IR 05000458/2012012

IR 05000458-12-012; 11/12/2012 - 11/15/2012; River Bend Station; Supplemental Inspection Inspection Procedure 95001

ML12363A170
Person / Time
Site:	River Bend
Issue date:	12/28/2012
From:	Hagar R NRC/RGN-IV/DRP/RPB-C
To:	Olson E Entergy Operations
Hagar B
References
IR-12-012
Download: ML12363A170 (30)

Text

December 28, 2012

SUBJECT:

RIVER BEND STATION - NRC INSPECTION PROCEDURE 95001 SUPPLEMENTAL INSPECTION REPORT 05000458/2012012

Dear Mr. Olson:

On November 15, 2012, the U.S. Nuclear Regulatory Commission (NRC) staff completed a supplemental inspection pursuant to Inspection Procedure 95001, Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area, at your River Bend Station. The enclosed inspection report documents the inspection results, which were discussed on November 15, 2012, with you and other members of your staff.

The objectives of this supplemental inspection were to provide assurance that: (1) the root causes and contributing causes for the risk significant issues were understood; (2) the extent-of-condition and extent-of-cause of the issues were identified; and (3) to provide assurance that the corrective actions for risk significant performance issues are sufficient to address the root causes and contributing causes and to prevent recurrence. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commissions rules and regulations and with the conditions of your license. The inspector reviewed selected procedures and records, observed activities, and interviewed personnel.

The inspection concluded that your evaluations and corrective actions for the white performance indicator, Unplanned Scrams with Complications, were adequate. Your evaluations identified causes involving inadequate plant modification, inadequate preventative maintenance activities, inadequate use of industry operating experience, and failure to follow procedures. River Bend Station has taken, or plans to take, corrective actions in these areas. Your staff also performed an extent-of-condition and cause review and identified other challenges.

Four NRC-identified findings and one self-revealing finding of very low safety significance (Green) were identified during this inspection. Four of these findings were determined to involve violations of NRC requirements.

If you contest these non-cited violations, 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 IV; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at River Bend Station.

If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region IV, and the NRC Resident Inspector at River Bend Station.

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 public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's Agencywide Document Access and Management 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,

/RA/

Robert C. Hagar, Chief (Acting)

Project Branch C Division of Reactor Projects Docket No.: 05000458 License No.: NPF-47

Enclosures:

Inspection Report 05000458/2012012 w/ Attachment: Supplemental Information

REGION IV==

Docket: 05000458 License: NPF-47 Report: 05000458/2012012 Licensee: Entergy Operations, Inc.

Facility: River Bend Station Location: 5485 U.S. Highway 61 St. Francisville, LA 70775 Dates: November 12-15, 2012 Inspector: J. Josey, Senior Resident Inspector Approved By: Robert C. Hagar, Chief (Acting)

Project Branch C Division of Reactor Projects-1- Enclosure

SUMMARY OF FINDINGS

IR 05000458/2012012; 11/12/2012 - 11/15/2012; RIVER BEND STATION; Supplemental

Inspection - Inspection Procedure 95001 This report covered a four-day period of inspection by a senior resident inspector. Three Green non-cited violations and two Green findings of significance were identified. The significance of most findings is indicated by their color (Green, White, Yellow, or Red) using Inspection Manual Chapter 0609, Significance Determination Process. The cross-cutting aspect is determined using Inspection Manual Chapter 0310, Components Within the Cross Cutting Areas. Findings for which the significance determination process 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: Mitigating Systems

Green.

The inspector documented a self-revealing finding associated with the licensees failure to follow the requirements of Station Procedure EN-LI-102,

Corrective Action Process, and promptly identify and correct a condition adverse to quality. Specifically, on August 4, 2010, and again on February 14, 2011, station personnel found where the B reactor feedwater pumps auxiliary oil system pressure regulator set point had drifted high out of tolerance, but did not initiate condition reports for this condition adverse to quality. The licensee entered this issue into their corrective action program as Condition Reports CR-RBS-2011-09141 and CR-RBS-2012-07249.

The failure to follow the requirements of Station Procedure EN-LI-102 and identify and correct a condition adverse to quality was a performance deficiency.

The performance deficiency was more than minor, and is therefore a finding because it affected the Mitigating Systems Cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609,

Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. This finding had a cross-cutting aspect in the area of human performance associated with the work practices component, in that, the licensee failed to define and effectively communicates expectations regarding procedural compliance and personnel follow procedures. Specifically, station personnel failed to follow procedure H.4(b) (Section 4OA4.2.01).

Green.

The inspector identified a non-cited violation of 10 CFR Part 50,

Appendix B, Criterion XVI, Corrective Action, associated with the licensees failure to promptly identify and correct a condition adverse to quality.

Specifically, following a turbine trip/load reject and subsequent reactor scram, reactor vessel level rose to the point of receiving a high level isolation signal (Level 8), and the licensee failed to identify this as an unexpected condition. The licensee entered this issue into the corrective action program as Condition Report CR-RBS-2012-07250.

The failure to promptly identify and correct a condition adverse to quality was a performance deficiency. The performance deficiency is more than minor, and is therefore a finding because it affected the Mitigating Systems Cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. The finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to periodically trend and assess information from the corrective action program and other assessments in the aggregate to identify programmatic and common cause problems. P.1(b)

(Section 4OA4.2.01).

Green.

The inspector identified a non-cited violation of 10 CFR Part 50,

Appendix B, Criterion III, Design Control, associated with the licensees failure to ensure that design requirements were correctly translated into installed plant equipment. Specifically, the licensee failed to appropriately translate the feedwater control systems design of maintaining full feedwater capacity following a turbine trip with load rejection by avoiding loss of feedwater due to a high level isolation (Level 8) using the level set point modification module. The licensee entered this issue into the corrective action program as Condition Report CR-RBS-2012-02249 and CR-RBS-2012-07254.

The failure to ensure that design requirements were correctly translated into installed plant equipment was a performance deficiency. This performance deficiency is more than minor, and is therefore a finding, because it affected the Mitigating Systems Cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. This finding did not have a cross-cutting aspect because the most significant contributor did not reflect current licensee performance (Section 4OA4.2.01).

Green.

