IR 05000528/2022003
| ML22293A290 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 10/24/2022 |
| From: | John Dixon NRC/RGN-IV/DORS/PBD |
| To: | Heflin A Arizona Public Service Co |
| Sanchez A | |
| References | |
| IR 2022003 | |
| Download: ML22293A290 (26) | |
Text
October 24, 2022
SUBJECT:
PALO VERDE NUCLEAR GENERATING STATION - INTEGRATED INSPECTION REPORT 05000528/2022003 AND 05000529/2022003 AND 05000530/2022003
Dear Mr. Heflin:
On September 30, 2022, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Palo Verde Nuclear Generating Station. On October 7, 2022, the NRC inspectors discussed the results of this inspection with Mr. T. Horton, Senior Vice President, and other members of your staff. The results of this inspection are documented in the enclosed report.
One finding of very low safety significance (Green) is documented in this report. This finding involved a violation of NRC requirements. We are treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2 of the Enforcement Policy.
If you contest the violation or the significance or severity of the violation documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC Resident Inspector at Palo Verde Nuclear Generating Station.
If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC Resident Inspector at Palo Verde Nuclear Generating Station. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely, John L. Dixon, Jr., Chief Projects Branch D Division of Operating Reactor Safety Docket Nos. 05000528, 05000529 and 05000530 License Nos. NPF-41, NPF-51 and NPF-74
Enclosure:
As stated
Inspection Report
Docket Numbers:
05000528, 05000529 and 05000530
License Numbers:
Report Numbers:
05000528/2022003, 05000529/2022003 and 05000530/2022003
Enterprise Identifier:
I-2022-003-0006
Licensee:
Arizona Public Service
Facility:
Palo Verde Nuclear Generating Station
Location:
Tonopah, AZ
Inspection Dates:
July 1 to September 30, 2022
Inspectors:
L. Merker, Senior Resident Inspector
N. Cuevas, Resident Inspector
E. Lantz, Resident Inspector
Approved By:
John L. Dixon, Jr., Chief
Projects Branch D
Division of Operating Reactor Safety
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at Palo Verde Nuclear Generating Station, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.
List of Findings and Violations
Failure to Follow Procedures Results in Partial Loss of Offsite Power Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events Green NCV 05000528/2022003-01, 05000529/2022003-01, and 05000530/2022003-01 Open/Closed
[H.12] - Avoid Complacency 71153 The inspectors reviewed a self-revealed, Green, non-cited violation of technical specification 5.4.1.a, Regulatory Guide 1.33, Revision 2, appendix A, section 9.a, for the licensees failure to ensure that maintenance that could affect the performance of safety-related equipment was properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. Specifically, the licensees failure to follow procedures during the work planning and clearance processes resulted in an unintended personnel contact event with an energized portion of the Unit 2, 13.8 kV intermediate bus causing a partial loss of offsite power to Units 1 and 3. The partial loss of offsite power to Units 1 and 3 resulted in the valid actuation and loading of the Unit 1 emergency diesel generator B and Unit 3 emergency diesel generator A.
Additional Tracking Items
Type Issue Number Title Report Section Status LER 05000528, 05000530/2021-001-00 LER 2021-001-00 for Palo Verde Nuclear Generating Station, Unit 1 and Unit 3 Emergency Diesel Generator Actuation on Loss of Offsite Power to Class 4.16 kV Buses 71153 Closed LER 05000528, 05000530/2021-001-01 LER 2021-001-01 for Palo Verde Nuclear Generating Station, Unit 1 and Unit 3 Emergency Diesel Generator Actuation on Loss of Offsite Power to Class 4.16 kV Buses 71153 Closed LER 05000530/2021-001-01 LER 2021-001-01 for Palo Verde Nuclear Generating Station (PVNGS) Unit 3,
Reactor Trip During Control 71153 Closed
Element Assembly Alignment Activities LER 05000530/2021-001-00 LER 2021-001-00 for Palo Verde Nuclear Generating Station (PVNGS) Unit 3,
Reactor Trip During Control Element Assembly Alignment Activities 71153 Closed
PLANT STATUS
Units 1, 2, and 3 operated at or near full power for the duration of the inspection period.
INSPECTION SCOPES
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed activities described in IMC 2515, Appendix D, Plant Status, observed risk significant activities, and completed on-site portions of IPs. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
REACTOR SAFETY
71111.01 - Adverse Weather Protection
Impending Severe Weather Sample (IP Section 03.02) (1 Sample)
- (1) The inspectors evaluated readiness for impending adverse weather conditions for monsoon thunderstorms, on July 14, 2022.
External Flooding Sample (IP Section 03.03) (1 Sample)
- (1) The inspectors evaluated that flood protection barriers, mitigation plans, procedures, and equipment are consistent with the licensees design requirements and risk analysis assumptions for coping with external flooding on September 28, 2022.
