strategies in the event of loss of safety functions, and adhered to licensee and TS requirements. The inspectors observed portions of the shutdown. cooldown. heat up and start up processes.

Additionally. the inspectors performed an initial containment Mode 3 walk down to eVl:lluate the as-found condition of containment. The inspectors also performed a final Mode 3 walk down to ensure that no loose material or debris, which could be transported to the containment sump, were present. The inspectors reviewed eRs to determine if conditions adverse to quality were entered for resolution. Documents reviewed for the inspection are listed in the Attachment. Some of the specific activities the inspectors observed and performed included:

• Reactor shutdown and cool down;

• Reactor water level drain down to the reactor flange;

• Midloop and reduced inventory operations;

• Reactor head lift;

• Fuel handling, core loading, and fuel element assembly tracking;

• Containment as-found walk down:

• Review of outage risk plan;

• Orange Risk - Replacement of main transformer insulators;

• Alloy 600 weld overlay project;

• Service Water piping inspections;

• Circulating Water pump "A" replacement;

• In-core instrument thimble replacement;

• RCS vacuum fill;

• Containment Integrated Leak Rate Test;

• Containment as-left walk down;

• Reactor Heat up;

• Reactor Start up;

• low Power Physics Testing;

• Reactor power ascension; and

• Unit 2 Generator synchronization to the grid.

.1 Implementation of Design Change Results in an Unplanned Shutdown of Reactor

Introduction:

A self-revealing. Green finding (FIN) was identified for Dominion's failure to take adequate precautions and adequately schedule maintenance on a Unit 2 motor operated disconnect (MOD) associated with the main transformer. The maintenance on the MOD disrupted a switch connection and caused increasing conductor temperatures.

which forced Dominion to perform an unplanned shutdown of the Unit 2 reactor.

Description:

On October 6,2009, with Unit 2.at 100 percent power, Dominion maintenance personnel began implementing design change notice (DCN) DM2-00-093 09 to install a rain guard intended to prevent water intrusion into the motor of the MOD for 15G-2X 1-4. While decoupling the vertical drive shaft of the MOD, a shift in the disconnect switch occurred. This resulted In arcing on the disconnect switch and increasing surface temperatures. Continued operation in this condition could have resulted in failure of the switch which in turn would have caused a reactor trip. Due to this condition, an unplanned shutdown of Unit 2 was performed.

MOlDs constructed of this design are known to occasionally have tension remaining post closure of the switch. and decoupling of the shaft can result in shifting of the switch.

This is what occurred on October 6, 2009 when Dominion attempted to perform maintenance on the MOD.

The Dominion root cause evaluation (RCE) determined the root cause to be a programmatic failure to identify and manage risk related to 345 kilovolt (kV) work. A significant contributing factor was an inadequate process for identification and management of risk during the design change process (implementation of the DCN).

The RCE states in part. "CM-AA-RSK-1 001, Engineering Risk Assessment, has inconsistent guidance for evaluating potential for engineering error. In addition.

guidance is entirely subjective for evaluation of potential consequence of engineering failure."

The weakness of procedure CM-AA-RSK-1001 resulted in the DCN not receiving the additional reviews that elevated risk switchyard work would normally get. The additional reviews would have added additional precautions, potential scope of work changes, and postponement of the work for a few days at which point Unit 2 would have been offline for a planned refueling outage.

Analysis:

The inspectors determined that Dominion's failure to adequately manage the risk to plant stability associated with the installation of the DCN was a performance deficiency. The cause was reasonably within Dominion's ability to foresee and correct.

and should have been prevented. Traditional Enforcement did not apply, as the issue did not have actual or potential safety consequence. had no willful aspects, nor did it impclct the NRC's ability to perform its regulatory function.

A review of NRC Inspection Manual Chapter 0612, Appendix E, "Minor Examples,"

revealed that no minor examples applied to this finding. This finding was more than minor because it was associated with the Equipment Performance attribute of the Initiating Events cornerstone, and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, Dominion did not adequately assess and manage the risk involved in implementing DCN DM2-00-093-09, which resulted in the need to perform an unplanned shutdown of the Unit 2 reactor on October 6,2009. The inspectors performed a Phase 1 screening in accordance with NRC Inspection Manual Chapter (IMC) Attachment 0609.04, "Phase 1 - Initial Screening and Characterization of Findings." The inspectors determined the finding was of very low safety significance (Green) because it did not contribute to the likelihood that mitigation equipment or functions would not be available.