The inspector identified a finding associated with the licensees failure to follow the requirements of Station Procedure EN-LI-102, Corrective Action Process, and correct a condition adverse to quality. Specifically, the licensee identified that both inadequate guidance and oversight of a supplemental worker as a cause for the inadequate crimp on the B reactor feedwater pump, however the corrective actions taken only addressed the oversight of supplemental workers, and no actions were taken to address the insufficient guidance provided by the station work order. The licensee entered this issue into their corrective action program as Condition Report CR-RBS-2012-07253.

The failure to follow the requirements of Station Procedure EN-LI-102 and correct a condition adverse to quality was a performance deficiency. The performance deficiency is more than minor, and is therefore a finding, because it affected the Mitigating Systems Cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green). because the finding: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. This finding had a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to thoroughly evaluate problems such that the resolutions address causes

P.1(c) (Section 4OA4.2.01).

Green.

The inspector identified a non-cited violation of 10 CFR Part 50,

Appendix B, Criterion XVI, Corrective Action, associated with the licensees failure to promptly identify and correct a condition adverse to quality.

Specifically, during a root cause evaluation associated with a lockout relay failure, the licensee identified that the maintenance organizations improper procedure use and adherence was an extent of cause (condition adverse to quality). The licensee credited actions in another root cause evaluation to correct the identified extent of cause, however the actions taken did not address the maintenance organizations procedure use and adherence issue. The licensee entered this issue into the corrective action program as Condition Report CR-RBS-2012-07250.

The failure to promptly identify and correct the maintenance organizations improper procedure use and adherence issue was a performance deficiency.

The performance deficiency is more than minor, and is therefore a finding, because it affected the Mitigating Systems Cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, and is therefore a finding. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green). because the finding: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. The finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to thoroughly evaluate problems such that the resolutions addressed causes P.1(c) (Section 4OA4.2.02).

REPORT DETAILS

4OA4 Supplemental Inspection

.1 Inspection Scope

The U.S. Nuclear Regulatory Commission performed this supplemental inspection in accordance with Inspection Procedure 95001, Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area, for the purpose of assessing the licensees evaluation of a White performance indicator for Unplanned Scrams with Complications, which affected the initiating events cornerstone in the reactor safety strategic performance area. The objectives of this inspection were to:

• Provide assurance that the root and contributing causes of risk-significant performance issues were understood;

• Provide assurance that the extent-of-condition and extent-of-cause of risk-significant performance issues were identified;

• Provide assurance that the licensees corrective actions for risk-significant performance issues were, or will be, sufficient to address the root and contributing causes and to prevent recurrence The licensee entered the Regulatory Response Column of the NRCs Action Matrix in the second quarter of 2012 as a result of the subject performance indicator crossing the threshold from Green (very low safety significance) to White (low to moderate safety significance). The indicator change was associated with two unplanned scrams with complications.

The first scram occurred on December 23, 2011. With the plant operating at 100 percent power, the main turbine tripped unexpectedly, resulting in a reactor scram.

Operators implemented the appropriate station response procedures, and began to stabilize reactor vessel pressure and water level. However, a subsequent high reactor water level isolation signal (Level 8) resulted in a trip of all three reactor feedwater pumps, and as reactor water level lowered back through the normal operating range, operators attempted to restart a reactor feedwater pump, but component malfunctions were encountered on the "B" and "C" reactor feed pumps. Operators recognized that with the rate at which reactor water level was lowering a low level isolation (Level 3) was imminent and manually initiated the reactor core isolation cooling system to maintain reactor water level. The licensee subsequently determined that the scram was caused by a spurious backup over-speed trip signal resulting from an electrical discharge from the turbine shaft in the vicinity of the electro hydraulic control system turbine speed pickup probe. NRC Integrated Inspection Report 05000458/2012002 (ML12135A462)documented finding 05000458/2012002-09, Failure to Properly Fabricate and Install the mid-Standard Turbine Shaft Brush, for the licensees failure to fabricate the mid-standard turbine shaft brush in accordance with vendor technical instructions.

The second scram occurred on May 24, 2012. With the reactor operating at 33 percent power and the C reactor feedwater pump in service, operators attempted to start the B reactor feedwater pump. Shortly after the start attempt a fault occurred in the B pumps motor termination box which was not isolated by the motor feeder breaker and resulted in an electrical transient which caused the main supply breaker for the nonsafety-related 13.8 kV supply bus NPS-SWG1B to trip to clear the fault. This resulted in the loss of power to all running feedwater, circulating water, and normal service water pumps. The standby service water system actuated as designed in response to low normal service water pressure. Operators initiated a manual reactor scram and manually initiated the reactor core isolation cooling system to provide high pressure makeup to the reactor.

Operators manually operated selected safety relief valves for reactor pressure control and for reactor cooldown. Operators also manually initiated the high pressure core spray system during the recovery from the event; however it was not aligned to the reactor vessel. The licensee subsequently determined that the fault was caused by an inadequately crimped terminal lug on the B reactor feedwater pump, and the lockout relay on the B pump failed to operate as designed due to age related mechanical binding which was the result of inadequate maintenance. Augmented Inspection Team Follow-Up Inspection Report 05000458/2012010 (ML12328A178) documented: non-cited violation 05000458/2012010-04, Failure to Implement Effective Corrective Actions for Lockout Relay Failures, for licensees failure to promptly identify and correct mechanical binding in lockout relays, which resulted in a loss of main feedwater and normal service water; and non-cited violation 05000458/2012010-05, Failure to Test Lockout Relays in Accordance with Vendor Testing Practices, for the licensees failure to establish adequate preventive maintenance instructions for lockout relays in accordance with vendor recommendations, which resulted in a fire.

The licensee performed a root-cause evaluation for each of the complicated scram events, as well as an apparent-cause evaluation to determine the cause of the fault that initiated the 2012 scram event. In addition, the licensee performed an effectiveness review preceding this inspection in order to assess their readiness for the supplemental inspection.

On October 9, 2012, the licensee told the NRC staff of their readiness for a supplemental inspection per Inspection Procedure 95001.

The inspector reviewed the licensees root-cause and apparent-cause evaluations associated with the subject scrams, plus other evaluations conducted in support of or as a result of the root-cause evaluations. The inspector reviewed corrective actions that were taken or planned to address the identified causes. The inspector also interviewed licensee personnel. The inspector completed these activities to verify that the root and contributing causes and the contribution of safety culture components were understood, and that corrective actions taken or planned were appropriate to address the causes and preclude repetition.

