IR 05000528/2014007

IR 05000528-14-007, 05000529-14-007, and 05000530-14-007, 03/11/2014 - 03/29/2014, Palo Verde Nuclear Generating Station; Problem Identification and Resolution (Biennial)

ML14134A307
Person / Time
Site:	Palo Verde
Issue date:	05/14/2014
From:	Geoffrey Miller Division of Reactor Safety IV
To:	Edington R Arizona Public Service Co
E. Ruesch
References
IR-14-007
Download: ML14134A307 (29)

Text

UNITED STATES May 14, 2014

SUBJECT:

PALO VERDE NUCLEAR GENERATING STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 50-528/2014007, 50-529/2014007, AND 50-530/2014007

Dear Mr. Edington:

On March 29, 2014, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution biennial inspection at the Palo Verde Nuclear Generating Station, Units 1, 2, and 3. On March 29, the NRC inspection team discussed the results of this inspection with Mr. D. Mims and other members of your staff. On April 24, 2014, the lead inspector discussed updated inspection results with Mr. D. Wheeler. The inspection team documented the results of this inspection in the enclosed inspection report.

Based on the inspection sample, the inspection team determined that Palo Verdes corrective action program, and your staffs implementation of the corrective action program, were adequate to support nuclear safety.

In reviewing your corrective action program, the team assessed how well your staff identified problems at a low threshold, your staffs implementation of the stations process for prioritizing and evaluating these problems, and the effectiveness of corrective actions taken by the station to resolve these problems. The team also evaluated other processes your staff used to identify issues for resolution. These included your use of audits and self-assessments to identify latent problems and your incorporation of lessons learned from industry operating experience into station programs, processes, and procedures. The team determined that your stations performance in each of these areas supported nuclear safety. However, the team identified some problems with your staffs development of corrective actions for issues your program identified as significant. Additionally, Palo Verde continues to have challenges with the quality of evaluations of operability for degraded and nonconforming conditions affecting safety-related structures, systems, and components, and with the restoration of these degraded and nonconforming conditions to full qualification.

Finally, the team determined that your stations management maintains a safety-conscious work environment in which your employees are willing to raise nuclear safety concerns through at least one of the several means available. However, the team noted some indications of challenges to the continued maintenance of the stations safety-conscious work environment.

While your staff is aware of these challenges and is taking actions to address them, the indications have existed for approximately one year; corrective actions to date have not been successful at eliminating the identified issues. The inspection team documented two findings of very low safety significance (Green) in this report. One of these findings involved a violation of NRC requirements. Further, inspectors documented a licensee-identified violation that was determined to be of very low safety significance. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2.a of the NRC Enforcement Policy.

If you contest the violations or their significance, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC resident inspector at the Palo Verde Nuclear Generating Station.

If you disagree with a cross-cutting aspect assignment or a finding not associated with a regulatory requirement 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 Palo Verde Nuclear Generating Station.

In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390, Public Inspections, Exemptions, Requests for Withholding, a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRCs Public Document Room or from the Publicly Available Records (PARS) component of the NRC's Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Geoffrey B. Miller, Chief Technical Support Branch Division of Reactor Safety Docket Nos.: 50-528, 50-529, 50-530 License Nos: NPF-41, NPF-51, NPF-74 Enclosure:

Inspection Report 50-528/2014007, 50-529/2014007, and 50-530/2014007 w/Attachments Electronic Distribution to Palo Verde Nuclear Station

ML14134A307 SUNSI Review Non-Sensitive Publicly Available Keyword:

By: EAR Sensitive Non-Publicly Available SUNSI OFFICE DRP/PBD DRS/EB1 DRS/EB2 C:DRP/PBD DRS/TSB C:DRS/TSB NAME MBaquera: JBraisted NOkonkwo NTaylor ERuesch GMiller PH SIGNATURE /RA/E /RA/ /RA/ /RA/ /RA/ /RA/

DATE 5/8/2014 5/5/2014 5/5/2014 5/8/14 5/10/14 5/14/14

U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket(s): 50-528, 50-529, 50-530 License: NPF-41, NPF-51, NPF-74 Report: 05000528/2014007, 05000529/2014007, 05000530/2014007 Licensee: Arizona Public Service Company Facility: Palo Verde Nuclear Generating Station, Units 1, 2, and 3 Location: 5951 South Wintersburg Road Tonopah, Arizona Dates: March 11 through March 29, 2014 Team Lead: E. Ruesch, Senior Reactor Inspector Inspectors: M. Baquera, Resident Inspector J. Braisted, Ph.D., Reactor Inspector N. Okonkwo, Reactor Inspector Approved By: G. Miller, Branch Chief Technical Support Branch Division of Reactor Safety-1- Enclosure