This finding had a cross-cutting aspect in the Human Performance cross-cutting area, Work Control component, because Dominion did not appropriately incorporate risk insights and work scheduling of activities consistent with nuclear safety. H.3(a)J

Enforcement:

No violation of regulatory requirements occurred, because the MOD switch and the main transformer are non-safety related. Dominion has taken corrective action to modify the appropriate procedures, and has entered this issue into their corrective action program(CR 351109). Enforcement action does not apply because the performance deficiency did not involve a violation of a regulatory r~quirement.

Because this finding does not involve a violation of regulatory requirements, and has very low safety significance (Green), it is identified as a finding (FIN). (FIN

===05000336/2009005-02 Implementation of Design Change Results in an Unplanned Shutdown of Reactor)

.2 RCS Drain Down Loss of Configuration Control

Introduction:

A Green, self-revealing NCVof Millstone Technical Specification (TS) .

6.8.1 (a), "Procedures,~ was identified for Dominion's failure to adequately implement procedures during partial draining of the reactor coolant system (RCS) in preparation for defueling the reactor. Dominion did not properly align the reactor vessel vent path prior to partially draining the RCS as required by Dominion procedure OP-2301 E, "Draining the RCS (ICCE)."

Description:

On October 10, 2009, Dominion performed a partial drain*down of the fully fueh3d reactor vessel to the radioactive waste processing system in preparation for removing the reactor vessel head and defueling the reactor. The reactor vessel vent path was not properly established because manual valve 2-RC-447 had been mispositioned (locked shut instead of locked open) during the valve line-up for the evolution. Without an open vent path in the reactor vessel, the vessel inventory was not reduced when the ReS was being drained. When the RCS mid-loop wide range level instruments (LT-112 and lI-112) came on scale at +99 inches, the reactor vessel level monitoring system (RVLM) still indicated that the reactor vessel level was greater than

+135 inches. The operators stopped the RCS drain down evolution and determined that thE~ vent path had not been properly aligned to the reactor vessel in accordance with Dominion procedure OP-2301E-005, "Preferred RCS Vent Path Alignment." Upon investigation, Dominion discovered that they did not align valve 2-RC-447 to vent the reactor vessel head during the RCS drain down in preparation for defueling the reactor.

This resulted in the reactor vessel remaining full of water while the pressurizer and steam generator tubes were being drained. Operators failed to immediately realize that the~ RCS level indication did not accurately reflect the level in the reactor vessel. This condition constituted a loss of positive control during the RCS drain down.

Analysis:

The inspectors determined that Dominion's failure to properly align a vent path to the reactor vessel in accordance with Dominion procedure OP-2301 E-005, "Preferred RCS Vent Path Alignment," was a performance deficiency. The cause was reasonably within Dominion's ability to foresee and correct, and should have been prevented. Traditional Enforcement did not apply, as the issue did not have actual or potential safety consequence, had no willful aspects, nor did it impact the NRC's ability to perform its regulatory function.

A review of NRC Inspection Manual Chapter 0612, Appendix E, "Minor Examples,*

revealed that no minor examples applied to this finding. The finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events cornerstone, and affected the cornerstone objective to limit the likelihood of those events that challenge critical safety functions during shutdown operations.

Specifically, the operators failed to properly position 2-RC-447 to vent to the reactor vessel during partial drain down of the reactor.

The inspectors determined the significance of this finding using NRC Inspection Manual Chapter 0609, Appendix "G," "Shutdown Operations Significant Determination Process."

The issue was determined to be of very low safety significance (Green) because the OpE:lrators performed continuous RCS inventory balances during the drain down, and toolk prompt appropriate corrective action as soon as a level deviation became apparent between the RCS level instruments (LT-112 and U-112) and the in-core RVLMs heated core thermocouples. Immediate corrective actions included stopping the drain down and verifying the valve alignment.

This finding had a crossoocutting aspect in the Human Performance cross-cutting area, Work Practices component, because Dominion failed to define and effectively communicate expectations regarding procedural compliance, and personnel follow procedures. H.4(b) ,

Enforcement:

Millstone TS 6.8.1 (a) "Procedures,* requires, in part, that written procedures be established, implemented and maintained covering the activities described in Appendix "A" of NRC Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operation)." Section 2.k requires general plant operating procedures for, "Preparation for Refueling and Refueling Equipment Operation." Draining the RCS in preparation for defueling the reactor was required to be accomplished using Section 4.2 of Dominion procedure OP-2301 E, "Draining the RCS (ICCE)." Contrary to the above, Dominion did not correctly implement procedure OP-230'1 E-005 to establish the correct valve line-up for draining the ReS. This resulted in a loss of positive control over ReS level during a risk significant evolution. Because this violation is of very low safety significance (Green), and has been entered into Dominion's corrective action program (CR 351853), it is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy. (NCV 05000336/2009005-03 ReS Drain Down Loss of Configuration Control)

