IR 05000458/2023002
| ML23221A327 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 08/09/2023 |
| From: | David Proulx NRC/RGN-IV/DORS/PBC |
| To: | Hansett P Entergy Operations |
| References | |
| IR 2023002 | |
| Download: ML23221A327 (1) | |
Text
SUBJECT:
RIVER BEND STATION - INTEGRATED INSPECTION REPORT 05000458/2023002
Dear Phil Hansett:
On June 30, 2023, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at River Bend Station. On July 10, 2023, the NRC inspectors discussed the results of this inspection with you and other members of your staff. The results of this inspection are documented in the enclosed report.
Three findings of very low safety significance (Green) are documented in this report. All of these findings involved violations of NRC requirements. We are treating these violations as non-cited violations consistent with section 2.3.2 of the Enforcement Policy.
Two licensee-identified violations which were determined to be of very low safety significance are documented in this report. We are treating these violations as non-cited violations consistent with section 2.3.2 of the Enforcement Policy.
If you contest the violations or the significance or severity of the violations documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; 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 U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC Resident Inspector at River Bend Station.
August 9, 2023 This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely, David L. Proulx, Acting Chief Reactor Projects Branch C Division of Operating Reactor Safety Docket No. 05000458 License No. NPF-47
Enclosure:
As stated
Inspection Report
Docket Number:
05000458
License Number:
Report Number:
Enterprise Identifier:
I-2023-002-0012
Licensee:
Entergy Operations, Inc.
Facility:
River Bend Station
Location:
St. Francisville, Louisiana
Inspection Dates:
April 1, 2023, to June 30, 2023
Inspectors:
B. Baca, Health Physicist
D. Childs, Resident Inspector
R. Easter, Resident Inspector
R. Kumana, Senior Reactor Inspector
J. O'Donnell, Senior Health Physicist
C. Wynar, Senior Resident Inspector
Approved By:
David L. Proulx, Acting Chief
Reactor Projects Branch C
Division of Operating Reactor Safety
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at River Bend Station, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Two licensee-identified non-cited violations are documented in report sections: 71111.13 and 71124.0
List of Findings and Violations
Inadequate Risk Mitigating Actions for Inservice Shutdown Cooling Train Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000458/2023002-01 Open/Closed
[H.8] -
Procedure Adherence 71111.13 The inspectors identified a Green finding and associated non-cited violation of Title 10 of the Code of Federal Regulations 50.65(a)(4) for failing to manage an increase in risk from maintenance activities. Specifically, the licensee failed to protect the in service decay heat removal system by posting protected equipment signs.
Inappropriate Risk Screened Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000458/2023002-02 Open/Closed
[H.11] -
Challenge the Unknown 71111.13 The inspectors identified a Green non-cited violation of Title 10 of the Code of Federal Regulations 50.65(a)(4) for failing to assess an increase in risk from maintenance activities.
Specifically, during refueling outage RF-22, with shutdown cooling systems A and B inoperable, the licensee incorrectly determined that risk was green when in fact risk was elevated to orange and the licensee failed to implement additional measures per Procedure OSP-0037, revision 42, Shutdown Operations Protection Plan (SOPP).
Improper Entry Into a High Radiation Area Cornerstone Significance Cross-Cutting Aspect Report Section Occupational Radiation Safety Green NCV 05000458/2023002-03 Open/Closed
[H.5] - Work Management 71124.01 The inspectors reviewed a self-revealed Green non-cited violation of Technical Specification 5.4.1.a, for failure to follow written procedures that resulted in an improper entry into a high radiation area. Specifically, a work crew removed shielding and insulation from a valve different than the valve for which they were briefed.
Additional Tracking Items
Type Issue Number Title Report Section Status Licensee Event Report 05000458/2022-003-00 Division 1 Standby Diesel Generator Speed Sensor Power Supply Failure 71153 Closed
PLANT STATUS
River Bend Station began the inspection period shut down as it continued refueling outage RF-22 from the previous inspection period. On June15, 2023, the station entered mode 2 and commenced start-up procedures. On June 17, 2023, the unit synced to the grid. On June 20, 2023, the unit returned to full rated thermal power and remained there for the rest of the inspection period.
INSPECTION SCOPES
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed activities described in IMC 2515, appendix D, Plant Status, observed risk significant activities, and completed on-site portions of IPs. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
REACTOR SAFETY
71111.04 - Equipment Alignment
Partial Walkdown Sample (IP Section 03.01) (2 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
(1)normal service water/standby service water on June 26, 2023 (2)division 1 control building chilled water system on June 26, 2023
71111.05 - Fire Protection
Fire Area Walkdown and Inspection Sample (IP Section 03.01) (5 Samples)
The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:
(1)turbine building 67-foot elevation, fire area TB-067, on April 12, 2023 (2)annulus area, fire area RC-6, on April 18, 2023 (3)diesel driven fire pump 1A room, fire area FP-1, on April 24, 2023 (4)standby cooling tower pump B transformer room, fire area PH-2/Z-2, on April 25, 2023
- (5) G-tunnel, fire area PT-1, on June 7, 2023
71111.06 - Flood Protection Measures
Flooding Sample (IP Section 03.01) (1 Sample)
The inspectors evaluated external flooding mitigation protections in the:
- (1) annulus area on April 21, 2023
71111.07A - Heat Exchanger/Sink Performance
Annual Review (IP Section 03.01) (1 Sample)
The inspectors evaluated readiness and performance of:
- (1) ultimate heat sink design basis review on June 26, 2023
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance
Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01) (1 Sample)
- (1) The inspectors observed and evaluated licensed operator performance in the control room during startup on June 15, 2023.
