IR 05000483/2009009

IR-05000483-09-009 on 06/22/2009 - 08/27/2009 for Callaway Plant; Preliminary White Finding

ML092730656
Person / Time
Site:	Callaway
Issue date:	09/30/2009
From:	Chamberlain D NRC/RGN-IV/DRP
To:	Heflin A AmerenUE
References
EA-09-200 IR-09-009
Download: ML092730656 (61)

Text

UNITED STATES NUC LE AR RE G UL AT O RY C O M M I S S I O N R E GI ON I V 612 EAST LAMAR BLVD , SU I TE 400 AR LI N GTON , TEXAS 76011-4125 September 30, 2009 EA-09-200 Mr. Adam C. Heflin, Senior Vice President and Chief Nuclear Officer AmerenUE P.O. Box 620 Fulton, MO 65251 Subject: NRC SPECIAL INSPECTION REPORT 05000483/2009009 -

CALLAWAY PLANT; PRELIMINARY WHITE FINDING

Dear Mr. Heflin:

On September 2, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Callaway Plant to evaluate the facts and circumstances surrounding the failure to start of the turbine-driven auxiliary feedwater pump due to an inadequately lubricated trip throttle valve. Based upon the risk and deterministic criteria specified in NRC Management Directive 8.3, NRC Incident Investigation Program, including possible generic implications, the NRC initiated a special inspection in accordance with Inspection Procedure 93812, Special Inspection. The basis for initiating the special inspection and the focus areas for review are detailed in the Special Inspection Charter (Attachment 2). The determination that the inspection would be conducted was made by the NRC on June 17, 2009, and the onsite inspection started on June 22, 2009. The enclosed report documents the inspection findings that were discussed on September 2, 2009, with you, and members of your staff.

The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission's rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures and records, observed activities, and interviewed plant personnel.

The enclosed report discusses one finding that appears to have low to moderate safety significance (White). As described in Section 1R2 of this report, the NRC concluded that the failure to adequately lubricate the turbine-driven auxiliary feedwater pump trip throttle valve during Refueling Outage 16 resulted in the pumps failure to start on May 25, 2009. The safety significance of this finding was assessed on the basis of the best available information, including influential assumptions, using the applicable Significance Determination Process and was preliminarily determined to be a White (i.e., low to moderate safety significance) finding.

Attachment 4 of this report provides a detailed description of the preliminary risk determination.

The finding is also an apparent violation of NRC requirements and is being considered for escalated enforcement action in accordance with the Enforcement Policy, which can be found on the NRCs Web site at http://www.nrc.gov/reading-rm/doc-collections/enforcement.

Union Electric Company 2 In accordance with NRC Manual Chapter 0609, Significance Determination Process, we intend to complete our evaluation using the best available information and issue our final determination of safety significance within 90 days of the date of this letter. The significance determination process encourages an open dialogue between the NRC staff and the licensee; however, the dialogue should not impact the timeliness of the staffs final determination.

Before we make a final decision on this matter, we are providing you with an opportunity to (1) attend a Regulatory Conference where you can present to the NRC your perspective on the facts and assumptions the NRC used to arrive at the finding and assess its significance, or (2) submit your position on the finding to the NRC in writing. If you request a Regulatory Conference, it should be held within 30 days of the receipt of this letter and we encourage you to submit supporting documentation at least one week prior to the conference in an effort to make the conference more efficient and effective. If a Regulatory Conference is held, it will be open for public observation. If you decide to submit only a written response, such submittal should be sent to the NRC within 30 days of your receipt of this letter. If you decline to request a Regulatory Conference or submit a written response, you relinquish your right to appeal the final Significance Determination Process determination, in that by not doing either, you fail to meet the appeal requirements stated in the Prerequisite and Limitation sections of Attachment 2 of Manual Chapter 0609.

Please contact Mr. Vincent Gaddy at (817) 860-8141 within 10 business days of the date of this letter to notify the NRC of your intentions. If we have not heard from you within 10 days, we will continue with our significance determination and enforcement decision. The final resolution of this matter will be conveyed in separate correspondence.

Because the NRC has not made a final determination in this matter, no Notice of Violation is being issued for these inspection findings at this time. In addition, please be advised that the characterization of the apparent violation described in the enclosed inspection report may change as a result of further NRC review.

The report also documents four NRC-identified findings, which were evaluated under the significance determination process as having very low safety significance (Green). These findings were determined to involve violations of NRC requirements. However, because of the very low safety significance and because they are entered into your corrective action program, the NRC is treating these findings as noncited violations consistent with Section VI.A.1 of the NRC Enforcement Policy. If you contest the noncited violations in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with copies to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV, 612 E. Lamar Blvd., Suite 400, Arlington, Texas 76011-4125; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspectors at the Callaway Plant. In addition, if you disagree with the characterization of any finding in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region IV, and the NRC Resident Inspector at the Callaway Plant. The information you provide will be considered in accordance with Inspection Manual Chapter 0305.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosures will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC=s document

Union Electric Company 3 system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html.

Sincerely,

/RA/

Dwight Chamberlain, Director Division of Reactor Projects Docket: 50-483 License: NPF-30 Enclosure: NRC Inspection Report 05000483/2009009 w/Attachments:

Attachment 1: Supplemental Information Attachment 2: Special Inspection Charter Attachment 3: Timeline Associated With Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve FCHV0312 Attachment 4: Preliminary Significance Determination Evaluation Mr. Luke H. Graessle Director, Operations Support AmerenUE P.O. Box 620 Fulton, MO 65251 E. Hope Bradley Manager, Protective Services AmerenUE P.O. Box 620 Fulton, MO 65251 Mr. Scott Sandbothe, Manager Regulatory Affairs AmerenUE P.O. Box 620 Fulton, MO 65251 R. E. Farnam Assistant Manager, Technical Training AmerenUE P.O. Box 620 Fulton, MO 65251

Union Electric Company 4 J. S. Geyer Radiation Protection Manager AmerenUE P.O. Box 620 Fulton, MO 65251 John ONeill, Esq.

Pillsbury Winthrop Shaw Pittman LLP 2300 N. Street, N.W.

Washington, DC 20037 Missouri Public Service Commission P.O. Box 360 Jefferson City, MO 65102-0360 Deputy Director for Policy Department of Natural Resources P.O. Box 176 Jefferson City, MO 65102-0176 Mr. Rick A. Muench, President and Chief Executive officer Wolf Creek Nuclear Operating Corporation P.O. Box 411 Burlington, KS 66839 Kathleen Logan Smith, Executive Director and Kay Drey, Representative, Board of Directors Missouri Coalition for the Environment 6267 Delmar Boulevard, Suite 2E St. Louis, MO 63130 Mr. Lee Fritz, Presiding Commissioner Callaway County Courthouse 10 East Fifth Street Fulton, MO 65251 Director, Missouri State Emergency Management Agency P.O. Box 116 Jefferson City, MO 65102-0116 Mr. Scott Clardy, Administrator Section for Disease Control Missouri Department of Health and Senior Services P.O. Box 570 Jefferson City, MO 65102-0570

Union Electric Company 5 Certrec Corporation 4200 South Hulen, Suite 422 Fort Worth, TX 76109 Mr. Keith G. Henke, Planner II Division of Community and Public Health Office of Emergency Coordination Missouri Department of Health and Senior Services 930 Wildwood Drive P.O. Box 570 Jefferson City, MO 65102 Chief, Technological Hazards Branch FEMA Region VII 9221 Ward Parkway, Suite 300 Kansas City, MO 64114-3372

Union Electric Company 6 Electronic distribution by RIV:

Regional Administrator (Elmo.Collins@nrc.gov)

Deputy Regional Administrator (Chuck.Casto@nrc.gov)

DRP Director (Dwight.Chamberlain@nrc.gov)

DRP Deputy Director (Anton.Vegel@nrc.gov)

DRS Director (Roy.Caniano@nrc.gov)

DRS Deputy Director (Troy.Pruett@nrc.gov)

Senior Resident Inspector (David.Dumbacher@nrc.gov)

Resident Inspector (Jeremy.Groom@nrc.gov)

Branch Chief, DRP/B (Vincent.Gaddy@nrc.gov)

Senior Project Engineer, DRP/B (Rick.Deese@nrc.gov)

CWY Site Secretary (Dawn.Yancey@nrc.gov)

Public Affairs Officer (Victor.Dricks@nrc.gov)

Team Leader, DRP/TSS (Chuck.Paulk@nrc.gov)

RITS Coordinator (Marisa.Herrera@nrc.gov)

Regional Counsel (Karla.Fuller@nrc.gov)

Congressional Affairs Officer (Jenny.Weil@nrc.gov)

OEMail Resource DRS STA (Dale.Powers@nrc.gov)

OEDO RIV Coordinator (Leigh.Trocine@nrc.gov)

