ML041910206
| ML041910206 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 07/08/2004 |
| From: | Chamberlain D Division of Reactor Safety IV |
| To: | Overbeck G Arizona Public Service Co |
| References | |
| 4-2002-052, EA-04-100 IR-04-011 | |
| Download: ML041910206 (25) | |
See also: IR 05000528/2004011
Text
July 8, 2004
Gregg R. Overbeck, Senior Vice President, Nuclear
Arizona Public Service Company
P.O. Box 52034
Phoenix, AZ 85072-2034
SUBJECT: PALO VERDE NUCLEAR GENERATING STATION, UNITS 1, 2, AND 3 - NRC
INSPECTION REPORT 05000528/2004011, 05000529/2004011,
05000530/2004011 AND INVESTIGATION REPORT 4-2002-052
Dear Mr. Overbeck:
This refers to the inspection conducted by the Nuclear Regulatory Commission (NRC) into the
circumstances of an October 4, 2002, incident involving the movement of irradiated fuel. The
purpose of the inspection was to follow up on a failure to follow procedural requirements that
resulted in damage to an irradiated fuel assembly. In addition, certain aspects of this incident
were investigated by the NRCs Office of Investigations. On June 10, 2004, Mr. Anthony Gody
of my staff discussed the results of the NRCs review of this incident with you and members of
your staff.
This inspection was an examination of activities conducted under your license as they relate to
safety and compliance with the Commissions rules and regulations and with the conditions of
your license. Within these areas, the inspection consisted of selected examination of
procedures and representative records, observations of activities, and interviews with
personnel.
Based on the results of this inspection, an apparent violation of NRC requirements was
identified involving a failure to promptly and adequately communicate important aspects of this
incident to appropriate Palo Verde Nuclear Generating Station (PVNGS) management
personnel. A detailed discussion of the apparent violation is in the enclosed inspection report.
Based on its review of all of the circumstances surrounding this incident, the NRC is concerned
that this communication failure may have involved willfulness, i.e., careless disregard for
PVNGS procedural requirements that are designed to assure that incidents of this significance
are promptly communicated to appropriate levels of plant management. Specifically, it appears
that details regarding the seriousness of the incident and steps taken by the spent fuel handling
machine operator immediately following the incident were not communicated to appropriate
levels of plant management. The NRC is concerned that these communication failures
prevented PVNGS management from assessing the circumstances of this incident in a timely
manner and taking appropriate corrective actions before fuel handling resumed.
Arizona Public Service Company -2-
This apparent violation is being considered for escalated enforcement action in accordance with
the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement
Policy), NUREG-1600. The current Enforcement Policy is available on the NRCs Web site at
www.nrc.gov; select What We Do, Enforcement, then Enforcement Policy. Since the NRC
has not made a final determination in this matter, no Notice of Violation is being issued for this
apparent violation at this time. In addition, please be advised that the characterization of the
apparent violation described in the enclosed inspection report may change as a result of further
NRC review.
As discussed with you by telephone, before making a final enforcement decision in this matter,
the NRC would like to discuss the apparent violation in a predecisional enforcement
conference. The conference, which will be closed to public observation and transcribed, has
been scheduled for August 20, 2004, in the NRCs Region IV office in Arlington, Texas. The
decision to hold a predecisional enforcement conference does not mean that the NRC has
made a final determination that a violation has occurred or that enforcement action will be
taken. This conference is being held to obtain information to assist the NRC in making an
enforcement decision. This may include information to determine whether a violation occurred,
information to determine the significance of a violation, including whether willfulness was
involved, and information related to any corrective actions taken or planned. The conference
will provide an opportunity for you to provide your perspective on these matters and any other
information that you believe the NRC should take into consideration in making a final
enforcement decision. You will be advised by separate correspondence of the results of our
deliberations on this matter. No response regarding the apparent violation is required at this
time.
In addition to the apparent violation, the NRC also has identified four issues that were evaluated
under the risk significance determination process as having very low safety significance
(green). Three of the findings were determined to be violations of NRC requirements. These
violations, which are described in the enclosed inspection report, are being treated as noncited
violations, consistent with Section VI.A of the Enforcement Policy. If you contest the violations
or the significance of the noncited violations, you should provide a response within 30 days of
the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory
Commission, ATTN: Document Control Desk, Washington DC 20555-0001, with copies to the
Regional Administrator, NRC Region IV, the Director, Office of Enforcement, United States
Nuclear Regulatory Commission, Washington, DC 20555-0001, and the NRC Resident
Inspector at PVNGS.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its
enclosure will be made available electronically for public inspection in the NRC Public
Document Room or from the NRCs document system (ADAMS), accessible from the NRC
Web site at http://www.nrc.gov/reading-rm/adams.html.
