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IR 05000528-12-002, 05000529-12-002, 05000530-12-002, 01/01/2012 - 03/31/2012; Palo Verde Nuclear Generating Station; Integrated Resident & Regional Inspection Report; Maintenance Risk Assessment & Emergency Work Evaluation,Operation Evalua
	ML12136A479
Person / Time
Site:	Palo Verde
Issue date:	05/15/2012
From:	Ryan Lantz; NRC/RGN-IV/DRP/RPB-D
To:	Edington R; Arizona Public Service Co
References
	IR-12-002
	Download: ML12136A479 (56)
	v • d • e

UNITED STATES NUCLEAR REGULATORY COMMISSION May 15, 2012

SUBJECT:

PALO VERDE NUCLEAR GENERATING STATION -- NRC INTEGRATED INSPECTION REPORT 05000528/2012002, 05000529/2012002, and 05000530/2012002

Dear Mr. Edington:

On March 31, 2012, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Palo Verde Nuclear Generating Station Units 1, 2, and 3. The enclosed inspection report documents the inspection results which were discussed on April 6, 2012, with Mr. R.

Bement, Senior Vice President, Site Operations, and other members of your staff.

The inspections examined 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.

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

Four NRC-identified and three self-revealing findings of very low safety significance (Green)

were identified during this inspection.

These findings were determined to involve violations of NRC requirements. Additionally, the NRC has determined that one traditional enforcement Severity Level IV violation occurred. The traditional enforcement violation was associated with the aforementioned findings. Further, a licensee-identified violation that was determined to be of very low safety significance is listed in this report. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.

If you contest these non-cited 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, Region IV; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; 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 Regional Administrator, Region IV; and the NRC Resident Inspector at Palo Verde Nuclear Generating Station.

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

Sincerely,

/RA/

Ryan Lantz, Chief Project Branch D Division of Reactor Projects Docket Nos.: 50-528, 50-529, 50-530 License Nos.: NPF-41, NPF-51, NPF-74

Enclosure:

NRC Inspection Report 05000528/2012002, 05000529/2012002, and 05000530/2012002 w/Attachment: Supplemental Information

REGION IV==

Docket: 50-528, 50-529, 50-530 License: NPF-41, NPF-51, NPF-74 Report: 05000528/2012002, 05000529/2012002, 05000530/2012002 Licensee: Arizona Public Service Company Facility: Palo Verde Nuclear Generating Station, Units 1, 2, and 3 Location: 5951 South Wintersburg Road Tonopah, Arizona Dates: January 1 through March 31, 2012 Inspectors: M.A. Brown, Senior Resident Inspector M. Baquera, Resident Inspector D. Reinert, Resident Inspector E. Uribe, Reactor Inspector D. Bradley, Reactor Inspector G. Guerra, CHP, Emergency Preparedness Inspector S. Hedger, Operations Engineer Approved Ryan Lantz, Chief, Project Branch D By: Division of Reactor Projects

SUMMARY OF FINDINGS

IR 05000528, 529, 530/2012002, 01/01/2012 - 03/31/2012; Palo Verde Nuclear Generating

Station; Integrated Resident & Regional Inspection Report; Maintenance Risk Assessment &

Emergency Work Evaluation, Operation Evaluations, Correction of EP Weakness & Deficiency,

Identification & Resolution of Problems.

The report covered a 3-month period of inspection by resident inspectors and an announced baseline inspection by region-based inspectors. Eight Green non-cited violations of significance were identified. The significance of most findings is indicated by their color (Green, White,

Yellow, or Red) using Inspection Manual Chapter 0609, Significance Determination Process.

The cross-cutting aspect is determined using Inspection Manual Chapter 0310, Components Within the Cross Cutting Areas. Findings for which the significance determination process does not apply may be Green or be assigned a severity level after NRC management review.

The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006.

NRC-Identified Findings and Self-Revealing Findings

Cornerstone: Initiating Events

Green.

The inspectors reviewed a self-revealing non-cited violation of 10 CFR 50.65a(4), for the licensees failure to assess and manage an increase in risk prior to planned maintenance activities. Specifically, on January 25, 2012, the licensee failed to include the potential to deenergize a 4.16 kV bus when working on a control room hand switch in the risk assessment for Unit 2, resulting in an unplanned reactor power cutback. The licensee plans to revise procedures, as a corrective action, to develop and implement a structured operational risk assessment process for use by the senior reactor operator when authorizing un-scheduled work to commence in the field. The licensee entered this issue into the corrective action program as Palo Verde Action Request (PVAR) 4036588.