1R22 Surveillance Testing

a. Inspection Scope

The inspectors reviewed surveillance activities to determine whether the testing adequately demonstrated equipment operational readiness and the ability to perform the intended safety-related function. The inspectors attended pre-job briefings, reviewed selected prerequisites and precautions to determine if they were met, and observed the tests to determine whether they were performed in accordance with the procedural steps. Additionally, the inspectors reviewed the applicable test acceptance criteria to evaluate consistency with associated design bases, licensing bases, and TS requirements, and that the applicable acceptance criteria were satisfied. The inspectors als() evaluated whether conditions adverse to quality were entered into the corrective action program for resolution. Documents reviewed during the inspection are listed in the Attachment. The following surveillance activities were evaluated:

• SP-2613G Routine Surveillance Integrated Test of Facility 1 Components (ICCE)

Loss of Normal Power; and

• VPROC ENG09-2-011 Integrated Leak Rate Test of Containment.

b. Findings

No findings of significance were identified.

RADIATION SAFETY

Cornerstone: Occupational Radiation Safety

20S1 Access Control to Radiologically Significant Areas (71121.01 - 11 samples)

a. Inspection Scope

During the period November 2, 2009 and November 5, 2009, the inspectors performed the Following activities to verify that Dominion was properly implementing physical, administrative, and engineering controls for access to locked high radiation areas (LHRA) and other radiological controlled areas (RCA), and that workers were adhering to these controls when working in these areas during the Unit 2 refueling outage (2R19).

Implementation of these controls was reviewed against the criteria contained in 10 CFR 20, Unit 2 TS, and Dominion's procedures. This inspection activity represents completion of eleven samples relative to this inspection area.

Plant Walkdown and Radiation Work Permit (RWP) Reviews

• During the Unit 2 refueling outage, the inspectors identified exposure significant work areas in the Unit 2 reactor building containment, fuel handling building, and auxiliary building. The inspectors reviewed radiation survey maps and RWPs associated with these areas to determine if the radiological controls were acceptable;

• The inspectors performed independent surveys ofselected areas in the Unit 2 containment building and auxiliary building to confirm the accuracy of survey maps, the adequacy of postlngs, and that technical specification locked high radiation areas (TSLHRA) were properly secured and posted. Areas in containment surveyed included: the SG cubicles, radwaste storage areas, pressurizer relief tank, access port to under vessel area, and RCP areas;

• In evaluating RWPs, the inspectors reviewed electronic dose/dose rate alarm set points to determine if the set points were consistent with survey indications and plant policy. The inspectors verified that workers were knowledgeable of the actions to be taken when a dosimeter alarms or malfunctions for tasks being performed under selected RWPs. Work activities reviewed included scaffolding removal. insulation installation, and upper guide structure transfer; and

• The inspectors reviewed Personnel Contamination Reports (PCR), airbome sampling results, personnel dosimetry data, and whole body counting results to assess the effectiveness of airborne monitoring and contamination controls. The inspectors also reviewed the associated dose assessment for a worker who fell into the spent fuel pool during pre-outage preparations. The inspectors determined that no intake of radioactive material resulted in an internal dose exceeding 10 mrem.

Jobs-in-Progress Review

• The inspectors observed the preparations and various work stages for several tasks including containment demobilization and transfer of the reactor upper guide structure into the reactor vessel, fuel assembly transfers, and in service inspections.

The inspectors observed various aspects of these activities from the centralized monitoring system (CMS) to determine if remotely monitored work area dose rates and worker dose, and the coordination of activities by the CMS staff, were adequately communicated to the workers.

High Risk Significant. High Dose Rate Controls

• The inspectors reviewed the preparations made for various potentiaJly high dose rate jobs and the resulting dose assessments to determine if exposure monitoring was effective in controlling personnel exposure. Tasks reviewed included the transfer of the upper guide structure back into the reactor vessel, alloy 600 inspections/

mitigation, and the thimble tube replacement;

• The inspectors inventoried keys to TSLHRA stored at the Unit 2 Control Point to verify that Dominion accounted for all keys. During tours of Unit 2, the inspectors verified that locked high radiation areas (LHRA) were properly secured and posted; and

• The inspectors verified that Unit 2 LHRAs in containment, such as the regenerative heat exchanger and under vessel area, were properly secured and posted and that surrounding area dose rates and postings met regulatory criteria.

