IR 05000461/2019040
| ML19212A633 | |
| Person / Time | |
|---|---|
| Site: | Clinton  |
| Issue date: | 07/31/2019 |
| From: | Kenneth Riemer NRC/RGN-III/DRP/B1 |
| To: | Bryan Hanson Exelon Generation Co, Exelon Nuclear |
| References | |
| EA-18-014 IR 2019040 | |
| Download: ML19212A633 (15) | |
Text
July 31, 2019
SUBJECT:
CLINTON POWER STATION, UNIT 195001 SUPPLEMENTAL INSPECTION REPORT 05000461/2019040 AND ASSESSMENT FOLLOW-UP LETTER
Dear Mr. Hanson:
On June 21, 2019, the NRC completed a supplemental inspection using Inspection Procedure 95001, Supplemental Inspection for one or two White Inputs in a Strategic Performance Area.
The NRC performed this inspection to review the stations actions in response to a White Finding/Violation in the Mitigating Systems Cornerstone, which was documented and finalized in NRC Inspection Report 05000461/2018050 and after being notified of your readiness for this inspection via letter dated April 17, 2019. On June 21, 2019, the NRC discussed the results of this inspection, and conducted a Regulatory Performance meeting to discuss the implementation of your corrective actions, with Mr. J. Kowalski and other members of your staff.
The results of this inspection are documented in the enclosed report.
This supplemental inspection was conducted to provide assurance the root causes and contributing causes of the Division 2 emergency diesel generator (EDG) air start system being inadvertently left isolated and thus inoperable on May 12, 2018, were understood. In addition, the inspectors verified the extent of condition and extent of cause of any performance issues were identified and the corrective actions for any performance issues were sufficient to address the causes in addition to preventing recurrence.
The NRC determined your staff's evaluation identified the primary root cause of the White Finding to be that contrary to Exelon fleet governance for plant equipment status control that the operators solely utilized operations narrative logs to track the plant equipment configuration.
The extent of condition was determined to be all emergency core cooling equipment that had been manipulated during the on-going refueling outage. The corrective actions to prevent recurrence included the identification and elimination of allowances in existing plant procedures that allowed the use of operating logs to solely track plant equipment status.
After reviewing Clinton's performance in addressing the White Finding/Violation related to the Division 2 EDG air start system being inadvertently left isolation and thus inoperable, the NRC concluded your actions met the objectives of Inspection Procedure 95001. Therefore, in accordance with the guidance in Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program, the White Finding/Violation will only be considered in assessing plant performance for a total of four quarters. The unit returned to the Licensee Response Column of the NRC's Action Matrix as of July 1, 2019. In addition, one finding of very low safety significance (Green) is documented in this report.
This finding involved a violation of NRC requirements. We are treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2.a of the Enforcement Policy.
If you contest the violations or significance or severity of the violations documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region III; the Director, Office of Enforcement; and the NRC Resident Inspector at Clinton.
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 III; and the NRC Resident Inspector at Clinton.
This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA/
Kenneth R. Riemer, Chief Branch 1 Division of Reactor Projects
Docket No. 05000461 License No. NPF-62
Enclosure:
As stated
Inspection Report
Docket Number:
05000461
License Number:
Report Number:
Enterprise Identifier: I-2019-040-0002
Licensee:
Exelon Generation Company, LLC
Facility:
Clinton Power Station, Unit 1
Location:
Clinton, IL
Inspection Dates:
June 03, 2019 to June 14, 2019
Inspectors:
B. Bartlett, Project Engineer
J. Havertape, Resident Inspector
C. St. Peters, Reactor Engineer
Approved By:
Kenneth R. Riemer, Chief
Branch 1
Division of Reactor Projects
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a 95001 supplemental inspection at Clinton Power Station, Unit 1 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.