SUMMARY

IR 05000528/2014007, 05000529/2014007, 05000530/2014007; 03/11/2014 - 03/29/2014;

PALO VERDE NUCLEAR GENERATING STATION; Problem Identification and Resolution (Biennial)

The inspection activities described in this report were performed between March 11 and March 29, 2014, by three inspectors from the NRCs Region IV office and the resident inspector at Palo Verde. The report documents two findings of very low safety significance (Green). One of these findings involved violations of NRC requirements. Additionally, NRC inspectors documented in this report one licensee-identified violation of very low safety significance. The significance of inspection findings is indicated by their color (Green, White, Yellow, or Red),

which is determined using Inspection Manual Chapter 0609, Significance Determination Process. Their cross-cutting aspects are determined using Inspection Manual Chapter 0310,

Components Within the Cross-Cutting Areas. Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement Policy. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process.

Assessment of Problem Identification and Resolution Based on its inspection sample, the team concluded that the licensee maintained a corrective action program in which individuals generally identified issues at an appropriately low threshold.

Once entered into the corrective action program, the licensee generally evaluated and addressed these issues appropriately and timely, commensurate with their safety significance.

The licensees corrective actions were generally effective, addressing the causes and extents of condition of problems. However, opportunities for improvement existed in many of the corrective action program sub processes.

The licensee appropriately evaluated industry operating experience for relevance to the facility and entered applicable items in the corrective action program. The licensee incorporated industry and internal operating experience in its root cause and apparent cause evaluations.

The licensee performed effective and self-critical nuclear oversight audits and self-assessments.

The licensee maintained an effective process to ensure significant findings from these audits and self-assessments were addressed.

The licensee maintained a safety-conscious work environment in which personnel were willing to raise nuclear safety concerns without fear of retaliation. However, the team noted that there were some low-level safety-conscious work environment issues that had been identified by the licensee in late 2012 or early 2013; as of the conclusion of the inspection, the licensee had not made significant progress in addressing all of these issues.

Cornerstone: Mitigating Systems

Green.

The inspectors identified multiple examples of a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations personnel to follow station procedures used to perform operability determinations. Specifically, operations personnel failed to provide sufficient technical justification for the reasonable assurance of operability of a degraded condition involving one train of containment spray system and nonconforming conditions associated with diesel fuel oil piping.

The inspectors concluded the failure of operations personnel to follow station procedures to perform operability determinations was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609,

Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent and systematic process to make decisions (H.13).

Green.

The inspectors identified a Green finding for the failure of station personnel to follow procedures to implement root cause evaluations. Specifically, approximately one third of the root cause evaluations reviewed by inspectors resulted in a probable cause with further information needed to validate the cause. Of this subset, eighty percent of the evaluations did not adhere to station processes.

The failure of station personnel to follow station procedures to implement root cause evaluations was a performance deficiency. The performance deficiency was more than minor, therefore a finding, because if left uncorrected the performance deficiency could become a more significant safety concern in that significant conditions adverse to quality could reoccur prior to the implementation of appropriate corrective action. The finding is associated with multiple cornerstones, though it is most closely associated with the Mitigating Systems Cornerstone and the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04,

Initial Characterization of Findings, and 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent and systematic approach when making decisions (H.13).

Licensee-Identified Violations

A violation of very low safety significance that was identified by the licensee has been reviewed by the inspectors. Corrective actions taken or planned by the licensee have been entered into the licensees corrective action program. This violation and its corrective action tracking numbers are listed in Section 4OA7 of this report.

REPORT DETAILS

4OA2 Problem Identification and Resolution

The team based the following conclusions on a sample of corrective action documents that were open during the assessment period, which ranged from November 10, 2012, to the end of the on-site portion of this inspection on March 28, 2014.

.1 Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The team reviewed approximately 230 Palo Verde Action Requests (PVARs) and condition report disposition requests (CRDRs),1 including associated root cause analyses and apparent cause evaluations, from approximately 30,000 that the licensee had initiated or closed between November 10, 2012, and March 28, 2014. The majority of these (approximately 25,000) documented lower-level issues that did not require cause evaluations. The inspection sample focused on higher-significance CRDRs for which the licensee evaluated and took actions to address the cause of the condition. In performing its review, the team evaluated whether the licensee had properly identified, characterized, and entered issues into the corrective action program, and whether the licensee had appropriately evaluated and resolved the issues in accordance with established programs, processes, and procedures. The team also reviewed these programs, processes, and procedures to determine if any issues existed that may impair their effectiveness.