71111.04 - Equipment Alignment
Partial Walkdown Sample (IP Section 03.01) (3 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
- (1) Unit 1, high-pressure safety injection train B after emergent maintenance on safety injection train A, on July 8, 2022
- (2) Unit 1, low-pressure safety injection train A during summer reliability window, on September 13, 2022
- (3) Unit 1, auxiliary feedwater train A during summer reliability window, on September 14, 2022
71111.05 - Fire Protection
Fire Area Walkdown and Inspection Sample (IP Section 03.01) (4 Samples)
The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:
- (1) Unit 2, upper cable spreading room, fire zone 20, on July 15, 2022
- (2) Unit 1, class 1E 4kV switchgear A, fire zone 5A, on August 5, 2022
- (3) Unit 2, lower cable spreading room, fire zones 11A, 11B, 12, 13, and 14, on September 7, 2022
- (4) Unit 1, emergency diesel generator B and emergency diesel generator B control rooms, fire zones 21B and 22B, on September 26, 2022
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance
Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01) (1 Sample)
- (1) The inspectors observed and evaluated licensed operator performance in the main control room during Units 1 and 3 alignment of electrical buses to the alternate offsite power sources following the loss startup transformer AE-NAN-X02, on August 15, 2022.
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
- (1) The inspectors observed and evaluated licensed operator requalification simulator exam activities, on August 31, 2022.
71111.12 - Maintenance Effectiveness
Maintenance Effectiveness (IP Section 03.01) (2 Samples)
The inspectors evaluated the effectiveness of maintenance to ensure the following structures, systems, and components (SSCs) remain capable of performing their intended function:
- (1) Units 1, 2, and 3, review of the 10 CFR 50.65(a)(3) periodic evaluation, on September 26, 2022
- (2) Unit 3, plant protection system channel A, on September 29, 2022
Quality Control (IP Section 03.02) (2 Samples)
The inspectors evaluated the effectiveness of maintenance and quality control activities to ensure the following SSC remains capable of performing its intended function:
- (1) Units 1, 2, and 3, metal bellows pump and motor assembly for the radiation monitoring system, on August 26, 2022
- (2) Units 1, 2, and 3, relief valve for the essential chillers, on August 26, 2022
71111.13 - Maintenance Risk Assessments and Emergent Work Control
Risk Assessment and Management Sample (IP Section 03.01) (3 Samples)
The inspectors evaluated the accuracy and completeness of risk assessments for the following planned and emergent work activities to ensure configuration changes and appropriate work controls were addressed:
- (1) Unit 3, high risk for emergent work to retorque packing on safety injection tank 1B nitrogen supply valves SIA-HV-649 and SIB-HV-642 and perform weld repairs on safety injection tank 1B pressure relief piping, on August 1, 2022
- (2) Unit 1, emergent work on train A safety injection pumps' combined recirculation to refueling water tank valve SIA-UV-660, on August 8, 2022
- (3) Unit 3, high risk for emergent work on balance of plant engineered safety features actuation system load sequencer train B, on September 26, 2022
71111.15 - Operability Determinations and Functionality Assessments
Operability Determination or Functionality Assessment (IP Section 03.01) (5 Samples)
The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:
- (1) Unit 3, pressurizer spray control valves RCE-PV-100E and RCE-PV-100F functionality assessment due to unexpected pressure decrease after boron equalization, on August 3, 2022
- (2) Unit 2, emergency diesel generators A and B operability determination due to a fuel oil line modification discrepancy with design drawings, on August 16, 2022
- (3) Units 1, 2, and 3, pressurized auxiliary spray control valves CHB-HV-203 and CHA-HV-205 functionality assessment due to previously observed leakage, on September 6, 2022
- (4) Unit 1, atmospheric dump valve SGB-HV-178 accumulator nitrogen pressure reducing valve SGE-PCV-303 operability determination due to outlet pressure exceeding the maximum pressure specification, on September 7, 2022
- (5) Unit 3, balance of plant-engineered safety features actuation system train B load sequencer module operability determination due to a failed auto test, on September 29, 2022
71111.18 - Plant Modifications
Severe Accident Management Guidelines (SAMG) Update (IP Section 03.03) (1 Sample)
- (1) The inspectors verified the site severe accident management guidelines were updated in accordance with the PWR generic severe accident technical guidelines and validated in accordance with NEI 14-01, Emergency Response Procedures and Guidelines for Beyond Design Basis Events and Severe Accidents, revision 1.