List of Findings and Violations
Failure to Complete an Effectiveness Review for a Corrective Action to Prevent Recurrence that Challenged the Corrective Actions Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems Green NCV 05000461/2019040-01 Open/Closed
[H.14] -
Conservative Bias 95001 An NRC identified Green finding and an associated Non-Cited Violation of 10 CFR Part 50,
Appendix B, Criterion II, Quality Assurance Program, for the failure to accomplish activities affecting quality in accordance with the Quality Assurance Topical Report, whose requirements are implemented through the corrective action program procedure PI-AA-125,
Corrective Action Program, was identified when the licensee failed to verify that corrective measures would preclude recurrence for a significant condition adverse to quality (SCAQ).
Specifically, the licensee performed a review of the effectiveness of a corrective action to prevent recurrence (CAPR) prior to sufficient time elapsing to challenge the corrective action.
Additional Tracking Items
Type Issue #
Title Report Section Status NOV 05000461/2018050-01 Failure to Follow Multiple Procedures 95001 CLOSED
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 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.
OTHER ACTIVITIES
- TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL
95001 - Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area
Inspectors reviewed the licensees root causes, contributing causes, extent of condition, and extent of cause determinations. Inspectors assessed whether the licenses corrective actions to address the root and contributing causes were sufficient to prevent recurrence. The highlights of the performance review and NRCs assessment are documented below. The inspectors reviewed those items taken in response to an apparent violation of Title 10 of the Code of Federal Regulations (CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, and Technical Specification 3.8.2, Condition B.3, concerning the failure to follow multiple procedures regarding the emergency diesel generators (EDGs). The inspectors assessed whether the licensees corrective actions to address the root and contributing causes were sufficient to prevent recurrence.
Description of the mispositioning event: On May 9, 2018, Clinton Power Station (CPS), Unit 1, was in Mode 5 during Refueling Outage C1R18. Earlier on May 9, 2018, the Division 2 EDG had been inoperable and unavailable as a result of a 1B1 bus outage. At 5:25 p.m., Clearance Order (C/O) 139455 was removed from the Division 2 EDG as part of 1B1 restoration activities.
This C/O included a special instruction that stated Restore Div 2 DG [diesel generator] to standby per CPS 3506.01P002 [Division 2 Diesel Generator Operations; Revision 3a] in conjunction with C/O removal. Procedure CPS 3506.01P002 was not performed in conjunction with the C/O closure. Instead, a senior reactor operator (SRO 1) placed a note in the control room log stating CPS 3506.01P002 needed to be performed after restoration of the Division 2 shutdown service water (SX) system. Because CPS 3506.01P002 was not completed as part of the C/O closure, the position of the Division 2 EDG air receiver isolation valves was being controlled by the control room log entry instead of through an approved licensee process. By not completing CPS 3506.01P002 at that time, Division 2 EDG air receiver isolation valves (1DG160 and 1DG161) were left shut. Following the closure of the C/O, this log entry was the only method the licensee used to track the need to restore the Division 2 EDG to standby per CPS 3506.01P002.
On May 10, 2018, during the day shift, a senior reactor operator (SRO 2) directed a non-licensed operator to perform a portion of CPS 3506.01P002 to restore fuses for the Division 2 EDG lubrication system, which had previously been removed from service prior to the 1B1 bus maintenance. When the non-licensed operator had completed the partial procedure, SRO 2 had already turned over duties to a different senior reactor operator (SRO 3), so the non-licensed operator returned the partially completed procedure to SRO 3.
Even though the complete CPS 3506.01P002 procedure had not been performed, SRO 3 believed that all activities required to restore the Division 2 EDG had been completed. On May 11, 2018, at 2:30 a.m., SRO 3 declared the Division 2 EDG available after Division 2 SX was restored and made available. At this time, the Division 2 EDG starting air valves (1DG160 and 1DG161) remained closed, isolating starting air from the EDG air start motors, making the EDG unable to start on any demand signal.