ROPreports WilliamJones@nrc.gov Gregory.Bowman@nrc.gov Mark.Haire@nrc.gov Christi.Maier@nrc.gov Nick.Hilton@nrc.gov June.Cai@nrc.gov John.Wray@nrc.gov MaryAnn.Ashley@nrc.gov Gerald.Gulla@nrc.gov Alexander.Sapountzis@nrc.gov Robert.Summers@nrc.gov Doug.Starkey@nrc.gov File located: R:_Reactors\CW\2009\2009009RP-JRG.doc ML092730656 SUNSI Rev Compl. : Yes No ADAMS  : Yes No Reviewer Initials VGG Publicly Avail : Yes No Sensitive Yes : No Sens. Type Initials VGG RIV: RI:DRP/B RI:DRP/C SRI:DRP/B SRA ACES JGroom MChambers DDumbacher DLoveless MHaire

/RA-E/VGG for /RA-E/VGG for /RA-E/VGG for /RA/ /RA/WJ for MH 9/15/09 9/22/09 9/16/09 9/21/09 9/23/09 OE NRR C:DRP/B D:DRP GBowman MCunningham VGaddy DChamberlain

/RA-E/VGG for /RA-E/VGG for /RA/ /RA/

9/23/09 9/28/09 9/28/09 9/30/09 OFFICIAL RECORD COPY T=Telephone E=E-mail F=Fax

U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket: 05000483 License: NPF-30 Report: 05000483/2009009 Licensee: Union Electric Company Facility: Callaway Plant Location: Junction Highway CC and Highway O Fulton, MO Dates: June 22 through August 27, 2009 Inspectors: J. Groom, Resident Inspector, Callaway Plant M. Chambers, Resident Inspector, Cooper Nuclear Station D. Dumbacher, Senior Resident Inspector, Callaway Plant D. Loveless, Senior Reactor Analyst Approved By: D. Chamberlain, Director Division of Reactor Projects 1 Enclosure

SUMMARY OF FINDINGS

IR 05000483/2009009; 06/22/09 - 08/27/09; Callaway Plant; Special inspection into turbine-

driven auxiliary feedwater pump failure to start.

The report covered one week of onsite inspection and in office review through August 27, 2009.

Two resident inspectors performed the inspection with assistance from a senior resident inspector and a senior reactor analyst. One apparent violation and four green noncited violations 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. 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

• TBD. The team identified a self-revealing apparent violation of Technical Specification 3.7.5, Auxiliary Feedwater System, due to the failure to adequately lubricate turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312. During May 25, 2009, surveillance testing, the turbine-driven auxiliary feedwater pump did not start as expected due to hardened grease on the valve spindle of FCHV0312. The previous lubrication preventative maintenance had been missed and lack of lubrication increased friction between the sliding nut and spindle preventing FCHV0312 from opening. Following lubrication FCHV0312 and the turbine-driven auxiliary feedwater pump tested satisfactorily. The licensee entered this deficiency in their corrective action program as Callaway Action Request 200904216.

This finding is greater 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. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as potentially risk significant since the finding represented a loss of system safety function because the turbine-driven auxiliary feedwater pump PAL02 failing eliminates the capability of the plant to cope with a station blackout. The finding required a Phase 2 analysis. When evaluated per Manual Chapter 0609, Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations, and the Callaway Plant Phase 2 pre-solved table item Turbine Driven Auxiliary Feedwater Pump Fails to Start, the inspectors determined this finding to be potentially risk significant. The finding was forwarded to a senior reactor analyst for review. The preliminary outcome of the Phase 3 significance determination analysis, Attachment 4, determined the finding was of low to moderate safety significance.

The inspectors determined that this finding had a crosscutting aspect in the area of human performance associated with the work practices component because the licensee failed to follow the procedural guidance provided when changing the scope of a preventive maintenance task H.4(b)(Section 1R2).

Green.

The team identified a noncited violation of Technical Specification 5.4.1.a,

Procedures, for the failure to provide adequate procedural guidance for the lubrication of auxiliary feedwater pump turbine trip throttle valve FCHV0312. The inspectors found that 2002 corrective actions to improve the lubrication procedure were not fully developed and the procedure lubrication guidance was ambiguous in that it did not specify the amount of lubricant to apply or what valve subcomponents to lubricate. The licensee entered this deficiency in their corrective action program as Callaway Action Request 200905032.

This finding is greater than minor because it was associated with the Mitigating Systems Cornerstone attribute of procedural quality and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.

Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. This finding did not have a crosscutting aspect since the 2003 lubrication procedure revision was not reflective of current licensee performance (Section 1R3).

Green.

The team identified a noncited violation of 10 CFR Part 50, Appendix B,

Criterion III, Design Control, for the failure to adequately evaluate the use of Mobile 28 grease for the turbine-driven auxiliary feedwater pump trip throttle valve. The licensees 1995 evaluation included no documentation for the appropriate relubrication interval of the valve. Additionally, the inspectors identified that the valve exhibited temperatures ranging from 235°F to near 300°F compared to the 215°F valve temperature used in the evaluation. The inspectors questioned if the use of Mobile 28 grease was appropriate since operating experience suggests that Mobile 28 grease has a tendency to thicken and harden at temperatures exceeding 250°F and elevated temperatures increased the lubricants tendency to lose oils and could result in increased stem friction.

Following questioning by the inspectors, the licensee initiated Callaway Action Request 200905067 and Request for Resolution 200905651 to determine if Mobile 28 grease was an appropriate lubricant for valve FCHV0312 (Section 1R3).

This finding is greater than minor because it was associated with the Mitigating Systems Cornerstone attribute of design control and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. This finding did not to have a crosscutting aspect since the inadequate 1995 lubrication evaluation was not reflective of current licensee performance (Section 1R3).

Green.

The team identified a noncited violation of 10 CFR Part 50, Appendix B,

Criterion V, Instructions, Procedures, and Drawings, regarding the licensees failure to follow the requirements of Callaway Procedure APA-ZZ-00500,

Corrective Action Program. Specifically, licensee personnel failed to initiate Callaway action requests for adverse conditions of high hand wheel forces, galled subcomponents, and hardened, gritty grease found during the 2007 rebuild of the spare turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312. The licensee has entered this issue into their corrective action program as Callaway Action Request 200905053.

This finding is greater than minor because, if left uncorrected, failure to fully utilize the corrective action program could become a more significant safety concern. The inspectors determined that this finding impacted the Mitigating Systems Cornerstone attribute of procedural quality and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.

Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. The cause of this finding is related to the problem identification and resolution crosscutting component of the corrective action program because licensee personnel failed to implement a corrective action program with a low threshold for identifying issues

P.1(a)(Section1R3).

Green.

The team identified a noncited violation of Technical Specification Limiting Condition for Operation 3.0.4 for entering Mode 3 with the turbine-driven auxiliary feedwater pump inoperable. Specifically, on November 3, 2008, while in Mode 4 for Refueling Outage 16, an unexpected overspeed trip of the turbine occurred during postmaintenance testing. Callaway operations staff inappropriately concluded that a water slug from the auxiliary steam line was the cause of the turbine overspeed. Following entry into Mode 3, during preparations for turbine-driven auxiliary feedwater pump testing, the licensee found the servo control valve installed during the outage was faulty. When questioned by the inspectors, the licensee determined that the faulty servo control valve discovered in Mode 3 was responsible for the overspeed of the turbine-driven auxiliary feedwater pump that occurred in Mode 4 and that the equipment was inoperable during the mode change that occurred on November 4, 2008. The licensee entered this deficiency in their corrective action program as Callaway Action Request 200905313.

This finding is greater than minor because it is associated with the Mitigating Systems Cornerstone attribute of equipment performance and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.

Using Manual Chapter 0609.04, Phase 1 - Initial Screening and

Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. The inspectors determined that this finding has a crosscutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to fully evaluate the overspeed of the turbine-driven auxiliary feedwater pump that occurred on November 3, 2008 P.1(c)(Section 4OA2).

Licensee-Identified Violations

None

REPORT DETAILS

REACTOR SAFETY

Cornerstones: Initiating Events, Mitigating Systems, Barrier Integrity, and Emergency Preparedness 1R1 Special Inspection Scope On May 25, 2009, during a planned slave relay test of the auxiliary feedwater actuation system, the turbine-driven auxiliary feedwater pump failed to start on demand.

Subsequent troubleshooting determined that the trip throttle valve for the turbine did not actuate properly which prevented steam from being admitted to the turbine. Electrical continuity checks revealed that the torque switch on the valve operator tripped which stopped the motor-operated valve actuator. Inspection of the trip throttle valve showed that the lubricant used on the valve spindle and sliding nut was dried. In accordance with Management Directive 8.3, NRC Incident Investigation Program, the NRC determined that a special inspection was warranted, in part, based on the potential safety significance and because of potential generic issues associated with lubricating motor-operated valves.