71111.19 - Post-Maintenance Testing
Post-Maintenance Test Sample (IP Section 03.01) (2 Samples)
The inspectors evaluated the following post-maintenance testing activities to verify system operability and/or functionality:
- (1) Unit 2, charging pump A testing following biennial maintenance, on July 14, 2022
- (2) Unit 3, emergency diesel generator train A testing following speed regulating governor replacement, on September 6, 2022
71111.22 - Surveillance Testing
The inspectors evaluated the following surveillance testing activities to verify system operability and/or functionality:
Surveillance Tests (other) (IP Section 03.01) (3 Samples)
- (1) Unit 3, class 1E 125 Vdc battery charger A testing, on July 19, 2022
- (2) Unit 2, containment spray pump A inservice testing, on September 12, 2022
- (3) Units 1, 2, and 3, pressurizer backup heater capacity surveillance testing, on September 27, 2022
Inservice Testing (IP Section 03.01) (1 Sample)
- (1) Unit 2, turbine-driven auxiliary feedwater pump inservice testing, on September 12, 2022
RCS Leakage Detection Testing (IP Section 03.01) (2 Samples)
- (1) Unit 3, manual calculation of reactor coolant system water inventory balance during adverse trend, on August 3, 2022
- (2) Unit 2, reactor coolant system water inventory balance missed surveillance, on September 29, 2022
FLEX Testing (IP Section 03.02) (1 Sample)
- (1) Units 1, 2, and 3, and N+1 diverse and flexible coping strategies spent fuel pool makeup pump testing, on August 31, 2022
71114.06 - Drill Evaluation
Drill/Training Evolution Observation (IP Section 03.02) (1 Sample)
- (1) The inspectors evaluated an emergency preparedness drill on August 9,
OTHER ACTIVITIES - BASELINE
===71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:
MS06: Emergency AC Power Systems (IP Section 02.05)===
- (1) Unit 1 (July 1, 2021, through June 30, 2022)
- (2) Unit 2 (July 1, 2021, through June 30, 2022)
- (3) Unit 3 (July 1, 2021, through June 30, 2022)
MS07: High Pressure Injection Systems (IP Section 02.06) (3 Samples)
- (1) Unit 1 (July 1, 2021, through June 30, 2022)
- (2) Unit 2 (July 1, 2021, through June 30, 2022)
- (3) Unit 3 (July 1, 2021, through June 30, 2022)
MS08: Heat Removal Systems (IP Section 02.07) (3 Samples)
- (1) Unit 1 (July 1, 2021, through June 30, 2022)
- (2) Unit 2 (July 1, 2021, through June 30, 2022)
- (3) Unit 3 (July 1, 2021, through June 30, 2022)
MS09: Residual Heat Removal Systems (IP Section 02.08) (3 Samples)
- (1) Unit 1 (July 1, 2021, through June 30, 2022)
- (2) Unit 2 (July 1, 2021, through June 30, 2022)
- (3) Unit 3 (July 1, 2021, through June 30, 2022)
MS10: Cooling Water Support Systems (IP Section 02.09) (3 Samples)
- (1) Unit 1 (July 1, 2021, through June 30, 2022)
- (2) Unit 2 (July 1, 2021, through June 30, 2022)
- (3) Unit 3 (July 1, 2021, through June 30, 2022)
71152A - Annual Follow-up Problem Identification and Resolution Annual Follow-up of Selected Issues (Section 03.03)
The inspectors reviewed the licensees implementation of its corrective action program related to the following issues:
- (1) Units 1, 2, and 3, effectiveness of corrective actions related to potential auxiliary feedwater system discharge piping voiding, on August 26, 2022
- (2) Units 1, 2, and 3, effectiveness of corrective actions related to control element drive mechanism control system component failures, on September 9, 2022
71153 - Follow Up of Events and Notices of Enforcement Discretion Event Report (IP Section 03.02)
The inspectors evaluated the following licensee event reports (LERs):
- (1) LER 05000528, 05000530/2021-001-00 and LER 05000528, 05000530/2021-001-01, Unit 1 and Unit 3 Emergency Diesel Generator Actuation on Loss of Offsite Power to Class 4.16 kV Buses Agencywide Documents Access and Management System (ADAMS) Accession Nos. ML21349B373 and ML22154A554. The inspectors reviewed the original and updated LER submittals and determined that the cause of the condition described in the LER was reasonably within the licensees ability to foresee and correct and therefore was reasonably preventable. A performance deficiency and violation of NRC requirements was identified and is described in the inspection results section of this report.
- (2) LER 05000530/2021-001-00 and LER 05000530/2021-001-01, Unit 3, Reactor Trip During Control Element Assembly Alignment Activities (ML22034A997 and ML22195A281). The inspectors reviewed the original and updated LER submittals and determined that the cause of the condition described in the LER was not reasonably within the licensees ability to foresee and correct and therefore was not reasonably preventable. No performance deficiency nor violation of NRC requirements was identified.
INSPECTION RESULTS
Failure to Follow Procedures Results in Partial Loss of Offsite Power Cornerstone Significance Cross-Cutting Aspect Report Section Initiating Events Green NCV 05000528/2022003-01, 05000529/2022003-01, and 05000530/2022003-01 Open/Closed
[H.12] - Avoid Complacency 71153 The inspectors reviewed a self-revealed, Green, non-cited violation of technical specification 5.4.1.a, Regulatory Guide 1.33, Revision 2, appendix A, section 9.a, for the licensees failure to ensure that maintenance that could affect the performance of safety-related equipment was properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. Specifically, the licensees failure to follow procedures during the work planning and clearance processes resulted in an unintended personnel contact event with an energized portion of the Unit 2, 13.8 kV intermediate bus causing a partial loss of offsite power to Units 1 and 3. The partial loss of offsite power to Units 1 and 3 resulted in the valid actuation and loading of the Unit 1 emergency diesel generator B and Unit 3 emergency diesel generator A.
Description:
Offsite 525 kV AC power is supplied to each units 13.8 kV intermediate buses via a preferred and alternate secondary winding from two of the three startup transformers.
Each 13.8 kV intermediate bus provides power to one class 1E 4.16 kV bus, which provides power to one train of safety-related equipment. On a loss of offsite power, the associated trains safety-related emergency diesel generator provides power to the class 1E 4.16 kV safety bus.
On October 20, 2021, the licensee was performing planned maintenance in the switchgear cubicles of the Unit 2 13.8 kV train B intermediate bus. An electrician performing work in the B cubicle of the switchgear inadvertently contacted an energized, 13.8 kV element resulting in an electrical fault which tripped open the 525 kV breakers and de-energized startup transformer AE-NAN-X02. This resulted in a loss of power to the Unit 1 train B and Unit 3 train A 13.8 kV intermediate buses and consequently, a loss of power to the respective class 1E 4.16 kV safety buses. As designed, the Unit 1 emergency diesel generator B and Unit 3 emergency diesel generator A automatically started upon the undervoltage conditions and restored power to their respective class 1E 4.16 kV safety buses.