Radiation Worker and Radiation Protection Technician Performance

• Several radiologically related CRs and PCRs were reviewed to evaluate if the incidents resulted from repetitive worker errors and to determine if an observable pattern traced to a similar cause was evident;

• During site tours, radiation protection technicians and radworkers were questioned regarding their knowledge of plant radiological conditions and controls associated with their jobs. Additionally. the inspectors observed radiation protection technicians effectively control and coordinate in-containment tasks by using the centralized remote monitoring system; and

• The inspectors reviewed field observation reports made by the Nuclear Oversight staff to determine the degree in which the independent department was actively engaged in critically monitoring worker performance during 2R19.

b. Findings

No findings of significance were Identified.

20S2 ALARA Planning and Controls (71121.02 -7 samples)a.

Inspection SCQDe During the period November 2,2009 through November 5,2009, the inspectors performed the following activities to verify that Dominion was properly implementing opElrational, engineering, and administrative controls to maintain personnel exposure as low as reasonably achievable (ALARA) for tasks performed during the Unit 2 refueling outage. Implementation of these controls was reviewed against the criteria contained in 10 CFR 20, applicable industry standards, and Dominion's procedures. This inspection activity represents completion of seven samples relative to this inspection area.

Radiological Work Planning

• The inspectors reviewed pertinent information regarding Unit 2 outage exposure history. current exposure trends, and ongoing activities to assess current performance and outage exposure challenges. The inspectors determined the site's three-year rolling collective average exposure and compared it to current trends;

• The inspectors reviewed the refueling outage work scheduled during the outage period and the associated work activity exposure estimates. Scheduled work included thimble tube cutting, alloy 600 inspections, valve maintenance, fuel assembly transfers, fuel transfer system up-ender upgrades, and various support activities. The inspectors compared the current actual dose accrued for these tasks with the initial exposure estimates;

• Additionally, the inspectors reviewed the ALARA Reviews (AR), Work-In-Progress (WIP) ARs, ALARA challenge board presentations, and ALARA pre-job briefing materials that addressed estimating and controlling dose for other outage activities.

Jobs reviewed included: insulation removal and installation, scaffolding removal and installation, reactor disassembly, pressurizer heater replacement, and boric acid inspections. WIP ALARA reviews were evaluated for boric acid corrosion control inspections, alloy 600 inspection and mitigation, health physics outage support, pressurizer heater replacement, and temporary shielding installation;

• The inspectors evaluated the effectiveness of exposure mitigation requirements specified in RWPs and associated ALARA reviews. Jobs reviewed include reactor vessel disassembly (RWP 302, AR 2-09-01), thimble tube replacement (RWP 406, AR 2-09-35), pressurizer heater replacement (RWP 401, AR 2-09-29), insulation removal and installation (RWP326, AR 2-09-14), and scaffolding removal and installation (RWP 331, AR 2-09-13);

• The inspectors evaluated the departmental interfaces between radiation protection, operations, maintenance crafts, and engineering to identify missing ALARA program elements and interface problems. The evaluation was accomplished by reviewing recent ALARA Council meeting minutes and ALARA challenge board presentations.

The inspectors also attended daily outage status meetings to assess interdepartmental coordination and communications; and

• Through job site observations and radiation survey measurements, the inspectors determined if work activity planning included the use of temporary shielding. system flushes, and operational considerations (Le. scheduling work when SGs were fIlled to further minimize worker exposure). The inspectors reviewed temporary shielding effectiveness measurements and performed independent measurements on various system components in the reactor building and auxiliary building work areas to determine if temporary shielding was appropriately used.

Verification of Dose Estimates and Exposure Tracking Systems

• The inspectors reviewed the assumptions and basis for the annual site collective 19xposure and the Unit 2 refueling outage dose projection; and

• The inspectors reviewed Dominion's exposure tracking system to determine whether the level of dose tracking detail, exposure report timeliness, and distribution was sufficient to support the control of outage project exposures. Included in this review were departmental dose assessments and individual dose records.

Job Site Inspection and ALARA Controls

• The inspectors observed activities performed in containment including valve inspections/repairs, upper guide structure transfer, and scaffolding & shielding demobilization. The inspectors verified that the appropriate radiological controls were implemented including pre~job briefings, radiation protection technician coverage, contamination mitigation, proper dosimetry, and that workers were knowledgeable of radiological conditions.

Source Term Reduction and Control

• The inspectors reviewed the current status and historical trends of the Unit 2 source term. Through interviews with the Radiation Protection, Chemistry Manager, and the ALARA Supervisor, the inspectors evaluated Dominion's source term measurements (Le. reactor coolant system piping dose rates and control strategies). The inspectors reviewed reactor coolant chemistry data to evaluate the effectiveness of post shutdown source term reduction efforts. Specific strategies being employed included: use of macro-porous cleanup resins, system flushes, installation of temporary shielding, use of temporary filtration system, and chemistry controls.