.2.01 Problem Identification

a. Inspection Procedure 95001 requires that the inspector determine that the licensees evaluation documented who identified the issue (i.e., licensee-identified, self-revealing, or NRC-identified) and under what conditions the issue was identified.

A self-revealing inadequate modification of the mid-Standard Turbine Shaft Brush was identified when an electrostatic discharge due to inadequate shaft grounding caused a turbine trip and subsequent reactor scram on December 23, 2011.

A self-revealing inadequate crimp on a motor lug and a self-revealing failure of a lockout relay was identified when the B reactor feedwater pump was started. Specifically, a fault occurred in the motor termination box which was not isolated by the motor feeder breaker and resulted in an electrical transient which caused the main supply breaker for the nonsafety-related 13.8 kV supply bus NPS-SWG1B to trip. This resulted in the loss of power to all running feedwater, circulating water, and normal service water pumps and required operators to manually scram the reactor.

The inspector verified that this information was documented in the licensees evaluations.

b. Inspection Procedure 95001 requires that the inspection staff determine that the licensees evaluation of the issue documented how long the issue had existed and prior opportunities for identification.

The licensee determined that the inadequate modification of the mid-Standard Turbine Shaft Brush had existed since its installation in November 2004. The licensees evaluation looked at previous occurrences at the station, however, their review failed to identify a prior opportunity for correction. Specifically, the licensee initiated Condition Report CR-RBS-2011-1050 because the high-pressure bearing on the generator end had minor indications similar to electrolysis damage seen in previous outages, but failed to recognize this as a symptom of inadequate shaft grounding. The licensee initiated Condition Report CR-RBS-2012-7295 to capture the missed opportunity in the stations corrective action program.

The licensee determined that the inadequate crimp on the B reactor feedwater pump motor lug had existed since the installation of the motor in February 2008. The licensees evaluation reviewed previous occurrences at the station and determined that there were no prior opportunities to identify this issue. The inspector concurred, that it did not appear that the licensee had a prior opportunity to identify this issue.

The licensee determined that the inadequate maintenance of the lockout relay began in February 1996. The licensees evaluation looked at previous occurrences at the station and identified a prior opportunity for identification of this issue. Augmented Inspection Team Follow-Up Inspection Report 05000458/2012010 (ML12328A178) documented:

non-cited violation 05000458/2012010-04, Failure to Implement Effective Corrective Actions for Lockout Relay Failures, for the licensees failure to promptly identify and correct mechanical binding in lockout relays, which resulted in a loss of main feedwater and normal service water. That inspection report also documented non-cited violation 05000458/2012010-05, Failure to Test Lockout Relays in Accordance with Vendor Testing Practices, for the licensees failure to establish adequate preventive maintenance instructions for lockout relays in accordance with vendor recommendations, which resulted in a fire.

c.

Inspection Procedure 95001 requires that the inspection staff determine that the licensees evaluation documents the plant-specific risk consequences, as applicable, and compliance concerns associated with the issues.

The NRC determined that the licensees failure to fabricate the mid-standard turbine shaft brush in accordance with vendor technical instructions was of very low safety significance (Green) as documented in NRC Integrated Inspection Report 05000458/2012002 (ML12135A462), as finding 05000458/2012002-09, Failure to Properly Fabricate and Install the mid-Standard Turbine Shaft Brush.

The NRC determined that the licensees failure to perform appropriate maintenance on lockout relays was of very low safety significance (Green), as documented in Augmented Inspection Team Follow-Up Inspection Report 05000458/2012010 (ML12328A178), as non-cited violation 05000458/2012010-04, Failure to Implement Effective Corrective Actions for Lockout Relay Failures, for the licensees failure to promptly identify and correct mechanical binding in lockout relays, which resulted in a loss of main feedwater and normal service water; and non-cited violation 05000458/2012010-05, Failure to Test Lockout Relays in Accordance with Vendor Testing Practices, for the licensees failure to establish adequate preventive maintenance instructions for lockout relays in accordance with vendor recommendations, which resulted in a fire.

The NRC determined that the licensees failure to adequately crimp the motor lug on the B reactor feedwater pump was of very low safety significance (Green) as documented in Section

.2.01 .d of this report.

The inspector concluded that the licensees cause evaluations adequately documented the risk consequences and compliance concerns associated with each of these issues.

d. Findings

(1)

Introduction.

The inspector documented a Green self-revealing finding associated with the licensees failure to follow the requirements of Station Procedure EN-LI-102, Corrective Action Process, and promptly identify and correct a condition adverse to quality.

Description.

On August 4, 2010, following the shutdown of the B reactor feedwater pump, the licensee noted that auxiliary oil pump FWL-P5B was cycling on and off. The auxiliary oil pump is supposed to start and supply oil to components following shutdown of the pump. To stop the cycling, operators took the pumps control switch from auto to start, and the pump remained running. The licensee entered this issue into the corrective action program as Condition Report CR-RBS-2010-03509. They closed this condition report to Work Order 245868, which directed calibrating the auxiliary oil systems pressure switch and calibrating and, if necessary replacing Agastat time-delay relays. However, the licensee only calibrated the auxiliary oil systems pressure switch; because they noted no issues and could not get the problem to repeat. Therefore the licensee took no further actions.

On August 6, 2010, auxiliary oil pump FWL-P5B failed to shutoff when the B reactor feedwater pump was started. The licensee did not initiate a condition report for this issue. Instead, the licensee performed troubleshooting under Work Order 246447 and found that the pressure regulating valve was not regulating properly. The licensee did not initiate a condition report when the problem with the pressure regulating valve was identified either. Instead, the licensee replaced the valve and set the new regulator within the required control band.

On January 14, 2011, the licensee again noted that following the shutdown of the B reactor feedwater pump, auxiliary oil pump FWL-P5B was cycling on and off. To stop the cycling, operators took the pumps control switch from auto to start, and the pump remained running. The licensee entered this issue into the stations corrective action program as Condition Report CR-RBS-2011-00296. They closed this condition report to Work Order 261951 which directed calibrating the auxiliary oil systems pressure switch, which the licensee did without noting an issue. No further actions were taken by the licensee.