Sincerely,
//RA//
Dwight D. Chamberlain, Director
Division of Reactor Safety
Arizona Public Service Company -3-
Dockets: 50-528; 50-529; 50-530
Licenses: NPF-41; NPF-51; NPF-74
Enclosure:
Inspection Report 05000528/2004-011; 05000529/2004-011
w/Attachment Supplemental Information
cc w/enclosure:
Steve Olea
Arizona Corporation Commission
1200 W. Washington Street
Phoenix, AZ 85007
Douglas K. Porter, Senior Counsel
Southern California Edison Company
Law Department, Generation Resources
P.O. Box 800
Rosemead, CA 91770
Chairman
Maricopa County Board of Supervisors
301 W. Jefferson, 10th Floor
Phoenix, AZ 85003
Aubrey V. Godwin, Director
Arizona Radiation Regulatory Agency
4814 South 40 Street
Phoenix, AZ 85040
M. Dwayne Carnes, Director
Regulatory Affairs/Nuclear Assurance
Palo Verde Nuclear Generating Station
Mail Station 7636
P.O. Box 52034
Phoenix, AZ 85072-2034
Hector R. Puente
Vice President, Power Generation
El Paso Electric Company
310 E. Palm Lane, Suite 310
Phoenix, AZ 85004
Jeffrey T. Weikert
Assistant General Counsel
El Paso Electric Company
Mail Location 167
123 W. Mills
El Paso, TX 79901
Arizona Public Service Company -4-
John W. Schumann
Los Angeles Department of Water & Power
Southern California Public Power Authority
P.O. Box 51111, Room 1255-C
Los Angeles, CA 90051-0100
John Taylor
Public Service Company of New Mexico
2401 Aztec NE, MS Z110
Albuquerque, NM 87107-4224
Cheryl Adams
Southern California Edison Company
5000 Pacific Coast Hwy. Bldg. DIN
San Clemente, CA 92672
Robert Henry
Salt River Project
6504 East Thomas Road
Scottsdale, AZ 85251
Brian Almon
Public Utility Commission
William B. Travis Building
P.O. Box 13326
1701 North Congress Avenue
Austin, TX 78701-3326
Arizona Public Service Company -5-
Electronic distribution by RIV:
Regional Administrator (BSM1)
DRP Director (ATH)
DRS Director (DDC)
Senior Resident Inspector (GXW2)
Branch Chief, DRP/D (TWP)
Senior Project Engineer, DRP/D (JAC)
Staff Chief, DRP/TSS (PHH)
RITS Coordinator (KEG)
Jennifer Dixon-Herrity, OEDO RIV Coordinator (JLD)
PV Site Secretary (vacant)
C. Nolan, OE (MCN)
G. Sanborn, ACES (GFS)
M. Vasquez, ACES (GMV)
S. Lewis, OGC (SHL)
PV Site Secretary (vacant)
ADAMS: : Yes * No Initials: __JFD____
- Publicly Available * Non-Publicly Available * Sensitive : Non-Sensitive
DOCUMENT: R:\_PV\2004\PV2004-011rp-jfd.wpd
OE:OB SOE:OB C:OB ACES C:PBD D:DRS
JFDrake/lmb PCGage ATGody GSanborn TPruett DDChamberlain
/RA/ GEWerner for /RA/ RXWise for CJPaulk for /RA/
7 /1 /04 7/8 /04 7/8/04 7/8 /04 7/8/04 7/8/04
OFFICIAL RECORD COPY T=Telephone E=E-mail F=Fax
ENCLOSURE
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Dockets: 50-528; 50-529; 50-530
Licenses: NPF-41; NPF-51; NPF-74
Report No.: 05000528/2004-011; 05000529/2004-011; 05000530/2004-011
Licensee: Arizona Public Service Company
Facility: Palo Verde Nuclear Generating Station, Units 1, 2, and 3
Location: 5951 S. Wintersburg Road
Tonopah, Arizona
Dates: January 26 through June 10, 2004
Inspectors: J. F. Drake, Operations Engineer, Operations Branch
P. C. Gage, Senior Operations Engineer, Operations Branch
Approved By: Anthony T. Gody, Chief
Operations Branch
Division of Reactor Safety
-2-
SUMMARY OF FINDINGS
IR 05000528/2004011; 05000529/2004011; 05000530/2004011; January 26 through June 10,
2004; Palo Verde Nuclear Generating Station, Units 1, 2, and 3
The report covered a period of an announced inspection by two regional operations engineers
Three Green noncited violations, one Green finding, and one apparent violation with the safety
significance to be determined were identified. The significance of most findings is indicated by
its color (Green, White, Yellow, Red) using Inspection Manual Chapter 0609, "Significance
Determination Process." Findings for which the Significance Determination Process does not
apply may be green or be assigned a severity level after NRC management review. The NRCs
program for overseeing the safe operation of commercial nuclear power reactors is described in
NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000.
NRC-Identified and Self Revealing Findings
Cornerstone: Initiating Events
Inspector Identified Findings
GREEN. The inspectors identified a noncited violation of Technical Specification 5.4.1
associated with a failure to operate the spent fuel handling machine in accordance with
Procedure 78OP-9FX03, Spent Fuel Handling Machine, Revision 16. There were
three instances of this: (1) On October 4, 2002, the spent fuel handling machine
operator moved fuel assemblies of two differing weights and was not cognizant of
design differences of the fuel assemblies and did not stop fuel movement when the load
was greater than 50 lbs. different from expected; (2) On October 4, 2002, the spent fuel
handling machine operator failed to verify that the hoist was in its full up position prior to
moving a spent fuel assembly, and (3) later on October 4, 2002, another spent fuel
handling operator failed to verify that the hoist was in its full up position prior to moving a
spent fuel assembly. In both Examples (2) and (3), the operators failed to verify the UP
LIMIT light was on and failed to verify the hoist indicator was at the UPLIMIT. As a
result, in Example (3), the one fuel assembly was damaged. These issues were
contrary to Procedure 78OP-9FX03 and resulted in damage to the lower grid assembly
of Fuel Assembly P1M316.
This finding is greater than minor because it had an actual impact of damage to an
irradiated fuel assembly and, therefore, could be reasonably viewed as a precursor to a
significant event. If the fuel cladding had failed, it could have caused a release of fission
products to the environment. The finding is of very low safety significance because all
mitigation systems were available during the fuel movement operations and should have
prevented an unplanned release of radioactive material to the environment above the
limits of 10 CFR Part 100. This finding also had crosscutting aspects in the area of
human performance. (Section 4OA2 1.b.1.a)
GREEN. The inspectors identified a noncited violation of Technical Specification 5.4.1
associated with an inadequate abnormal operating procedure. Specifically, the
inspectors determined that PVNGS Procedure 40AO-9ZZ22, Fuel Damage,
-3-
Revisions 1 through 6, were not adequate in that the entry conditions never required
operations personnel to enter the procedure and take actions to mitigate the event.
Step 1.1 states, in part, Section 3.0, Irradiated Fuel Damage may be entered when any
of the following conditions exist . . . when equipment or component failures result in any
of the following: irradiated fuel assembly contacting a solid structure; bubbles emerging
from a spent fuel assembly; bent, twisted, or warped spent fuel assembly; or visual
damage to spent fuel pin cladding. Since this abnormal operating procedure was never
entered, applicable actions were never considered during the Fuel Assembly P1M316
event.
This finding is greater than minor because actions taken in response to fuel handling
errors could result in significant fuel cladding damage and effect the barrier cornerstone.
The finding is of very low safety significance because all mitigation systems were
available and should have prevented an unplanned release of radioactive material to the
environment above the limits of 10 CFR Part 100. This finding also had crosscutting
aspects in the area of problem identification and resolution. (Section 4OA2 1.b.1.b)
GREEN. The inspectors identified a self-revealing finding of very low safety significance
(green) associated with the material condition of the spent fuel handling machine. A
number of issues related to material condition, which affected spent fuel handling
machine operations, was identified. These included intermittent overload and underload
conditions with no identified cause, upender limit switches that often failed or required
adjustments during fuel movement, an unreliable hydraulic power unit for the upender
machine which occasionally resulted in the upender drifting from the vertical position,
and the spent fuel handling machine trolley occasionally stopped for no apparent
reason.