On May 12, 2018, at 8:00 a.m., the licensee completed OP-AA-108-106, Equipment Return to Service, Revision 5, for the Division 2 Nuclear System Protection System (NSPS), Division 2 essential switchgear cooling (VX), Division 2 direct current (DC), and Division 2 EDG, and declared each of these systems operable. The licensee did not perform post-maintenance testing on the Division 2 EDG as no maintenance was performed on the EDG.
On May 14, 2108, at 12:30 a.m., since the licensee was unaware that the Division 2 EDG was inoperable and unavailable due to its inability to start caused by the 1DG160 and 1DG161 valves being closed, the licensee began a scheduled maintenance window for the Division 1 4160 Vac bus (1A1). As a result of taking bus 1A1 out of service, the Division 1 EDG was declared inoperable and unavailable along with other equipment powered from bus 1A1, including the low pressure core spray (LPCS) and Residual Heat Removal (RHR) A systems.
On May 16, 2018, at 1:30 a.m., the licensee completed filling and venting the high pressure core spray (HPCS) system following an extended maintenance window.
On May 17, 2018, at 3:03 p.m., a non-licensed operator performing shift rounds identified that the 1DG160 and 1DG161 valves were closed and reported this condition to the control room.
The licensee declared the Division 2 EDG inoperable and unavailable and investigated the condition. The licensee restored the valves to the open position and declared the Division 2 EDG available at 3:45 p.m. After the licensee performed OP-AA-108-106, the licensee declared the Division 2 EDG operable at 9:04 p.m.
1. Problem Identification
a. The licensee's root cause report did not state who identified the miss-positioned valves, however; the condition report and an assessment report stated that the EDG air start valves being closed was identified by a licensee non-licensed equipment operator. This was after there had been multiple opportunities to identify the miss-positioned valves during routine operator rounds. No licensee document clearly stated why the NRC was treating this issue as self-revealing and was not giving credit for licensee identification. Nevertheless, the licensee did treat the issue with the appropriate significance and did address why there was a failure of the operators to identify the miss-positioned valves in a timely manner. The failure of the root cause report to contain important information that the inspectors then struggled to find elsewhere was a common theme for this inspection. The licensee's self assessment contained many of the missing pieces of information and along with corrective action documents and interviews the inspectors were able to find and assess the required information.
b. The licensee's root cause report clearly stated when the issue occurred and when it was identified and corrected. The licensee root cause report and corrective actions also addressed the prior opportunities to identify. The non-licensed equipment operators failed to identify the miss-positioned valves during their routine rounds from nightshift on May 11, 2018 at 2:30 a.m. when the Division 2 EDG was considered to be operable until May 17, 2018, at 3:03 p.m.
when a non-licensed equipment operator found the Division 2 EDG air receiver outlet valves out of position.
c. The licensee's root cause report stated that the plant shutdown risk changed to Red and was then adjusted downward to Orange. The root cause report did not address the elevated risk to the plant as a result of the one of the Divisions of back up power being unavailable for approximately six and a half days and what other equipment was unavailable during this time frame. The licensee's root cause report also stated that the event was significant because a Licensee Event Report needed to be issued but that both offsite power sources were available and energized so there were no adverse consequences. The licensee's condition reports, causal evaluations, and corrective actions demonstrated an understanding of the significance of the miss-positioning event. Similar to item 1.a, above the root cause report did not contain much information regarding the risk to the plant but the inspectors were ultimately able to use other sources of licensee information to reach a conclusion.