The licensees failure to assess and manage an increase in risk prior to planned maintenance activities was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affects the equipment performance attribute of the Initiating Events Cornerstone and its objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Because the licensee utilizes a qualitative risk assessment for these maintenance activities, Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, Flowchart 2, could not be used to determine the risk significance of the finding. Using the qualitative review process of Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, the finding is determined to have very low safety significance (Green) because it did not result in any additional loss of defense in depth systems, and an assessment by the senior reactor analyst determined the increase in risk due to the initiating event was very small. This finding had a cross-cutting aspect in the area of human performance associated with the resources component because the licensee failed to ensure complete and accurate procedures and work packages are adequate to assure nuclear safety H.2(c) (Section 1R13).

SL-IV. The inspectors identified a Severity Level IV non-cited violation of License Conditions 2.C.7, 2.C.6, and 2.F for Palo Verde Units 1, 2, and 3, respectively, for the licensees failure to maintain the reactor coolant pumps in compliance with fire protection requirements. Specifically, the licensee failed to evaluate changes to a maintenance procedure that resulted in the addition of oil in excess of the capacity of the oil collection system, which was a condition adverse to fire protection. The licensee has removed the excess oil from Unit 3 reactor coolant pumps and is evaluating further corrective actions for the issue. The licensee entered this issue into the licensees corrective action program as PVAR 3305719.

The failure to perform a fire protection program impact evaluation of changes to a maintenance procedure to add oil to the reactor coolant pumps was a performance deficiency. The performance deficiency is more than minor and therefore a finding, because it adversely affected the external factors attribute of the Initiating Events Cornerstone and its objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Screening under IMC 0609, Appendix F,

Fire Protection Significance Determination Process, the condition represented a low degradation of the fire protection program element of fire prevention through control of combustible materials because of the over flow of oil spilling out of the reservoir. However, the problem impacted the NRCs ability to perform its oversight function and was assessed using the traditional enforcement process.

In accordance with Section 6.1.d.2 of the NRC Enforcement Policy, dated July 12, 2011, this violation is categorized as Severity Level IV because the resulting changes were evaluated by the Significance Determination Process as having very low safety significance (Green) (Section IR15).

Cornerstone: Mitigating Systems

Green.

The inspectors identified a non-cited violation of 10 CFR 50, Appendix B,

Criteria V, Instructions, Procedures, and Drawings, after Arizona Public Service failed to follow station procedures and enter issues into the corrective action program. Specifically, the inspectors identified that Palo Verde Action Requests had not been created, contrary to the requirements of procedure 01DP-0AP12,

Palo Verde Action Request Processing, when significant delays in completing maintenance on safety related components occurred. The licensee entered the issue into the corrective action program as Condition Report Disposition Request 4078014. The licensee initiated corrective actions to conduct training on the requirements to enter issues into the corrective action program and is evaluating further corrective actions.

The failure of plant personnel to enter issues into the corrective action program was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding was evaluated under the Significance Determination Process, Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, to be of very low safety significance (Green) because the finding: (1) is not a design or qualification issue; (2) did not represent an actual loss of safety function of the system or train; (3) did not result in the loss of one or more trains of non-technical specification equipment; and (4)did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The finding has a cross-cutting aspect in the area of human performance associated with the work practices component because the licensee failed to define and effectively communicate expectations to maintenance department personnel regarding the prompt initiation of Palo Verde Action Requests into the corrective action program H.4(b) (Section 1R13).

Green.

The inspectors reviewed a self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct a condition adverse to quality associated with essential chilled water system gas accumulation in all three units. Specifically, more frequent biocide additions to the essential chilled water systems resulted in significant bacterial off gassing and voiding in the systems in all three units. The licensee entered the issue into the corrective action program as Condition Report Disposition Request 3850945, initiated corrective actions to vent the systems and monitor for gas accumulation, and is evaluating further corrective actions for the issue.

The inspectors determined the failure of the licensee to promptly identify and correct a condition adverse to quality associated with essential chilled water system gas accumulation in all three units was a performance deficiency. The inspectors concluded the performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.

The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04,

Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding: (1) is not a design or qualification issue; (2) did not represent an actual loss of safety function of the system or train; (3) did not result in the loss of one or more trains of non-technical specification equipment; and (4) did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to trend and assess information from the corrective action program and other assessments to identify this common cause problem P.1(b) (Section 4OA2).

Green.

The inspectors reviewed a self-revealing non-cited violation of 10 CFR 50 Appendix B, Criterion V, for the failure of the licensee to provide an adequate operating procedure for cold leg boration. Specifically, on November 19, 2011,

Unit 1 operators exceeded the allowed maximum pressure of the low pressure safety injection system during cold-leg boration of the safety injection piping.