The team reviewed a sample of performance metrics, system health reports, operability determinations, self-assessments, trending reports and metrics, and various other documents related to the licensees corrective action program. The team evaluated the licensees efforts in determining the scope of problems by reviewing selected logs, work orders, self-assessment results, audits, system health reports, action plans, and results from surveillance tests and preventive maintenance tasks. The team reviewed daily PVARs and attended the licensees Action Request Review Committee, Condition Review Group, Operability Determination Challenge Board, and Corrective Action Review Board meetings to assess the reporting threshold and prioritization efforts, and to observe the corrective action programs interfaces with the operability assessment and work control processes. The teams review included an evaluation of whether the licensee considered the full extent of cause and extent of condition for problems, as well as a review of how the licensee assessed generic implications and previous occurrences Palo Verde has a single-point-of-entry action request system in which personnel document all identified conditions in PVARs. Following screening of the PVAR by the stations Action Request Review Committee (ARRC), CRDRs are generated for conditions that have the potential to adversely affect the safe, reliable, and economic production of electricity, as required by 01DP-0AP12, Palo Verde Action Request Processing, Appendix D, CRDR Condition Guidelines. Evaluations of conditions are performed under these CRDRs. After evaluation, Condition Report Action Items (CRAIs) are generated to correct the identified conditions. Issues documented in PVARs that do not meet CRDR criteria are handled using other work mechanisms outside the corrective action program.

of issues. The team assessed the timeliness and effectiveness of corrective actions, completed or planned, and looked for additional examples of problems similar to those the licensee had previously addressed. The team conducted interviews with plant personnel to identify other processes that may exist where problems may be identified and addressed outside the corrective action program.

The team reviewed corrective action documents that addressed past NRC-identified violations to evaluate whether corrective actions addressed the issues described in the inspection reports. The team reviewed a sample of corrective actions closed to other corrective action documents to ensure that the ultimate corrective actions remained appropriate and timely.

The team considered risk insights from both the NRCs and Palo Verdes risk models to focus the sample selection and plant tours on risk-significant systems and components.

The team focused a portion of its sample on the motor-driven auxiliary feedwater (MDAFW) system and its associated electrical systems, which the team selected for a five-year in-depth review. The team conducted walk-downs of the MDAFW system and other plant areas to assess whether licensee personnel identified problems at a low threshold and entered them into the corrective action program.

b. Assessments Palo Verdes corrective action program is complex. While the high-level workflow is generally straightforward, the terminology and tracking scheme is at times difficult to follow. Specifically, it is difficult to link PVARs that initially identify conditions to the CRDRs that evaluate the conditions to the CRAIs that correct the conditions. The licensee has recognized that in part due to this difficulty, its corrective action process is extremely cumbersome. The licensee has initiated a CAP-1 project to attempt to eliminate these complexities by mid-2015.

1. Effectiveness of Problem Identification During the 17-month inspection period, licensee staff generated approximately 30,000 PVARs. Of these, 18,000 resulted in the initiation of a CRDR. The team determined that based on the sample reviewed, most conditions that required generation of a condition report by station procedure 01DP-0AP12, Palo Verde Action Request Processing, had been appropriately entered into the corrective action program.

However, the team noted examples where the licensee had failed to properly identify conditions in accordance with procedures: during a walk-down of the MDAFW system on March 27, the inspectors identified two potentially adverse conditions that had not been identified or evaluated by licensee personnel:

• Multiple welds on safety-related stainless steel auxiliary feedwater piping exhibited signs of corrosion in the heat-affected zones. Though this potentially adverse condition existed on multiple welds, it had not been identified and the potential degradation had not been characterized by the licensee. The licensee had previously identified this condition on another unit, but failed to consider all unites in its extent of condition review. The licensee documented this observation in PVAR 4516797.

• Multiple safety-related manually operated rising stem globe valves had degraded lubrication or were unlubricated. These valves were marked as being required for 10 CFR 50.54(hh)(2) contingency operation. The licensee documented this observation in PVAR 4516793.

Additionally, during interviews with station personnel, a substantial number of nonsupervisory personnel noted a lack of training on PVAR initiation. All were familiar with the function of the corrective action program and the importance of initiating a PVAR for identified conditions that needed attention, but many stated that they had received no how-to training. The team observed a session of the licensees new-hire training and confirmed that information provided on the corrective action program was background level; the instructor emphasized to the new hires the importance of initiating PVARs for identified conditions, but did not provide any hands-on training or step through the PVAR initiation process.

Overall, the team concluded that the licensee generally maintained a low threshold for the formal identification of problems and entry into the corrective action program for evaluation. Licensee personnel initiated over 1,700 PVARs per month during the inspection period, over 1,000 of which resulted in the initiation of a CRDR. All personnel interviewed by the team understood the requirements for condition report initiation; most expressed a willingness to enter newly identified issues into the corrective action program at a low threshold.