The inspectors reviewed the licensees cause evaluation and identified three examples of the licensees failure to follow procedures, which directly contributed to the worker inadvertently contacting an energized 13.8 kV element:
- (1) During the clearance review, walkdown, and pre-job brief, the job leader assigned to the maintenance activity used the copy of the station electrical distribution main single line drawing, 13-E-MAA-0001, that was already used and marked up by a previous independent check to verify the adequacy of the clearance. Procedure 40DP-9OP29, Power Block Clearance and Tagging, revision 67, step 4.4.1 states, in part, to review ALL the following in the work document to understand the scope of work and the protection needed for personnel and equipment protection. This review is an independent review, and the reviewer shall pull all drawings, procedures, work documents, or other review sources independently. By using the marked-up drawings, the job leader did not perform the required independent review using a clean copy of the drawings. A proper, independent review of plant drawings to understand the scope of work and protection needed for personnel and equipment protection would have shown that while clearance 422839 de-energized the 13.8 kV line side power entering the C cubicle, cross-connecting power from the 13.8 kV line side power entering the A cubicle was still present in the B cubicle.
- (2) Repetitive maintenance work order 5253920 for the cleaning and inspection of Unit 2 non-class 1E 13.8 kV outdoor switchgear, 2ENANS06, is a generic work order written for the entire cleaning and inspection of the S06 switchgear, which includes individual cubicles designated AA, A, B, C, and D. Two clearances were written for the work order to de-energize the two different sources of power coming into the various cubicles. Clearance 422838 de-energized the 13.8 kV line side power to the breaker in the A cubicle, while clearance 422839 de-energized the 13.8 kV line side power to the breaker in the C cubicle.
On October 20, 2021, the employee designated as the clearance acceptor performed the procedurally required walkdown of clearance 422839 for the work to be performed under work order 5253920 to verify that the planned work location was inside the clearance boundary. Procedure 40DP-9OP29, Power Block Clearance and Tagging, revision 67, step 4.8.2.E states, in part, to ensure clearance is walked down for the items in the clearance related to the specific work document of the discipline. Step 4.8.2.E.4 states, in part, that clearance walkdown consists of ANY of the following activities, as applicableVerify work location is inside the clearance boundaries. Contrary to these steps, the clearance acceptors walkdown failed to identify that the planned work in the B cubicle was outside of the clearance 422839 boundary prior to accepting the clearance.
- (3) Procedure 01DP-0IS13, Palo Verde Generating Station Electrical Safe Work Practices, revision 16, step 4.5.2 states, in part, that the initial Live-Dead-Live (LDL) check shall be performed to test each and every exposed electrical conductor or circuit part within the restricted approach boundary/minimum approach distance to verify the absence of nominal system voltage. Before commencing, the crew discussed the scope of the work to be performed and performed a live-dead-live check in the C cubicle. Upon verifying that no voltage existed in the C cubicle, they deemed that the cubicles they planned to work were all de-energized and proceeded with the clean and inspection. They believed this was acceptable due to their understanding that clearance 422839 had removed power from all except the A cubicle and that a live-dead-live check in the C cubicle would verify that all exposed electrical elements within their planned work boundary had been de-energized. This initial live-dead-live check and the crews mindset that the clearance was acceptable resulted in them not performing the subsequent live-dead-live checks in the other cubicles as required.
When reviewing the licensees cause evaluation, inspectors noted that throughout the work planning and clearance process, the licensee believed that all aspects of the planning process had been done correctly. This overconfidence drove the workgroups actions during the process, resulting in the three examples of the failure to follow procedures described above. The inspectors assessed that this belief and expectation of a successful outcome was the most significant contributing cause of the procedural violations.
Corrective Actions: Operators restored offsite power to the affected buses from the alternate sources. The licensee entered the issue into the corrective action program and performed a cause evaluation. The licensee developed and executed a plan to reinforce worker responsibility and sensitivity to the clearance process and electrical safe work practices that included increased supervisor involvement, sitewide training focused on the learnings from this event, updating of current station trainings on clearance and tagging and electrical safety to incorporate lessons learned, and updating station procedures to more clearly define work comprising multiple clearances.
Corrective Action References: Condition reports 21-12436, 21-12511, and 21-12543
Performance Assessment:
Performance Deficiency: The failure to follow procedures was a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Human Performance attribute of the Initiating Events cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, on October 20, 2021, the licensees failure to follow procedures during the work planning and clearance processes resulted in an unintended personnel contact event with an energized portion of the Unit 2, 13.8 kV intermediate bus causing a partial loss of offsite power to Units 1 and 3. The partial loss of offsite power to Units 1 and 3 resulted in the valid actuation and loading of the Unit 1 emergency diesel generator B and Unit 3 emergency diesel generator A.
Significance: The inspectors assessed the significance of the finding using IMC 0609 Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Using Exhibit 1, Initiating Events Screening Questions, the finding was screened as having very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition (e.g., loss of condenser, loss of feedwater).
Cross-Cutting Aspect: H.12 - Avoid Complacency: Individuals recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Individuals implement appropriate error reduction tools. Specifically, since the workgroup went into the work believing that the clearance was sufficient for their work area, they did not perform the required additional verifications during the work validation activities and in the field to confirm the clearance was adequate for the work scope.
Enforcement:
Violation: Technical specification 5.4.1.a states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33, revision 2, appendix A, February 1978. Regulatory Guide 1.33, revision 2, appendix A, section 9.a, requires, in part, that maintenance that can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.