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
- (1) The inspectors observed and evaluated time critical operator actions for SWP-MOV96A on May 25, 2023.
71111.13 - Maintenance Risk Assessments and Emergent Work Control
Risk Assessment and Management Sample (IP Section 03.01) (4 Samples)
The inspectors evaluated the accuracy and completeness of risk assessments for the following planned and emergent work activities to ensure configuration changes and appropriate work controls were addressed:
(1)yellow risk during reactor pressure vessel testing and control rod manipulations on April 26, 2023 (2)risk assessment for decay heat removal on April 30, 2023 (3)alternate decay heat removal configuration 3 not protected on April 30, 2023 (4)risk management actions for division 2 out of service on June 30, 2023
71111.15 - Operability Determinations and Functionality Assessments
Operability Determination or Functionality Assessment (IP Section 03.01) (5 Samples)
The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:
(1)flow-accelerated corrosion on class 1 reactor water cleanup piping on April 4, 2023 (CR-RBS-2023-02143)
(2)emergency core cooling system control building chilled water system chiller/emergency diesel generator operability on April 11, 2023 (CR-RBS-2023-01183, CR-RBS-2023-01184, and CR-RBS-2023-01287)
(3)standby service water cross connect valve SWP-MOV505A failure on June 5, 2023 (CR-RBS-2023-00149)
(4)division 2 battery cell 60 crack on June 5, 2023 (CR-RBS-2023-04362)
(5)standby service water operability on June 15, 2023 (CR-RBS-2023-01238)
71111.20 - Refueling and Other Outage Activities
Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)
- (1) The inspectors evaluated refueling outage RF-22 activities from February 11, 2023, to June 15, 2023.
71111.24 - Testing and Maintenance of Equipment Important to Risk
The inspectors evaluated the following testing and maintenance activities to verify system operability and/or functionality:
Post-Maintenance Testing (PMT) (IP Section 03.01) (10 Samples)
(1)work order (WO) 00593872, residual heat removal A injection line check valve, on April 17, 2023
- (2) WO 52978012, recirculation pump A, on May 3, 2023
- (3) WO 00572234, reactor plant component cooling water system vital loop isolation Valve, CCP-MOV 335 replacement, on May 9, 2023
- (4) WO 00572248, reactor plant component cooling water system vital loop isolation valve CCP-MOV 130 replacement, on May 9, 2023
- (5) WO 00569704, reactor core isolation cooling rosemont transmitter replacement, on May 23, 2023
- (6) WO 00565260, reactor core isolation cooling steam supply valve E51-MOVF063 replacement, on May 24, 2023 (7)rod 24-25 replacement work order on June 12, 2023
- (8) WO 00592525, standby service water fan breaker SWP-FN1M breaker, on June 26, 2023
- (9) WO 53021560, containment unit cooler standby service water supply valve SWP-MOV502A, on June 30, 2023 (10)condition reports CR-2023-01242/01296, main steam isolation valve sealing system supply valve E33-VF029C replacement, on June 30, 2023
Surveillance Testing (IP Section 03.01) (3 Samples)
- (1) STP-052-3701, revision 30, Control Rod Scram Testing, on June 15, 2023
- (2) STP-050-0702, revision 24, Vessel Pressure Test, on June 15, 2023
- (3) STP-205-6301, revision 28, LPSC Pump and Valve Quarterly Operability, on June 30, 2023
71114.06 - Drill Evaluation
Drill/Training Evolution Observation (IP Section 03.02) (1 Sample)
The inspectors evaluated:
- (1) simulator scenario with emergency classification on May 16,
RADIATION SAFETY
71124.01 - Radiological Hazard Assessment and Exposure Controls
Radiological Hazard Assessment (IP Section 03.01) (1 Sample)
- (1) The inspectors evaluated how the licensee identifies the magnitude and extent of radiation levels and the concentrations and quantities of radioactive materials and how the licensee assesses radiological hazards.
Instructions to Workers (IP Section 03.02) (1 Sample)
- (1) The inspectors evaluated how the licensee instructs workers on plant -related radiological hazards and the radiation protection requirements intended to protect workers from those hazards.
Contamination and Radioactive Material Control (IP Section 03.03) (2 Samples)
The inspectors observed/evaluated the following licensee processes for monitoring and controlling contamination and radioactive material:
(1)survey of potentially contaminated material leaving the radiologically controlled area during a refueling outage (2)removal of contaminated tubing from the condenser during the condenser tube replacement
Radiological Hazards Control and Work Coverage (IP Section 03.04) (3 Samples)
The inspectors evaluated the licensee's control of radiological hazards for the following radiological work:
(1)diving in the reactor vessel controlled using radiation work permit (RWP) 20231727, revision 1 (2)reactor water cleanup (RWCU) heat exchanger piping replacement controlled using RWP 20231751, revision 2 (3)condenser tube replacement controlled using RWP 20231423, revision 1 High Radiation Area and Very High Radiation Area Controls (IP Section 03.05) (5 Samples)
The inspectors evaluated licensee controls of the following high radiation areas (HRAs) and very high radiation areas:
- (2) HRA fuel building 98-foot spent fuel pool demineralizer room
- (3) HRA auxiliary building 95-foot reactor core isolation cooling room
- (4) HRA radwaste building 106-foot liner bay
- (5) HRA radwaste building 90-foot phase separator header room Radiation Worker Performance and Radiation Protection Technician Proficiency (IP Section 03.06) (1 Sample)
- (1) The inspectors evaluated radiation worker and radiation protection technician performance as it pertains to radiation protection requirements.