2. Effectiveness of Prioritization and Evaluation of Issues

The sample of corrective action documents reviewed by the team focused primarily on issues screened by the licensee as having higher-level significance, including those that received cause evaluations, those classified as significant conditions adverse to quality, and those that required engineering evaluations. The team also reviewed a number of PVARs that included or should have included immediate operability determinations to assess the quality, timeliness, and prioritization of these determinations.

The team identified several examples where the licensee failed to properly address new information obtained after the initial screening was complete:

• Over the course of the inspection period, the licensees measuring and test equipment (M&TE) program had several times failed to meet station expectations contained in procedure 01PR-0AP04, Corrective Action Program, Revision 8. This procedure defined adverse conditions as including

(1) identified trends in performance or frequencies of occurrence which indicate performance outside an expected or established standard, and

(2) identified gaps in performance between recognized industry standards or regulatory expectations and Palo Verde performance, process effectiveness, program effectiveness or equipment performance. However, the PVARs initiated in response to these M&TE adverse trends were not classified as adverse CRDRs as required. After a review of the licensees M&TE program, the team determined that the licensee was appropriately addressing each individual issue that aggregated into these adverse trends. Therefore, this failure to address adverse conditions in accordance with station procedures was a minor performance deficiencyit alone did not adversely impact a cornerstone objective nor have the potential to lead to a more significant safety concern. The licensee documented this issue as PVARs 4516950, 4516951, 4516953, and 4517173.

• The licensees Nuclear Assurance Departments (NAD) corrective action audit 2013-008, completed in October 2013, concluded that equipment conditions determined by operations to be either degraded or nonconforming and to require operability determinations or functionality assessments were not always tracked and scheduled to ensure resolution. This licensee-identified performance deficiency is documented in Section 40A7 below. The licensee has since implemented actions to correct these conditions, but continued to have problems evaluating degrading conditions and ensuring their resolution. One example of such a problem is documented in Section 4OA2.5.a, below. In addition, though this issue was added to the Station Quality Issue list as one of the top three issues being tracked by NAD, some supervisors and managers interviewed by the team were not aware of the ongoing issue.

• The team noted that the metrics tracking the closure of cause evaluations may not accurately represent the time taken to evaluate and prioritize more-significant issues. Specifically, the data initially provided to the team indicated that apparent cause evaluations took a median of 121 days from condition identification until evaluation closure, and root cause analyses took a median of 103 days. The licensee later indicated that the data was inaccuratethat cause evaluation timeliness indicators only considered MRC assignment date to initial approval of the evaluation by the responsible manager, but did not consider any later revisions to the evaluation or action plan. The team noted that the licensees performance indicator data may not accurately reflect the timeliness of acceptable root and apparent cause evaluations, which may mask performance trends or corrective action timeliness issues.

Additionally, the team identified potential vulnerabilities in the stations process for evaluating and prioritizing issues:

• The licensees action request review committee (ARRC) performs the initial screening of all PVARs. The ARRC charter requires a quorum only for complex issues. What constitutes a complex issue is not clearly defined.

Further, the team noted that even when quorum is required, only three of six functional areas are required to be represented. Though the team did not identify any misclassifications as a result, it noted that this could result in inconsistent screening or misclassification of issues.

• The team observed two meetings of the licensees corrective action review board (CARB). Though all members were qualified, and quorum was met in both cases in accordance with the CARB charter, only one of the CARB members was in attendance at both of the observed meetings. Further, the team noted significant inconsistencies in the way CARB operated between the two meetings. Through interviews, the team determined that it was not uncommon for the individuals meeting the CARB quorum to vary significantly from meeting to meeting.

• Similar to the inconsistencies in CARB membership, the team noted that the stations operability determination challenge boardwhich provides oversight for the quality of operability determinations and functionality assessments for degraded or non-conforming structures, systems, and componentsdid not have a consistent meeting time or consistent membership. The team questioned whether this inconsistency of priority given oversight of operability determinations met the stations expectation for addressing an issue noted by NAS as one of the top three station quality issues. The licensee documented this issue for evaluation in PVAR 4511706.

Additionally, the team identified inconsistencies in the licensees process for addressing significant conditions adverse to quality when offsite analysis was required to confirm the cause of the conditions. The team noted that there appeared to be a correlation between this inconsistency in CARB approved products and the inconsistency of operation of the CARB, discussed above. The licensee documented this concern in PVARs 4512109 and 4512157.

Overall, the team determined that the licensees process for screening and prioritizing issues that had been entered into the corrective action program supported nuclear safety. However, opportunities for improvement existed in many of the corrective action program subprocesses.

3. Effectiveness of Corrective Actions In general, the corrective actions identified by the licensee to address adverse conditions were effective. However, the team noted a number of instances in which corrective actions had been untimely or incompletely accomplished:

• As discussed in Section 4OA2.4 below, the licensee identified low-level safety-conscious work environment concerns in late 2012 or early 2013.