Contrary to the above, on October 20, 2021, the licensee failed to ensure that maintenance that could affect the performance of safety-related equipment was properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. Specifically, the licensee failed to follow procedures during the work planning and clearance processes resulted in an unintended personnel contact event with an energized portion of the Unit 2, 13.8 kV intermediate bus causing a partial loss of offsite power to Units 1 and 3.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
On October 7, 2022, the inspectors presented the integrated inspection results to Mr. T. Horton, Senior Vice President, and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Calculations
13-MC-ZJ-200
As Built Control Building Flooding Calculation
Corrective Action
Documents
2-07104, 22-07740, 22-8544, 22-9923
Drawings
03-C-ZVC-554
Underground Utilities Unit 3 Plan Zone V3E
Drawings
13-C-ZVA-002
Site Drainage General Arrangement Plan
Drawings
13-C-ZVC-065
Site Rough Grading Plan Area 1
Drawings
13-C-ZVC-066
Site Rough Grading Plan Area 2
Drawings
13-C-ZVC-070
Site Rough Grading Plan Area 6
Drawings
13-C-ZVC-074
Site Rough Grading Plan Area 10
Drawings
13-C-ZVC-100
Site Storm Drainage Dikes and Channels Sheet 1
Drawings
13-P-SJE-301
Control BLDG Level A Plumbing Plan Between Elevation 74
foot and 100 foot,
Drawings
13-P-ZAE-201
Auxiliary BLDG Level C Plumbing Plan Between Elevation
51.5 foot & 70 foot
Drawings
13-P-ZAE-202
Auxiliary BLDG Level B Plumbing Plan Between Elevation
foot & 80 foot
Drawings
A0-M-STP-001
P&I Diagram Sanitary & Treatment
Miscellaneous
SWIMS Database, Potential Tornado borne missile zones
07/14/2022
Miscellaneous
DMWO 4541553 ENG
Miscellaneous
EDG 2011-00003, 2012-00703, 2022-00141
Miscellaneous
13-MS-A135
Evaluation of Internal Flooding in Safety Related Structures
as a Result of Localized Ponding at the Power Block During
a LIP Event in Support of NRC 50.54(f) Letter and the
PVNGS Flood Hazard Reevaluation Report
Miscellaneous
OpESS 2012/01-
High Wind Generated Missile Hazards
2/29/2011
Procedures
Control and Monitoring of Potential Tornado Borne Missiles
Procedures
Acts of Nature
Corrective Action
Documents
18-12153, 19-02418, 17-15589
Drawings
01-M-AFP-001
P & I Diagram Auxiliary-Feedwater System
Drawings
01-M-SGP-002
P & I Diagram Main Steam System
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Drawings
01-M-SIP-001
P&I Diagram Safety Injection and Shutdown Cooling
Drawings
01-M-SIP-002
P&I Diagram Safety Injection and Shutdown Cooling
Miscellaneous
PVNGS DBM, Safety Injection System
Procedures
Essential Auxiliary Feedwater System
Procedures
Auxiliary Feedwater Pump AFA-P01 Monthly Valve
Alignment
Procedures
Train A LPSI and CS System Alignment Verification
Procedures
High Pressure Safety Injection System Alignment
Verification
Calculations
13-MC-FP-808
Combustible Loads - Diesel Generator Building
Corrective Action
Documents
FSCCR 5460282, 22-07435, 22-07441, FSCCR 5457823
Drawings
01-M-FPF-304
Control Building Isometric Fire Protection System CO2
System
Drawings
01-M-FPP-004
P & I Fire Protection System (CO2 System)
Miscellaneous
DBM, Fire Protection System
Miscellaneous
Design Basis Manual, Fire Protection System, Section 6.3.
Cable Spreading Room
Miscellaneous
Pre-fire Strategies Manual
Procedures
Fire System Impairments and Notifications
Procedures
Control of Transient Combustibles
Procedures
Appendix-R Emergency Lighting Fixture Battery Discharge
Test (Wall Mounted Type KE, KF, and KG)
Corrective Action
Documents
2-08517, 22-08549
Miscellaneous
SES-0-06-E-07
Licensed Operator Continuing Training Simulator
Examination Scenario
Procedures
Conduct of Operations
Procedures
Procedures
Procedures
13.8 kV Electrical System (NA)
Procedures
4.16 kV Non-Class 1E Power (NB)
Procedures
4.16 kV Class 1E Power (PB)
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Corrective Action
Documents
18-10997, 19-06968, 21-04389, 22-03023, 22-05196, 22-
06466, 22-06976, 22-08693, 22-08931, 20-11630, 21-
03436, 21-10609, 22-01440, 22-02575, 21-15168, 22-00896
Miscellaneous
System Training Manual: Essential Chilled Water System
(EC)
Miscellaneous
Performance Criteria Formulation Bases for SB System
(Reactor Protection)
Miscellaneous
Unit 2 Emergency Diesel Generator Train B Performance
Monitoring Group Report
03/29/2022
Miscellaneous
Maintenance Rule (a)(3) Periodic Assessment for the Period
July 2020 - December 2021
Miscellaneous
13-VTD-C150-
0003
Carrier Air Conditioning Company Item List & Specification
Sheets
Miscellaneous
MEE-03980
Evaluate and Approve the Use of the Superior In-line Relief
Valve P/N 3061X1) as a Replacement for the Henry In-line