This finding is greater than minor because it had an actual impact resulting in damage to
an irradiated fuel assembly and, therefore, could be reasonably viewed as a precursor to
a significant event. If the fuel cladding had failed, it could have caused a release of
fission products. The finding is of very low safety significance because all mitigation
systems were available and should have prevented an unplanned release of radioactive
material to the environment above the limits of 10 CFR Part 100. (Section 4OA2 1.b.2)
TBD. The inspectors identified an apparent violation of 10 CFR Part 50, Appendix B,
Criterion XVI. Specifically, the licensee established measures to assure that conditions
adverse to quality are promptly identified and corrected in Procedure 90DP-0IP10,
Condition Reporting. Procedure 90DP-0IP10, Revision 15, Step 3.1.2, required that
the shift manager be promptly notified if a condition required immediate action to ensure
the safety of plant personnel or equipment. Additionally, Procedure 90DP-0IP10,
Appendix B, requires verbal notification to the leader and to the appropriate shift
manager. The SFHM operator failed to notify the shift manager and department leader
for fuel operations that he took actions which he felt were necessary to place the fuel
assembly in a safe condition. Additionally, it appears that details regarding the
seriousness of the incident and steps taken by the SFHM operator immediately following
the incident were not communicated to appropriate levels of plant management (See
Section 4OA2 1.b). The failure to notify the shift manager and department leader for
fuel operations resulted in an inappropriate organizational response to the Fuel
-4-
Assembly P1M316 event that did not involve station management in the decision-
making process.
This apparent violation was greater than minor because it had an actual impact on
management response for damage to an irradiated fuel assembly and, therefore, could
be reasonably viewed as a precursor to a significant event. If the fuel cladding had
failed, it could have caused a release of fission products. The safety significance of this
finding will be determined pending the outcome of the predecisional enforcement
conference. (Section 4OA2 1.b.3)
GREEN. The inspectors identified a noncited violation of 10 CFR Part 50, Appendix B,
Criterion XVI, Corrective Action, for failing to effectively correct conditions adverse to
quality that contributed to the damage to irradiated Fuel Assembly P1M316.
Specifically, Criterion XVI states, in part, that . . . conditions adverse to quality, such as
malfunctions, deficiencies, deviations, defective material and equipment, and
nonconformances are promptly identified and corrected." The licensee failed to
effectively correct conditions adverse to quality, which included repeated violations of
equipment operating procedures and conduct of operations procedures, as well as
long-standing degraded material condition of the fuel handling equipment, that ultimately
contributed to the damage of irradiated Fuel Assembly P1M316.
This finding is greater than minor because it had an actual impact of damage to an
irradiated fuel assembly and, therefore, could be reasonably viewed as a precursor to a
significant event. If the fuel cladding had failed, it could have caused a release of fission
products. The finding is of very low safety significance because all mitigation systems
were available and should have prevented an unplanned release of radioactive material
to the environment above the limits of 10 CFR Part 100. This finding also had
crosscutting aspects in the area of problem identification and resolution. (Section 4OA2
1.b.4)
REPORT DETAILS
4. OTHER ACTIVITIES
4OA2 Problem Identification and Resolution
1. Spent Fuel Handling
a. Inspection Scope
The inspectors evaluated the circumstances surrounding a series of spent fuel handling
errors that culminated in damage to an irradiated fuel assembly (P1M316) on October 4,
2002, and a failure to enter the issues related to the fuel handling errors into the
corrective action program until NRC involvement. The scope of the inspection included
a review of: (1) procedural requirements associated with spent fuel handling in the fuel
building, such as, communications with licensed operators and the control room, the
conduct of operations, equipment operating procedures, abnormal and emergency
operations, and the decision making command structure following an abnormal event
involving potentially damaged fuel; (2) training and qualifications of refueling machine
operators, spent fuel handling machine (SFHM) operators, senior reactor operators
limited to fuel handling (LRSO), and other personnel involved in the movement of fuel;
(3) the specific circumstances associated with fuel movement errors which occurred on
October 4, 2002; (4) the failure to identify and correct operating issues associated with
previous fuel handling issues; and (5) a detailed review of external factors, such as, the
material condition and reliability of refueling equipment, quality of and adherence to
procedures, refueling operations command and control, fatigue, schedule related
pressures, human interactions, effectiveness of peer reviews, etc.
b. Assessment
Introduction. On October 4, 2002, improper spent fuel handling operations at the facility
resulted in damage to an irradiated fuel assembly. While specific corrective actions had
been implemented from previous events, they were not entirely effective in addressing
the cumulative effects of fuel handling issues. These problems were found to include
procedural issues, ineffective communications, and a tolerance for operating degraded
equipment.
In the Procedure Issues Section below, the inspectors identified one self-revealing
Green noncited violation associated with the licensees failure to follow refueling
procedure and one self-revealing Green noncited violation associated with an
inadequate abnormal operating procedure for damaged fuel. In the Material Condition
Issues Section below, the inspectors identified one self-revealing Green finding
associated with the poor material condition of the SFHM and its effect on operations. In
the Communications Issues Section below, the inspectors identified one apparent
violation associated with inadequate communications between the SFHM operator, the
shift manager, and the department leader for fuel handling. Finally, in the Corrective
Actions Section below, the inspectors identified one self-revealing Green noncited
violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for failing to
effectively correct numerous operating issues associated with previous fuel movements
which ultimately resulted in damage to Fuel Assembly P1M316.
-2-
Event Description, Root and Contributing Causes
According to the licensees investigation, at approximately 10 p.m. on October 4, 2002,
the SFHM operator grappled Fuel Assembly P1M316 from the upender machine.
While hoisting Fuel Assembly P1M316 out of the upender, the SFHM operator thought
the UPLIMIT light on the SFHM control console was lit, which was one of the
indications that Fuel Assembly P1M316 had cleared the upender machine. The SFHM
Procedure 78OP-9FX03, Revision 16, Step 4.3.18, stated, Raise hoist until UPLIMIT
light is on. Check hoist indicator to ensure UPLIMIT has been reached. Although the
UPLIMIT light was believed to be checked, the hoist indicator was not checked by the
operator. The SFHM operator trolleyed the SFHM out of the fuel handling zone of the
spent fuel pool and gave permission to the second operator to sequence the upender
machine to the containment position. As the upender machine was sequencing to the
containment position, the SFHM trolley motion stalled. Once the operators recognized
that Fuel Assembly P1M316 had not cleared the upender machine, the upender
machine sequence was stopped. According to interviews with personnel both directly
and remotely involved in the event, approximately 7 inches of the lower part of Fuel
Assembly P1M316 was stuck in the upender machine while the top of Fuel
Assembly P1M316 was still grappled to the SFHM. Descriptions of the actual position of
Fuel Assembly P1M316 were varied, but it is believed that the upender was
approximately 5 to 10 degrees from vertical, and the SFHM trolley had traveled
approximately 1.5 to 3 feet from the upender position.