The inspection charter required the team to:

(1) review the circumstances related to the discovery of the degraded condition,

(2) assess the licensees determination of cause and effectiveness of actions taken to resolve and prevent recurrence of these problems, and

(3) assess the effectiveness of licensee programs to maintain the physical condition of the turbine-driven auxiliary feedwater pump trip throttle valve including the licensee's lubrication and valve replacement programs. The team evaluated if the licensee took appropriate actions to address these issues including extent of condition, extent of cause, and common cause questions. The inspectors reviewed the licensees Generic Letter 89-10 program to ensure appropriate testing was being performed that would demonstrate the turbine-driven auxiliary feedwater pump trip throttle valves ability to function under design-basis conditions.

The team conducted their reviews in accordance with NRC Inspection Procedure 93812, Special Inspection Procedure. The special inspection team reviewed procedures, corrective action documents, as well as design and maintenance records for the equipment of concern. The team interviewed key station personnel regarding the events, reviewed the root cause analysis, and assessed the adequacy of corrective actions. The team walked down and inspected the equipment in the field and spare equipment in the warehouse. A list of specific documents reviewed is provided as

1. The charter for the special inspection is provided as Attachment 2.

1R2 Review of the Failure of Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve Background On May 25, 2009, Callaway Plant operators performed Procedure OSP-SA-0007A, Train A AFAS Slave Relay Test. The procedure is designed to demonstrate that the auxiliary feedwater actuation system slave relays are operable and capable of starting the turbine-driven auxiliary feedwater pump. The turbine-driven auxiliary feedwater pump is a steam-driven pump which utilizes a Terry turbine as a prime mover supplied by steam from steam generators B and C. The steam line to the turbine contains normally closed, motor-operated, spring loaded trip throttle valve FCHV0312. Upon initiation of an auxiliary feedwater actuation signal, the trip throttle valve operator moves in the closed direction in order to latch the mechanical linkage of the valve stem. A limit switch is used to detect when the trip throttle valve has reached the latched position.

Once in the latched position, the direction of the motor operator is reversed and the trip throttle valve opens admitting steam to the governor flow control valve, which is normally fully open, starting the turbine-driven auxiliary feedwater pump. During the performance of Step 6.2.8 of Procedure OSP-SA-0007A, the turbine-driven auxiliary feedwater pump did not start as expected. Following the failed start, the licensee discovered that valve FCHV0312 had traveled approximately 70 percent of the closed stroke in an attempt to latch the valve operator but had stopped prior to latching the valve.

Troubleshooting was conducted on May 25, 2009, under Job 09003598, Task 910.

During that job, the licensee determined that the closed torque switch had opened which stopped the motor-operated valve actuator. Callaway operators then declutched and manually operated the trip throttle valve actuator. During manual operation of the actuator, the sliding nut and screw spindle were observed to have an audible squeak while moving. A sample of the grease taken from the valve spindle was later examined using infrared spectrometry. The results of that analysis showed that the chemical composition was comparable to that of Mobile 28 grease and showed no other traces of either zinc or lithium which are found in Exxon Nebula EP-1 or EP-2 greases, the other two greases used on valve stems at the Callaway Plant. Those results indicated that the grease found on the valve FCHV0312 on May 25, 2009, was not mixed with other, non-approved greases.

Following troubleshooting, the licensee performed Job 09003598, Task 510, to lubricate the trip throttle valve. During that job, the licensee cleaned, inspected, and lubricated the trip throttle valve sliding nut, screw spindle, split coupling and trip linkages. The valve was manually operated during the performance of the job to allow access to all valve components. The mechanical maintenance technician who operated the valve noted that excessive forces were necessary to manipulate the valve and an audible squeak could be heard as the valve spindle rotated. As the valve was lubricated, the maintenance staff observed that the valve hand wheel became easier to manipulate and the audible squeak subsided. Once the valve was adequately lubricated, the licensee performed postmaintenance testing under Job 09003598, Task 920, to confirm the valve could operate as designed.

Missed Lubrication of Valve FCHV0312 Callaway replaces the trip throttle valve every third refueling outage with a refurbished valve that was previously removed from the system (Preventive Maintenance 0824900).

The turbine-driven auxiliary feedwater pump trip throttle valve that failed to open on May 25, 2009, was replaced under Job 0551578 during Refueling Outage 16 (October 2008). The valve was replaced with a similar valve that was removed from service during Refueling Outage 13 in April 2004 and refurbished in September 2007.

Replacement Preventive Maintenance 0824900 did not have specific lubrication instructions. Lubrication of valve FCHV0312 is accomplished by Preventive Maintenance Task 0810863 which is completed every refueling outage and was scheduled for Refueling Outage 16 as Job 07506359. The maintenance supervisor assigned to coordinate Job 07506359 made a job routing request, to engineering inquiring if additional inspection was required on valve FCHV0312 since the valve had recently been replaced. Although not specifically referenced, the portion of the job requested to be closed without action was Section 6.3, Trip Throttle Valve Lubrication and Inspection. The motor-operated valve system engineer replied to the job routing request that the valve had been diagnostically tested satisfactorily and that no additional inspection was needed. The engineer did not consult with the technician requesting closure and did not verify that the lubrication job task being closed was completed by the installation procedure. Consequently, the lubrication portion of Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection, was not performed. Since the valve was not lubricated during Refueling Outage 16, the last lubrication of the valve prior to the May 25, 2009, failure occurred during the refurbishment of the valve in September 2007. The lack of lubrication on valve FCHV0312 resulted in increased friction between the sliding nut and spindle which prevented the valve from opening on demand May 25, 2009.

a. Inspection Scope

The team evaluated the events leading to and the licensee response to the failure to start of the Callaway turbine-driven auxiliary feedwater pump. In order to review each area of the special inspection charter issued on June 17, 2009, the team reviewed calculations, design documents, licensing documents, work orders, modification packages, and corrective action documents. The team evaluated licensee compliance with the applicable regulatory requirements and applicable codes and standards.

The team interviewed key station personnel from operations, design and system engineering, maintenance, and the corrective action program.

The team assessed licensee implementation of their corrective action program, design controls, and procedure implementation.

b. Findings

Introduction.

The team identified a self-revealing apparent violation of Technical Specification 3.7.5, Auxiliary Feedwater System, due to the failure to adequately lubricate turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312.

Description.

On May 25, 2009, Callaway Plant operators performed surveillance testing Procedure OSP-SA-0007A, Train A AFAS Slave Relay Test, to test the slave relays used to start the turbine-driven auxiliary feedwater pump. During the performance of Step 6.2.8 of Procedure OSP-SA-0007A, the turbine-driven auxiliary feedwater pump did not start as expected. During troubleshooting, the licensee discovered that the turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312 had traveled in the closed direction in an attempt to latch the valve operator but had stopped prior to completing its stroke. Electrical continuity checks revealed that the motor-operated valve closed torque switch had opened. Callaway operators declutched and manually operated the trip throttle valve actuator. An audible squeak was observed during manual operation indicating mechanical binding within the sliding nut and valve spindle. Following troubleshooting, the licensee performed Job 09003598 to lubricate the trip throttle valve.

Once the valve was adequately lubricated, the licensee successfully performed postmaintenance testing.

Callaway replaces the trip throttle valve every third refueling outage with a refurbished valve that was previously removed from the system. The turbine-driven auxiliary feedwater pump trip throttle valve that failed to open on May 25, 2009, was replaced during Refueling Outage 16 in October 2008. The valve was replaced with a similar valve that was removed from service during Refueling Outage 13 in April 2004 and refurbished in September 2007. The replacement procedure did not have specific lubrication instructions. Lubrication of the valve was scheduled to be performed a few days after replacement as Job 07506359. The maintenance supervisor assigned to coordinate the lubrication incorrectly assumed that the valve was adequately lubricated since it had been recently replaced. Callaway Procedure APA-ZZ-00320, Work Execution, Section 4.12, allows for a job to be canceled if it is determined that the work is not necessary or has been completed by another job. The maintenance supervisor initiated a job routing request to engineering inquiring if additional inspection was required on valve FCHV0312 since the valve had recently been replaced. Although not specifically referenced, the portion of the job requested to be closed was Section 6.3, Trip Throttle Valve Lubrication and Inspection.

Callaway engineering replied to the job routing request that the valve had been diagnostically tested satisfactorily and that no additional inspection was needed. The engineers response only answered the specific question asked by the job routing request and did not examine the procedural requirements that were the subject of the request. The engineer did not consult with the technician requesting closure and did not verify that the lubrication job task being closed was completed by the installation procedure. Based on the input received from engineering, the mechanical maintenance supervisor closed the lubrication portion of Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection. The mechanical maintenance supervisor failed to identify that the entire work scope of the superseded work document was included in the superseding work document which did not meet the requirements of licensee Procedure APA-ZZ-00320. Since the valve was not lubricated during Refueling Outage 16, the last lubrication of the valve occurred during the refurbishment of the valve in September 2007. The lack of lubrication on valve FCHV0312 resulted in increased friction between the sliding nut and spindle which caused the valve not to open upon demand on May 25, 2009.