However, as of the conclusion of the on-site portion of this inspection in March 2014, the licensees corrective actions had failed to make significant progress in addressing some of these concerns. The licensee documented this issue in PVAR 4516392.

• The licensee and the NRC have repeatedly identified issues with the licensees boric acid corrosion control program (BACCP) since 2007. These same weaknesses continued to be identified through 2013. Since 2011, the NRC issued three Green non-cited violations (NCVs) related to the licensees BACCP procedure.2 The corrective actions implemented for these NCVs were not initially effective. Further, the CRDR written to address the third violation was not screened as an apparent cause as required by 01DP-0AP12, Appendix E, Condition Classification Instruction. The team determined that this performance deficiency was minor in accordance with NCV 05000528,529,530/2011003-01, Failure to Include Screening Criteria in the Boric Acid Corrosion Control Program (ML112240044); NCV 05000530/2012003-04, Failure to Perform Boric Acid Evaluation (ML12223A116); NCV 05000530/2012004-03, Inadequate Boric Acid Evaluation (ML12319A635)

NRC Inspection Manual Chapter 0612. The licensee documented these concerns in PVARs 4515463 and 4515691.

• On July 2, 2013, the licensee experienced a catastrophic failure of a 4.16kV cubicle when a tie-wrap suspending a ground cable in the top of the cubicle failed, allowing the ground cable to contact the bus bars.

The licensee performed a root cause evaluation of this condition in CRDR 4430704. The licensee determined that the root cause of the condition was inadequate design documentation for installation of the ground cablesthe documentation addressed bottom-entry cables only; the failed cable was top-entry into the cubicle and had required a field route. The team noted that while the corrective actions and CAPRs implemented in response to this condition addressed the attachment method for all cables, they did not include the development of detailed design information for top-entry cables.

The licensee documented this issue in PVAR 4516191.

Overall, the team concluded that the licensee generally identified effective corrective actions for the problems evaluated in the corrective action program. The licensee generally implemented these corrective actions in a timely manner, commensurate with their safety significance, and reviewed the effectiveness of the corrective actions appropriately.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The team examined the licensee's program for reviewing industry operating experience, including reviewing the governing procedure and self-assessments. A sample of 13 operating experience notifications that had been issued during the assessment period was reviewed to assess whether the licensee had appropriately evaluated the notification for relevance to the facility. The team then examined whether the licensee had entered those items into their corrective action program and assigned actions to address the issues. The team reviewed a sample of root cause evaluations and corrective action documents to verify if the licensee had appropriately included industry-operating experience.

b. Assessment Overall, the team determined that the licensee was adequately evaluating industry-operating experience for relevance to the facility, based on the reviewed sample. The licensee had entered applicable items in the corrective action program in accordance with station procedure 65DP-0QQ01. The team concluded that the licensee was evaluating industry operating experience when performing root cause and apparent cause evaluations. Both internal and external operating experience was being incorporated into lessons learned for training and pre-job briefs.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors reviewed a sample of ten licensee self-assessments, surveillances, and audits to assess whether the licensee was regularly identifying performance trends and effectively addressing them. The team reviewed audit reports to assess the effectiveness of assessments in specific areas. The team evaluated the use of self- and third party assessments, the role of the nuclear assurance department, and the role of the performance improvement group related to licensee performance. The specific self-assessment documents reviewed are listed in Attachment 1.

b. Assessment The inspectors determined that the internal self-assessments and audits were generally thorough, detailed, in-depth, and critical. Inspectors noted that the effectiveness of corrective actions initiated to address self-assessment findings was not always effective.

Examples of this are seen in the boric acid corrosion control program assessments and audits. Over the course of the inspection, audits had repeat findings in these reviews and required third parties (e.g., INPO, NRC) to identify issues that resulted in effective corrective actions.

.4 Assessment of Safety-Conscious Work Environment

a. Inspection Scope

The team interviewed 39 individuals in five focus groups. The purpose of these interviews was

(1) to evaluate the willingness of licensee staff to raise nuclear safety issues, either by initiating a condition report or by another method,

(2) to evaluate the perceived effectiveness of the corrective action program at resolving identified problems, and

(3) to evaluate the licensees safety-conscious work environment (SCWE). The focus group participants included personnel from Security Programs, Emergency Planning, Operations, Work Management, Maintenance, Engineering (Design, Plant, Fuels, and Engineering Support), Radiation Protection, and Chemistry. At the teams request, the licensees regulatory affairs staff selected the participants blindly from these work groups, based partially on availability. To supplement these focus group discussions, the team interviewed the Employee Concerns Program manager to assess his perception of the site employees willingness to raise nuclear safety concerns. The team reviewed the Employee Concerns Program case log and select case files. The team also reviewed the minutes from the licensees most recent safety culture monitoring panel meetings.

b. Assessment 1. Willingness to Raise Nuclear Safety Issues All individuals interviewed indicated that they would raise nuclear safety concerns.