Radiation Worker Performance

• The inspectors observed radiation worker and radiation protection technician performance for selected tasks. Tasks observed included containment demobilization activities, and reactor re-assembly. The inspectors determined that the individuals were aware of radiological conditions and access controls that applied to their tasks; and

• The inspectors reviewed eRs, related to radiation worker and radiation protection technician errors, and PCRs to determine if an observable pattern traceable to a common cause was evident.

Declared Pregnant Workers

• The inspectors determined that one declared pregnant worker was employed to perform outage related activities in the radiological controlled areas. The inspectors verified that the individual's exposure was appropriately monitored, per procedural requirements, and controlled to meet regulatory criteria.

Problem Identification and Resolution

• The inspectors reviewed elements of Dominion's corrective action program related to implementing the radiological controls program to determine if problems were being entered into the program for resolution. Included in this review were relevant eRs, Nuclear Oversight field observation reports, and a program audit.

b. Findings

No findings of Significance were identified.

OTHER ACTIVITIES

lOA] 40A1 Performance Indicator (PI) Verification (71151 - 4 samples)

.1 Cornerstone: Mitigating Systems

a. Inspection Scope

The inspectors reviewed Dominion submittals for the Pis listed below to verify the accuracy of the data reported during that period. The PI definitions and guidance contained in Nuclear Energy Institute (NEI) 99-02, "Regulatory Assessment Performance Indicator Guideline," Revision 5, were used to verify the basis for reporting each data element. The inspectors reviewed portions of the operations logs, monthly operating reports, and LERs, and discussed the methods for compiling and reporting the Pis with cognizant licensing and engineering personnel. Documents reviewed during the inspection are listed in the Attachment.

• Safety System Functional Failures (SSFF) [MS06]; and Unit 3

• SSFF [MS05J.

b. Findings

No findings of significance were identified .

.2 Occupational Exposure Control Effectiveness [OR01]

a' Inspection Scope The inspectors reviewed implementation of Dominion's Occupational Exposure Control Effectiveness Performance Indicator Program. Specifically, the inspectors reviewed CRs, and associated documents for occurrences involving locked high radiation areas, very high radiation areas, and unplanned exposures. The PI definitions and guidance contained in Nuclear Energy Institute {NEI} 99-02, "Regulatory Assessment Performance Indicator Guideline," Revision 5, were used to verify the basis for reporting each data element. This inspection activity represents the completion of one sample relative to this inspection area. completing the annual inspection requirement.

b. Findings

No findings of significance were identified.

.3 RETS/ODCM Radiological Effluent Occurrences [PR01]

a. Inspection Scope

The inspectors reviewed relevant effluent release reports for the period October 1, 2008 through October 30, 2009, for issues related to the public radiation safety performance indicator, which measures radiological effluent release occurrences that exceed 1.5 mrem/qtr whole body or 5.0 mrem/qtr organ dose for liquid effluents; 5 mrads/qtr gamma air dose; 10 mrads/qtr beta air dose; and 7.5 mrads/qtr organ dose for gaseous effluents. The PI definitions and guidance contained in Nuclear Energy Institute (NEI)99-02, "Regulatory Assessment Performance Indicator Guideline," Revision 5, were used to verify the basis for reporting each data element. This inspection activity represents the completion of one sample relative to this inspection area, completing the annual inspection requirement.

No findings of significance were identified.

40A2 Identification and Resolution of Problems (71152 - 5 sam pies)

.1 Review of Items Entered into the Corrective Action Program

a. Inspection Scope

As required by Inspection Procedure 71152, "Identification and Resolution of Problems,"

and in order to help identify repetitive equipment failures or specific human performance issues for follow-up, the inspectors performed a daily screening of items entered into Dominion's corrective action program. This was accomplished by reviewing the desl~ription of each new CR and attending daily management review committee meEltings.

The Inservice Inspection program inspector reviewed a sample of corrective action reports related to problems in Inservice Inspection in order to determine if problems wen3 identified and corrected in a timely fashion. The inspector determined the nonconforming conditions identified were reported, characterized, evaluated and appropriately disposed of commensurate with their importance to safety. Documents reviewed during the inspection are listed in the Attachment.

No findings of significance were identified.

.2 Ogerator WorkwAround (2 samples)

a. Inspection Scope

The inspectors reviewed the current listing of operator work-arounds for Units 2 and 3.

The review was performed to verify that Dominion procedures and practices provided necessary guidance to plant personnel, that the cumulative effects of the known operator work-arounds were addressed, and that the overall impact on the affected systems were assessed. The inspectors independently assessed the cumulative impact of known operator work-arounds to determine if they adversely affected the ability of operators to implement operating procedures (both normal and off-normal) and respond to plant transients. In support of this assessment, the inspectors reviewed various eRs regarding operatorwork-arounds and verified that work-a rounds were being identified.

tracked, and resolved in accordance with Dominion's corrective action program. This inspection effort represented one sample for Unit 1 and one sample for Unit 2.