The licensee initiated Significant Condition Adverse to Quality Callaway Action Request 200904216 to investigate the failure of the turbine-driven auxiliary feedwater pump to start due to an inadequately lubricated trip throttle valve. The licensees root cause analysis determined that the failure to lubricate valve FCHV0312 was due to the failure to fully review the closure of the lubrication portion of Procedure MPM-FC-QK001 during Refueling Outage 16. The licensee also determined that while the actual timing of the failure could not be determined, it was reasonable to assume that the turbine-driven auxiliary feedwater pump was inoperable for a time frame greater than the technical specification allowed completion time.

Long term corrective actions were implemented to revise the replacement preventive maintenance procedure to include a lubrication section. Additionally, the licensee identified several enhancements to their lubrication program including an evaluation of the preventive maintenance frequency and an evaluation of lubricants used on valve FCHV0312. The inspectors noted that the corrective actions identified in the root cause analysis did not address programmatic issues concerning work execution and a lack of protocol for the initiation and response to job routing requests. Specifically, Procedure APA-ZZ-00320 allows for a single individual to close incomplete preventive maintenance tasks.

Analysis.

The performance deficiency associated with this finding involved the licensees failure to ensure valve FCHV0312 was adequately lubricated such that it remained operable. Specifically, Section 6.3 Trip Throttle Valve Lubrication and Inspection, of Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection, was closed without adequate review. The lack of lubrication resulted in increased friction within the valve which caused the valve not to open on May 25, 2009.

This finding is greater 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. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as potentially risk significant since the finding represented a loss of system safety function because the turbine-driven auxiliary feedwater pump PAL02 failing eliminates the capability of the plant to cope with a station blackout. The finding required a Phase 2 analysis. When evaluated per Manual Chapter 0609, Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations, and the Callaway Plant Phase 2 pre-solved table item Turbine Driven Auxiliary Feedwater Pump Fails to Start, the inspectors determined this finding to be potentially risk significant. The finding was forwarded to a senior reactor analyst for review. The senior reactor analyst performed the Phase 3 analysis, Attachment 4, and determined that preliminarily, the finding was of low to moderate safety significance.

The inspectors determined that this finding had a crosscutting aspect in the area of human performance associated with the work practices component because the licensee failed to follow the procedural guidance provided when changing the scope of a preventive maintenance task H.4(b).

Enforcement.

Technical Specification 3.7.5, Auxiliary Feedwater System, requires, in part, that three trains of auxiliary feedwater shall be operable in Modes 1, 2 or 3. The technical specifications required that if one train of auxiliary feedwater is inoperable for greater than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, actions be taken to be in Mode 3 within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and Mode 4 within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. Contrary to the required action statements, on May 25, 2009, the turbine-driven auxiliary feedwater pump train was found to be inoperable due to a lack of lubrication of trip throttle valve FCHV0312. Subsequent review determined that the lack of lubrication resulted in the turbine-driven auxiliary feedwater pump being inoperable for greater than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. Pending determination of the findings final safety significance, this finding is identified as Apparent Violation (AV)05000483/2009009-01, Turbine-Driven Auxiliary Feedwater Pump Inoperable Due to Inadequately Lubricated Trip Throttle Valve.

1R3 Review of Lubrication and Valve Replacement Program for Valve FCHV0312 Valve Lubrication The licensee has two preventive maintenance tasks that lubricate valve FCHV0312.

The first is Preventive Maintenance 0810863 which is a Terry turbine equipment check and is performed every refueling outage. The second is Preventive Maintenance 0818214 which is a turbine-driven auxiliary feedwater pump equipment check that is performed every 72 weeks. The scheduling of the two preventive maintenance tasks is such that Preventive Maintenance 0810863 is performed every refueling outage and Preventive Maintenance 0818214 is performed in the middle of the operating cycle. The requirements to lubricate the trip throttle valve are contained in Step 6.3 of Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection. That procedure directs mechanical maintenance personnel to clean, inspect and lubricate the valve at the sliding nut, trunnion screws, the screw spindle, the trip linkages and pins, and at the split coupling. The frequency of lubrication is consistent with industry standards and vendor guidance which recommends a minimum 18 to 24-month lubrication frequency.

The trip throttle valve is lubricated with Mobile 28 grease which is a high temperature, anti-wear grease composed of a polyalphaolefin synthetic base fluid with an organo-clay thickener. Mobile 28 grease, designed for lubrication of splines, screws and worm gears, falls between the National Lubricating Grease Institute Grade No. 1 and No. 2.

The recommended operating temperature is -55°C to 180°C (-67°F to 356°F) with appropriate relubrication intervals. Mobile 28 is recommended by the trip throttle valve vendor as an acceptable lubricant. The licensee first began using Mobile 28 grease for valve FCHV0312 in 1995 under Request for Resolution 16006A. That evaluation determined that Mobile 28 was an acceptable lubricant based on the valve vendors recommendations and based on the operating temperatures and physical characteristics of the lubricant.

Valve FCHV0312 is used as a steam admission valve for the turbine-driven auxiliary feedwater pump. The valve is physically arranged downstream of two air operated valves that provide a source of steam from steam generators B and C. Each line is equipped with a bypass line that allows steam to be present at the trip throttle valve to maintain the line warm and free of moisture. Because valve FCHV0312 is a steam admission valve, it is constantly exposed to elevated temperatures. When reviewing operating experience, the team found that Mobile 28 grease, in tests performed for NUREG/CR-6750, Performance of MOV Stem Lubricants at Elevated Temperature, experienced physical characteristic changes when exposed to elevated temperatures.

Of particular concern in the operating experience was the observation that Mobile 28 changed from bright red in color to almost black when heated and that the lubricant appeared to have thickened and hardened. Additionally, an absorption test identified that elevated temperatures (around 250°F) increased the lubricants tendency to lose oils and could result in increased stem friction. The team noted that the licensees evaluation of the use of Mobile 28 grease was bounded at 215°F but actual operating conditions at valve FCHV0312 were approximately 300°F.

The team reviewed the licensees lubrication procedure and found that no guidance was provided as to the quantity of grease to use, how to properly purge the system of old lubricant, and at exactly what lubrication point new grease should be applied. At Callaway, these particular details are considered skill of the craft. During the root cause investigation, the licensee interviewed mechanical maintenance staff and confirmed there was not consistent information provided on the amount of lubricants to use or the specific points to lubricate. The root cause analysis associated with Callaway Action Request 200904219, Enhancement 2.0, recommended revisions to Preventive Maintenance 0810863 and 0818214, to specify lubrication locations, amount and type of lubricant to use, and instructions to manually stroke the valve while lubricating through the trunnion screws to assure the trip throttle valve is fully lubricated across the entire length of the spindle.

When reviewing the licensees lubrication program, the inspectors examined the licensees storage of lubricants and noted several expired consumables (grease, lubricants, oils, etc.) within the mechanical maintenance shop. The inspectors questioned the mechanical maintenance supervisor to determine if potential existed for use of expired lubricants in safety related applications. Based on interviews, the inspectors determined that the potential to use expired consumables in safety related applications exists since there is no procedural guidance that requires verification of a products expiration date prior to use, it is simply an expectation. The licensee reviewed the work history associated with these products and verified that these materials were not used during work on safety related components. This issue was entered into the licensees corrective action program as Callaway Action Request 200905038.

Additionally, the inspectors observed that the licensees trip throttle valve lubrication specification within the plant equipment database called for Exxon Nebula EP-1 which is not a vendor approved grease for the trip throttle valve. The team verified that current work instructions and procedures require the use of Mobile 28 grease. The team considered this a minor administrative issue and the licensee entered the discrepancy into their corrective action program as Callaway Action Request 200905032.

Valve Replacement and Refurbishment Currently, the licensee replaces the trip throttle valve every third refueling outage with a refurbished valve that was previously removed from the system (Preventive Maintenance 0824900). The frequency of replacement is consistent with industry standards and vendor guidance which recommends a minimum 6-year replacement frequency. Callaways frequency is more conservative because internal operating experience has demonstrated that the trip throttle valve develops too much seat leakage during the fourth operating cycle which results in increased corrosion of safety related components on the 1988 foot elevation of the auxiliary buildings as well as an increase in nonoperating bearing oil temperatures. The procedure used to rebuild the valve is contained within the preventive maintenance task. The scope of the work during a valve refurbishment includes:

• Disassembly of the valve

• General inspection of all valve components

• Blue check of valve seating surfaces to ensure 100 percent circumferential contact

• Dimensional measurements and component tolerance verification. Excessively worn parts are replaced

• Gasket replacement and valve lubrication

• Reassembly of the valve During the most recent refurbishment of valve FCHV0312 performed under Job W219154 in September 2007, the valve vendor was on site to provide technical assistance. A field service report (FS-47107) was issued following completion of the job and documented several adverse conditions associated with the valve. The team inspected the spare turbine-driven auxiliary feedwater pump trip throttle valve and found that the spare valves spindle and sliding nut lubricant was thick and had darkened in color when compared to fresh lubricant. The inspectors also observed that there appeared to be evidence of galling of the spindle to valve stem thrust washer surfaces.

a. Inspection Scope

The team evaluated the licensees programs and procedures for maintaining the turbine-driven auxiliary feedwater pump trip throttle valve. Specifically, the team reviewed procedures associated with valve lubrication and refurbishment, preventive maintenance tasks including preventive maintenance change history, and the licensees evaluation of the lubricants used and the frequency of lubrication. The team compared the licensees programs to applicable industry and vendor guidance associated with the trip throttle valve. The team found that the licensee has performed many equipment and program improvements to the turbine-driven auxiliary feedwater pump system that address industry standards and operating experience such as trip throttle valve spindle upgrades, a digital control system upgrade, governor valve stem material improvements, maintenance procedure revisions, and start-up transient performance monitoring and trending. Team interviews with station personnel noted that the licensee actively participates in industry organizations that seek to improve industry auxiliary feedwater system performance.