2. Root Cause, Extent-of-Condition, and Extent-of-Cause Evaluation
a. The licensee utilized an Event and Causal Factors Chart with Barrier Analysis along with Cause and Effects Analysis, Programmatic and Organizational Contributors in addition to Error Precursors and Flawed Defenses. In addition, the licensee performed a common cause analysis (CCA). The CCA was performed due to having two White Findings open at the same time as at the time of this event a second White Finding related to the failure of an essential service water pump remained open. The licensee determined that the cause was due to the failure to follow corporate governance procedures related to equipment status control.
b. The licensee's level of detail in the performance of their root cause analysis, extent of condition, and extent of cause was commensurate with the importance of the issue and was of sufficient detail to identify the root cause(s), extent of condition and extent of cause.
c. The licensee performed an assessment of prior opportunities to identify and determined that there was a previous occurrence which, if lessons learned had been applied, might have prevented this issue from occurring. An item related to this issue is documented as a Performance Deficiency in the results section of this inspection report. The inspectors also determined that in addition to the missed lessons learned that the licensee added some emphasis on the use of logs to track equipment status following the previous event. The use of logs was allowed under certain conditions; but these conditions were not highlighted during the previous event with the result that negative training on the tracking of equipment using narrative logs influenced to some degree the failure to properly track equipment status during this event.
d. The licensee's extent of condition extended to a review of the position of all emergency core cooling equipment which had been manipulated during the refueling outage in which this error had occurred. This included the Division 1 EDG as well as the Division 3 EDG. The inspectors determined that the licensee's extent of condition was reasonable. The licensee's extent of cause extended to corporate governance procedures on plant equipment status control and their failure to follow the corporate procedure requirements despite repeated opportunities to learn from previous failures to follow corporate level procedures.
e. The licensee's review appropriately considered safety culture traits during their determination of the root cause, extent of condition and extent of cause. The licensee's safety culture analysis focused in on teamwork, communications, procedure adherence and documentation. The inspectors agreed that the licensee had issues in the particular areas highlighted by the licensee's assessment. The inspectors also ensured that the licensee's root cause, contributing causes, corrective actions to preclude recurrence (CAPR) and corrective actions addressed these safety culture aspects.
f.
The inspectors assessed the licensee's common cause analysis for the White Finding closed in NRC inspection report 05000461/2018041. The previous White Finding was due to a Division 3 Shutdown Service Water Pump failure to start.
The White Finding remained open until December 31, 2018, in accordance with NRC Inspection Manual Chapter 0305 and thus was open when this White Finding was identified. The licensee determined that there were six areas of common cause. These areas were procedure use and adherence, non-conservative decision making, risk sensitivity, values and norms, complacency and questioning attitude with challenging assumptions. Corrective actions by the licensee on the two White Findings had already addressed the issues identified.
The inspectors assessments determined that the licensee had adequately addressed the common cause analysis conclusions.
3. Corrective Actions
a. The licensee orally informed the inspectors that the condition report addressing this event was a significant condition adverse to quality (SCAQ). The inspectors noted that SCAQs are required by the licensee's procedures, Quality Assurance Topical Report (QATR), and NRC regulation 10 CFR Part 50, Appendix B, Criterion XVI, to have a CAPR. The licensee's CAPR focused on identifying and eliminating legacy site-specific procedures and guidance that allowed narrative control room logs to be the sole method for plant status control. The licensee had four contributing causes which were the method of partial procedure performance was incorrect, the turnover status of the restoration procedure was incorrect, a Senior Reactor Operator failed to review the restoration procedure completely (and there were some poor communications) and a different SRO did not correctly return the Division 2 EDG.to service.
b. The CAPR was implemented immediately and the CAs for the contributing causes were implemented in a timely manner. In NRC inspection report 05000461/2018092, the NRC concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence, and the date when full compliance was achieved was already adequately addressed on the docket in NRC inspection report 05000461/2018051. Nevertheless, as required by IP 95001 the inspectors performed an assessment of the licensee's corrective actions and their implementation and did not have any concerns.
c. The inspectors' review of the licensee's SCAQ root cause and associated CAPR determined that the actions were sufficient to prevent recurrence. The inspectors' assessment of the licensee's effectiveness review (EFR) determined that the EFR would not identify whether issues with the CAPR existed due to a failure to challenge the EFR. See the Green NCV in this inspection report.
d. The inspectors verified that each violation related to this inspection were addressed adequately. In addition, as stated in NRC inspection report 05000461/2018051, the licensee communicated accountability and emphasized procedure use and adherence, utilized just in time training to the operations department staff on procedure use requirements, conducted a three day stand down discussing case studies and lessons learned and revised the non-licensed equipment operator rounds to include the EDG starting air manifold pressures.