On January 21, 2011, the licensee initiated Condition Report CR-RBS-2011-00828 because of a concern associated with the B reactor feedwater pumps auxiliary oil system. Specifically, the initiator noted that Work Order 261951 had been performed to check the auxiliary oil system pressure switch because the auxiliary oil pump FWL-P5B was cycling, but the switch had been checked many times before with no issues noted.

However, the last time this issue occurred, the staff adjusted the pressure regulator and there seemed to be a problem other than the pressure switch that warranted investigation. The licensee closed this condition report to Work Order 263138, and while maintenance technicians were performing this work order, they found that the pressure regulator setpoint was high out of band. The licensee did not initiate a condition report when the problem with the pressure regulating valve was identified. Instead, maintenance personnel adjusted the pressure regulator setpoint back in band and closed the work order.

On December 23, 2011, while the unit was recovering from a high reactor water level isolation signal (Level 8) which had resulted in a trip of all three reactor feedwater pumps, operators attempted to restart the B reactor feedwater pump to restore reactor vessel level and noted that the auxiliary oil pump was cycling, which made the pump non-functional for restart. The licensee entered this issue into the corrective action program as Condition Report CR-RBS-2011-09030, which they closed to Condition Report CR-RBS-2011-09141 for resolution. During the corresponding evaluation, the licensee determined that the design margin for the pressure regulating valve was not adequate and required adjustment to a lower set point band, and that this had been the cause of the auxiliary oil pump cycling. As an interim action, the licensee set the pressure regulator setpoint to the low end of the allowed band while they revised the setpoint calculation.

During their review the licensee determined that contrary to the requirements of EN-LI-102, station personnel had failed to initiate condition reports when problems were identified; the auxiliary oil pump cycling, the pressure regulator not controlling, and the pressure regulator being found high out of band. Specifically, Station Procedure EN-LI-102, Corrective Action Process, section 4[1](b), requires, in part, that all station personnel are responsible for documenting problems by initiating condition reports. This resulted in the stations failure to promptly identify and correct the condition adverse to quality, the inappropriate pressure band setting for the pressure regulator.

The failure to initiate condition reports also resulted in the station not accurately tracking and trending equipment issues as required by EN-LI-102.

Analysis.

The failure to follow the requirements of Station Procedure EN-LI-102 and identify and correct a condition adverse to quality was a performance deficiency. The performance deficiency was determined to be more than minor, and is therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, in that the failure to promptly identify issues associated with the pressure regulator resulted in the pump not being functional when needed. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding:

(1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality;

(2) did not represent a loss of system and/or function;

(3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and

(4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. This finding had a cross-cutting aspect in the area of human performance associated with the work practices component, in that, the licensee failed to define and effectively communicates expectations regarding procedural compliance and personnel follow procedures.

Specifically, station personnel failed to follow procedure H.4(b).

Enforcement.

This finding does not involve enforcement action because no violation of regulatory requirements was identified. Because the finding does not involve a violation, has very low safety significance, and has been entered into the corrective action program as Condition Reports CR-RBS-2011-09141 and CR-RBS-2012-07249, it is identified as FIN 05000458/2012012-01, Failure to Identify and Correct a Condition Adverse to Quality.

(2)

Introduction.

The inspector identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, associated with the licensees failure to promptly identify and correct a condition adverse to quality.

Description.

On December 23, 2011, with the plant operating at 100 percent power, the main turbine tripped unexpectedly, which resulted in a reactor scram. Operators implemented the appropriate station response procedures, and began to stabilize reactor vessel pressure and water level. However, reactor vessel level rose to the point of receiving a high-level isolation signal (Level 8), which resulted in a trip of all three operating reactor feedwater pumps, and the isolation of the high pressure coolant injection and reactor core isolation cooling systems. This resulted in operators taking additional actions beyond those associated with a normal scram, so this scram was classified as a scram with complications.

The inspector noted that the licensee failed to classify the high-level isolation as an unexpected condition, or as a condition adverse to quality. Instead, the licensee stated that this was an expected occurrence and was due to the rapid closure of the turbine control and stop valves which resulted in fifteen of the sixteen steam relief valves opening for a short period of time, which in turn caused a swell in reactor water level and a high reactor water level isolation signal (Level 8). The station had experienced previous high-level isolations during plant scrams, and the inspector noted that the licensee had entered those instances into the stations corrective action program as unexpected conditions which required resolution.

The inspector determined that the station should not have received a high-level isolation following the turbine trip and scram, Furthermore, the inspector noted that:

• In General Electric Design Document 22A3778, "Feedwater Control System (Motor Driven Reactor Feed Pumps)," paragraph 4.1.6, Main Turbine Trip/Load Rejection and Level Control, states, in part; "Full feedwater capacity should be maintained following a normal turbine trip or load rejection. A potential later high level trip (L8) is to be avoided by using the level setpoint modification module (see Paragraph 4.1.15).

Also, paragraph 4.1.15, Level Setpoint Modification, states, in part, "Automatic setpoint setdown is required to help minimize the level variations during plant shutdown transients. The level setpoint shall be modified in a predetermined manner, as a function of time after reactor scram or low level scram."

• General Electric Design Specification Data Sheet GE-22A3778AB, "Feedwater Control System (Motor Driven Reactor Feed Pumps)," states that for the nominal setting for the Level Setpoint Modification; "It should be capable of stepping up approximately 18 inches for 10 seconds, and then stepping down approximately 36 inches (18 inches from normal). The step-up portion may be eliminated."

• USAR Section 14.2.12.3.24, Test Number 27- Turbine Trip and Generator Load Reject, states, in part, "Feedwater level control avoids loss of feedwater due to a high level (L8)trip during the event."

The inspector therefore determined that the licensee had failed to identify the high-level isolation as unexpected, and had failed to enter it into the stations corrective action program as required by EN-LI-102, section 4[1](b). In response to this determination, the licensee initiated Condition Report CR-RBS-2012-07251 to capture the missed identification of high level isolation as unexpected in the stations corrective action program.

The inspector also noted that the licensee had had not considered some available information associated with unexpected Level 8 isolations. Specifically, the licensee had failed to trend the information in the stations corrective action program associated with the receipt of Level 8 actuations. This resulted in the licensee failing to recognize this as an issue that required resolution.

Analysis.