71124.03 - In-Plant Airborne Radioactivity Control and Mitigation
Permanent Ventilation Systems (IP Section 03.01) (2 Samples)
The inspectors evaluated the configuration of the following permanently installed ventilation systems:
(1)control room (2)technical support center emergency ventilation filtration
Temporary Ventilation Systems (IP Section 03.02) (2 Samples)
The inspectors evaluated the configuration of the following temporary ventilation systems:
- (1) RWCU heat exchanger work activity high efficiency particulate air units (2)condenser work activity high efficiency particulate air units
Use of Respiratory Protection Devices (IP Section 03.03) (1 Sample)
- (1) The inspectors evaluated the licensees use of respiratory protection devices.
Self-Contained Breathing Apparatus for Emergency Use (IP Section 03.04) (1 Sample)
- (1) The inspectors evaluated the licensees use and maintenance of self-contained breathing apparatuses.
71124.04 - Occupational Dose Assessment
Internal Dosimetry (IP Section 03.03) (1 Sample)
The inspectors evaluated the following internal dose assessments:
- (1) Five workers internal dose assessments (assessments) while working in the RWCU heat exchanger room, four workers assessments while working in the A hotwell, four workers assessments while working on drywell valve E21-AOVF006, two workers assessments while working in the main steam tunnel, and 23 workers assessments during the condenser tube replacement activities.
71124.08 - Radioactive Solid Waste Processing & Radioactive Material Handling, Storage, &
Transportation
Shipment Preparation (IP Section 03.04)
- (1) The inspectors observed the preparation of radioactive shipments RBS-2023-CT-021 and RBS-2023-CT-022 for transport. Both shipments were UN2912, radioactive material, low specific activity (LSA-II), consisting of contaminated condenser tubes.
OTHER ACTIVITIES - BASELINE
===71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:
MS06: Emergency AC Power Systems (IP Section 02.05)===
- (1) April 1, 2022, through March 31, 2023
MS07: High Pressure Injection Systems (IP Section 02.06) (1 Sample)
- (1) April 1, 2022, through March 31, 2023
MS08: Heat Removal Systems (IP Section 02.07) (1 Sample)
- (1) April 1, 2022, through March 31, 2023
OR01: Occupational Exposure Control Effectiveness Sample (IP Section 02.15) (1 Sample)
- (1) October 1, 2022, through December 31, 2022 PR01: Radiological Effluent Technical Specifications/Offsite Dose Calculation Manual Radiological Effluent Occurrences (RETS/ODCM) Radiological Effluent Occurrences Sample (IP Section 02.16) (1 Sample)
- (1) October 1, 2022, through December 31, 2022
71152A - Annual Follow-up Problem Identification and Resolution Annual Follow-up of Selected Issues (Section 03.03)
The inspectors reviewed the licensees implementation of its corrective action program related to the following issue:
(1)water-tight shield building door leakage and reclassification on May 4, 2023
71153 - Follow Up of Events and Notices of Enforcement Discretion Event Report (IP Section 03.02)
The inspectors evaluated the following licensee event reports (LERs):
- (1) LER 05000458/2022-003-00, Division 1 Standby Diesel Generator Speed Sensor Power Supply Failure (ADAMS Accession No. ML22244A098)
The inspectors determined that the cause of the condition described in this LER was not reasonably within the licensee's ability to foresee or correct the cause discussed in the LER and therefore was not reasonably preventable. No performance deficiency or violation of NRC requirements was identified. This LER is closed.
INSPECTION RESULTS
Inadequate Risk Mitigating Actions for In Service Shutdown Cooling Train Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000458/2023002-01 Open/Closed
[H.8] -
Procedure Adherence 71111.13 The inspectors identified a Green finding and associated non-cited violation of Title 10 of the Code of Federal Regulations 50.65(a)(4) for failing to manage an increase in risk from maintenance activities. Specifically, the licensee failed to protect the in service decay heat removal system by posting protected equipment signs.
Description:
From February 25, 2023, to March 6, 2023, the licensee was shut down and in mode 5 for a scheduled refueling outage. While shut down in mode 5, the site technical specifications require a shutdown cooling (SDC) system in service for decay heat removal (DHR).
On February 25, 2023, the licensee established suppression pool cooling in alternate decay heat removal (ADHR) configuration 3 as the SDC system in service for DHR.
Licensee Procedure EN-OP-119, revision 016, Protected Equipment Postings, section 5.2.7 states, in part, that for the in service SDC loop, protect all system components that, if adversely affected, could result in loss of DHR. The licensee protects equipment by hanging protected equipment postings on all relevant areas and components. This was the only risk mitigating action (RMA) the licensee was required to complete.
On March 6, 2023, the inspectors identified that the licensee failed to protect the in service SDC system, ADHR, that was providing DHR and brought it to the control room's attention.
The inspectors determined that the licensee met the conditions of procedure EN-OP-119, section 5.2.7 and were thus required to protect ADHR configuration 3 per their RMAs.