Pressure instrument errors caused by the specific valve lineup in the operating procedure caused the operators to exceed the pressure limits. The licensee placed the procedure for cold leg boration on administrative hold as a corrective action to restore compliance. The licensee entered the issue into the corrective action program as Condition Report Disposition Request 3989295 and is evaluating further corrective actions.

The failure of the licensee to provide an adequate operating procedure was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding: (1) is not a design or qualification issue; (2) did not represent an actual loss of safety function of the system or train; (3) did not result in the loss of one or more trains of non-technical specification equipment; and (4) did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to thoroughly evaluate a problem such that the resolution addressed cause and extent of condition.

Specifically, the 2009 engineering evaluation identified the pressure instrument inaccuracies but did not consider the extent of condition and potential impact on plant operating procedures P.1(c) (Section 4OA2).

Green.

The inspectors identified a non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations and engineering personnel to follow station procedures to provide a technical justification for continued operation of a degraded structure, system, or component. Specifically, after identifying a potential for insufficient drainage for safety related building roofs, plant personnel failed to perform a functional assessment and failed to assess the non-conforming condition to the current licensing basis. The licensee performed the functional assessment and later revised the assessment after the inspectors challenged assumptions used in the assessment. The licensee entered the issue into the corrective action program as Palo Verde Action Requests 3958463 and 3952605.

The failure of the operations and engineering personnel to evaluate the operability of a safety-related structure, system, or component was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding is a design or qualification issue confirmed not to result in the loss of operability or functionality. The inspectors determined this finding has a cross-cutting aspect in the area of human performance associated with the component of decision making because the licensee failed to use conservative assumptions in decision making and adopts a requirement to demonstrate that the proposed action is safe in order to proceed rather than a requirement to demonstrate that it is unsafe in order to disapprove the action H.1(b) (Section 4OA2).

Green.

The inspectors identified a non-cited violation of 10 CFR Part 50,

Appendix B, Criterion III, Design Control, for the failure of the licensee to translate the safety-related roof drainage capability design basis into drawings and calculations. Specifically, inspectors determined that there were no roof drains installed, although the plant was designed to have roof drains as the primary means for removing water from safety-related building roofs, and the licensee could not provide any design documentation to support adequacy of the roof drainage capacity without roof drains. The licensee performed an engineering evaluation to support the structural integrity of the safety-related buildings in the event of a design basis probable maximum precipitation event and is evaluating further corrective action. The licensee entered the issue into the corrective action program as PVARs 3958463 and 3952605.

The inspectors concluded that the failure of the licensee to translate design basis information into drawings for safety-related building roof drainage was a performance deficiency. The inspectors concluded the performance deficiency was more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the performance deficiency under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding is a design or qualification issue confirmed not to result in the loss of operability or functionality. No cross-cutting aspect was assigned because the performance deficiency was not indicative of current performance (Section 4OA2).

Cornerstone: Emergency Preparedness

Green.

The inspectors identified a non-cited violation of 10 CFR 50.47(b)(10) for the licensees failure to develop and have in-place guidelines for the choice of protective actions during an emergency that were consistent with federal guidance. Specifically, the licensees procedure EP-0905, Protective Actions,

Revision 2, did not implement the guidance of EPA-400-R-92-001, Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, which states, in part, that evacuation is rarely justified when the projected dose does not exceed 1 rem (Total Effective Dose Equivalent). This issue is documented in the licensees corrective action program as Condition Report Disposition Request-3403829.

The licensees automatic process that extended protective action during plant conditions and changes in wind direction without considering radiation dose was identified as a performance deficiency. This performance deficiency is more than minor, and therefore a finding, because it adversely affects the Emergency Preparedness Cornerstone objective of implementing adequate measures to protect the health and safety of the public in the event of a radiological emergency, and is associated with the cornerstone attributes of emergency response organization performance and procedure quality. This finding was determined to be of very low safety significance (Green) because it was a failure to comply with NRC requirements, was associated with risk significant planning standard 10 CFR 50.47(b)(10), and was not a risk significant planning standard functional failure or a planning standard degraded function. The finding was not a functional failure or degraded planning standard function because appropriate protective action recommendations for the public would have been made for all areas where protective action guides were exceeded. The finding is related to the corrective action program component of the problem identification and resolution cross-cutting area because the licensee failed take appropriate corrective actions to address the safety issue in a timely manner

P1.d] (Section 1EP5).