The occurrence of a Level 8 isolation signal on December 23 was a condition adverse to quality, and the licensees failure to promptly identify and correct it was a performance deficiency. That performance deficiency is more than minor, and is therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, in that the failure to identify the high-level isolation as a condition adverse to quality and correct it would continue to result in the undesired isolation of mitigating equipment;. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green)because the finding:

(1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality;

(2) did not represent a loss of system and/or function;

(3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and

(4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. The finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to periodically trend and assess information from the corrective action program and other assessments in the aggregate to identify programmatic and common cause problems P.1(b).

Enforcement.

10 CFR 50, Appendix B, Criterion XVI, Corrective Actions, requires, in part, that, Measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, on December 23, 2011, measures established by the licensee did not assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances were promptly identified and corrected. Specifically, after the plant experienced a Level 8 isolation signal on December 23, 2012, the licensee failed to promptly identify receipt of that signal as a condition adverse to quality, and consequently failed to correct it. Because the finding is of very low safety significance (Green) and has been entered into the licensees corrective action program as Condition Reports CR-RBS-2012-02249 and CR-RBS-2012-07251, this violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the NRC Enforcement Policy: NCV 05000458/2012012-02, Failure to Promptly Identify and Correct a Condition Adverse to Quality.

(3)

Introduction.

The inspector identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, associated with the licensees failure to ensure that design requirements were correctly translated into installed plant equipment.

Description.

On December 23, 2011, with the plant operating at 100 percent power, the main turbine tripped (load reject) unexpectedly which resulted in a reactor scram.

Operators implemented the appropriate station response procedures, and began to stabilize reactor vessel pressure and water level. However, reactor vessel level rose to the point of receiving a high level isolation signal (Level 8), which resulted in tripping all three operating reactor feedwater pumps. The licensee determined that this was an expected occurrence, and attributed this to the rapid closure of the turbine control and stop valves which resulted in fifteen of the sixteen steam relief valves opening for a short period of time, which in turn caused a swell in reactor water level and a high reactor water level isolation signal (Level 8).

As noted above in Section

.2.01 .d(2), NCV 05000458/2012012-02, the inspector

determined that the station should not have received a high-level isolation following the turbine trip and scram.

By reviewing the results of Startup Test 1-ST-27, Turbine Trip and Generator Load Reject,, the inspector noted that the acceptance criteria stated, in part, Level 8 feed pump trip following transient shall not occur. However, during the test a Level 8 trip had occurred. In the test records, the licensee had noted that occurrence as an exception, due to leakage past the feed regulating valves. Following the test, the station had accepted the test results without further evaluation. The inspector also determined that the station operates the Level Setpoint Modification with nominal setpoints (i.e.,

unmodified) from General Electric Design Document 22A3778, and, in response to the inspectors request, the licensee was not able to find an evaluation or calculation that had reviewed the nominal setpoint for the Level Setpoint Modification to prevent receiving Level 8 after turbine trip and reactor scram. The inspector therefore concluded that the licensee had failed to appropriately translate the design into procedures and/or instructions to properly implement the automatic setpoint setdown feature. In response to this conclusion, the licensee initiated Condition Reports CR-RBS-2012-02249 and CR-RBS-2012-07254 to capture this issue in the stations corrective action program.

Analysis.

The failure to ensure that design requirements were correctly translated into procedures and/or instructions to properly implement the automatic setpoint setdown feature was a performance deficiency. This performance deficiency was determined to be more than minor, and is therefore a finding, because it was associated with the design control attribute of the Mitigating Systems Cornerstone, in that, this performance deficiency resulted in a high level isolation following a turbine trip/load reject, and thereby affecting the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding:

(1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality;

(2) did not represent a loss of system and/or function;

(3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and

(4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. This finding did not have a cross-cutting aspect because the most significant contributor did not reflect current licensee performance.

Enforcement.

10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in part, measures shall be established to assure that applicable regulatory requirements and the design basis, as defined in 10 CFR 50.2 and as specified in the license application, for those components to which this appendix applies are correctly translated into specifications, drawings, procedures, and instructions. Contrary to the above, from initial construction until March 30, 2012, measures established by the licensee failed to assure that applicable regulatory requirements and the design basis, as defined in 10 CFR 50.2 and as specified in the license application, for those components to which this appendix applies were correctly translated into specifications, drawings, procedures, and instructions. Specifically, those measures failed to assure that the design bases described in USAR Section 14.2.12.3.24 for the feedwater control system to avoid a loss of feedwater due to a high level (Level 8) isolation following a turbine trip/load reject was correctly translated into procedures and/or instructions to properly implement the automatic setpoint setdown feature. Because the finding is of very low safety significance (Green) and has been entered into the licensees corrective action program as Condition Reports CR-RBS-2012-02249 and CR-RBS-2012-07254, this violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the NRC Enforcement Policy: NCV 05000458/2012012-03, Failure to Maintain Design Control of the Feedwater Control System.

(4)

Introduction.

The inspector identified a Green finding associated with the licensees failure to follow the requirements of Station Procedure EN-LI-102, Corrective Action Process, and correct a condition adverse to quality.

Description.

On May 24, 2012, when operators attempted to start the B reactor feedwater pump, a fault occurred in the pump motor termination box which was not isolated by the motor feeder breaker. This fault resulted in an electrical transient which caused the main supply breaker for the nonsafety-related 13.8 kV supply bus NPS-SWG1B to trip, which resulted in a loss of power to all running feedwater, circulating water, and normal service water pumps. The licensee initiated Condition Report CR-RBS-2012-3665 to capture this issue in the stations corrective action program. The licensee performed an apparent-cause evaluation and documented it in this condition report.

By reviewing the licensees evaluation, the inspector noted that the licensee had determined that the fault had been caused by an inadequately crimped terminal lug on the B reactor feedwater pump. The licensee determined that the B reactor feedwater pump motor (SN 373231814) had been refurbished in 2008, by a vendor, and that this refurbishment had involved rewinding the motor. The vendor did not reinstall the terminal lugs. Instead, the vendor shipped the lugs with the refurbished pump to the licensee for the licensee to install. A different vendor subsequently installed the terminal lugs under Work Order 116285. The licensee determined that the work instructions in Work Order 116285 had been inadequate for this task, and that the oversight provided for the vendor performing the lug installation had been insufficient. These two aspects were captured as one apparent cause, which the licensee characterized as Inadequate Guidance and Oversight of a Supplemental Worker.