Corrective Actions: The licensee entered this issue into their corrective action program and immediately posted the ADHR equipment as protected equipment.
Corrective Action References: CR-RBS-2023-02254, CR-RBS-2023-02944, and CR-RBS-2023-03257
Performance Assessment:
Performance Deficiency: Title 10 of the Code of Federal Regulations (10 CFR) 50.65(a)(4)requires the licensee to assess and manage the increase in risk that may result from maintenance activities before performing them. The inspectors determined that during the refueling outage while DHR systems were required to be operating, the licensee failed to assess and manage the increase in risk by taking required RMAs and was therefore a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Equipment Performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to protect the in service SDC system of DHR increased the likelihood that the only method of DHR could be lost.
Significance: The inspectors assessed the significance of the finding using IMC 0609, appendix K, Maintenance Risk Assessment and Risk Management SDP. The inspectors requested that the licensee perform a risk assessment of the specific configuration. In their assessment, the licensee estimated the risk deficit and incremental core damage probability was less than 1.0E-6. A regional senior reactor analyst independently reviewed the licensees assessments and confirmed the licensees risk estimates. The inspectors applied this information to the flowcharts in appendix K to determine this finding had very low safety significance (Green).
Cross-Cutting Aspect: H.8 - Procedure Adherence: Individuals follow processes, procedures, and work instructions. The licensee failed to follow their risk management procedure and perform the required RMAs.
Enforcement:
Violation: Title 10 CFR 50.65(a)(4) requires the licensee to assess and manage the increase in risk that may result from maintenance activities.
Contrary to the above, from February 25, 2023, to March 6, 2023, the licensee failed to assess and manage the increase in risk before performing maintenance activities.
Specifically, the licensee failed to implement appropriate RMAs for the ADHR system when they did not hang protected equipment postings while the ADHR system was in service for DHR.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with section 2.3.2 of the Enforcement Policy.
Inappropriate Risk Screened Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000458/2023002-02 Open/Closed
[H.11] -
Challenge the Unknown 71111.13 The inspectors identified a Green non-cited violation of Title 10 of the Code of Federal Regulations 50.65(a)(4) for failing to assess an increase in risk from maintenance activities.
Specifically, during refueling outage RF-22, with shutdown cooling systems A and B inoperable, the licensee incorrectly determined that risk was green when in fact risk was elevated to orange and the licensee failed to implement additional measures per Procedure OSP-0037, revision 42, Shutdown Operations Protection Plan (SOPP).
Description:
The inspectors reviewed the Outage Risk Management Report for the station during refueling outage RF-22. From February 28, 2023, to March 6, 2023, the station entered technical specifications (TS) limiting condition for operation (LCO) 3.4.10 condition A for one or two residual heat removal (RHR) SDC subsystems inoperable. The TS bases describes a RHR subsystem as a motor driven pump, two heat exchangers in series, and associated piping and valves. Both loops have the common suction from the same recirculation loop. The suction for the A and B division of RHR SDC are MOVF008 and MOVF009, respectively. Both valves were tagged out for maintenance.
Procedure OSP-0037 contains attachment 15, Shutdown Cooling Function Color States.
This is a matrix of various combinations of DHR systems available, decay heat level, and status of the reactor pressure vessel (flooded or not flooded). Utilizing this matrix, the licensee is able to determine what risk color they will be in. According to the matrix, if ADHR is your only SDC system available and you have medium decay heat and are flooded, the assessed risk should be orange. The licensee incorrectly assumed RHR B in fuel pool cooling assist mode counted as a RHR SDC subsystem and therefore assumed they had one RHR and ADHR system available making the risk green. However, as defined by TS bases, the RHR SDC subsystem includes the suction of the recirculation lines which were unavailable due to maintenance on the MOVF008 and MOVF009 valves.
Furthermore, attachment 15 states that the matrix is based off of reference calculation G13.18.12.3*171, Shutdown Safety Function Defense-in-Depth Color Codes.
Section 3.1 of this calculation states: If the LCO is not met and an Action statement (i.e., ADHR methods) is entered with the decay heat level medium, then the status color for the Shutdown Cooling function is ORANGE. The LCO was not met, and the licensee had logged they were in action statement A of TS 3.4.10. Procedure OSP-0037 requires additional measures for assessed orange risk such as, manager approval for entry into orange conditions, risk mitigation contingency plans in place prior to voluntarily entering this condition, and work around the clock to minimize time in this condition. Therefore, the licensee incorrectly assessed risk based on their procedures and calculations resulting in a violation of 10 CFR 50.65.a.4.
Corrective Actions: The licensee entered this issue into their corrective action program.
Corrective Action References: CR-RBS-2023-03257
Performance Assessment:
Performance Deficiency: Title 10 CFR 50.65(a)(4) requires the licensee to assess and manage the increase in risk that may result from maintenance activities before performing them. The inspectors determined that when the licensee entered the TS LCO for both trains of RHR SDC being inoperable on February 28, 2023, until March 5, 2023, when the licensee exited the LCO, the licensee inappropriately assessed risk as green when per OSP-00037 the risk should have been assessed as orange. Failure to follow procedure to assess risk is a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Equipment Performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.