The team interviewed key station personnel from operations, design and system engineering, maintenance, and the corrective action program.

b. Findings

===.1

Introduction.

The team identified a green noncited violation of Technical===

Specification 5.4.1.a, Procedures, for the failure to provide adequate procedural guidance for the lubrication of valve FCHV0312.

Description.

On May 17, 2002, the licensee initiated Callaway Action Request 200203228 to request a change to the preventive maintenance frequency for the turbine-driven auxiliary feedwater pump trip throttle valve. While researching the preventive maintenance requirements for the valve, the lead responder to the Callaway action request documented an additional concern with the trip throttle valve lubrication procedure in that the spindle coupling is not fully accessible in either the fully open or fully closed positions. The Callaway action request recommended that during lubrication, the trip throttle valve be manually mid-positioned to fully lubricate the valve stem and bushings. The licensee initiated Preventive Maintenance AF 6084 to make a change to the lubrication procedure for valve FCHV0312 such that it would address the concerns raised in Callaway Action Request 200203228. On May 16, 2003, the Callaway action request noted that Preventive Maintenance 818214 would be changed to include procedural guidance that the valve may be manually repositioned to allow access to valve components.

The inspectors reviewed Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection, and found that the corrective actions suggested by Callaway Action Request 200203228 were not fully developed and that the procedure, as written, provided ambiguous guidance on how to lubricate valve FCHV0312. Specifically, the inspectors noted that the procedure only gives the option of repositioning the valve to access certain components but does not require the valve be manually mid-positioned to ensure adequate lubrication. The procedure does not specify what components of concern are to be lubricated when the valve is manually repositioned. The inspectors also observed during a system walkdown that the valve design is such that the valve spindle, in addition to the valve coupling, is not fully accessible from a static position since the sliding nut obstructs access to the spindle threads. While the sliding nut is equipped with Zerk type grease fittings that are ported to allow the lubricant to be applied to the spindle, the entire length of the spindle could only be lubricated through this point if the valve was manually operated while grease was injected at the fitting location. The inspectors also noted the procedure does not specify lubrication locations or the amount of lubricant to use and how to achieve a proper purge of old lubricant.

The inspectors questioned engineering and maintenance staff on how these issues were addressed during trip throttle valve lubrications and were told that this level of work was within the skill of the craft.

In addition to the inadequacies identified by the NRC, the licensees root cause investigation team also identified that the lubrication procedure for the turbine-driven auxiliary feedwater pump trip throttle valve has several inadequacies that could lead to improperly lubricating the valve. The licensees review included interviews with mechanical maintenance staff which confirmed there was not consistent information provided on the amounts of lubricants to use or the specific points to lubricate. The root cause analysis associated with Callaway Action Request 200904219 recommended Enhancement 2.0 to revise the valve lubrication procedure to specify lubrication locations, amount and type of lubricant to use and instructions to manually stroke the valve while lubricating through the trunnion screws to assure the trip throttle valve is fully lubricated across the entire length of the spindle.

Analysis.

The performance deficiency associated with this finding involved the licensees failure to ensure the procedures required to lubricate valve FCHV0312 were adequate. This finding is greater than minor because it was associated with the Mitigating Systems Cornerstone attribute of procedural quality and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. This finding did not to have a crosscutting aspect since the 2003 lubrication procedure revision was not reflective of current licensee performance.

Enforcement.

Technical Specification 5.4.1.a, Procedures, required that written procedures be established and implemented covering activities specified in Appendix A, Typical Procedures for Pressurized Water Reactors, of Regulatory Guide 1.33, Quality Assurance Program Requirements (Operation), February 1978. Regulatory Guide 1.33, Appendix A, Section 9.a, required procedures for performance of maintenance.

Contrary to the above, from May 16, 2003, until June 26, 2009, Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection, was not adequate to ensure that valve FCHV0312 was adequately lubricated. Because of the very low safety significance of this finding and because the licensee has entered this issue into their corrective action program as Callaway Action Requests 200904216 and 200905077, this violation is being treated as a noncited violation in accordance with Section VI.A.1 of the Enforcement Policy: NCV 05000483/2009009-02, Failure to Maintain an Adequate Lubrication Procedure for Valve FCHV0312.

===.2

Introduction.

The team identified a green noncited violation of 10 CFR Part 50,===

Appendix B, Criterion III, Design Control, for the failure to adequately evaluate the use of Mobile 28 grease for the turbine-driven auxiliary feedwater pump trip throttle valve.

Description.

On March 2, 1993, the licensee initiated Suggestion Occurrence Solution 199300209 to document that during preventive maintenance, turbine-driven auxiliary feedwater pump trip throttle Valve FCHV0312, failed to open. Action 3 to Suggestion Occurrence Solution 199300209 determined the cause to be hardened Nebula EP-1 grease around the valve spindle and sliding nut. Remedial action for Suggestion Occurrence Solution 199300209 included changing the preventive maintenance frequency from every 24 weeks to every 12 weeks and initiation of Request for Resolution 13409A to evaluate a substitute grease for the actuator sliding nut and spindle. Request for Resolution 13409A requested a change from Nebula EP-1 grease to Shell Narina EP-0 or Aeroshell Grease 5 due to hardening of grease at the valve.

Valve FCHV0312 is used as a steam admission valve to the turbine-driven auxiliary feedwater pump. The valve is physically arranged downstream of two air operated valves that provide steam from the Steam Generators B and C. Since valve FCHV0312 is used as a steam admission valve, it is continuously exposed to high temperatures.

The disposition of Request for Resolution 13409A determined that no change should be implemented since the proposed lubricant replacements were not acceptable greases for addressing long term hardening due to high temperatures at valve FCHV0312.

On April 24, 1995, the licensee initiated Request for Resolution 16006A to change the grease used on trip throttle valve FCHV0312. Request for Resolution 16006A referenced Request for Resolution 13409A and noted that the Nebula EP-1 grease currently in use was not recommended for applications where continuous high temperatures can cause oil evaporation, resulting in hardening of the grease. The request for resolution documented that the valve vendor was contacted and recommended a high-temperature lithium-based grease such as Mobile 28. Mobile 28 grease is a high-temperature, anti-wear grease composed of a synthetic base fluid with a non-soap thickener. The final disposition of Request for Resolution 16006A approved the use of Mobile 28 grease in place of Exxon Nebula EP-1 for valve FCHV0312 since it was recommended by the valve manufacturer and the temperature of the valve FCHV0312 screw spindle was approximately 215°F which is within the temperature range recommended by the grease manufacturer.

The inspectors reviewed Request for Resolution 16006A and noted that the evaluation provided no documentation as to what constitutes an appropriate relubrication interval as recommended in the vendor data sheet for Mobile 28. Additionally, the inspectors questioned if the assumed temperature of 215°F at the Valve FCHV0312 screw spindle was consistent with the current plant configuration. The licensee measured the temperature of various components on Valve FCHV0312 on June 23, 2009. Those measurements indicated that the valve exhibited temperatures ranging from 235°F at the sliding nut to 272°F at the valve coupling. Additional measurements were taken on June 29, 2009, following a planned surveillance of the turbine-driven auxiliary feedwater pump. Those measurements showed temperatures near 300°F at the valve coupling.

Since the valve displayed temperatures exceeding those in Request for Resolution 16006A, the inspectors questioned if the use of Mobile 28 grease was appropriate, particularly since operating experience performed by Idaho National Lab and documented in NUREG/CR-6750, Performance of MOV Stem Lubricants at Elevated Temperature, suggested Mobile 28 grease has a tendency to thicken and harden at temperatures exceeding 250°F. Additionally, the test performed in NUREG/CR-6750 identified that elevated temperatures increased the lubricants tendency to release oils and could result in increased stem friction.