The licensee identified that the root cause of the October 4, 2002, fuel damage event
was that the SFHM operator failed to ensure that Fuel Assembly P1M316 was clear of
the upender machine before moving the SFHM trolley away and authorizing the
movement of the upender machine back to the containment position. This was
contrary to Procedure 78OP-9FX03 and resulted in damage to the lower grid of Fuel
Assembly P1M316. Other notable issues contributed to the failure to verify that Fuel
Assembly P1M316 was clear of the upender machine before moving the SFHM, these
included: inadequate self- and peer-checking, inadequate procedure use, schedule
pressure, unclear definitions of responsibilities and authorities between the SFHM
operator and the peer checker, inadequate communications on the spent fuel handling
machine, weaknesses in training of fuel handling personnel, and a number of equipment
design and reliability issues resulting in a lack of sensitivity to certain alarms and
indications. Each of these issues, their regulatory implications, and corrective actions
are discussed in the sections below.
Recovery Actions, Root and Contributing Causes
As discussed above, the SFHM operator recognized that Fuel Assembly P1M316 was
stuck in the upender machine because the SFHM trolley had stalled during SFHM
trolley movement. The SFHM operator stated that he believed he had notified the on-
shift LSRO and the reactor engineer stationed in the control room of the problem with
Fuel Assembly P1M316. The SFHM operator stated that he also believed that the shift
manager had been appropriately notified. The licensees investigation found that
implementation of the procedural requirement to maintain direct communications
between the control room and personnel at the refueling station described in
Procedure 72IC-9RX03, Nuclear Administrative and Technical Manual, Appendix C,
-3-
was not effective. This became apparent through interviews, which demonstrated that,
in reality, communications between personnel on the SFHM, LSRO1 in the containment
building, the reactor engineer, and the shift manager did not result in a clear
understanding of what occurred with Fuel Assembly P1M316.
After the SFHM trolley had stalled and the SFHM operator found the electrical SFHM
controls inoperable, the SFHM operator then installed a manual hand wheel on the
SFHM trolley and manually hand cranked the SFHM trolley toward the upender machine
in an effort to more vertically orient Fuel Assembly P1M316. During interviews, the
SFHM operator indicated that the safest orientation for Fuel Assembly P1M316 was
vertical over the hoist. The hand-cranking evolution, although not prohibited by
procedures, was conducted without authorization from LSRO1 or from the control room.
During interviews, LSRO1 indicated that he ordered the SFHM operator to stop fuel
movement in the fuel building. The actual timing of LSRO1s order and hand-cranking
of the SFHM trolley could not be confirmed. Therefore, the team could not establish if
the SFHM trolley was moved after the order was given. Regardless, no other individuals
but those on the SFHM were aware that the SFHM trolley had been manually
repositioned over the upender machine. Interviews with the SFHM operator indicated
that the SFHM trolley was manually moved to place Fuel Assembly P1M316 in a safe
condition. With respect to the premise behind moving the SFHM trolley manually to
place Fuel Assembly P1M316 in a safe condition, the team concluded that the manual
movement of the SFHM trolley with Fuel Assembly P1M316 suspended between the
SFHM and the upender machine without LSRO1 and shift manager involvement was not
appropriate. Furthermore, the team concluded that it would have been a more
appropriate decision to evaluate the potential for additional damage to or dropping Fuel
Assembly P1M316 before manually hand-cranking the SFHM trolley. After reviewing
the design of the grapple assembly and the position of Fuel Assembly P1M316, the
team concluded the following: (1) Fuel Assembly P1M316 was stable following the
overload trip of the SFHM trolley, and (2) dropping Fuel Assembly P1M316 during hand-
cranking was not a probable event.
In an effort to understand the communications that took place between the SFHM
operator and others on the communications circuit, a number of personnel were
interviewed. The LSRO1 indicated that he remembered being informed by the SFHM
operator that Fuel Assembly P1M316 was stuck in the upender. The LSRO1 indicated
that even though he asked a number of pertinent questions, he was not getting a clear
picture of what happened in the fuel building. The LSRO1 indicated that he surmised
that the SFHM trolley had been moved out of the refueling zone because the interlocks
would have prevented the upender machine from sequencing to the containment
position until the SFHM trolley was at that location. After LSRO1 gave the order to stop
all activities in the fuel building, he contacted another licensed operator limited to fuel
movement (LSRO2), who was not on watch at the time to investigate the status of Fuel
Assembly P1M316. When LSRO2 arrived in the fuel building, he noted that personnel
on the SFHM were about to install a handwheel on the hoist and ordered them to stop.
The LSRO2 asked the personnel on the SFHM what they intended to do and if they had
moved the upender machine. The SFHM operator replied they were about to manually
lift Fuel Assembly P1M316 out of the upender machine and no, they had not moved
the upender machine. It was determined through interviews with the fuel handling team
that the upender machine actually had been sequenced to the containment position
-4-
after the SFHM trolley had been moved out of the fuel handling zone and that the SFHM
trolley had been manually repositioned over the upender after the overload trips had
been received prior to LSRO2 arriving in the fuel building.
The licensee identified that the root cause of the improper actions associated with not
involving LSRO1 and the shift manager in the decision making process following the
Fuel Assembly P1M316 event was that SFHM operators lacked sensitivity to fuel
handling events. Contributing causes identified by the licensee included: (1) previous
corrective actions to improve communications were not effective, (2) pre-job briefings
did not address the notification process for off-normal conditions, (3) the event checklist
did not accomplish its purpose, (4) training and pre-job briefs did not ensure SFHM
operators were knowledgeable of the entry conditions for the abnormal operating
procedure for fuel damage, and (5) senior reactor operators limited to fuel handling were
reluctant to establish communications directly with control room supervision. Each of
these issues, their regulatory implications, and corrective actions are discussed in the
sections below.
Corrective Actions, Root and Contributing Causes
On October 9, 2002, an NRC manager contacted the department leader for fuel
operations to discuss fuel bowing issues. During that discussion, the NRC manager
inquired about operator errors noted in reactor engineering logs. The NRC manager
found that the department leader was not aware of what the operator errors referred to
(ultimately, the Fuel Assembly P1M316 event) and that no corrective actions had been
taken. Following the teleconference, the licensee initiated a Significant Condition
Report/Deficiency Report (CRDR) 2559423 and an investigation was commenced. On
October 10, 2002, the licensee conducted inspections of Fuel Assembly P1M316 and
found damage that resulted in the fuel assembly not being reloaded.