Significance: The inspectors assessed the significance of the finding using IMC 0609, appendix K, Maintenance Risk Assessment and Risk Management SDP. The inspectors requested that the licensee perform a risk assessment of the specific configurations of both conditions. In their assessments, the licensee estimated the risk deficits and incremental core damage probabilities for each condition were less than 1.0E-6. A regional senior reactor analyst independently reviewed the licensees assessments and confirmed the licensees risk estimates. The inspectors applied this information to the flowcharts in appendix K to determine this finding had very low safety significance (Green).
Cross-Cutting Aspect: H.11 - Challenge the Unknown: Individuals stop when faced with uncertain conditions. Risks are evaluated and managed before proceeding.
Enforcement:
Violation: Title 10 CFR 50.65(a)(4) requires the licensee to assess and manage the increase in risk that may result from maintenance activities. Contrary to the above, from February 28, 2023, to March 6, 2023, the licensee failed to assess and manage the increase in risk before performing maintenance activities. Specifically, the licensee failed to recognize and assess the appropriate risk for the period both trains of RHR SDC were inoperable.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with section 2.3.2 of the Enforcement Policy.
Licensee-Identified Non-Cited Violation 71111.13 This violation of very low safety significance was identified by the licensee and has been entered into the licensees corrective action program and is being treated as a non-cited violation, consistent with section 2.3.2 of the Enforcement Policy.
Violation: Title 10 CFR 50.65(a)(4) requires the licensee to assess and manage the increase in risk that may result from maintenance activities. Contrary to the above, from February 11, 2023, to February 14, 2023, the licensee failed to assess and manage the increase in risk before performing maintenance activities. Specifically, the licensee failed to implement appropriate RMAs required to protect division 1 while the unit is shut down and division 2 work was in progress.
Significance/Severity: Green. The inspectors assessed the significance of the finding using IMC 0609, appendix K, Maintenance Risk Assessment and Risk Management SDP. The inspectors requested that the licensee perform a risk assessment of the specific configurations of both conditions. In their assessments, the licensee estimated the risk deficits and incremental core damage probabilities for each condition were less than 1.0E-6.
A regional senior reactor analyst independently reviewed the licensees assessments and confirmed the licensees risk estimates. The inspectors applied this information to the flowcharts in appendix K to determine this finding had very low safety significance (Green).
Corrective Action References: The licensee performed the appropriate RMAs and entered this issue into their corrective action program under CR-RBS-2023-01132.
Improper Entry Into a High Radiation Area Cornerstone Significance Cross-Cutting Aspect Report Section Occupational Radiation Safety Green NCV 05000458/2023002-03 Open/Closed
[H.5] - Work Management 71124.01 The inspectors reviewed a self-revealed Green non-cited violation of Technical Specification 5.4.1.a, for failure to follow written procedures that resulted in an improper entry into a high radiation area. Specifically, a work crew removed shielding and insulation from a valve different than the valve for which they were briefed.
Description:
On February 14, 2023, at 11:50 pm, the drywell lead radiation protection technician (DW-LT) briefed a work crew consisting of two insulators and two pipe fitters along with a supervisor for each craft on the radiological conditions and travel path to remove shielding and insulation on valve E13-AOVF041B (F041B). This valve was the RHR B injection line check valve on the 130-foot drywell elevation. The DW-LT also briefed a radiation protection technician (RPT1) on the radiological conditions expected. The insulation supervisor informed the group that he knew where valve F041B was located.
The radiological conditions that were briefed for valve F041B were 1,000 millirem per hour (mrem/hr) on contact with the valve body, 300 mrem/hr general area (at 30 centimeters [cm]),
and a contamination level of 10,000 disintegrations per minute per 100 square centimeters (dpm/100 cm2). The RWPs used by the craft personnel were RWP 2023-1910 for the insulators and RWP 2023-1933 for the pipe fitters, with self-reading dosimeter dose rate setpoints of 702 mrem/hr for both sets of workers.
On February 15, 2023, at 12:00 am, the work crew and RPT1 entered the drywell, and instead of going to valve F041B on the 130-foot drywell elevation, the work crew went to the 141-foot drywell elevation to the low pressure core spray (LPCS) pump injection check valve E21-AOVF006 (F006). The group was led to valve F006 by the insulation supervisor. None of the work crew questioned the supervisor about the location and elevation of the valve being different than what was briefed and shown on the survey maps. The work crew did not take any maps or other documentation on the valves location into the drywell for reference. The workers then began removing the shielding and insulation.
Approximately two hours into the job, RPT1 directed the workers to stop work and leave the area because the dose rates measured were different (higher) than those briefed. Additional support was called for by RPT1 and a second RP technician (RPT2) was sent with another meter and a ruler to confirm that the dose rates did not exceed the HRA posting limit. When RPT2 went to the 130-foot drywell elevation where the work crew was briefed to work on valve F041B, the work crew was not there. Technician RPT2 found RPT1 waiting at valve F006, one elevation above on the 141-foot drywell elevation about 5 minutes later. After the arrival of RPT2 at valve F006, the work crew realized they had removed shielding and insulation from the wrong valve.
Upon exiting the radiologically controlled area, two of the insulators were determined to be contaminated when they alarmed the radiation monitor. A third person alarmed the radiation monitor leaving the plant. Based on radiation survey RBS-2023-00484, the accessible dose rates confirmed by RPT2 at valve F006 were 3,500 mrem/hr on contact and 600 mrem/hr general area (at 30 cm), along with a maximum contamination level of 400,000 dpm/100 cm2.