The inspector noted that the licensees corrective actions for this identified cause were to:

(1) perform a complete re-write of Station Procedure EN-MA-126, Control of Supplemental Personnel;

(2) verify the qualifications of the vendors technicians to ensure they meet the stations qualifications requirements; and

(3) determine if the process for contracting supplemental workers was followed for the lugging done in Work Order 116285. The inspector determined that while these actions addressed the oversight part of the identified root cause, none of these corrective actions addressed the inadequate guidance provided by the work order. The inspector determined that in their evaluation, the licensee had focused only on the issue associated with vendor control aspect, and had failed to thoroughly evaluate the issue associated with station work orders. As a result, the licensee had failed to thoroughly evaluate the root cause and implement corrective actions to address all the identified causes.

The inspector therefore determined that the licensee had failed to follow the requirements of Station Procedure EN-LI-102, Corrective Action Process, in that they failed to correct an identified condition adverse to quality. In response to this determination, the licensee initiated Condition Report CR-RBS-2012-07253 to capture this issue in the stations corrective action program.

Analysis.

The failure to follow the requirements of Station Procedure EN-LI-102 and correct an identified condition adverse to quality was a performance deficiency. The performance deficiency is more than minor, and is therefore a finding, because it affected the procedure quality attribute of the Mitigating Systems Cornerstone and affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, in that the failure to correct inadequate work instructions could affect other equipment. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process For Findings At-Power, the inspector determined that the finding is of very low safety significance (Green) because the finding:

(1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality;

(2) did not represent a loss of system and/or function;

(3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and

(4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. The inspector determined that the apparent cause of this finding was that the in their evaluation described in CR-RBS-2012-3665, the licensee had focused on the issue associated with vendor control aspect, and had failed to thoroughly evaluate the issue associated with station work orders.

Therefore, this finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to thoroughly evaluate problems such that the resolutions address causes.

Specifically, the licensees corrective actions failed to address to address the identified cause of an inadequate procedure P.1(c).

Enforcement.

This finding does not involve enforcement action because no violation of regulatory requirements was identified. Because the finding does not involve a violation, has very low safety significance, and has been entered into the corrective action program as Condition Report CR-CNS-2012-07253, it is identified as FIN 05000458/2012012-04, Failure to Correct an Identified Condition Adverse to Quality.

.2.02 Root Cause, Extent-of-Condition, and Extent-of-Cause

a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee evaluated the problem using a systematic methodology to identify the root and contributing causes.

In the root-cause evaluation for the 2011 scram event, the licensee used a Failure Modes Analysis and Why Analysis to identify causal factors and root causes. In the root-cause evaluation for the 2012 scram event, the licensee used a Failure Modes Analysis and an Event and Causal Factor Chart to identify causal factors and root causes. In the apparent-cause analysis for the motor fault the licensee used a Failure Modes Analysis and Why Analysis to identify causal factors and root causes.

The inspector concluded that the licensee had evaluated the issues using systematic methodologies to identify root and contributing causes.

b. Inspection Procedure 95001 requires that the inspection staff determine that the licensees root-cause evaluation was conducted to a level of detail commensurate with the significance of the problem.

The licensees root-cause evaluations included extensive timelines of the events and employed various techniques to analyze the events, as discussed in Section

.2.02 .a.

The licensees root-cause evaluations were generally through and identified the root causes for the scram events. For each of the events, the root-cause evaluation included a sufficient level of detail to determine the actual or probable cause, as well as the contributing causes.

c. Inspection Procedure 95001 requires that the inspection staff determine that the licensees root-cause evaluation included a consideration of prior occurrences of the problem and knowledge of prior operating experience.

The licensees evaluations included evaluations of both internal and industry operating experience. The licensees evaluations of industry operating experience provided sufficient detail such that general conclusions could be established regarding any similarities.

The inspector determined that the licensees evaluation failed to identify a missed opportunity for prior identification of the electrostatic discharge due to inadequate shaft grounding which caused the November 2011 scram. Specifically, the licensee had initiated Condition Report CR-RBS-2011-1050 because the high-pressure bearing on the generator end had minor indications similar to electrolysis damage seen in previous outages, but failed to recognize this as a symptom of inadequate shaft grounding. The licensees corresponding evaluation failed to identify CR-RBS-2011-1050 as a missed opportunity. The licensee initiated Condition Report CR-RBS-2012-7295 to capture the missed opportunity in the stations corrective action program.

d. Inspection Procedure 95001 requires that the inspection staff determine that the licensees root-cause evaluation addressed the extent-of-condition and the extent-of-cause of the problem.

For the December 23, 2011, event, the licensees evaluation determined that the extent-of-condition was limited to turbine-generator because the high-pressure turbine bearings and the front standard component bearings were known to be likely areas for electrostatic discharge if the shaft grounding is not adequate. As a corrective action, the licensee planned to inspect these bearings during the next refueling outage. The licensees evaluation also considered the extent-of-cause associated with inadequate modification implementation, electromagnetic interference, less than adequate preventative maintenance, and failure to follow procedures. The licensee determined that any plant modification with field-fabricated components was potentially susceptible to incorrect installation, but noted that most modifications do not require the station to field-fit components. For the electromagnetic interference on plant equipment, the licensee determined that this has previously been recognized, and that areas around other sensitive equipment were posted in the plant. The licensee also determined that station procedures provide specific guidance to review proposed modifications for preventative maintenance requirements when new components are added.

Furthermore, the licensee determined that procedure compliance could be an issue that was applicable to more groups at the station, and noted that the station has an ongoing emphasis on verbatim procedure compliance.