The inspectors identified several issues related to the implementation of the licensees
problem identification and resolution program. The first issue was that the initial actions
taken by the SFHM operator to recover Fuel Assembly P1M316 were not in accordance
with procedures on conduct of operations and condition reporting (see below). Second,
the licensee failed to take corrective actions to resolve previous operational issues
surrounding the fuel movement (some of which involved procedural violations, see
below). This was particularly important since it was noted in the licensees subsequent
investigation that a precursor event had occurred when an SFHM operator was moving
an irradiated fuel assembly while it was not at the UPLIMIT position. Third, no CRDR
had been initiated and no verbal notification to the SFHM operators leader (department
leader for fuel operations) or the shift manager until the NRC manager contacted the
department leader for fuel operations 5 days later. Although the SFHM operator drafted
a statement regarding the events that took place while he was on watch before he left
for home, he did not share that statement with anyone. These issues were contrary to
the condition reporting process (see below). The actual communications that took place
were vague and failed to communicate the pertinent details of the Fuel Assembly
P1M316 event nor did the SFHM operator communicate the subsequent recovery
actions taken independently by the SFHM operator on his own volition. The SFHM
operator indicated that he needed to take those actions to place Fuel Assembly P1M316
in a safe condition.
-5-
.1 Procedure Issues
.1a Failure to follow Procedures
Introduction. Three examples of a Green noncited violation were identified for failure to
follow procedures as prescribed in Technical Specification 5.4.1.
Description. On October 4, 2002, during core offload, there were three instances where
licensee personnel failed to operate the spent fuel handling machine in accordance with
Procedure 78OP-9FX03, Spent Fuel Handling Machine, Revision 16. As a result of
failing to follow procedures, Fuel Assembly P1M316 was damaged and was
subsequently not reloaded into the core due to the damage. These errors were
documented in CRDR 2711453.
In the root cause analysis for CRDR 2711453 and subsequent interviews with refueling
personnel, it was determined that there had been numerous overload trips of the spent
fueling handling machine, with no apparent cause. The licensee identified the cause of
these overload trips as being associated with the overload setpoint of the spent fuel
handling machine (approximately 1633+ 12.5lbs). The core was loaded with two
different fuel assembly designs. One fuel assembly weighed approximately 1600 lbs.
and the other weighed approximately 1750 lbs. The SFHM operators were not aware of
the differences in the weight of the fuel assemblies and did not follow Procedure
Step 4.3.17, which required the operator to monitor fuel assembly weights and to stop
and determine the problem if the load was greater than 50 lbs over the expected load.
There were two instances where the SFHM operators failed to verify the hoist had
reached its upper travel limit. Procedure Step 4.3.18, required the operators to verify
that the UPLIMIT light was lit and that the UPLIMIT was reached. The UPLIMIT
was verified by checking a manual position indicator called a Durant counter. Earlier in
the day, the licensee documented an event where the SFHM operators traversed the
spent fuel handling machine trolley out of the fuel handling zone without the fuel
assembly being fully retracted. No fuel damage occurred during this event; however, it
was a precursor to the next event that resulted in fuel damage.
As fuel movement continued, the operators damaged Fuel Assembly P1M316. This
damage was the result of failing to verify the fuel assembly was at the UPLIMIT prior to
moving the fuel assembly away from the upender in the spent fuel pool. For details on
this event see Section 4AO2 1.b.
Analysis. The deficiency associated with this event was that licensee personnel failed to
follow procedures required by Technical Specifications, which resulted in fuel damage.
This finding was more than minor because damage to irradiated Fuel Assembly P1M316
occurred as a result of a failure to follow prescribed procedures. The operating issues
associated with fuel handling operations could be reasonably viewed as a precursor to a
more significant event affecting the barrier integrity cornerstone. The finding is of very
low safety significance because all mitigation systems were available and should have
prevented an unplanned release of radioactive material to the environment above the
limits of 10 CFR Part 100. This finding had crosscutting aspects in the area of human
performance.
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Enforcement
Technical Specification 5.4.1 requires, in part, that written procedures be established,
implemented, and maintained as recommended in Appendix A of Regulatory
Guide 1.33, "Quality Assurance Program Requirements (Operation)," Revision 2,
February 1978. Regulatory Guide 1.33, Revision 2, Appendix A, provides the typical
activities that should be covered by written procedures. Section 2.l. specifies that
general plant operating procedures be developed for refueling and core alterations.
Accordingly, (1) Procedure 78OP-9FX03, Step 4.3.17, required the SFHM operator to
"Monitor load cell indication. It should be +/-50 lbs. of assembly weight (if exceeded, stop
and determine problem before continuing)," and (2) Procedure 78OP-9FX03,
Step 4.3.18, required the SFHM operator to, Raise hoist until UP LIMIT light is on.
Check hoist indicator to ensure UPLIMIT has been reached, prior to moving irradiated
fuel as required by the fuel transfer form.
Contrary to the above: (1) On October 4, 2002, the SFHM operator moved fuel
assemblies of two differing weights and was not cognizant of design differences of the
fuel assemblies and did not stop fuel movement when the load was 50 lbs. greater than
expected. One fuel assembly design weighed approximately 1600 lbs. and the other
weighed approximately 1750 lbs. Because of the lack of knowledge of the two differing
designs of fuel weight, the operator could not have adequately followed the guidance of
the procedural steps listed above. (2) On October 4, 2002, on two occasions, SFHM
operators failed to verify that the hoist was in its full up position prior to moving a spent
fuel assembly. The operators failed to verify the UPLIMIT light was on and failed to
verify the hoist indicator was at the UPLIMIT. As a result, one fuel assembly was
damaged. Because these examples of failure to follow refueling procedures are of very
low safety significance and have been entered into the licensees corrective action
program (CRDR 2711971), this violation is being treated as a noncited violation,
consistent with Section VI.A of the NRC Enforcement Policy: Noncited
Violation 05000528; 05000529;05000530/2004011-01, Failure to Follow Refueling
Procedure 78OP-9FX03, Spent Fuel Handling Machine, Revision 16.
.1b Inadequate Procedure
Introduction. A Green noncited violation was identified for failure to establish an
adequate procedure for an abnormal condition (damaged irradiated fuel assembly) as
prescribed in Technical Specification 5.4.1.
Description. The inspectors determined that the fuel damage abnormal operating
procedure was not adequate. Following the Fuel Assembly P1M316 event, the licensee
identified that SFHM operators were not adequately trained or pre-briefed on the entry
conditions for Procedure 40AO-9ZZ22, Fuel Damage. This, combined with
inadequately defined entry conditions for Procedure 40AO-9ZZ22, contributed to the
failure to take the appropriate actions immediately following the Fuel Assembly P1M316
event. The inspectors determined that PVNGS Procedure 40AO-9ZZ22, Revisions 1
through 6, were inadequate, in that, the entry conditions did not require operations
personnel to enter the procedure and take any immediate actions to mitigate the event.