Additional corrective actions reviewed during this inspection were related to the contributing causes and were reviewed but were not directly related to the violations.
for self-identification of an old design issue. Therefore, the risk-significant issue was not evaluated against the IMC 0305 criteria for treatment of an old design issue.
5. Assessment of licensees evaluation and corrective actions. The inspectors completed
all aspects of IP 95001, including the common cause analysis for multiple White inputs and determined that the licensee met the requirements to close this White input.
INSPECTION RESULTS
Failure to Complete an Effectiveness Review for a Corrective Action to Prevent Recurrence that Challenged the Corrective Actions Cornerstone Significance Cross-Cutting Aspect Report Section Mitigating Systems
Green NCV 05000461/2019040-01 Open/Closed
[H.14] -
Conservative Bias 95001 An NRC identified Green finding and an associated Non-Cited Violation of 10 CFR Part 50, Appendix B, Criterion II, Quality Assurance Program, for the failure to accomplish activities affecting quality in accordance with the Quality Assurance Topical Report, whose requirements are implemented through the corrective action program procedure PI-AA-125, Corrective Action Program, was identified when the licensee failed to verify that corrective measures would preclude recurrence for a significant condition adverse to quality (SCAQ).
Specifically, the licensee performed a review of the effectiveness of a corrective action to prevent recurrence (CAPR) prior to sufficient time elapsing to challenge the corrective action.
Description:
Following the discovery of the inoperable diesel generator discussed in this inspection report and in NRC inspection reports 05000461/2019-050 and 05000461/2019-051 the licensee initiated corrective actions. The corrective actions included designating the failure to control the configuration of the Division 2 diesel generator (DG) as an SCAQ and performing a root cause investigation. The licensee determined that the root cause was that contrary to fleet governance for plant status control that the operators relied solely upon operator narrative logs track the plant configuration.
The licensee generated one CAPR and four effectiveness reviews (EFR) as part of their corrective actions from the above root cause. The CAPR states, Identify and eliminate legacy site-specific procedures/guidance that allow logs as a sole method for plant status control. Effectiveness review one stated, Six months following the event, Review one month of logs and verify ZERO instances of controlling plant configuration control solely via a log entry.
The failure to control the status of the DG occurred during a refueling outage (RFO) and the conditions during a RFO are different than during on line operations. For example, during the RFO a Work Execution Center was established by the licensee and considerable efforts are made to keep as much work as possible out of the control room and in the WEC. This is due to the large and varying amounts of work that is performed across the length and breadth of the plant. This large work amount and the extra work groups helped to change and then keep track of various plant configurations and the use of the narrative logs was utilized during this work.
During on line conditions the amount of work, while complex and at times complicated, did not rise to the same level of challenging conditions that exist during a RFO. During the six months following the event the licensee did not have another RFO but did have one maintenance outage. In addition, there were several on line maintenance activities where equipment was also removed and restored to service which altered plant configurations.
None of this work challenged the plant operators to the same level as a RFO would have challenged the site.
The inspectors determined that insufficient time had elapsed to allow the corrective actions of the CAPR to be challenged and thus the EFR was not effective.
Exelon Generation Company Quality Assurance Topical Report (QATR), NO-AA-10, Revision 93 was established in accordance with 10 CFR Part 50, Appendix B, Criterion II. Chapter 16, Corrective Action Describes the company program to identify and correct conditions adverse to quality.
Section 16.2.2.1 of the QATR, Significant Conditions Adverse to Quality (SCAQ) states, in part, In cases of significant conditions adverse to quality the cause of the condition is determined and documented, resolution determined and documented, and corrective action taken and documented to preclude recurrence.