Licensee procedures required the workers to be briefed on the radiological conditions of the work area and travel path when entering HRAs. Specifically, Procedure EN-RP-101, revision 16, Access Controls for Radiologically Controlled Areas, section 5.4.1.3, required a brief of personnel entering HRAs on radiological conditions using attachment 8, Typical HRA/LHRA/VHRA Brief Checklist. Attachment 8 stated requirements to enter HRAs included that a worker be briefed and knowledgeable of radiological conditions in the work area and travel path and only enter areas they have been briefed on.
The workers were not briefed on the dose rates or contamination levels for valve F006, which they incorrectly worked on, and therefore were unaware of the radiological hazard. This lack of awareness resulted in two of the workers and one supervisor alarming radiation monitors.
The licensee maintenance organization plans and schedules activities to maintain the safe operation of the plant. Valve F041B was the valve in the work plan. Not only was valve F006 not in the work plan, but it was also part of a protected train designated for maintaining the safe operation of the plant. The supervisor failed to use available information to verify the valve location. The workers and other supervisor failed to peer-check or question the location of the valve, though it was different than what was briefed.
Corrective Actions:
The licensee assessed this issue and implemented corrective actions. Immediate actions taken included:
- Individuals were restricted from the RCA.
- A causal analysis investigation was completed, and several actions were identified and completed.
- Internal dose assessments were completed for the individuals and doses assigned.
Corrective Action References: CR-RBS-2023-01155
Performance Assessment:
Performance Deficiency: The failure to follow procedures for entry into a HRA was a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Program & Process attribute of the Occupational Radiation Safety cornerstone and adversely affected the cornerstone objective to ensure the adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. Specifically, the failure to follow procedure requirements involving radiological controls increased the workers exposure. The workers went to a location they were not briefed to go and consequently encountered radiological conditions higher than those expected: 600 mrem/hr general area instead of 300 mrem/hr general area; and 400,000 dpm/100 cm2 instead of 10,000 dpm/100 cm2.
Significance: The inspectors assessed the significance of the finding using IMC 0609, appendix C, Occupational Radiation Safety SDP. The inspectors determined the finding to be of very low safety significance (Green) because
- (1) it was not associated with as low as is reasonably achievable (ALARA) planning or work controls,
- (2) there was no overexposure,
- (3) there was no substantial potential for an overexposure, and
- (4) the ability to assess dose was not compromised.
Cross-Cutting Aspect: H.5 - Work Management: The organization implements a process of planning, controlling, and executing work activities such that nuclear safety is the overriding priority. The work process includes the identification and management of risk commensurate to the work and the need for coordination with different groups or job activities. Specifically, the licensee failed to control and execute the work plan with nuclear safety as the overriding priority since one individuals overconfidence and the workers lack of questioning adversely affected the proper implementation of the planned work. These failures caused work to be done on a different component/system than was planned and scheduled which increased the workers exposure.
Enforcement:
Violation: TS 5.4.1.a, requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in NRC Regulatory Guide 1.33, revision 2, appendix A, February 1978. Appendix A, section 7.e.1 required procedures for access control to radiation areas. The licensee established Procedure EN-RP-101, revision 16, Access Controls for Radiologically Controlled Areas, which required a brief of personnel entering HRAs on radiological conditions using attachment 8, Typical HRA/LHRA/VHRA Brief Checklist. Attachment 8 stated the requirements to enter HRAs included a worker be briefed and knowledgeable of radiological conditions in the work area and travel path and only enter areas they have been briefed on.
Contrary to the above, on February 15, 2023, the licensee failed to follow procedure EN-RP-101 requirements for workers to only enter HRAs for which they had been briefed for the radiological conditions in the work area and travel path. Specifically, a work crew entered the drywell after having been briefed on RHR B injection line check valve (F041B) on the 130-foot drywell elevation and instead travelled to the 141-foot drywell elevation to the LPCS pump injection check valve (F006), where the radiological conditions were significantly different.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with section 2.3.2 of the Enforcement Policy.
Licensee-Identified Non-Cited Violation 71124.01 This violation of very low safety significance was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with section 2.3.2 of the Enforcement Policy.
Violation: TS 5.4.1 requires written procedures be established, implemented, and maintained covering activities in Regulatory Guide 1.33, revision 2, appendix A, February 1978.
Appendix A, section 7(e)(4) required procedures for contamination control. Procedure EN-RP-100, revision 13, Radiation Worker Expectations, implemented the requirements for personnel contamination control. In procedure EN-RP-100, step 5.6[2](k) regarding contamination control in contamination areas, the radiation worker was instructed to not touch their skin, hair, personal clothing, glasses, etc., with the outside surfaces of their gloves or other protective clothing while inside a contamination area.
Contrary to this requirement, on March 12, 2023, a radiation worker touched their skin, hair, personal clothing, glasses, etc., with the outside surfaces of their gloves and other protective clothing while in a contamination area. Specifically, a radiation worker was identified as having touched their face, specifically their face shield and safety glasses, with the outside surfaces of their gloves while inside a contamination area. A radiation protection technician coached the individual several times and, with continued improper radiological practices by the individual, was instructed to leave the radiological controlled area. As the radiation worker exited the radiological controlled area, the worker alarmed the contamination monitors, decontamination efforts were performed, and the worker was sent to receive whole body counts for dose assessment purposes. The individual was assigned 68 millirem committed effective dose equivalent.