For the May 24, 2012, event, the licensees apparent-cause evaluation for the inadequate crimp on the B reactor feedwater pump motor lug determined that the extent-of-condition was limited to lugging for medium-voltage motors. The licensee compiled a list of potentially susceptible medium-voltage motors and inspected the motor lugs, using thermography, of all but three of the motors during the forced outage. The other three motors were to be inspected during the operating cycle or the next refueling outage. The licensees root-cause evaluation for the lockout relays determined that the extent-of-condition was limited to the population of lockout relays that had not been actuated or functionally tested in the last six years. The licensee compiled a list of all potentially susceptible relays and performed testing. The licensees root-cause evaluation for the lockout relays also considered the extent-of-cause associated with inadequate procedure use and adherence, inadequate use of operating experience, and inadequate risk recognition for corrective actions. The licensee determined that the procedure use and adherence issue would be resolved by an evaluation being done in Condition Report CR-RBS-2012-2545. The licensee determined that the inadequate use of operating experience was due to human error associated with one individual. The licensee also determined that inadequate risk recognition for corrective actions could be associated with any corrective action, and implemented training for all station departments to correct this issue.

The inspector determined that the licensees evaluation of the identified extent-of-cause associated with inadequate procedure use and adherence documented in Condition Report CR-RBS-2012-2545 was inadequate. See Section 02.02.f for more details.

e. Inspection Procedure 95001 requires that the inspection staff determine that the licensees root cause, extent-of-condition, and extent-of-cause evaluations appropriately considered the safety culture components as described in IMC 0305.

Inspection Manual Chapter 0310, Components Within the Cross-Cutting Areas, defines safety culture as that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance.

For the December 23, 2011, event the licensees evaluation identified weaknesses in the cross-cutting areas of:

(1) human performance associated with the resources component H.2(c) associated with preventative maintenance task not being added or revised in response to prior events;

(2) human performance associated with the work practices component H.4(b) associated with the failure of station personnel to follow procedural requirements;

(3) problem identification and resolution associated with the corrective action program component P.1(a) associated with station personnels failure to initiate condition reports; and

(4) problem identification and resolution associated with the corrective action program component P.1(c) associated with previous actions taken for electromagnetic interference not addressing all possible causes. In their evaluation, the licensee identified actions to address these issues.

For the May 24, 2012, event, the licensees root-cause evaluation for the lockout relays identified a weakness in the cross-cutting area of problem identification and resolution associated with the operating experience component P.2(b) associated with the stations failure to appropriately incorporate operating experience into the maintenance process. In the apparent-cause evaluation for the inadequate crimp on the B reactor feedwater pump motor lug the licensee determined that identified a weakness in the cross-cutting area of human performance associated with the work practices component

H.4(c) associated with the stations inadequate supervisory and management oversight of contractor work activities. In their evaluations the licensee identified actions to address these issues.

f. Findings

Introduction.

The inspector identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, associated with the licensees failure to promptly identify and correct a condition adverse to quality.

Description.

On May 24, 2012, when operators attempted to start the B reactor feedwater pump a fault occurred in the B pumps motor termination box which was not isolated by the motor feeder breaker because the lockout relay failed to function. This fault resulted in an electrical transient which caused the main supply breaker for the nonsafety-related 13.8 kV supply bus NPS-SWG1B to trip to clear the fault, which resulted in a loss of power to all running feedwater, circulating water, and normal service water pumps. The licensee initiated Condition Report CR-RBS-2012-3534 to capture the lockout relay issue in the stations corrective action program. The inspector also noted that the population of affected lockout relays included safety related relays. The licensee performed a root cause analysis and documented it in this condition report.

The inspector reviewed the evaluation in CR-RBS-2012-3534, dated June 28, 2012, and noted that the licensee had determined that one root cause was that the task scope for the preventative maintenance was not sufficient because maintenance did not apply the appropriate maintenance strategy for the lockout relays. They also determined that the inappropriate maintenance strategy was the result of inadequate procedure use.

Therefore, the licensee determined that this root cause had an extent-of-cause with generic implications for maintenance procedural use and adherence. The licensee determined that this extent-of-cause would be addressed in the root-cause evaluation being performed for Condition Report CR-RBS-2012-2545. Therefore, the licensee closed the extent-of-cause to Condition Report CR-RBS-2012-2545 for resolution.

The inspector reviewed the licensees root cause analysis documented in Condition Report CR-RBS-2012-2545. The Inspector noted that the problem statement was:

The Maintenance Organization has not corrected improper performance issues associated with procedure use and adherence. This has the potential to negatively impact the quality of work, plant equipment conditions, and ultimately industrial and nuclear safety.

The inspector noted the licensee had determined that the root cause for this issue was that maintenance practices do not always ensure that the needed procedural/work package support is ready and correct before a task. They determined that contributing causes were:

(1) causal analysis depth had not been sufficient, and

(2) management changes had been too frequent to support correction of performance shortfalls. In CR-RBS-2012-2545, the inspector did not locate a corrective action that addressed the procedure use and adherence. Therefore, the inspector determined that Condition Report CR-RBS-2012-2545 did not address a condition adverse to quality identified in Condition Report CR-RBS-2012-3534.

The inspector informed the licensee of this concern and the licensee initiated Condition Report CR-RBS-2012-07250 to capture this issue in the stations corrective action program.

Analysis.

The failure to promptly identify and correct the issue associated with improper procedure use and adherence in the maintenance organization was a performance deficiency. The performance deficiency is more than minor, and is therefore a finding, because it was associated with the human performance attribute of the Mitigating Systems Cornerstone and affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, in that the failure to correct procedure use and adherence behavioral issues could render other equipment inoperable,. The inspector evaluated the finding using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power. The inspector determined that the finding is of very low safety significance (Green) because the finding:

(1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality;

(2) did not represent a loss of system and/or function;

(3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than its technical specification allowed outage time; and

(4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significance in accordance with the licensees maintenance rule program. The finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action component, because the licensee failed to thoroughly evaluate problems such that the resolutions addressed causes

P.1(c).

Enforcement.

10 CFR 50, Appendix B, Criterion XVI, Corrective Actions, requires, in part, that, Measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, between June 28, 2012, and November 15, 2012, measures established by the licensee did not assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances were promptly identified and corrected Specifically, after an extent-of-cause review associated with a root-cause evaluation identified a condition adverse to quality associated with inadequate procedure use and adherence in the maintenance organizations, those measures did not assure that the subject condition was corrected.

Because the finding is of very low safety significance (Green) and has been entered into the licensees corrective action program as Condition Report CR-RBS-2012-07250, this violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the NRC Enforcement Policy: NCV 05000458/2012012-05, Failure to Correct the Maintenance Organizations Inadequate Procedure Use and Adherence.