Section 16.2.3 of the QATR, Verification and Follow-up, states, in part, Trending and assessment results are evaluated to assure that corrective measures are implemented effectively and that actions to prevent recurrence are effective and appropriate. Section 16.2.3, also states, in part, The Company regularly reviews and analyses records to determine whether corrective measures will preclude recurrence [for SCAQs].
Licensee procedure PI-AA-125, Revision 6, Corrective Action Program Procedure, Step 4.3.6. states, in part, to perform effectiveness reviews in accordance with PI-AA-125-1004, Effectiveness Review Manual and the following requirementscomplete the EFR after implementation of the final CAPR or action and sufficient time has elapsed to challenge the action(s).
Corrective Actions: Corrective Action: As this was an EFR that should be performed following the next RFO no immediate corrective action was necessary. A new EFR was planned to be scheduled as part of AR 04254346.
Corrective Action References: Corrective Action Reference: AR 04254346, Inspection during 95001 determined that the EFR should have been performed following the next RFO.
Performance Assessment:
Performance Deficiency: Failure to verify that corrective measures would preclude recurrence for a SCAQ. Specifically, the licensee performed a review of the effectiveness of a CAPR prior to sufficient time elapsing to challenge the corrective action.
Screening: The inspectors determined the performance deficiency was more than minor because if left uncorrected, it would have the potential to lead to a more significant safety concern. Specifically, the failure to appropriately verify that the actions to prevent recurrence were effective could result in a repeat of this or a similar event.
Significance: The inspectors assessed the significance of the finding using IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power.
Cross-Cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices that emphasize prudent choices over those that are simply allowable. A proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop. Conservative bias was selected as the effectiveness review selected was performed early, most likely due to perceived schedule pressure to have all items closed prior to the performance of the 95001.
Enforcement:
Violation: 10 CFR Part 50, Appendix B, Criterion II, requires, in part, that the licensee shall establish a quality assurance program which complies with the requirements of this appendix.
This program shall be documented by written policies, procedures, or instructions and shall be carried out throughout plant life in accordance with those policies, procedures, or instructions.
Exelon Generation Company Quality Assurance Topical Report (QATR), NO-AA-10, Revision 93 was established in accordance with 10 CFR Part 50, Appendix B, Criterion II. Chapter 16, Corrective Action describes the licensee's program to identify and correct significant conditions adverse to quality.
Section 16.2.2.1 of the QATR, Significant Conditions Adverse to Quality (SCAQ) states, in part, In cases of significant conditions adverse to quality the cause of the condition is determined and documented, resolution determined and documented, and corrective action taken and documented to preclude recurrence.
Section 16.2.3 of the QATR, Verification and Follow-up, states, in part, Trending and assessment results are evaluated to assure that corrective measures are implemented effectively and that actions to prevent recurrence are effective and appropriate.
Licensee procedure PI-AA-125, Revision 6, Corrective Action Program Procedure, Step 4.3.6., required, in part, that the licensee perform effectiveness reviews in accordance with PI-AA-125-1004, Effectiveness Review Manual and to complete the effectiveness review after implementation of the final CAPR (Corrective Action to Prevent Recurrence) or action and sufficient time has elapsed to challenge the action(s).
Contrary to the above, as of June 5, 2019, the licensee failed to comply with the quality assurance program when an effectiveness review was not completed as required by procedure PI-AA-125 for a CAPR after sufficient time had elapsed to challenge the action.
Specifically, the licensee established CAPR 4138790 to correct the licensee's tracking of safety-related equipment that was returned to service in control room operator logs during a refueling outage, as described in CA 4138790-95, which was a significant condition adverse to quality. The licensee reviewed and analyzed the effectiveness of CAPR 4138790 on March 12, 2019, which was not sufficient time to challenge the action since a refueling outage had not occurred after implementation of the final CAPR on March 12, 2018.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Minor Performance Deficiency 95001 Minor Performance Deficiency: The inspectors determined that the root cause evaluation (RCE) included consideration of prior occurrences of the problem and knowledge of prior operating experience. The RCE examined internal and external operating experience for prior occurrences of configuration control and equipment status. During their review, the licensee noted multiple events at Clinton Power Station with similar problem statements and causes. In response, the licensee developed performance improvement plans in the areas of operator fundamentals, maintaining plant status control, as well as procedure use and adherence.