Documents reviewed during the inspection are listed in the Attachment.

b. Findings

and Opservations No findings of significance were identified. The inspectors determined that operator work-arounds were adequately classified, tracked, and assessed in accordance with Dominion procedures, and that the cumulative impact of the work,.arounds did not adversely impact the ability of the operators to implement the operating procedures .

.3 Semi-Annual Problem Identification & Resolution (PI&R) Trend Review (1 sample)

a. Inspection Scope

As required by Inspection Procedure 71152, the inspectors performed a review of the Dominion corrective action program and associated documents to identify trends that may indicate existence of safety significant issues. The inspectors review was focused on repetitive equipment and corrective maintenance issues, but also considered the results of daily inspector corrective action program item screening.

b. Findings and Observations

No findings of significance were identified.

The inspectors review determined that the trend reports reviewed adequately captured the site's negative trends. The inspectors noted that the trend reports were revised, based on the inspectors comments from the previous semi-annual trend review, to include a listing of open long~term adverse trends. The inspectors also noted that two long term trends and a few recurring issues that were listed in the second quarter report were not listed in the third quarter report and there was no discussion of the resolution of these items.

.4 Annual Sample - Omission of a Nondestructive Evaluation Examination on Replacement

Valve 3SIH*V028 in the Safety Injection System ===

a. Inspection Scope

The inspector reviewed the corrective action related to ACE 017370. The licensee Identified the omission of a nondestructive evaluation examination on the installation of replacement valve 3SIH*V028 in the safety injection system.

b. Findings and Observations

A field change, implementing an ASME Code Case, did not take into account the jurisdictional change in the edition of the ASME Code referred to in the Code Case.

Earlier editions of the Code, including the edition in force during the outage, did not require an examination of piping below a nominal size of four inches. However, ASME Code Case N-416-3 was invoked which requires examinations in conformance with the 1992 Edition of the Code. This edition changes the examination lower limit to two inches nominal pipe size.

The nondestructive examinations were undertaken in a timely fashion after the omission was identified. No indications were found as a result of the examinations.

40A3 Event Follow-up (71153 - 2 samples) .

.1 Unit 2 Notification Of Unusual Event Classification (NOUE) - Loss of Control Room

Annunciators

a. Inspection Scope

On November 15,2009, at 8:11 a.m .. Unit 2 experienced a loss of all control room annunciators lasting greater than 15 minutes while operating in Mode 5 (cold shutdown).

The shift manager classified the event at the level of a Notification of Unusual Event (NOUE). An electrical transient caused non-vital 120 volt AC Instrument busses, VR-11 and VR-21 , to cycle repeatedly on and off. which caused the power supply to the main control board annunciators to lose power and lock out. The operators took immediate action in accordance with AOP-2504A, "Loss of VR-11, nand AOP-2504B, ~Loss of VR- 21." The electrical transient was initiated when the "S" heater drain pump was started for post maintenance testing following an overhaul of the motor. In addition to the loss of annunciators, a letdown isolation occurred, and the operators secured the charging and letdown systems. A NOUE was declared at 8:26 a.m. after 15 minutes had elapsed without power to the annunciators. At 8:33 a.m., I&C technicians reset the annunciator power supply, and all main control board annunciators were restored to service. The crew determined that all safety functions were met. The NOUE declaration was subsequently terminated at 8:58 a.m.

The inspectors responded to the control room and evaluated the adequacy of operator actions in accordance with approved procedures and TS irnplications. The inspectors penformed walk downs and interviewed personnel to verify that the plant was stable, and that the annunciators had been restored to service. Documents reviewed during the inspection are listed in the Attachment.

b. Findings

Introduction:

A Green, self-revealing finding (FIN) was identified for Dominion's failure to complete effective corrective actions for known degraded conditions associated with the VR-11 and VR-21 120-volt AC non-vital instrument power supplies. Specifically, VR 11 and VR-21 were known to cycle on and off repeatedly whenever an electrical disturbance on the grid affected the input supply voltages from their respective regulating transformers. The degraded condition on the instrument buses had not been corrected despite prior opportunities. This condition led to a loss of annunciators and declaration of a Notification of Unusual Event (NOUE) on November 15, 2009.