The licensee initiated corrective actions which removed the individual from the radiological controlled area and restricted the individual from entering the radiological controlled area. The licensee coached the work group, to include the individual.
Significance/Severity: Green. The inspectors determined the finding to be of very low significance (Green) because
- (1) it was not related to ALARA planning,
- (2) there was no overexposure,
- (3) there was no substantial potential for overexposure, and
- (4) the ability to assess dose was not compromised.
Corrective Action References: CR-RBS-2023-02536.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
- On May 12, 2023, the inspectors presented the occupational radiation safety inspection results to Phil Hansett, Site Vice President, and other members of the licensee staff.
- On July 10, 2023, the inspectors presented the integrated inspection results to Phil Hansett, Site Vice President, and other members of the licensee staff.
THIRD PARTY REVIEWS Inspectors reviewed Institute of Nuclear Power Operations reports that were issued during the inspection period.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Calculations
G13.18.12.3*117
Shutdown Safety Function Defense-in-Depth Color Codes
Protected Equipment Postings
Shutdown Safety Management Program (SSMP)
Procedures
Shutdown Operations Protection Plan (SOPP)
Calculations
E-192
Standby Diesel Generator Loading Calculation
Engineering
Evaluations
License Amendment Request 2000-11
09/06/2000
Operability
Evaluations
CR-RBS-2023-
01183/01184
Operability Evaluation
2/24/2023
Corrective Action
Documents
CR-RBS-
23-03178
Procedures
STP-204-6603
RHR System Refuel Pressure Isolation Valve Test
Work Orders
WO 00572234, 00572248, 00593872
Plans for cutting tubes in 'A' Bay, Sections 5-9
ALARA Plans
RWP 2023-1751
RWCU HX Room Activities (NON RECU HX Replacement
Project)
2/08/2023
CR-RBS-
22-07079, 2023-00236, 2023-00517, 2023-00648, 2023-
00727, 2023-00784, 2023-01148, 2023-01155, 2023-01235,
23-01307
CR-RBS-2023-
01148
Case Narrative - RWCU Heat Exchange Room
CR-RBS-2023-
01155
Case Narrative - Drywell Insulators on Wrong valve
2/25/2023
Corrective Action
Documents
CR-RBS-2023-
01155
Conditional Analysis Template - Supplemental workers
removed shielding and insulation from the wrong component
03/17/2023
Corrective Action
Documents
Resulting from
Inspection
CR-RBS-
23-02661, 2023-02662, 2023-02698, 2023-04215, 2023-
216
Drywell 136' Survey of E12-AOV-F041B valve
03/09/2021
Fuel Building 113' Spent Fuel Pol Inventory
10/06/2022
Radiation
Surveys
Fuel building 113' - Spent fuel pool inventory
10/06/2022
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Reactor building 186' Pool inventory
10/06/2022
Reactor Building 186' Pool Inventory
10/06/2022
Drywell 130' Initial Entry Elevation Survey
2/11/2023
Drywell 141' Initial Entry Elevation Survey
2/11/2023
Drywell 141' Removal of Lead Shielding and Insulation
2/15/2023
Auxiliary building 95' RWCU pump rooms A and B
2/27/2023
Auxiliary building 95' RWCU pump rooms A and B - I&C
changing out thermocouples
03/01/2023
Auxiliary building 105' above RWCU pump room - Pre-job
survey for relief valve removal
03/07/2023
Drywell 141' Follow up survey on Valve E21-AOV-F006
2/15/2023
Auxiliary building 105' above RWCU pump room - CCP-
V52A and CCP-V52B cutout
03/09/2023
Reactor Building 147' Regen HX B and C drain down of shell
side
03/09/2023
Auxiliary building 95' RWCU pump rooms A and B
03/09/2023
Reactor Building 147' RWCU Regen and Non-regen Heat
Exchanger Room
03/10/2023
Reactor Building 147' RWCU HX Room - PCE 2303-006
Follow up survey
03/12/2023
Reactor Building 147' RWCU HX room - Post spill/decon
03/12/2023
RBS-AS-021323-
0137
Radwaste building 106' - Processing room system breach
2/13/2023
RBS-AS-021323-
0152
Reactor building 147 RWCU heat exchanger room
2/13/2023
RBS-AS-021723-
233
Turbine building 95' condenser bay - backup sample
2/17/2023
RBS-AS-031223-
1052
Reactor building 186' South G/A routine - Refuel
03/12/2023
RBS-AS-031223-
1054
Reactor building 186' North G/A routine - Refuel
03/12/2023
RBS-AS-031423-
1109
Reactor building 147' - RWCU HX room
03/14/2023
RBS-AS-031423-
Reactor building 147' - RWCU HX room
03/14/2023
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
26
RBS-AS-091522-
0467
Fuel building 113' - Mast decon
09/15/2022
23-1423
Main Condenser Tube Replacement Activities
23-1751
RWCU HX Room Activities (NON RECU HX Replacement
Project)
Radiation Work
Permits (RWPs)
23-1910
Insulation Activities, In Drywell
LO-RLO-2021-
00080
RP Pre-NRC Focused Self-Assessment Radiation Safety
Inspection: IP 71124.01 - Radiological Hazard Assessment
and Exposure Controls and IP 71124.03 - In-Plant Airborne
Radioactivity Control and Mitigation
08/25/2022
Self-Assessments
LO-RLO-2022-
00120
ALARA Planning & Controls
07/15/2022
AMAH196531
Posi3 USB Test Results-Complete SBA Check: Airhawk II
4500 PR14 Regulator AMAH196531
03/02/2023
AMAH196544