Relief Valve (P/N 5246-1) Supplied by the Carrier Corp
Miscellaneous
QRC 0417-22
Quality Receiving Checklist for APN 00157760 Metal
Bellows Pump and Motor Assembly
08/16/2022
Miscellaneous
QRC 1054-22
Quality Receiving Checklist for APN 00100154 Relief Valve
08/05/2022
Miscellaneous
VTD-E146-00004
ABB Electro-Mechanics, INC. Operation and Maintenance
Instruction for Plant Protection System
Procedures
Receipt Inspection
Procedures
PPS Bistable Trip Units Functional Test
Procedures
Log Power Functional Test
29
Procedures
Maintenance Rule
Procedures
Commercial Grade Dedication (CGD) Process
Work Orders
5433129, 5433130, 5433131, 5433132, 5433133, 5426759,
5434301, 5414704
Corrective Action
Documents
2-07482, 22-07965, 22-07259, 22-07261, 22-07304, 22-
10063
Drawings
03-M-SIP-002
P & I Diagram Safety Injection and Shutdown Cooling
System
Drawings
03-P-GAF-129
Containment Building Isometric Service Gas System High
Pressure Nitrogen
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Miscellaneous
Phoenix Risk Monitor - PVGS Unit 3, Work Week 2230
Schedule Risk Evaluation 7/25/2022-7/31/2022, as of
07/29/2022
Miscellaneous
Risk Management and Readiness Plan for Containment
Entry Authorized Work Scopes Outside Bio Shield
Miscellaneous
Protected Equipment Scheme for SIT 1B Inoperable
07/29/2022
Miscellaneous
Phoenix Risk Monitor -PVGS Unit 1, Current Risk Summary
Report as of 7/7/2022 01:05
07/07/2022
Miscellaneous
Protected Equipment For SIA-UV660 INOP
07/07/2022
Miscellaneous
Phoenix Risk Monitor -PVGS Unit 3 Current Risk Summary
Report, as of 09/26/2022, 07:23
Miscellaneous
18-16665-002
Engineering evaluation
Miscellaneous
20-10092-003
Engineering reply
Procedures
Online Integrated Risk
Procedures
Online Integrated Risk
Procedures
Protected Equipment
Procedures
Conduct of Operations
Procedures
Risk Management Actions
Procedures
RICT PRA Functionality Determination
Procedures
Procedures
4.16 kV Class 1E Power (PB)
Procedures
Procedures
Procedures
Procedures
Train A HPSI Injection and Miscellaneous SI Valves -
Quarterly - Inservice Test
Procedures
Notice of Enforcement Discretion
Work Orders
5398500, 5457808, 5477186
Corrective Action
Documents
21-06761, 20-14165, 20-14089, 19-14740, 22-08243, 22-
07989, 18-16090, 22-10063, 17-00288
Drawings
01-M-CHP-001
P & I Diagram Chemical and Volume Control System
Drawings
01-M-RCP-001
P & I Diagram Chemical and Volume Control System
Drawings
01-M-SGP-001
P & I Diagram Main Steam System
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Drawings
2-9305722-D
PCB Schematic, FBEVAS/CPIAS/CREFAS
Drawings
03-E-SAB-002
Elementary Diagram Engineered Safety Features Actuation
System BOP-ESFAS Manual Actuation
Drawings
03-E-SAB-004
Elementary Diagram ESF Actuation System BOP-ESFAS
Intertying Circuits Train A & Train B
Drawings
03-E-SAF-0002
Control Wiring Diagram Engineered Safety Features
Actuation System BOP-ESFAS Manual Actuation
Drawings
03-E-SAF-0004
Control Wiring Diagram Engineered Safety Features
Actuation System COP-ESFAS Intertying Circuits
Drawings
J691-00044
Inch Pressure Regulating Valve Project Control Drawing
Miscellaneous
DBM, Diesel Generator, Class 1E Standby Generation, Fuel
Oil Storage and Transfer System Design Basis Manual
Miscellaneous
Main Steam Design Basis Manual
Miscellaneous
PVGNS DBM, Chemical and Volume Control System
Miscellaneous
PVGS Operator Information Manual
April 2020
Miscellaneous
Formal Troubleshooting Game Plan, B BOP ESFAS
Sequencer Auto Test Failure in Unit 3
09/26/2022
Miscellaneous
11-F002
Licensing Document Change Request
Miscellaneous
13-J-085-033
Self-Acting Pressure Regulators
Miscellaneous
13-PN-0204
Fabrication and Installation of Nuclear Piping Systems for
Arizona Public Service Company, Palo Verde Generating
Station Units 1, 2, and 3
Miscellaneous
13-VTD-F183-
00002
FBEVAS/CREFAS/CPIAS Logic Module User and
Maintenance Manual for PVGS BOP ESFAS
Miscellaneous
13-VTD-T020-
00015
Target Rock Technical Manual for Pressure Regulating
Valves
Miscellaneous
18-16090-002
Engineering Evaluation
Miscellaneous
2-08243-003
Prompt Operability Determination
08/12/2022
Miscellaneous
33701270
Condition Report Action Item
Miscellaneous
3557798
Palo Verde Action Request
Miscellaneous
3566291
Condition Report Action Item
Miscellaneous
3566294
Condition Report Action Item
Miscellaneous
2-SG-006
Engineering Evaluation Report
01/06/1992
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Miscellaneous
ANPD-19591
Resolution of Open Items Addressed at NRC Design Review
of ESF Load Sequencer
Miscellaneous
EDC 2016-00115
Engineering Design Change
Miscellaneous
EDC 2016-00119
Engineering Design Change
Miscellaneous