Specifically, Step 1.1 states, in part, Section 3.0, Irradiated Fuel Damage may be
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entered when any of the following conditions exist . . . when equipment or component
failures result in any of the following: irradiated fuel assembly contacting a solid
structure; bubbles emerging from a spent fuel assembly; bent, twisted, or warped spent
fuel assembly; or visual damage to spent fuel pin cladding. The SFHM operator
contacted a solid structure and damaged the fuel assembly but did not enter
Procedure 40AO-9ZZ22. Although no actual fuel cladding damage occurred during this
event, the inspectors concluded the procedure failed to require any immediate corrective
actions.
Analysis. The inspectors determined this deficiency was an inadequate abnormal
procedure for combating emergencies as required by Technical Specification 5.4.1.
This finding is more than minor because actions taken in response to fuel handling
errors could result in significant fuel cladding damage and effect the barrier cornerstone.
The finding is of very low safety significance because all mitigation systems were
available and should have prevented an unplanned release of radioactive material to the
environment above the limits of 10 CFR Part 100. This finding had crosscutting aspects
in the area of problem identification and resolution.
Enforcement
Technical Specification 5.4.1 requires, in part, that written procedures be established,
implemented, and maintained as recommended in Appendix A of Regulatory
Guide 1.33, "Quality Assurance Program Requirements (Operation)," Revision 2,
February 1978. Regulatory Guide 1.33, Revision 2, Appendix A, provides the typical
activities that should be covered by written procedures. Section 6.x. specifies
procedures for combating emergencies for irradiated fuel damage, including immediate
operator actions.
Contrary to the above, Procedure 40AO-9ZZ22, Fuel Damage, Revisions 1 through 6,
failed to develop entry conditions and required steps that would have resulted in the
immediate operator actions taking place after irradiated Fuel Assembly P1M316 was
stuck in the upender (contacted a solid structure) and was damaged during movement
on October 4, 2004. Specifically, the inspectors determined Procedure 40AO-9ZZ22,
Revisions 1 through 6, were inadequate, in that, the entry conditions did not require
operations personnel to enter the procedure and take immediate actions to mitigate the
event. Step 1.1 states, Section 3.0, Irradiated Fuel Damage may be entered when any
of the following conditions exist: . . . when equipment or component failures result in any
of the following: irradiated fuel assembly contacting a solid structure; bubbles emerging
from a spent fuel assembly; bent, twisted, or warped spent fuel assembly; or visual
damage to spent fuel pin cladding. Since this abnormal operating procedure was never
entered, applicable actions were never considered during the Fuel Assembly P1M316
event. Because this example of an inadequate procedure is of very low safety
significance and has been entered into the licensees corrective action program
(CRDR 2711453), this violation is being treated as a noncited violation, consistent with
Section VI.A of the NRC Enforcement Policy: noncited violation 05000528; 05000529;05000530/2004011-02, Inadequate Procedure 40AO-9ZZ22, Fuel Damage,
Revisions 1 through 6.
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.2 Material Condition
Introduction. The inspectors identified a self-revealing Green finding associated
with a number of SFHM material condition issues that contributed to damage to Fuel
Assembly P1M316.
Description. A number of issues related to material condition, which affected SFHM
operation, were identified. These included intermittent overload and underload
conditions with no identified cause, upender limit switches that often failed or required
adjustments during fuel movement, an unreliable hydraulic power unit for upender
machine, which occasionally resulted in the upender drifting from the vertical position,
and an instance, when the SFHM trolley occasionally stopped for no apparent reason.
The intermittent overload and underload trips and alarms desensitized SFHM operators
to those alarms and may have contributed to the Fuel Assembly P1M316 event because
an overload condition stops hoist movement in a manner similar to the uplimit condition.
The overload condition could be mistaken for an uplimit condition if the SFHM operator
did not verify other indications. That could explain why Fuel Assembly P1M316 had not
cleared the upender machine prior to trolley movement. Past problems with the
upender, such as, limit switch adjustments and hydraulic leakage, resulted in the
upender drifting off vertical and causing overload conditions while moving irradiated fuel
in and out of the upender. These past problems, combined with misstatements about
operation of the upender during the Fuel Assembly P1M316 event, misled operators in
thinking that the Fuel Assembly P1M316 event may have been a result of upender
drifting problems.
During interviews of operators and technicians, the inspectors found that these material
condition problems occasionally resulted in operators opening control cabinets and
manipulating wires and hardware to get the machinery to operate again. In addition, the
inspectors noted that the licensee used a general open work order to document and
facilitate repairs to fuel handling equipment. The general open work order would be
periodically closed and disposed of since it was not considered a quality record. The
practice of not documenting material condition problems in a program capable of
tracking the issues resulted in several problems: (1) many material condition issues
were not retrievable, (2) material condition issues resulting in operational work-arounds
were not reported to station management unless they had a schedule impact,
(3) problem trending was not possible, and (4) no assessment of the cumulative impact
of the material condition problems and their impact on operations was conducted. On
May 17, 2002, CRDR 2506874 was written in an apparent effort to inform management
of continued problems with refueling equipment reliability. The CRDR indicated that
during the last two refueling outages . . . manual operations of limit switches or
associated equipment had to be used to complete core off-load or re-load . . . these are
not ideal means . . . and are precursors to more serious events. The inspectors
reviewed the closure of CRDR 2506874 and found that it had been closed in two other
CRDRs (2507835 and 2512708), which were limited to specific material issues rather
than an overall assessment of the cumulative impacts that the poor SFHM material
condition had on operations.
The licensee implemented a number of corrective actions on or after October 17, 2002,
to address the aforementioned material condition issues. The team reviewed these
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corrective actions and found them to be appropriate with some notable comments,
which are discussed in the Corrective Action section below.
Analysis. The inspectors identified a self-revealing Green finding associated with a
number of SFHM material condition issues that contributed to the Fuel
Assembly P1M316 event. These findings were more than minor because damage to
irradiated Fuel Assembly P1M316 occurred as a result of operational issues that
involved a failure to follow prescribed operating procedures complicated by SFHM
material condition issues. The operational issues associated with fuel handling
operations and Fuel Assembly P1M316 post event actions could be reasonably viewed
as precursors to a more significant event affecting the barrier integrity cornerstone. The
finding is of very low safety significance because all mitigation systems were available
and would have prevented an unplanned release of radioactive material to the
environment above the limits of 10 CFR Part 100 .
Enforcement. None.
.3 Communications
Introduction. An apparent violation was identified for inadequate communications
between the SFHM operator, the shift manager, and the department leader for fuel
handling as prescribed in Procedure 90DP-0IP10, Condition Reporting, Revision 15.