Description:

On November 15, 2009, Millstone Unit 2 was operating at 60 percent power when VR-11 and VR-21 began to rapidly turn on and off (power cycling) for approximately one minute. This rapid power cycling started when a fuse was being replaced in the "S" heater drain pump, which created an electrical ground condition. The rapid fluctuation of power to the non-safety instrument buses resulted in a Chemical and Volume Control System (CVCS) letdown isolation, and the rapid flashing of all main board annunciators. The regulated power supply for the main board annunciators subsequently deenergized and caused a loss of annunciation in the control room for 21 minutes. The operators responded by entering Abnormal Operating Procedure (AOP)2504A (and AOP-2504S), "Loss of VR-11 (VR-21 )," which directed isolating the charging system and stabilizing the plant. The Shift Manager entered the station emergency plan and declared a NOUE when the annunciators had remained in a non-functional state for 15 minutes in accordance with Emergency Action Level (EAL) EU-3, "Loss of Annunciators."

The probable cause of the event was the degraded power cycling response of VR-11 and VR-21 to an electrical disturbance. This vulnerability of VR-11 and VR-21 to electrical disturbances had most recently been identified on July 3, 2009, when an offsite grid disturbance caused VR-11 and VR-21 to exhibit a similar degraded system response. The original problem with VR-11 and VR-21 had been first identified and entered into the corrective action process as early as 2001. The long-term corrective action for this adverse condition was to power VR-11 and VR-21 from a large uninterruptible power supply (UPS) to prevent the rapid power cycling between the normal and alternate power supplies. To date, this has not been implemented. This corrective action has been scheduled for implementation in February 2010. Previous interim corrective actions had included disabling the normal supply regulated transformer supplies UAC1 and UAC2, temporarily removing some loads from VR-11 and VR-21 , and installing small UPS power supplies on isolated circuits, all of which did not prevent the November 15, 2009 event.

Previously, grid disturbances on June 28, 2008, February 2, 2009, April 30, 2009, and July 3, 2009 continued to challenge the Unit 2 operator's ability to operate the plant because of degraded system responses from the cycling of VR~11 and VR 21 during w these events. These actions included main feedwater regulating valve lockup, isolation of tl1e letdown system, unexpected steam dump response, and automatic startup of all three charging pumps. In each case, the previous interim corrective actions were ineffective in preventing VR 11 and VR-21 from rapidly cycling and disrupting plant w

system equipment alignments. Despite the ineffectiveness of the short term corrective actions, Dominion did not complete the long-term corrective action to install a UPS as the normal power source for VR-11 and VR-21 by the end of the refueling outage 2R19.

Analysis:

The inspectors determined that Dominion's failure to effectively implement interim corrective actions to prevent recurrence of the power cycling of VR-11 and VR 21 was a performance deficiency. The cause was reasonably within Dominion's ability to foresee and correct, and should have been prevented. Traditional Enforcement did not apply, as the issue did not have actual or potential safety consequence, had no willful aspects, nor did it impact the NRC's ability to perform its regulatory function.

A review of NRC Inspection Manual Chapter 0612, Appendix E, ~Minor Examples,"

revealed that no minor examples applied to this finding. The finding was more than minor be.cause it was associated with the Procedure Quality attribute of the Mitigating Systems cornerstone and affected the cornerstone objective of ensuring capability of systems that respond to initiating events to prevent undesirable consequences. The main board annunciators provide operators with critical notification and assessment capability during plant upset or transient conditions. Annunciators are used to direct operators to appropriate alarm response procedures, which further direct operators to AOPs and direct entry conditions into EOPs. Annunciators also provide early warning to operators of adverse trends in key plant parameters before the degradation becomes sig nificant.

The inspectors determined the significance of the finding using IMC 0609.04, "Phase 1 Initial Screening and Characterization of Findings." The finding was determined to be of very low safety Significance (Green) because the finding did not involve a design or qualification deficiency resulting in loss of operability or functionality, did not result in a loss of system safety function, and did not screen as potentially risk significant due to external initiating events. This finding had a cross-cutting aspect in the Problem Identification and Resolution cross-cutting area, Corrective Action Program component, because Dominion did not take appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with their safety Significance and complexity. [P.1 (d)]

Enforcement:

No violation of regulatory requirements occurred, because the annunciator system is non-safety related. Dominion took immediate action to expedite the installation of the UPS for VR-11 and VR-21. Enforcement action does not apply because the performance deficiency did not involve a violation of a regulatory requirement. Because this finding does not involve a violation of regulatory requirements, and has very low safety significance (Green), it is identified as a finding (FIN). (FIN 05000336/2009005-04 Inadequate and Untimely Corrective Actions Causes Loss of Annunciators and Declaration of a NOUE)

.2 Unit 3 Main Generator Ground Fault

a. Inspection Scope

On December 19, 2009 at 22:53, Millstone Unit 3 tripped from 100 percent power during a significant snow storm. A generator protection and main generator leads ground fault resulted in a turbine/generator trip with subsequent reactor trip and fast transfer to the Reserve Station Service Transformer (RSST). All safety systems responded as expected.