All felt that their management was receptive to nuclear safety concerns and was willing to address them promptly. All of the interviewees further stated that if they were not satisfied with the response from their immediate supervisor, they had the ability to escalate the concern to a higher organizational level. Most expressed positive experiences after raising issues to their supervisors and documenting issues in PVARs.

The team noted some indications of low-level issues in some work groups in which individuals may be hesitant to raise some concerns. This hesitance appeared to be isolated to concerns that the individuals did not believe affected nuclear safety.

Licensee management was aware of the issues and was enacting or planning to enact corrective actions. However, although management had evidence of these issues in late 2012 or early 2013, the team noted that as of the conclusion of the inspection in March 2014, the actions had not been fully effective in resolving them.

The licensee documented this issue in PVAR 4516392.

2. Employee Concerns Program All interviewees were aware of the Employee Concerns Program (ECP). All explained that management publicized the program through various means, such as posters, training, presentations, and discussion by supervisors or management at meetings. However, more than 20% of individuals stated that they would not use the ECP, or expressed a hesitance to do so, because they were not confident of the programs independence or impartiality. Approximately 15% of interviewees did not believe that confidentiality would be maintained if they brought an issue to the ECP, though several of these individuals said they would go to ECP anyway if necessary.

At the conclusion of the onsite portion of this inspection, the licensee was making changes to parts of its ECP that may improve perceptions of the program.

3. Preventing or Mitigating Perceptions of Retaliation When asked if there have been any instances where individuals experienced retaliation or other negative reaction for raising issues, all individuals interviewed stated that they had neither experienced nor heard of an instance of retaliation, harassment, intimidation, or discrimination at the site. The team noted that management appeared to be successfully implementing the organizations processes to mitigate any such issues.

.5 Findings

a. Failure To Provide Adequate Technical Justification For Operability Of Containment Spray And Diesel Fuel Oil Systems

Introduction.

The inspectors identified multiple examples of a Green non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations personnel to follow station procedures used to perform operability determinations. Specifically, operations personnel failed to provide sufficient technical justification for the reasonable assurance of operability of a degraded condition involving one train of the containment spray system and nonconforming conditions associated with diesel fuel oil piping.

Description.

On November 25, 2013, Unit 3 returned to operation after a refueling outage. During the outage, the emergency core cooling systems operate, and air entrainment is an expected occurrence. Historically, this air comes out of solution at system high points and creates voids in the system during the first 90 days following the outage. The licensee implements Procedure 40ST-9SI13, LPSI and CS Alignment Verification, on a monthly basis to assess this known voiding in the containment spray system. On December 3, 2013, the licensee discovered a void in a section of piping near vent valve SIA-V840 that exceeded the acceptance criteria of the surveillance procedure. The immediate operability determination concluded the system was operable after venting reduced the void size just below the acceptance criteria. The subsequent surveillance test, performed on December 26, 2013, identified the void in the same section of pipe had grown beyond the established acceptance criteria.

Procedure 40DP-9OP26, Operations PVAR Processing and Operability Determination/Functional Assessment, Step 3.2.6.4, requires that the immediate operability determination consider if the structure, system, or component is degrading further. The inspectors determined that the licensee failed to consider the phenomenon of air dissolution and the potential for continued degradation of the voiding. Engineering personnel subsequently determined that the system maintained sufficient margin and the degraded condition did not render the system inoperable. Through interviews, inspectors determined that the licensee did not use a consistent process when performing operability determinations and did not use the template in the procedure requiring a response to the question of continued degradation.

On October 30, 2013, during excavation activities in Unit 2 to replace cabling for the emergency diesel generator fuel oil transfer system, the licensee discovered that electrical duct banks were not in conformance with the design drawings. Specifically, the design required the duct banks to be buried in sand and covered by a 4-inch cap of concrete. However, the licensee discovered that train A conduit was encased in concrete and covered by a 4-foot cap of concrete. Additionally, on November 21, 2013, during excavation of the train B of fuel oil transfer system, the licensee discovered the concrete also encased conduit and other encased conduits not expected to be in the area. Operations personnel concluded these conditions were not nonconforming conditions. Therefore, personnel did not perform operability determinations and considered these conditions minor documentation issues. The appropriate configuration of the piping and surrounding strata is used in the determination of the seismic qualification of this safety-related system. Procedure 40DP-9OP26, Operations PVAR Processing and Operability Determination/Functional Assessment, Step 3.2.6.4, requires evaluation of nonconforming conditions and describes a nonconforming condition as an as-built or as-modified structure, system, or component that does not meet the current licensing basis. Inspectors determined that the licensee did not use a consistent process to evaluate operability and failed to consider all impacts to the current licensing basis (i.e., seismic qualifications).