Posi3 USB Test Results-Complete SBA Check: Airhawk II
4500 PR14 Regulator AMAH196544
03/02/2023
Calibration
Records
AMAH196551
Posi3 USB Test Results-Complete SCBA Test: Airhawk II
4500 PR14 Regulator AMAH196551
03/02/2023
Corrective Action
Documents
CR-RBS-
23-01762, 2023-01807, 2023-01984, 2023-02037, 2023-
2524, 2023-02536, 2023-02927
Corrective Action
Documents
Resulting from
Inspection
CR-RBS-
23-02694
LO-RLO-2019-
00029
RP Pre-NRC Focused Self-Assessment Radiation Safety
Inspection: IP 71124.01 - Radiological Hazard Assessment
and Exposure Controls and IP 71124.03 - In-Plant Airborne
Radioactivity Control and Mitigation
01/23/2020
Self-Assessments
LO-RLO-2021-
00080
RP Pre-NRC Focused Self-Assessment Radiation Safety
Inspection: IP 71124.01 - Radiological Hazard Assessment
and Exposure Controls and IP 71124.03 - In-Plant Airborne
Radioactivity Control and Mitigation
08/25/2022
Work Orders
Purchase Order
Bauer Unicus II compressor Annual Maintenance: UNII/13-
03/15/2023
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
(PO) 10688030
E1/230 (030424); Job Number 2603535
STP-402-8604, "Division I Main Control Room Fresh Air
System Laboratory Carbon Filter Analysis," revision 15
06/16/2021
STP-402-3602, Inservice Testing of Division II Control
Room Fresh Air System, revision 306
06/01/2021
STP-402-8605, "Division II Main Control Room Fresh Air
System Laboratory Carbon Filter Analysis," revision 6
07/29/2021
STP-402-4501, Control Room Fresh Air Flow Rate Test, Div
1, revision 10
11/09/2021
STP-402-4502, Control Room Fresh Air Flow Rate Test, Div
2, revision 304
2/17/2021
STP-402-3601, Inservice Testing of Division I Control Room
Fresh Air System, revision 307
06/07/2022
STP-402-8604, Division I Main Control Room Fresh Air
System Laboratory Carbon Filter Analysis," revision 15
06/06/2022
Personnel Contamination Events
Radiological Work Permits
Alpha Monitoring
Air Sampling
Dose Assessment
Whole Body Counting/In-Vitro Bioassay
Procedures
Operation of Counting Equipment
3017 TB-6'7 West Waterbox
2/12/2023
3017 TB-67' West Waterbox
2/15/2023
3109 TB-95' Condenser B
2/16/2023
3109 TB-95' Condenser B
2/17/2023
Main Condenser A-B
03/14/2023
Main Condenser A-B
03/19/2023
Main Condenser A-B
03/22/2023
Main Condenser A-B
03/23/2023
Alpha Side of Condenser
03/23/2023
Radiation
Surveys
RBS-AS-032323-
1380
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
03/23/2023
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
RBS-AS-040123-
1717
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities (Lapel)
04/01/2023
RBS-AS-040123-
21
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
27
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1733
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1738
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1739
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1751
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1755
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1756
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040123-
1770
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/01/2023
RBS-AS-040723-
1841
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/07/2023
RBS-AS-040723-
1842
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/07/2023
RBS-AS-040723-
1846
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/07/2023
RBS-AS-040723-
1848
RWP 20231423 Task 7-Main Condenser Tube Replacement
Activities
04/07/2023
RBS-AS-041123-
1888
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/11/2023
RBS-AS-041123-
1896
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/11/2023
RBS-AS-041123-
1898
RWP 20231423 Task 3-Main Condenser Tube Replacement
Activities
04/11/2023
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
RBS-2023-CT-
21
UN2912, Radioactive material, low specific activity (LSA-II),
trash condenser tubes
03/15/2023
Shipping Records
RBS-2023-CT-
2
UN2912, Radioactive material, low specific activity (LSA-II),
trash condenser tubes
03/15/2023
Miscellaneous
RCA entries greater than 100 millirem
71151
Self-Assessments
LO-RLO-2022-
00137
RP Pre-NRC Focused Self-Assessment Radiation Safety
Inspection
IP 71151-OR01 - Occupational Exposure Control
Effectiveness
09/30/2022
AX-108F
Service Water Piping (SWP) Tunnel #1, Auxiliary, & Control
Bldg.
G13.18.1.4-146
Evaluation due to External Flood Inleakage to Annulus Area
under PMF Event
G13.18.14.0*190
Post-Accident Heat Load Development for Power Uprate
Service Water Evaluations
Calculations
Standby cooling tower performance and evaporation losses
without drywell unit coolers
Corrective Action
Documents
CR-RBS-
22-00975, 2022-02284, 2022-03885, 2023-02335
51-9207360-000
Flood Hazard Reevaluation Report for River Bend Station
EDP-CS-17
Hazard Barrier Breach Evaluation
LBDCR 03.08-
019
Licensing Basis Design Change Request
09/20/2022
Engineering
Evaluations
RBS-CS-15-
00009
RBS Fukushima Flooding Hazard Re-Evaluation - Local
Intense Precipitation
71152A
Procedures
Time Critical Action Program Standard
7