N001-0604-00761
PVNGS Units 1, 2, and 3 Loss of AC Power with Auxiliary
Spray Valve Leakage
Procedures
Operations Department Repetitive Task Program Vol. 1
2
Procedures
Steam Generator Tube Rupture
Procedures
CVCS Normal Operations
Procedures
Procedures
ADVs - Inservice Test
Procedures
CH Valves - Inservice Test
Work Orders
4747946, 4747936, 2309967, 5464132, 5477186
Corrective Action
Documents
18-10012, 22-03600, 22-04693, 22-04716
Miscellaneous
Training Task Master List for SRO Task# 124000379337
Perform the Severe Accident Management Guidelines
07/15/2022
Miscellaneous
Procedure Comment Form: Main Control Room SAG-1:
Initial Response, and Main Control Room SAG-2: TSC
Recommending Strategies
06/28/2018
Miscellaneous
Procedure Comment Form: TSC SAG-3 through SAG-10,
DPG, and Tech Support Guidelines
07/05/2018
Miscellaneous
Procedure Comment Form: TSC SAG-3 through SAG-10,
DPG, and Tech Support Guidelines
07/26/2018
Miscellaneous
CRDR 4723203
Industry Initiative to Maintain Severe Accident Management
Guidelines
2/18/2019
Miscellaneous
NLR11C050300
Licensed Operator Continuing Training Classroom Lesson:
SAMG/B 5.b
10/06/2022
Miscellaneous
NLR12S020100
Licensed Operator Continuing Training Simulator Scenario:
Blackout, SAMGs
04/10/2012
Procedures
Severe Accident Management Guidelines Deviation
Document
Procedures
Severe Accident Guideline (SAG) Technical Guidelines,
Procedures
Severe Accident Management Guidelines Maintenance
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
Main Control Room SAG-1: Initial Response
Procedures
Main Control Room SAG-2: TSC Recommending Strategies
Drawings
2-M-CHP-002
P&I Diagram Chemical and Volume Control System
Procedures
Diesel Generator A Test
Procedures
Charging Pumps - Inservice Test
Procedures
Class 1E Diesel Generator Load Rejection, 24 Hour Rated
Load and Hot Start Test Train A
Work Orders
5332224, 5333244, 5332598
Calculations
2-EC-MA-0221
Load Equipment Minimum Operating Voltage Levels
Corrective Action
Documents
2-08037, 5471225, 5471705, 5471706, 22-09187, 22-
290, 22-09295, 22-09296, 22-09304, 16-14135, 22-
07988, 22-08026, 22-08028
Miscellaneous
PVGS DBM - Class 1E 125 VDC Power System
Miscellaneous
PVNGS Design Basis Manual - Reactor Coolant System
Miscellaneous
Design Basis Manual-Fuel Pool Cooling and Cleanup
System
Miscellaneous
Unit 2 Control Room Log
09/08/2022-
09/09/2022
Miscellaneous
PVGS DBM - Safety Injection System
Miscellaneous
2-E-ZZI-0003
Electrical Equipment Database
Miscellaneous
13-MC-SI-0220
Containment Spray System Hydraulic Analysis and Pump
Surveillance Testing Requirements
Miscellaneous
13-MS-031
Evaluation of Heat Loss to Containment from the Reactor
Coolant System
Miscellaneous
APW-89-0540000
Pressurizer Heater Capacity Study
Miscellaneous
CRAI 3566294
Miscellaneous
Godwin
HL100MC D4M
Pump Manual
Miscellaneous
MN725-A00935
RSB 5-1 Natural Circulation Cooldown Analysis for Power
Uprate and SG Replacement at PVNGS Units 1, 2, and 3
Miscellaneous
VTD-I075-00012
Ingersoll-Rand Installation, Operation, and Maintenance
Instructions for 8X23WDF Containment Spray Pumps
Procedures
Battery Charger Preventive Maintenance
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
Month Pressurizer Backup Heater Capacity Test
Procedures
Class 1E Battery Charger 18 Month Surveillance Test
Procedures
Functional Recovery
Procedures
Technical Support Center SAG-10: Control SFP Level
Procedures
FLEX Support Guidelines Mode 1, 2, 3, or 4
Procedures
EFRFDADS (Preferred) Calculation of RCS Water Inventory
Procedures
ERDADS (Preferred) Calculation of RCS Water Inventory
Procedures
Manual Calculation of RCS Water Inventory Balance
Procedures
RCS Heat loss Measurement
Procedures
RCS Heat loss Measurement
Procedures
RCS Heat loss Measurement
Procedures
Auxiliary Feedwater A - Inservice Test
Procedures
Containment Spray Pump and Check Valves-Inservice Test
Procedures
PR-0906
Diverse and Flexible Coping Strategies (FLEX)
Work Orders
5332176, 5346124, 5347966, 5347206, 5299848, 5299859,
299872
Corrective Action
Documents
2-08234, 22-08314, 22-08393, 22-08394
Miscellaneous
203 and 2204 Drill Report
09/08/2022
Miscellaneous
22 Emergency Preparedness Scenario 2204
Miscellaneous
[Emergency Action Level] Classification Matrix Hot
Conditions ([Reactor Coolant System] > 210°F)
Miscellaneous
[Protective Action Recommendation] Flowchart
Miscellaneous
Release Evaluation Flowchart
Miscellaneous
[Emergency Action Level] Classification Matrix All Conditions
Procedures
ERO Positions Emergency Operations Director (EOF)
71151
Miscellaneous
Units 1, 2, and 3 MSPI Run Demands Failures Report
7/1/2021 - 5/31/2022
08/26/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI Unavailability Reports 7/1/2021 -