Relays 59NL-3SPUB1 0 anq 59NH-3SPUB17 actuated on detecting a severe ground fault condition as measured through the main generator neutral. The relays opened the main generator output breakers and isolated the fault from the main generator to the generator output breaker. This resulted in a main turbine and reactor trip. After a time delay, the 59NB-3SPLIB 17 relay actuated, indicating a fault on the transformer side of the breaker, opening Unit 3 normal offsite power supply breakers, 13T and 14T, and causing a fast transfer to the reserve offsite power supply. Walkdowns determined that the "e" phase of the main generator output breaker was damaged. Unit 3 later entered Technical Specification Action Statement 3.0.3 for 73 minutes when snow plugged the filter for the Engineered Safety Feature (ESF) building emergency ventilation, making all safety-related pumps in the ESF building inoperable.

The inspectors responded to the control room and evaluated the adequacy of operator actions in accordance with approved procedures and TS implications. The inspectors performed walk downs and interviewed personnel to verify that the plant was stable, Documents reviewed during the inspection are listed in the Attachment.

b. Findings

No findings of significance were identified.

40A5 Other Activities Quarterly Resident Inspector Observations of Security Personnel and Activities

a. Inspection Scope

During the inspection period, the inspectors performed observations of security force personnel and activities to ensure that the activities were consistent with site security procedures and regulatory requirements relating to nuclear plant security. These observations took place during both normal and off-normal plant working hours. These quarterly resident inspector observations of security force personnel and activities did not constitute any additional inspection samples. Rather, they were considered an integral part of the inspectors' normal plant status reviews and inspection activities.

b. Findings

No findings of significance were identified.

40A6 Meetings, including Exit

Exit Meeting Summary

On January 13, 2010, the resident inspectors presented the overall inspection results to Mr. A. J. Jordan and members of his staff. The inspectors confirmed that no proprietary information was provided or examined during the inspection.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee personnel

E. Annino Dominion Licensing

G. Auria Nuclear Chemistry Supervisor

B, Barron Manager, Nuclear Oversight

B. Bartron Supervisor. licensing

P. Baumann Manager, Security

H. Beemon Supervisor. Nuclear Engineering

R. Borchardt Consulting Engineer, Reactor Engineering

R. Carey Consulting Engineer, ILRT, Inc.

C. Chapin Supervisor, Nuclear Shift Operations Unit 2

A. Chyra Nuclear Engineer. PRA

T. Cleary Licensing Engineer

G. Closius Licensing Engineer

L. Crone Supervisor, Nuclear Chemistry

J. Dorosky Health Physicist III

A. Elms Manager, Nuclear Engineering

M. Finnegan Supervisor, Health Physics, ISFSI

G. Gardner Dominion Engineering

A. Gharakhanian Nuclear Engineer III

M. Gobeli Nuclear Engineer III

W. Gorman Supervisor. Instrumentation & Control

J. Grogan Assistant Operations Manager

C. Houska I&C Technician

A. Jordan Site Vice President

C. Janus Nuclear Engineer III

J. Kunze Supervisor, Nuclear Operations Support

B. Krauth Licensing, Nuclear Technology Specialist

J. Laine Manager. Radiation Protection/Chemistry

M. Lalikos ISIINDE Engineering

P. Luckey Manager, Emergency Preparedness

R. MacManus Director, Nuclear Station Safety & Licensing

M. Marino VFD Modification Project Manager

C. Maxson Director, Engineering

M. O'Connor Manager, Operations

L. Perry Dominion lSI

R. Riley Supervisor, Nuclear Shift Operations Unit 3

M. Roche Senior Nuclear Chemistry Technician

J. Semancik Plant Manager

A. Smith Asset Management

S. Smith Manager, Engineering

J. Spence Manager, Training

P. Strickland VFD Modification Test Director

S. Turowskj Supervisor, Health Physics Technical Services

M. VanHalter Dominion Engineering

M. Vezzina Dominion lSI

C. Voumazos IT Specialist, Meteorological Data

R. West Dominion Engineering

J. Williams Dominion lSI

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

05000336/2009005-01 NCV - TS Surveillance Channel Calibration of ICCMS Not Performed. (Section 1R15)

05000336/2009005-02 FIN - Implementation of Design Change Results in an Unplanned Shutdown of Reactor. (SecUon 1R20)

05000336/2009005-03 NCV - RCS Drain Down loss of Configuration Control. (Section 1R20)

05000336/2009005*04 FIN -Inadequate and Untimely Corrective Actions Causes loss of Annunciators and Declaration of a NOUE. (Section 40A3)