Following questioning by the inspectors, the licensee initiated Callaway Action Request 200905067 and Request for Resolution 200905621 to determine if Mobile 28 grease was an appropriate lubricant for valve FCHV0312. The results of that analysis determined that the thread angle of the stem for valve FCHV0312 is similar to that of two of the stems tested in NUREG/CR-6750. While the coefficient of friction was determined to increase for those stems, the licensee determine that the maximum postulated coefficient of friction is bound by the current thrust and torque analysis for valve FCHV0312. The final conclusion of the Callaway action request was that while the recorded temperatures on valve FCHV0312 exceeded those evaluated for in Request for Resolution 16006A, the use of Mobile 28 grease is appropriate when coupled with an adequate relubrication interval. At the close of the inspection, the licensee was still evaluating the appropriate preventive maintenance frequency for lubrication of the valve.

Analysis.

The performance deficiency associated with this finding involved the licensees use of nonconservative assumptions in the 1995 evaluation of Mobile 28 grease as a lubricant for valve FCHV0312. This finding is greater than minor because it was associated with the Mitigating Systems Cornerstone attribute of design control and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as having very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. This finding did not have a crosscutting aspect since the inadequate 1995 lubrication evaluation was not reflective of current licensee performance.

Enforcement.

Title 10 of the Code of Federal Regulations, Part 50, Appendix B, Criterion III, Design Control, required, in part, that measures be established to assure that applicable regulatory requirements and the design basis, as defined in paragraph 50.2 and as specified in the license application, are correctly translated into specifications, drawings, procedures and instructions. Contrary to the above, on April 24, 1995, Callaway initiated Request for Resolution 16006A which failed to correctly translate the operating temperature of valve FCHV0312 when evaluating the use of Mobile 28 grease. The assumed temperature of 215°F degrees was nonconservative and operating experience indicated that actual temperatures experienced at valve FCHV0312 could result in thickening of the lubricant and loss of viscosity. Because of the very low safety significance of this finding and because the licensee has entered this issue into their corrective action program as Callaway Action Request 200905067, this violation is being treated as a noncited violation in accordance with Section VI.A.1 of the Enforcement Policy: NCV 05000483/2009009-03, Failure to Adequately Evaluate the Use of Mobile 28 Grease for the Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve.

===.3

Introduction.

The team identified a green noncited violation of 10 CFR Part 50,===

Appendix B, Criterion V, Instructions, Procedures, and Drawings, regarding the licensees failure to follow the requirements of Callaway Procedure APA-ZZ-00500, Corrective Action Program, associated with the turbine-driven auxiliary feedwater pump trip throttle valve.

Description.

On September 10, 2007, the licensee performed Job W219154 to rebuild the spare turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312. The scope of the work included as-found inspections, valve disassembly, valve reassembly, and postmaintenance testing. Job W219154 was performed with assistance from a vendor field representative who supervised disassembly, inspection, and rework of the valve. Upon completion of Job W219154, the licensee did not identify any degraded or nonconforming conditions. On September 14, 2007, the valve vendor issued a field service report associated with Job W219154 performed on September 10, 2009. The field service report noted several adverse conditions discovered during the performance of Job W219154 including:

• Hand wheel forces were found to be excessive when the valve was operationally tested.

• Some sticking was noted when the valve was manually stroked by pulling the latch-up lever, with the valve spring removed.

• Sticking was noted when the valve was manually stroked by pulling the pilot valve and stem with the coupling removed.

• The grease in the coupling was found to be dry and gritty. Additionally, grease on the contact areas of the yoke, bore, and sliding nut was found to be hard and gritty.

• The thrust washer and the screw spindle were found to be galled at the contact areas.

• A hard nonmetallic dark grey foreign substance was found on the pilot valve and stem at the bushing contact area.

• Inspection revealed several dimensional and visual discrepancies at the coupling, screw spindle, sliding nut, link pin, and trip hook shaft.

The valve vendor also noted that the licensees auxiliary feedwater pump turbine trip throttle valve overhaul procedure was inadequate with regards to safe disassembly of the valve. The field service report documented that improper disassembly of the valve could possibly result in damage to valve parts and could result in personnel injury. The vendors recommended that prior to any rebuild of the valve, the licensee review and revise their procedure to comply with industry standards. The inspectors found that the licensee did revise their overhaul procedure to address the safety concerns and comply with industry standards. Finally, the vendor recommended several preventive maintenance items for valve FCHV0312 including a weekly, manual exercising of the valve and a monthly lubrication with a high temperature, lithium based grease at all fittings in the actuator portion of the valve and at the coupling.

The inspectors reviewed the vendor report associated with Job W219154 and noted that several of the conditions met the requirements specified in Procedure APA-ZZ-00500, Corrective Action Program, for entry into the corrective action program. Specifically, Section 4.1 required that a Callaway action request be generated for a condition that could credibly impact nuclear safety, radiological safety, personnel safety, or plant reliability. Additional review by the licensee also determined that since the licensees corrective action program procedure does not require shift manager notification for identification of an adverse condition associated with equipment previously installed in the plant, the possibility exists that the impact on operability for adverse conditions could be overlooked even if there is possible extent of condition concerns.

Analysis.

The performance deficiency associated with this finding involved the licensees failure to follow the requirements of Callaway Procedure APA-ZZ-00500, Corrective Action Program. Specifically, licensee personnel failed to initiate condition reports for multiple adverse conditions found during the 2007 rebuild of the spare turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312. This finding is greater than minor because if left uncorrected, the failure to fully utilize the corrective action program could become a more significant safety concern. The inspectors determined that this finding impacted the mitigating systems Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as having very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage times, and did not affect seismic, flooding, or severe weather initiating events. The cause of this finding is related to the problem identification and resolution crosscutting component of the corrective action program because licensee personnel failed to implement a corrective action program with a low threshold for identifying issues P.1(a).

Enforcement.

Title 10 of the Code of Federal Regulations, Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be prescribed by documented instructions or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions or drawings. Contrary to the above, on September 14, 2007, the licensee failed to enter several adverse conditions identified during rebuild of their safety related turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312 into their corrective action program as required by Section 4.1 of Procedure APA-ZZ-00500, Corrective Action Program, Revision 44, that states a Callaway action request be initiated for a condition that could credibly impact nuclear safety, radiological safety, personnel safety, or plant reliability. Because of the very low safety significance of this finding and because the licensee has entered this issue into their corrective action program as Callaway Action Request 200905053, this violation is being treated as a noncited violation in accordance with Section VI.A.1 of the Enforcement Policy:

NCV 05000483/2009009-04, Failure to Enter Conditions Adverse to Quality Associated with the Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve into the Corrective Action Program.

1R4 Review of Root Cause Analysis, Extent of Condition and Corrective Actions On June 8, 2009, the licensee established a root cause analysis team to investigate the facts and identify the causes associated with the failure of the turbine-driven auxiliary feedwater pump trip throttle valve. The team conducted their review in accordance with Procedure APA-ZZ-00500, Appendix 12, Significant Adverse Condition. The licensees procedure requires the team to:

• Identify and validate root and contributing causes

• Conduct an extent of condition review

• Determine extent of cause

• Develop corrective actions The licensees final root cause analysis was completed on July 16, 2009.

Root Cause Methodology The licensee performed their analysis utilizing a structured root cause analysis method in accordance with Procedure APA-ZZ-00500, Appendix 12, Significant Adverse Condition - Significance Level 1. A fault tree was developed for FCHV0312 to determine the valves failure mechanism. An event and causal factors chart was created to document the sequence of events and the casual factors that led to the failure of valve FCHV0312. The results of that analysis determined valve FCHV0312 was not lubricated properly because, during Refuel 16, the lubrication portion of Procedure MPM-FC-QK-001, Auxiliary Feedwater Pump Turbine Annual Inspection, was not performed which resulted in increased valve spindle friction. This increased friction caused the valves torque switch to trip which prevented the valve from opening.

Root Cause and Corrective Actions to Prevent Recurrence The licensee determined that the root cause of the event was that the maintenance supervisor did not review the full scope of the replacement preventive maintenance procedure when closing the lubrication portion of Procedure MPM-FC-QK-001, Auxiliary Feedwater Pump Turbine Annual Inspection, during Refueling Outage 16.

Procedure APA-ZZ-00320, Work Execution, Section 4.12, required the maintenance supervisor to perform a review to ensure the entire work scope of the superseded work document is included in the superseding document.

As a corrective action to prevent recurrence, the licensee proposed revision to the replacement preventive maintenance procedure to incorporate valve lubrication requirements.

Enhancements and Other Issues As part of their investigation, the licensee identified multiple other issues which are defined as nonsignificant issues that licensee management wishes to capture within the corrective action program. Other issues identified by the licensee included:

• Revise the lubrication program to improve control and storage of lubricants within the plant. The inspectors identified that several expired lubricants were stored within the mechanical maintenance shop. See section 1R5.

• Revise the lubrication procedure for the turbine-driven auxiliary feedwater pump trip throttle valve to include amounts and type of lubricant to use and the need to manually stroke the valve to ensure the valve is fully lubricated.

• Determine if training on lubrication practices is required. Interviews with maintenance personnel revealed that there is not consistent knowledge on the proper use and application of lubricants.