5/31/2022
08/24/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI EDG System May 2022 UAI
Derivation Reports
06/15/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI EDG System May 2022 URI
06/17/2022
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Derivation Reports
71151
Miscellaneous
Units 1, 2, and 3, MSPI EDG System May 2022 PLE
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI RHR CS Systems May 2022 UAI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI RHR CS Systems May 2022 URI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI RHR CS Systems May 2022 PLE
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI EW SP Systems May 2022 UAI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI EW SP Systems May 2022 URI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI EW SP Systems May 2022 PLE
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI HPSI System May 2022 UAI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI HPSI System May 2022 URI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI HPSI System May 2022 PLE
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI AFW System May 2022 UAI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI AFW System May 2022 URI
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, MSPI AFW System May 2022 PLE
Derivation Reports
06/17/2022
71151
Miscellaneous
Units 1, 2, and 3, All Systems May 2022 MSPI Margin
Reports
06/15/2022
71151
Miscellaneous
Units 1, 2, and 3, Control Room Operator Logs 7/1/2021 -
5/31/2022
09/25/2021
71151
Miscellaneous
Units 1, 2, and 3, PI Summary Report 07/2021-06/2022
07/08/2022
71151
Miscellaneous
13-NS-C075
MSPI Bases Document
71151
Miscellaneous
13-NS-C075
MSPI Bases Document
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
71151
Miscellaneous
13-NS-C075
MSPI Bases Document
71151
Miscellaneous
13-NS-C075
MSPI Bases Document
71151
Miscellaneous
13-NS-C075
MSPI Bases Document
71151
Procedures
Maintenance Rule
71151
Procedures
Performance Index Data Mitigating Systems Cornerstone
71151
Procedures
NRC ROP PI Data Collection, Verification and Submittal
Corrective Action
Documents
2-05673, 21-08605, 21-08666, 21-09934, 21-12252, 21-
11574, 21-14465, 20-11172, 20-13761, 20-15237, 21-
10885, 21-11296
Miscellaneous
Design Basis Manual - Auxiliary Feedwater System
Miscellaneous
CRDR 335114
Miscellaneous
ERET 2826879
Miscellaneous
CRDR 2857195
Miscellaneous
CRAI 2872382
Miscellaneous
CRDR 4481512
Miscellaneous13-420
Ultrasonic Thickness Report
Miscellaneous13-528
Ultrasonic Thickness Report
Miscellaneous
13-MS-A137
Development of AF System Pipe Arc Length Acceptance
Criteria Associated with Calculated Max Void Volumes
Miscellaneous14-054
Ultrasonic Thickness Report
Miscellaneous14-055
Ultrasonic Thickness Report
Miscellaneous
20-1188
Ultrasonic Thickness Report
Miscellaneous
21-12252-006
Level Three Evaluation Report
Miscellaneous
21-14465-007
Level One Cause Evaluation
Miscellaneous
2-00769-003
MRFF Evaluation
Miscellaneous
2-00769-008
Engineering Reply
Miscellaneous
2-05673-004
MRFF Evaluation
Miscellaneous
2-05673-005
Level Three Evaluation Report
Miscellaneous
2-733
Ultrasonic Thickness Report
Miscellaneous
VTD-E146-00008
ABB Electro-Mechanics inc Technical Manual for Control
element Drive Mechanism Control System (CEDMCS)
Procedures
Auxiliary Feedwater A - Inservice Test
Procedures
Auxiliary Feedwater B - Inservice Test
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
Auxiliary Feedwater Pump A - Comprehensive Test
Procedures
Auxiliary Feedwater Pump B - Comprehensive Pump Test
Work Orders
5398840, 5359440, 5307466, 5412999, 5410408, 5298870,
5359440, 5421125, 5456143
Corrective Action
Documents
21-12436, 22-08531, 21-14465
Drawings
2-E-NAA-0002
Single Line Diagram: 13.8 kV Non-class 1E Power System
Intermediate SWGR 2E-NAN-S06 & Start-up XFMR AE-
NAN-X02
Drawings
13-E-MAA-0001
Main Single Line Diagram
Miscellaneous
Level 1 CAQ Root Cause Analysis Report, 21-14465-007
Miscellaneous
2838
2068-3 NAN-S06/S04/X04 Bus Clearance
08/19/2021
Miscellaneous
2839
2068-2 NAN-S04/S06/X04 Clearance
08/19/2021
Miscellaneous
CRAI 4488583
Miscellaneous
Valid Specified System Actuations of Unit 1 and Unit 3
10/21/2021
Miscellaneous
VTD-E146-00008, ABB Electro-Mechanics Inc Technical Manual for Control
element Drive Mechanism Control System (CEDMCS)
Procedures
Palo Verde Generating Station Electrical Safe Work
Practices
Procedures
Palo Verde Generating Station Electrical Safe Work
Practices
Procedures
Conduct of Maintenance
Procedures
Power Block Clearance and Tagging
Procedures
Power Block Clearance and Tagging
Work Orders
253920, 5394082