On December 9, 2013, the licensee identified concrete covering the diesel fuel oil lines as conditions that were going to slow down work and evaluated the nonconforming condition for operability of the system. The immediate operability determination performed did not consider the seismic qualifications of the diesel fuel oil piping encapsulated in concrete. The condition of encapsulation was not entered into the corrective action program either by amending the previous PVAR or by generating a new PVAR. Inspectors challenged the operability determination for lack of technical justification to address seismic concerns. The immediate operability determination was amended, but did not review the entire extent of condition to include the encapsulated diesel fuel oil lines and did not follow Procedure 40DP-9OP26, Operations PVAR Processing and Operability Determination/Functional Assessment, Step 3.4.1, which requires an engineering work request to formally confirm information relied upon in an immediate operability determination. Engineering personnel performed an evaluation under CRDR 4494915 to demonstrate the initial 4 feet of concrete in contact with the diesel fuel oil piping was not a challenge to operability. However, it did not review the encapsulation. In addition, the evaluation did not take corrective action to address the nonconforming condition. The evaluation also called into question the design configuration in the other units, but the licensee failed to recognize it as an adverse condition needing to be addressed in the corrective action program. Inspectors once again challenged the operability determination and the licensees handling of this condition. On February 22, 2014, engineering personnel were able to determine that the encapsulated section of diesel fuel oil piping was short enough that it did not challenge operability of the system and addressed the adverse conditions identified in CRDR 4494915. Inspectors determined that the licensee did not use a consistent process to evaluate operability and bypassed procedural requirements due to a lack of understanding of the process.

Analysis.

The inspectors concluded the failure of operations personnel to follow station procedures to perform operability determinations was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609 Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent, systematic process to make decisions (H.13).

Enforcement.

Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, between October 30, 2013, and February 21, 2013, the licensee failed to accomplish activities affecting quality in accordance with prescribed instructions and procedures. Specifically, Procedure 40DP 9OP26, Operations PVAR Processing and Operability Determination/Functional Assessment, Revision 35, Step 3.2.6.4, required that an operability determination consider the possibility for continued degradation in the assessment. This procedure also requires an assessment of a nonconforming condition to all aspects of the current licensing basis. However, the licensee did not evaluate for continued void growth in the containment spray system piping, despite a known growth mechanism and on multiple occasions the licensee failed to evaluate diesel fuel oil piping for seismic concerns when the installed configuration was not reflected in the design documentation. Because this finding was determined to be of very low safety significance and was entered into the licenses corrective action program as Palo Verde Action Request 4511237, this violation is being treated as a non-cited violation consistent with Section 2.3.2.a of the NRC Enforcement Policy:

NCV 05000528;529;530/2014007-01, Failure To Provide Adequate Technical Justification For Operability Of Containment Spray And Diesel Fuel Oil Systems.

b. Failure to Follow Station Process for Root Cause Evaluation

Introduction.

The inspectors identified a Green finding for the failure of station personnel to follow procedures to implement root cause evaluations. Approximately one third of the root cause evaluations reviewed by inspectors resulted in a probable cause with further information needed to validate the cause. Of this subset, eighty percent of the evaluations did not adhere to station processes.

Description.

Inspectors reviewed root cause evaluations completed over a two year period beginning in November 2012. Of these evaluations, five determined that no root cause could be determined and probable cause was assessed. This is an allowable path as described in Section 3.5 of Procedure 90DP-IP12 Root Cause CRDR Evaluation. There are two scenarios described within Section 3.5. Section 3.5.1 is when no root cause exists and no further analysis is likely to result in a root cause, and Section 3.5.2.a is when further analysis is likely to result in a root cause. Of the five root cause evaluations that followed the probable cause path, all stated that they utilized the Section 3.5.2.a methodology. In order to complete the investigation and approve the evaluation, the licensee must document the probable cause, establish corrective actions to mitigate reoccurrence of the condition, establish effectiveness review actions, and establish actions to incorporate finding of long term or offsite analysis. The Corrective Action Review Board (CARB) is then required to review and approve the evaluation if it meets the standards established in Procedure 90DP-IP12 Root Cause CRDR Evaluation, and Procedure 90DP-0IP10 Condition Reporting. After CARB approval, the evaluation is than put on hold without corrective actions to prevent recurrence being implemented until subsequent analysis is complete. Licensee personnel then incorporate any information gained from the analysis, and resubmit it to CARB for final approval. There are no timeliness requirements to complete this final cause analysis or to implement final corrective actions to prevent recurrence.