Description. The inspectors identified one apparent violation associated with inadequate
communications between the SFHM operator, the shift manager, and the department
leader for fuel handling. As discussed earlier, LSRO1 indicated he was unable to obtain
a clear picture of what had happened in the fuel building. Also during interviews, the
shift manager and other licensed operators in control indicated that they were not aware
of the spent fuel handling errors that culminated in damage to Fuel Assembly P1M316.
Although the SFHM operator wrote a statement describing the event at the end of the
shift, he did not share the statement with responsible licensee managers until several
days after the event. Finally, the organizational response to the Fuel Assembly P1M316
event indicated that communications between the shift manager, LSRO1, and the SFHM
operator were ineffective in keeping the licensee management informed of the status of
Fuel Assembly P1M316.
As a result of the inadequate communications, responsible licensee managers were not
aware of the event, its significance, and the circumstances until NRC questioning 5 days
later. Given the SFHM operators normal position in the organization (LSRO1 and
LSRO2's supervisor) and familiarity with the condition reporting procedure, it appears he
should have ensured that communication to the appropriate levels of management
occurred to properly identify the causes of the event and to take effective corrective
actions before resuming fuel movement.
Analysis. TBD. The inspectors identified an apparent violation of PVNGS corrective
action procedure. The apparent violation involved inadequate notification and
communications between the SFHM operator, the shift manager, and the department
leader for fuel operations. This finding was more than minor because damage to
irradiated Fuel Assembly P1M316 occurred and ineffective communications contributed
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to the inadequate organizational response to place equipment in a safe condition and
correct operational issues prior to resuming fuel movement. The operational issues
associated with fuel handling operations and Fuel Assembly P1M316 post event actions
could be reasonably viewed as precursors to a more significant event affecting the
barrier integrity cornerstone.
Enforcement. Criterion XVI of 10 CFR Part 50, Appendix B, states, in part, that,
[m]easures shall be established to assure that conditions adverse to quality, such as
malfunctions, deficiencies, deviations, defective material and equipment, and
nonconformances are promptly identified and corrected. In the case of significant
conditions adverse to quality, the measures shall assure that the cause of the condition
is determined and corrective action taken to preclude repetition. The identification of the
significant condition adverse to quality, the cause of the condition, and the corrective
action taken shall be documented and reported to appropriate levels of management.
Accordingly, the licensee established measures to assure that conditions adverse to
quality were promptly identified and corrected in Procedure 90DP-0IP10.
Procedure 90DP-0IP10, Step 3.1.2, required that the shift manager be promptly notified
if a condition required immediate action to ensure the safety of plant personnel or
equipment. Procedure 90DP-0IP10, Appendix B, indicated that if the condition required
immediate action to ensure the safety of plant personnel or equipment, the originator
shall provide verbal notification to his or her leader and to the appropriate shift manager.
In addition, it required a CRDR to be completed as soon as practical.
Contrary to the above, on October 4, 2002, the SFHM operator failed to notify the shift
manager and department leader for fuel operations that he took actions which he felt
were necessary to place the fuel assembly in a safe condition. Additionally, it appears
that details regarding the seriousness of the incident and steps taken by the SFHM
operator immediately following the incident were not communicated to appropriate levels
of plant management (See Section 4OA2 1.b). The failure to notify the shift manager
and department leader for fuel operations resulted in an inappropriate organizational
response to the Fuel Assembly P1M316 event that did not involve station management
in the decision-making process. (AV 05000528; 05000529;05000530/2004011-03)
.4 Corrective Actions
Introduction. The inspectors noted a number of failures to correct the operational issues
associated with refueling activities. This contributed to the damage to Fuel
Assembly P1M316 and was a self-revealing Green noncited violation of 10 CFR Part 50,
Appendix B, Criterion XVI, Corrective Action.
Description. The inspectors reviewed condition reports, root cause analyses, interviews,
and evaluation reports that revealed a broad pattern of operational issues that had not
been corrected before the damaged Fuel Assembly P1M316 event. These previous
operational issues included: failure to conduct adequate pre-job briefs, moving the
spent fuel handling machine with a fuel assembly without the UPLIMIT light, no
second/peer checker, lack of oversight at the spent fuel pool, failure to use the Event
Check List for notification of off normal issues, and failure to reset the SFHM overload
setpoint. The licensee identified all (except moving the SFHM without the "UPLIMIT"
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light, which became self-revealing after damage occurred to Fuel Assembly P1M316) of
the above operational issues after the fall 2001 and spring 2002 refueling outages. The
licensee took corrective actions to address each of these issues; however, while specific
fuel handling program issues were addressed, the corrective actions were not adequate
to correct broad operational issues. For instance, the licensee instituted pre-job briefs,
but the briefs failed to identify the occurrence of hoist overloads and necessity to ensure
the fuel assembly was clear of the upender. In addition, a peer checker was assigned to
the SFHM, but no procedural requirements or guidance was given to or discussed with
the peer checker. In fact, this peer checker was relatively new to the site and had never
done fuel movement and was not aware of his responsibilities as a peer checker. The
inspectors found that these same issues contributed to the damage to Fuel
Assembly P1M316.
The licensee implemented a number of corrective actions before the Fuel
Assembly P1M316 event to address the operational issues. As noted by the licensees
investigation, the corrective actions taken before October 4, 2002, were ineffective at
preventing the Fuel Assembly P1M316 event.
As discussed in Section 4OA2 b.1, the procedural requirements to verify that the
indicated weight of a fuel assembly being moved is within + 50 lbs. of the expected
weight could not be effectively implemented. The problem was, in part, due to no
documentation being provided to the fuel handlers as to the expected weight of the
assembly. In addition, the different assembly weights combined with one set of alarm
setpoints resulted in a number of overload alarms when no overload condition existed.
Preconditioning of operators to alarms resulted in a decrease in the sensitivity to
potential abnormal conditions. The licensee had in fact identified the differences in fuel
assembly weights and had reset the refueling machine overloads to a higher setpoint,
but did not reset the SFHM overload setpoints.
Analysis. The inspectors identified a noncited violation associated with a failure to
properly implement corrective actions associated with previous conditions adverse to
quality. This finding was more than minor because damage to irradiated Fuel
Assembly P1M316 occurred as a result of identified adverse conditions not being
corrected. The operational issues associated with fuel handling operations and Fuel
Assembly P1M316 post event actions could be reasonably viewed as precursors to a
more significant event affecting the barrier integrity cornerstone. The finding is of very
low safety significance because all mitigation systems were available and should have
prevented an unplanned release of radioactive material to the environment above the
limits of 10 CFR Part 100. The finding had crosscutting aspects in the area of problem
identification and resolution.