Several enhancements were identified that are considered actions that improve a process or design but do not correct the problem associated with the turbine-driven auxiliary feedwater pump trip throttle valve. Since enhancements are considered as improvements and not actions to correct a problem, there is no procedural requirement to implement an enhancement. Enhancements identified by the licensee included:

• Evaluate a change from Mobile 28 grease to a better performing lubricant for the turbine-driven auxiliary feedwater pump trip throttle valve.

• Evaluate a change to the lubrication periodicity for the turbine-driven auxiliary feedwater pump trip throttle valve.

• Evaluate the work execution procedure and programs to determine if changes are necessary to the review and approval procedure for closing work tasks.

a. Inspection Scope

The team reviewed the licensees root cause analysis to determine if it was conducted to a level of detail commensurate with the significance of the problem. As part of their review, the inspectors interviewed key station personnel from operations, design and system engineering, maintenance, and the corrective action program. Additionally, the team interviewed the root cause team members and the members from the licensees Corrective Action Review Board.

The team reviewed the licensees corrective actions to ensure they addressed the extent of condition and whether they were adequate to prevent recurrence. In particular, the team reviewed station procedures and processes to determine if any other motor-operated valves may have been improperly lubricated.

b. Observations and Findings

The inspectors determined that the licensees analysis accurately captured the root cause of the event. Since the event was determined to be caused by an individual human error, the inspectors noted that the licensee appropriately identified a need to implement a defense-in-depth mechanism to ensure the turbine-driven auxiliary feedwater pump trip throttle valve is adequately lubricated. The inspectors found that the corrective action to prevent recurrence would likely ensure that the valve is fully lubricated in the future. Effectiveness reviews were implemented by the licensee to ensure the corrective actions implemented were sufficiently robust as to address the root cause.

The inspectors did note that the final root cause analysis report was narrowly focused and failed to consider all potential causal factors associated with the failure of the turbine-driven auxiliary feedwater pump trip throttle valve. The team found that the final root cause analysis lacked adequate justification to exclude several of the identified enhancements and other issues as contributors to the event. Specifically, the inspectors noted the following:

• The replacement procedure for valve FCHV0312 did not have specific lubrication instructions. The team confirmed through interviews that typical replacement procedures include instructions to restore the replaced equipment to a functional status. The difference between the valve FCHV0312 replacement procedure and typical replacement procedures caused the mechanical maintenance supervisor to assume the valve was adequately lubricated at completion of the replacement.

• Engineering did not perform an adequate review of the job routing request inquiring if additional inspection of the valve was required. The lack of technical rigor was largely attributable to the fact that no protocol exists on how job routing requests should be evaluated and a fundamental misunderstanding between departments on the intention of such requests.

• Communications between maintenance and engineering lacked sufficient detail to ensure the required preventive maintenance tasks for valve FCHV0312 were accomplished.

Additionally, the inspectors noted several potential flawed defenses and latent organizational weaknesses which were not documented in the final report. Specifically, the inspectors noted that:

• The replacement program for valve FCHV0312 allows for the valve to be not adequately lubricated if the replacement and lubrication preventive maintenance tasks are performed out of sequence. Reliance is placed on proper scheduling that increases the probability of equipment problems due to human error.

• Procedure APA-ZZ-00320 provides ambiguous guidance on how to close work documents. Additionally, the procedure, as written, allows for single individuals to close preventive maintenance tasks. The lack of a required second or peer check when closing incomplete preventive maintenance tasks could result in less than adequate technical review.

• The lubrication frequency for valve FCHV0312 does not provide sufficient margin in that if a preventive maintenance task is missed or deferred, the potential exists to impact equipment operation.

The team noted that the comprehensiveness of the final root cause analysis was impacted by a failure of the licensee to interview all pertinent individuals and fundamental errors in the use of systematic analytical techniques such as TapRoot and event and causal factor charting. Additionally, less than adequate management oversight of the root cause process, such as management sponsor and Corrective Action Review Board reviews, allowed the final root cause to be issued without thoroughly evaluating all significant causal factors.

The items identified by the inspection team were discussed with the licensee. As a result, the licensee initiated Callaway Action Request 200906143 to examine the quality of the root cause analysis performed and to determine if programmatic issues in cause evaluation exist.

1R5 Review of Operating Experience

a. Scope

The team reviewed internal operating experience by obtaining a list of plant corrective action documents related to the auxiliary feedwater system and selecting those documents related to lubrication and maintenance of the turbine-driven auxiliary feedwater pump trip throttle valve. The team further reviewed the licensees review of industry operating experience for the auxiliary feedwater system and lubrication problems with motor-operated valves. The team review included inspection of the licensees operating experience program and specific review of related operating experience during the root cause investigation for the May 25, 2009, failure of the turbine-driven auxiliary feedwater pump trip throttle valve.

For external operating experience, the NRC Operating Experience Branch provided the results of keyword searches related to motor-operated valve stem lubrication issues, Terry turbine Gimpel 4-Inch valves, and findings associated with turbine-driven pumps.

The NRC Operating Experience Branch provided a list of licensee event reports, NRC information notices, NUREG documents and other operating experience information.

The team selected operating experience information that was applicable to this inspection and reviewed whether the licensee had addressed the items in their root cause analyses related to these events or had processed the information through their operating experience program. As part of their review, the inspectors performed an auxiliary feedwater system walkdown to determine if applicable industry operating experience had been incorporated into system design and maintenance practices.

b. Findings and Observations

During a system walkdown, the inspectors noted that the orientation of the turbine-driven auxiliary feedwater pump electrical trip solenoid was rotated 180 degrees from the required configuration. With the solenoid in such a configuration, the connecting pin did not rest on the horizontal base of the mounting bracket and was approximately 1 inch below the required position. Additionally, the configuration is such that the solenoid link appeared to be resting on the trip crank pin and the solenoid plunger was at a slight angle which would require additional force to actuate. The licensee evaluated this nonconforming condition and determined that the electrical trip solenoid would still be available to perform its function. The nonconforming condition was entered into the licensees corrective action program as Callaway Action Request 200905004.

1R6 Review of Generic Letter 89-10 and Periodic Verification Program

a. Inspection Scope

The team reviewed the licensees Generic Letter 89-10 program for the turbine-driven auxiliary feedwater pump trip throttle valve including the licensees periodic verification program. As part of their review, the inspectors examined the licensees response to Generic Letter 89-10, Safety Related Motor Operated Valve Testing and Surveillance, and Generic Letter 96-05, Periodic Verification of Design Basis Capability of Safety-Related Motor-Operated Valves. Additionally, the inspectors reviewed the licensees engineering analysis of the system and dynamic and static testing results to ensure the turbine-driven auxiliary feedwater pump trip throttle valve is adequately designed for and has the ability to function under design-basis conditions

b. Findings and Observations

The team determined that the licensee had not appropriately followed their Generic Letter 89-10 program for the turbine-driven auxiliary feedwater pump trip throttle valve.

The licensees program is based on periodic verification that performs a static diagnostic test every 6 years or four refueling outages and a dynamic test every three refueling outages, for torque-controlled rising-stem valves that do not have at least 25 percent capability margin above their design operating requirements. The testing frequency is established with the assumption that stem lubrication is performed every 18 months as documented in the licensees Generic Letter 96-05 response. The licensee failed to meet this requirement when valve FCHV0312 lubrication was not performed in Refueling Outage 16 resulting in valve FCHV0312 not being lubricated for approximately 20 months. The performance deficiency associated with the licensees failure to adequately lubricate the turbine-driven auxiliary feedwater pump trip throttle valve FCHV0312 is described in Section 1R2 of this report.

While comparing the licensees Generic Letter 96-05 response to Calculation FC-20, Manual Operation of FCHV0312, the inspectors identified that the licensees value listed for differential thrust to open was 3172 pounds-force but the licensees generic letter response indicated the design differential thrust to open valve FCHV0312 is 4350 pounds-force. Additionally, dynamic testing from Refueling Outage 16 in October 2008 determined that the differential thrust to open with error was 5316 pounds-force. Subsequent review by the licensee determined that the value contained within the plant equipment database was not up to date and contained a nonconservative value for design differential pressure thrust to open. While the information contained in the licensees database was not up to date for the current plant configuration, the current required open thrust was determined to be bounded by the maximum allowed differential pressure thrust for valve FCHV0312 which is 7106 pounds. The licensee entered the discrepancy into their corrective action program as Callaway Action Request 200905239.

1R7 Potential Generic Issues

a. Scope

The team evaluated the failure of Callaways turbine-driven auxiliary feedwater pump trip throttle valve due to inadequate lubrication to determine whether any potential generic issues should be communicated to the industry (e.g., information notices, generic letters, and bulletins).

b. Findings and Observations

The team determined that this issue may warrant a generic communication informing other licensees of the types of problems encountered. Specifically, the team determined that the design of the system is such that when the turbine-driven auxiliary feedwater pump trip throttle valve is used as a steam admission valve it exposes the component to prolonged elevated temperatures which requires special consideration in terms of stem lubricant selection and frequency of lubrication. The team will discuss this issue with the NRC Office of Nuclear Reactor Regulation for possible issuance as an information notice. The team did not identify any other potentially generic safety issues during the inspection.