.2.03 Corrective Actions

a. Inspection Procedure 95001 requires that the inspection staff determine that appropriate corrective actions are specified for each root and contributing cause or that the licensee has an adequate evaluation for why no corrective actions are necessary.

For the December 23, 2011, scram the licensee took immediate corrective action to restore the main turbine by replacing the mid-standard turbine shaft brush and verifying that it made proper contact with the shaft. In addition, the licensee inspected other shaft grounding brushes to ensure they made proper contact. To prevent recurrence, the licensees corrective action was to correct the angle of mid-standard turbine shaft brush to make the brush seat properly on the shaft, and to enable the brush wear indicator to read accurately. Additional actions specified for the contributing causes were to revise preventative maintenance tasks to verify all grounds are properly installed to turbine equipment, verifying turbine grounds each outage, and briefing station personnel on the importance of verbatim procedural compliance.

For the May 24, 2012, scram, the licensee took immediate corrective action to restore the lockout relays by performing functional testing of the suspect population of lockout relays. They also took immediate corrective action to restore the motor lugging for medium voltage motors by performing thermography for the potentially affected motors.

To prevent recurrence, the licensees corrective action was to review preventative maintenance tasks for those non-critical components whose failure could lead to the failure of a critical component, to ensure that they were performing the appropriate level of maintenance. For the contributing causes, the licensee determined training requirements needed to address inadequate risk recognition for corrective actions of cause evaluations.

The inspector determined that generally the licensees proposed corrective actions were appropriate to address the root and contributing causes identified for each event, with the exception of the issue identified in Section

.2.01 .d(4), FIN 05000458/2012012-04.

b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee prioritized corrective actions with consideration of risk significance and regulatory compliance.

Station Procedure EN-LI-102, Corrective Action Process, states, in part, immediate actions are taken as necessary to minimize the consequence of the condition. The licensees immediate corrective actions for both of the scram events focused on restoring functionality of the affected equipment. The licensee gave these actions the highest priority and accomplished them on an acceptable schedule. To address the root and contributing causes, the licensee prioritized other corrective actions in accordance with Station Procedure EN-LI-102. That is, to each action, they assigned a completion date and a responsible manager, and they tracked each action to completion through the corrective action program.

The inspector concluded that the corrective actions taken by the licensee were prioritized with appropriate considerations of risk significance and regulatory compliance.

c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee established a schedule for implementing and completing the corrective actions.

The licensee established due dates for the corrective actions in accordance with Station Procedure EN-LI-102, Corrective Action Process. The due dates were documented in the licensees cause evaluations CR-RBS-2011-09053, CR-RBS-2012-03054, and CR-RBS-2012-3665.

The inspector concluded that that an appropriate schedule had been established for implementing and completing the corrective actions.

d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee developed quantitative or qualitative measures of success for determining the effectiveness of the corrective actions to preclude repetition.

The licensees root cause analyses and recommended corrective actions were reviewed and approved by the stations corrective action review board. Each corrective action was assigned a responsible manager and the actions were tracked for completion in the stations corrective action program. Additionally, Station Procedure EN-LI-102, Corrective Action Process, requires the licensee to evaluate the effectiveness of corrective actions to prevent recurrence.

The licensee plans to determine the effectiveness of corrective actions for the December 23, 2011, scram by verifying that the mid-standard turbine shaft brush contacts the shaft per vendor requirements, and that wear indicator indicates NEW with the new brush installed, before the end of Refueling Outage 17. The licensee plans to determine the effectiveness of corrective actions for the May 24, 2012, scram by verifying that the non-critical preventative maintenance tasks have a maintenance strategy from the appropriate maintenance templates within one year.

The inspector concluded that quantitative measures of success had been developed for determining the effectiveness of the corrective actions to preclude repetition.

e.

Inspection Procedure 95001 requires that the inspection staff determine that the licensees planned or taken corrective actions adequately address a Notice of Violation that was the basis for the supplemental inspection, if applicable.

The NRC did not issue a Notice of Violation to the licensee. Therefore, this inspection requirement was not applicable.

f. Findings

No findings were identified.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On November 15, 2012, the inspector presented the inspection results to Mr. Eric Olson, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspector asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

T. Bolke, Senior Licensing Specialist

J. Boulanger, Manager, Maintenance

D. Burnett, Manager, Emergency Preparedness

G. Bush, Manager, Material, Procurement, and Contracts

A. Carter, Senior Health Physics Specialist

M. Chase, Manager, Training

J. Clark, Manager, Licensing

C. Colman, Manager, Engineering Programs & Components

F. Corley, Manager, Design Engineering

R. Creel, Superintendent, Plant Security

M. Feltner, Manager, Planning and Scheduling, Outages

C. Forpahl, Manager, System Engineering

A. Fredieu, Manager, Outage

R. Gadbois, General Manager, Plant Operations

T. Gates, Assistant Operations Manager - Shift

H. Goodman, Director, Engineering

G. Hackett, Manager, Radiation Protection

R. Heath, Manager, Chemistry

W. Holland, Supervisor, Radiation Protection

K. Huffstatler, Senior Licensing Specialist

G. Krause, Assistant Operations Manager - Training

E. Neal, Supervisor, Radiation Protection

E. Olson, Site Vice President

J. Roberts, Director, Nuclear Safety Assurance

T. Santy, Manager, Security

T. Shenk, Assistant Operations Manager - Support

M. Spustack, Supervisor, Engineering

D. Vines, Manager, Corrective Actions and Assessments

J. Vukovics, Supervisor, Reactor Engineering

L. Woods, Manager, Quality Assurance

Attachment 3

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

Failure to Identify and Correct a Condition Adverse to Quality

05000458/2012012-01 FIN (Section 4OA4.2.01)

Failure to Promptly Identify and Correct a Condition Adverse to

05000458/2012012-02 NCV Quality (Section 4OA4.2.01)

Failure to Maintain Design Control of the Feedwater Control

05000458/2012012-03 NCV System (Section 4OA4.2.01)

Failure to Correct an Identified Condition Adverse to Quality

05000458/2012012-04 FIN (Section 4OA4.2.01)

Failure to Correct the Maintenance Organizations Inadequate

05000458/2012012-05 NCV Procedure Use and Adherence (Section 4OA4.2.02)