Inspectors found this process difficult to navigate and were challenged to determine the status of these evaluations. The licensee created a flow chart, as seen in Figure 1, to explain the process.

Figure 1 As a testament to the complexity, information provided by the licensee initially did not reflect where the licensee considered the evaluations to be in their process. Root cause evaluations provided as complete were considered to be in an interim state, despite being approved and completed as described by Step 3.5.2.3 of Procedure 90DP-IP12 Root Cause CRDR Evaluation. Inspectors identified a lack of timeliness metrics once an evaluation is determined to meet Section 3.5.2.a criteria and questioned the adequacy of the licensees metrics to ensure prompt identification of cause. In the review, inspectors determined four of the five probable causes did not follow approved procedural guidance. CRDR 4484404 and CRDR 4481512 did not establish effective corrective actions to mitigate reoccurrence of the condition. CRDR 4462969 was never approved by CARB, yet the probable cause was accepted and considered complete per metrics. CRDR 4474316 had a root cause but was processed in accordance with a probable cause and approved by CARB. In addition, CRDR 4474316 was not revised in accordance with Procedure 90DP-0IP10 Condition Reporting, Step 3.8.3, as required.

The four evaluations that did not meet the standards were required to be reviewed by CARB. Through review of the CARBs interactions and available meeting minutes, inspectors determined that CARB was not enforcing the use of a consistent process and allowed for the lack of procedural compliance. This issue was documented in the stations corrective action program as PVAR 4512157.

Analysis.

The failure of station personnel to follow station procedures to implement root cause evaluations was a performance deficiency. The performance deficiency was more than minor, therefore a finding, because if left uncorrected the performance deficiency could become a more significant safety concern in that significant conditions adverse to quality could reoccur prior to the implementation of appropriate corrective action. The finding is associated with multiple cornerstones, though it is most closely associated with the Mitigating Systems Cornerstone and the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent and systematic approach when making decisions (H.13).

Enforcement.

Enforcement action does not apply because the performance deficiency did not involve a violation of a regulatory requirement. Specifically, scope of issues evaluated by the procedures and processes was not limited to safety related equipment.

This finding does not involve a violation of a regulatory requirement and has very low safety significance, it is identified as a finding: FIN 05000528;529;530/2014007-02, Failure to Follow Station Process for Root Cause Evaluation.

4OA6 Meetings, Including Exit

On March 28, 2014, the inspectors presented the inspection results to Mr. D. Mims, Sr. Vice President Regulatory & Oversight, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

On April 24, 2014, the lead inspector discussed updated inspection results with Mr. D. Wheeler, Director, Performance Improvement. Mr. Wheeler acknowledged the issues presented.

4OA7 Licensee-Identified Violations

The following violation of very low safety significance (Green) was identified by the licensee.

This violation of NRC requirements meets the criteria of the NRC Enforcement Policy for disposition as a non-cited violation.

• On September 24, 2013, the licensees Nuclear Assurance Department identified in corrective action audit 2013-008 that the station had not established an effective schedule for completion of corrective actions for systems, structures, and components that had been determined to be degraded or nonconforming. These degraded or nonconforming conditions were conditions adverse to quality. Title 10 CFR 50, Appendix B, Criterion XVI requires that the licensee establish measures to ensure that conditions adverse to quality are promptly identified and corrected. Contrary to this requirement, the licensee failed to establish measures to ensure that these conditions adverse to quality were promptly corrected. This violation is of very low safety significance (Green) because the degraded structures, systems, and components remained operable. The licensee entered the condition into its corrective action program, performed an apparent cause evaluation under CRDR 4458511, and initiated corrective actions to restore compliance.

ATTACHMENTS:

1. Supplemental Information 2. Information Request 3. Supplemental Information Request

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

N. Aarons-Cooke, Engineer

D. Elkington, Sr. Regulatory Affairs Consultant

D. Hautala, Sr. Engineer

J. Heard, Team Leader Nuclear Maintenance

D. Heckman, Sr. Regulatory Affairs Consultant

M. Kohrt, STA Section Leader

B. Lindenlaub, Sr. Engineer

F. Orshack, Sr. Regulatory Affairs Consultant

R. Roehler, Licensing Section Leader

J. Sontchi, Performance Improvement Section Leader

J. Waltman, Maintenance Department Leader

C. Wilson, Engineer

NRC Personnel

T. Brown, Senior Resident Inspector

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

05000528;529;530/ NCV Failure To Provide Adequate Technical Justification For Operability 2014007-01 of Containment Spray and Diesel Fuel Oil Systems

05000528;529;530/ FIN Failure to Follow Station Process for Root Cause Evaluation 2014007-02