The inspectors reviewed the operating experience listed in the RCE. During this review, they identified a minor performance deficiency associated with the implementation of the corrective action program. In CR 2718753 the licensee documented a significance level 3 configuration control event in which a normally locked open valve was found in the shut position. The inspectors noted that no corrective action was specified for this event in the assignments section of the condition report, contrary to Attachment 3, Frequently Used Condition Report Assignment Types, of PI-AA-125, Corrective Action Procedure, Revision 4.
Immediate corrective action of restoring the valve to its required position was taken by the licensee.
Screening: The inspectors determined the performance deficiency was minor. The inspectors determined that the performance deficiency was minor because the condition adverse to quality was corrected, action tracking items were assigned to address the cause determined in the work group evaluation, and the issue was entered into the corrective action program as CR
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
- On June 21, 2019, the inspectors presented the 95001 supplemental inspection results to Mr. J. Kowalski and other members of the licensee staff.
- On June 7, 2019, the inspectors presented the Interim Debrief of Technical Issues to Mr. J. Weissinger, Operations Director and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
95001
Corrective Action
Documents
EOID: 1CO609, 1CO01T Tank Outlet Valve Found Closed
09/22/2016
NRC Question on Procedure CPS 3514.01C006
05/25/2018
Evaluation of Required PMT Following Breaker Racking
06/11/2018
CPS Procedure 1401.09 Contains Conflicting Guidance
06/13/2018
Improvement Opportunity Identified for Locked Valves
06/19/2018
Inadequate Actions to Address Gaps in Configuration Control 06/24/2018
95001 Commonality Assessment for White Finding
2/14/2019
RCR 4022176
Failure to Correct an Identified Degraded Condition Results
in a Division 3 SX Pump Failure and NRC Corrective Action
White Finding
06/15/2017
RCR 4138790
Division 2 Emergency Diesel Generator Air Receivers Found
Isolated During Rounds
Corrective Action
Documents
Resulting from
Inspection
95001: Questions during Walkdown of Div 3 DG Room
06/04/2019
Div 2 DG 95001 Inspection
06/04/2019
95001 - NRC Question on Barrier Analysis
06/05/2019
95001: Shift Roles and Responsibilities Regarding RTS and
Operability
06/06/2019
95001: NRCID Cctions to Close Conditions Adverse to
Quality
06/06/2019
95001: NRCID with Root Cause Report 4138790 not
Identifying All the Potential Plant Consequences
06/07/2019
Miscellaneous
Exelon Quality Assurance Topical Report
Request 023
Listing of Operations Department Crew Clock Resets for the
Year Prior to June 4, 2019
Procedures
Human Performance Tools and Verification Practices
Human Performance Review Board
Operations Roles and Responsibilities
General Area Checks and Operator Field Rounds
OP-AA-102-107-
1001
Operations On-Line Work Management
Watch Standing Practices
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Control of Equipment and System Status
Locked Equipment Program
Equipment Return to Service
Operations Narrative Logs and Records
Shift Turnover and Relief
Operations Refueling Outage Readiness and Execution
OU-CL-104
Shutdown Safety Management Program
Issue identification and Screening Process
Corrective Active Procedure
Corrective Action Procedure
Root Cause Analysis Manual
Effectiveness Review Manual
Self-Assessments
Operations Functional Area Audit Report
09/23/2015
Operations Functional Area Audit Report
10/03/2017
Readiness assessment - Supplemental Inspection for
Division II DG Starting Air Isolation Event
2/22/2019