Enforcement. Criterion XVI of 10 CFR Part 50, Appendix B, states, in part, that,
Measures shall be established to assure that conditions adverse to quality, such as
malfunctions, deficiencies, deviations, defective material and equipment, and
nonconformances are promptly identified and corrected.
Contrary to the above, the licensee failed to effectively correct conditions adverse to
quality that contributed to the damage of irradiated Fuel Assembly P1M316. Because
the damage to Fuel Assembly P1M316 did not involve damage to the cladding, the
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ineffective corrective actions were of very low safety significance and have been entered
into the licensees corrective action program as CRDR 2711971. This violation is being
treated as a noncited violation consistent with Section VI.A of the NRC Enforcement
Policy: Noncited Violation 05000528; 05000529;05000530/2004011-04, Ineffective
Corrective Actions.
4OA6 Meetings, Including Exit
On June 10, 2004, the inspectors presented the inspection results to Greg Overbeck
and other members of his staff who acknowledged the findings. The inspectors
confirmed that proprietary information was not provided or examined during this
inspection
ATTACHMENT
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee personnel
G. Overbeck, Senior Vice President
David Mauldin, Vice President Engineering and Support
D. Smith, Plant Manager
W. Chapin, Nuclear Fuel Management Department Leader
S. Bauer, Regulatory Affairs Department Leader
J. Taylor, Operations Department Leader
P. Crawley, Life Cycle Management Director
C. Seaman, Nuclear Fuel Management Director
R. Henry, Site Representative
R. Buzzard, Regulatory Affairs Senior Consultant
K. Manne, Senior Attorney
J. Gutierrez, Attorney
NRC personnel
N. Salgado, Senior Resident Inspector
J. Melfi, Resident Inspector
LIST OF ITEMS OPENED AND CLOSED
Opened and Closed
05000528; 05000529; NCV Failure to Follow Refueling Procedure 78OP-9FX03,05000530/2004011-01 Spent Fuel Handling Machine, Revision 16, resulting in
damage to irradiated Fuel Assembly P1M316
(Section 40A2 1.b.1.a)
05000528; 05000529; NCV Inadequate Procedure 40AO-9ZZ22, Fuel Damage,05000530/2004011-02 Revisions 1 through 6 (Section 40A2 1.b.1.b)
05000528; 05000529; NCV Inadequate corrective actions contributed to damage to
05000530/2004011-04 fuel assembly. (Section 40A2 1.b.4)
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Opened
05000528; 05000529; AV Failure to effectively notify the shift manager and
05000530/2004011-03 department leader for fuel operations resulted in an
inappropriate organizational response to the Fuel
Assembly P1M316 event that did not involve station
management in the decision-making process
(Section 40A2 1.b.3)
LIST OF DOCUMENTS REVIEWED
Procedures
78OP-9FX03 Spent Fuel Handling Machine, Revision 14
78OP-9FX03 Spent Fuel Handling Machine, Revision 15
78OP-9FX03 Spent Fuel Handling Machine, Revision 16
78OP-9FX03 Spent Fuel Handling Machine, Revision 17
78OP-9FX03 Spent Fuel Handling Machine, Revision 18
78OP-9FX03 Spent Fuel Handling Machine, Revision 19
78OP-9FX03 Spent Fuel Handling Machine, Revision 20
78OP-9FX03 Spent Fuel Handling Machine, Revision 21
78OP-9FX02 Fuel Transfer Machine, Revision 7
78OP-9FX02 Fuel Transfer Machine, Revision 8
78OP-9FX02 Fuel Transfer Machine, Revision 9
78OP-9FX01 Refueling Machine Operations, Revision 12
78OP-9FX01 Refueling Machine Operations, Revision 13
78OP-9FX01 Refueling Machine Operations, Revision 14
78OP-9FX01 Refueling Machine Operations, Revision 15
78OP-9FX01 Refueling Machine Operations, Revision 16
78ST-9FH02 Fuel Building Crane Travel, Revision 5
40DP-9AP18 Abnormal Operating Procedures Users Guide, Revision 2
40DP-9OP33 Shift Turnover, Revision 12
72IC-9RX03 Core Reloading, Revision 15
72IC-9RX03 Core Reloading, Revision 16
72IC-9RX03 Core Reloading, Revision 17
72IC-9RX03 Core Reloading, Revision 18
72IC-9RX03 Core Reloading, Revision 19
72IC-9RX03 Core Reloading, Revision 20
72IC-9RX03 Core Reloading, Revision 21
40AO-9ZZ22 Fuel Damage, Revision 1
40AO-9ZZ22 Fuel Damage, Revision 2
40AO-9ZZ22 Fuel Damage, Revision 3
40AO-9ZZ22 Fuel Damage, Revision 4
40AO-9ZZ22 Fuel Damage, Revision 5
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40AO-9ZZ22 Fuel Damage, Revision 6
40AO-9ZZ22 Irradiated Fuel Damage, Revision 0
40DP-9OP02 Conduct of Shift Operations, Revision 17
40DP-9OP02 Conduct of Shift Operations, Revision 18
40DP-9OP02 Conduct of Shift Operations, Revision 19
40DP-9OP02 Conduct of Shift Operations, Revision 20
40DP-9OP02 Conduct of Shift Operations, Revision 21
40DP-9OP02 Conduct of Shift Operations, Revision 22
40DP-9OP02 Conduct of Shift Operations, Revision 23
40DP-9OP02 Conduct of Shift Operations, Revision 24
40DP-9OP02 Conduct of Shift Operations, Revision 25
40DP-9OP02 Conduct of Shift Operations, Revision 26
40DP-9OP02 Conduct of Shift Operations, Revision 27
40DP-9OP02 Conduct of Shift Operations, Revision 28
78TI-9RX01 Spent Fuel Inspection, Revision 1
30DP-9MP12 Overhead Hoisting Systems, Revision 10
90DP-0IP10 Condition Reporting, Revision 15
84DP-0RM30 Record Control and Turnover, Revision 15
72DP-9NF01 Control of SNM and Inventory, Revision 9
40ST-9ZZM6 Operations Mode 6 Surveillance Logs, Revision 5
70DP-0OP18 Engineering Test Conduct
01DP-0EM10 Fitness for Duty Program, Revision 13
40OP-9ZZ23 Outage GOP, Revision 25
Limited Senior Reactor Operator Initial Training Program
Fuel Handlers Training Program
Training Records for Fuel Handlers
Training Records for Reactor Engineers
Training Records for LSROs
Qualification Records for various operators
Palo Verde Nuclear Fuel System Design Dimensions Fuel Assembly plus Rod Assemblies
Condition Report Deficiency Reports related to Refueling from 27 April 2001 to 24 January 2004.
Work Orders associated with refueling equipment
Controlled Work Packages for refueling equipment