4OA2 Identification and Resolution of Problems

a. Inspection Scope

The team reviewed maintenance, corrective actions, and modification history related to the auxiliary feedwater system to evaluate whether any longstanding issues continued to impact current performance. The team also reviewed the operating experience database and previous inspection reports. The team interviewed the root cause team, the system engineer, and other personnel.

b. Findings and Observations

Introduction.

The team identified a green noncited violation of Technical Specification Limiting Condition for Operation 3.0.4 for entering Mode 3 with the turbine-driven auxiliary feedwater pump inoperable.

Description.

On November 3, 2008, while in Refueling Outage 16, the licensee replaced the servo control valve for the turbine-driven auxiliary feedwater pump governor. During postmaintenance testing in Mode 4, an unexpected overspeed trip of the turbine occurred. Callaway operations staff inappropriately concluded that since the turbine was running using the auxiliary steam system at the time of the postmaintenance test, the cause of the overspeed of the turbine was likely due to a water slug within the system.

Without determining an exact cause of the overspeed, the testing was re-performed satisfactorily. Successful performance of the postmaintenance test cleared a mode change restraint which allowed the plant to enter Mode 3 on November 4, 2008.

While in Mode 3, the licensee performed Jobs 06113631 and 07506205 to test the turbine-driven auxiliary feedwater pump using the normal steam supply. During performance of the jobs, the instrumentation and controls engineer noted that the channel two, governor valve position indicator was erratic. Troubleshooting was performed and it was found that the servo control valve replaced during Refueling Outage 16 was faulty. At 4:50 p.m. on November 5, 2008, the licensee entered the applicable technical specification and initiated repairs to the turbine-driven auxiliary feedwater pump. Postmaintenance testing was performed and the licensee exited the technical specification at 12:15 p.m. on November 6, 2008.

The team reviewed corrective action documents associated with the turbine overspeed and the faulty governor servo control valve. The inspectors questioned if the two corrective action documents were related and specifically, if the cause of the turbine overspeed that occurred in Mode 4 could have been related to the faulty governor servo control valve discovered while the unit was in Mode 3. Additionally, the team questioned if the turbine-driven auxiliary feedwater pump could have been inoperable during the mode change that occurred on November 4, 2008, in violation of Technical Specification Limiting Condition for Operation 3.0.4.

The licensee reviewed the Refueling Outage 16 work history associated with the turbine-driven auxiliary feedwater pump governor and found that currents for the servo position sensor were lower than expected and the abnormal readings indicated that the remote servo valve was not operating properly. Based on this evidence, the licensee concluded that the faulty servo control valve discovered on November 5, 2008, was responsible for the overspeed of the turbine-driven auxiliary feedwater pump that occurred in Mode 4 and that the equipment was inoperable during the transition to the Mode 3 change that occurred on November 4, 2008.

Analysis.

The performance deficiency associated with this finding involved the licensees failure to ensure the turbine-driven auxiliary feedwater pump was operable prior to entering Mode 3. This finding is greater than minor because it is associated with the Mitigating Systems Cornerstone attribute of equipment performance and it affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the issue screened as very low safety significance because it was not a design or qualification deficiency that resulted in a loss of operability or functionality, did not create a loss of system safety function of a single train for greater than the technical specification allowed outage time and did not affect seismic, flooding, or severe weather initiating events. The inspectors determined that this finding has a crosscutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to fully evaluate the overspeed of the turbine-driven auxiliary feedwater pump that occurred on November 3, 2008 P.1(c).

Enforcement.

Technical Specification Limiting Condition for Operation 3.0.4. required, in part, that when a limiting condition for operation is not met, entry into a mode or other specified condition shall only be made when the associated actions of Limiting Condition for Operation 3.0.4, paragraphs a, b or c are met. Contrary to the above, on November 4, 2008, the licensee entered Mode 3 without meeting Limiting Condition for Operation 3.7.5.c, Auxiliary Feedwater System, and without meeting the associated actions of Limiting Condition for Operation 3.0.4, paragraphs a, b or c. Because of the very low safety significance of this finding and because the licensee has entered this issue into their corrective action program as Callaway Action Request 200905313, this violation is being treated as a noncited violation in accordance with Section VI.A.1 of the Enforcement Policy: NCV 05000483/2009009-05, Failure to Ensure Turbine-Driven Auxiliary Feedwater Pump is Operable Prior to Entry into Mode 3.

4OA3 Event Follow-up

(Closed) Licensee Event Report (LER) 05000483/2009002-00: Turbine-Driven Auxiliary Feedwater Pump Failed to Start During Surveillance Test On May 25, 2009, the Callaway plant turbine-driven auxiliary feedwater pump failed to start during a planned surveillance run. The licensee determined that the failure of the turbine-driven auxiliary feedwater pump was due to an inadequately lubricated trip throttle valve. The valve was inadequately lubricated because the licensee inappropriately closed the lubrication portion of Procedure MPM-FC-QK001, Auxiliary Feedwater Pump Turbine Annual Inspection, during Refueling Outage 16. Subsequent review by the licensee determined that while the exact timing of the valve failure could not be determined, but it was reasonable to assume that the degraded condition existed for a period greater than the Technical Specification allowed completion time for the auxiliary feedwater system. Consequently, the event resulted in a reportable event per the requirements of 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plants Technical Specifications. Additionally, since the motor-driven auxiliary feedwater pump train A was inoperable just prior to discovery of the degraded condition, the event was determined to be reportable per 10 CFR 50.73(a)(2)(v), as a condition that could have prevented fulfillment of a safety function and 10 CFR 50.73(a)(2)(ii)(B), as an analyzed condition that significantly degraded plant safety. The licensee submitted a licensee event report on July 21, 2009. The inspectors reviewed the licensees submittal and determined that the report adequately documented the summary of the event including the potential safety consequences and corrective actions required to address the performance deficiency. The inspectors identified a self-revealing violation of Technical Specification 3.7.5, "Auxiliary Feedwater System. The enforcement aspects of the violation are discussed in Section 1R2 of this report as AV 05000483/2009009-01, "Turbine-Driven Auxiliary Feedwater Pump Inoperable Due to Inadequately Lubricated Trip Throttle Valve." This LER is closed.

4OA6 Meetings, Including Exit

On June 26, 2009, the team presented the preliminary results of this inspection at the end of the onsite week to Mr. A. Heflin, Vice President Nuclear and Chief Nuclear Officer, and other members of his staff who acknowledged the findings. The team verified that no proprietary information was retained.

On September 2, 2009, the team leader presented the final results of the inspection to Mr. A. Heflin, Vice President Nuclear and Chief Nuclear Officer, and other members of the licensee staff who acknowledged the findings. The team verified that no proprietary information was retained.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

F. Bagby Jr., Supervisor, Nuclear Maintenance, Mechanical

L. Beaty, System Engineer

F. Bianco, Shift Manager, Operations

M. Covey, Shift Manager, Operations

D. Davidson, Operations Technician, Operations

K. Duncan, Shift Manager, Operations

T. Elwood, Supervising Engineer, Regulatory Affairs/Licensing

W. Gruer, Operating Supervisor, Operations

M. Hall, Assistant Manager, Nuclear Engineering

M. Hoehn II, Acting Supervising Engineer, NSSS Systems

J. Imhoff, System Engineer

R. Lane, General Supervisor, Mechanical Maintenance

S. Maglio, Assistant Manager, Regulatory Affairs

K. Mills, Manager, Plant Engineering

S. Petzel, Engineer, Regulatory Affairs

J. Pitts, Supervising Engineer, Performance

S. Sandbothe, Manager, Regulatory Affairs

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Open

050000483/2009009-01 AV Turbine-Driven Auxiliary Feedwater Pump Inoperable Due to Inadequately Lubricated Trip Throttle Valve (Section 1R2)

Opened and Closed

050000483/2009009-02 NCV Failure to Maintain an Adequate Lubrication Procedure for Valve FCHV0312 (Section 1R3)

050000483/2009009-03 NCV Failure to Adequately Evaluate the Use of Mobile 28 Grease for the Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve (Section 1R3)

050000483/2009009-04 NCV Failure to Enter Conditions Adverse to Quality Associated with the Turbine-Driven Auxiliary Feedwater Pump Trip Throttle Valve into the Corrective Action Program (Section 1R3)

050000483/2009009-05 NCV Failure to Ensure Turbine-Driven Auxiliary Feedwater Pump is Operable Prior to Entry into Mode 3 (Section 4OA2)

Attachment 1

Closed

05000483/2009002-00 LER Turbine-Driven Auxiliary Feedwater Pump Failed to Start During Surveillance Test (Section 4OA3)