Licensee-Identified Violations

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

REPORT DETAILS

Summary of Plant Status

Unit 1 operated at essentially full power during the inspection period until February 25, 2012.

Unit 1 reduced power to 40 percent to repair a condenser tube leak in the 2A hotwell. Unit 1 returned to essentially full power on February 29, 2012 and remained there for the remainder of the inspection period Unit 2 operated at essentially full power during the inspection period until January 25, 2012.

Unit 2 underwent an unplanned downpower due to a loss of a main feedwater pump which resulted in a reactor power cut back. Unit 2 returned to essential full power on January 26, 2012 and remained there for the remainder of the inspection period.

Unit 3 operated at essentially full power during the inspection period until March 17, 2012 where it came off line for the start of 3R16 Refueling Outage. Unit 3 remained shut down for the remainder of the inspection period.

REACTOR SAFETY

Cornerstones: Initiating Events, Mitigating Systems, and Barrier Integrity

1R04 Equipment Alignment

Main article: IP 71111.04

Partial Walkdown

a. Inspection Scope

The inspectors performed partial system walkdowns of the following risk significant systems:

January 12, 2012, Unit 2, low pressure safety injection, train B

January 18, 2012, Unit 2, emergency diesel generator, train A

March 5, 2012, Unit 3, high pressure safety injection, train B The inspectors selected these systems based on their risk significance relative to the reactor safety cornerstones at the time they were inspected. The inspectors attempted to identify any discrepancies that could affect the function of the system, and, therefore, potentially increase risk. The inspectors reviewed applicable operating procedures, system diagrams, Updated Final Safety Analysis Report (UFSAR), technical specification requirements, administrative technical specifications, outstanding work orders, condition reports, and the impact of ongoing work activities on redundant trains of equipment in order to identify conditions that could have rendered the systems incapable of performing their intended functions. The inspectors also inspected accessible portions of the systems to verify system components and support equipment were aligned correctly and operable. The inspectors examined the material condition of the components and observed operating parameters of equipment to verify that there were no obvious deficiencies. The inspectors also verified that the licensee had properly identified and resolved equipment alignment problems that could cause initiating events or impact the capability of mitigating systems or barriers and entered them into the corrective action program with the appropriate significance characterization. Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of three partial system walkdown samples as defined in Inspection Procedure 71111.04-05.

b. Findings

No findings were identified.

1R05 Fire Protection

Main article: IP 71111.05

.1 Quarterly Fire Inspection Tours

a. Inspection Scope

The inspectors conducted fire protection walkdowns that were focused on availability, accessibility, and the condition of firefighting equipment in the following risk significant plant areas:

January 18, 2012, Unit 2, diesel building, all elevations

January 19, 2012, Unit 3, control building, all elevations

January 19, 2012, Unit 3, main steam support structure 80 foot elevation

January 23, 2012, Unit 1, control building

March 15, 2012, Unit 3, auxiliary building, 100 foot elevation The inspectors reviewed areas to assess if licensee personnel had implemented a fire protection program that adequately controlled combustibles and ignition sources within the plant; effectively maintained fire detection and suppression capability; maintained passive fire protection features in good material condition; and had implemented adequate compensatory measures for out of service, degraded or inoperable fire protection equipment, systems, or features, in accordance with the licensees fire plan.

The inspectors selected fire areas based on their overall contribution to internal fire risk as documented in the plants Individual Plant Examination of External Events with later additional insights, their potential to affect equipment that could initiate or mitigate a plant transient, or their impact on the plants ability to respond to a security event. Using the documents listed in the attachment, the inspectors verified that fire hoses and extinguishers were in their designated locations and available for immediate use; that fire detectors and sprinklers were unobstructed; that transient material loading was within the analyzed limits; and fire doors, dampers, and penetration seals appeared to be in satisfactory condition. The inspectors also verified that minor issues identified during the inspection were entered into the licensees corrective action program.

Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of five quarterly fire protection inspection samples as defined in Inspection Procedure 71111.05-05.

b. Findings

No findings were identified.

.2 Annual Fire Protection Drill Observation

Main article: IP 71111.05A

a. Inspection Scope

On January 19, 2012, the inspectors observed a fire brigade activation for a simulated fire in the train B auxiliary feedwater pump room. The observation evaluated the readiness of the plant fire brigade to fight fires. The inspectors verified that the licensee staff identified deficiencies; openly discussed them in a self-critical manner at the drill debrief, and took appropriate corrective actions. Specific attributes evaluated were

(1) proper wearing of turnout gear and self-contained breathing apparatus;

(2) proper use and layout of fire hoses;

(3) employment of appropriate firefighting techniques;

(4) sufficient firefighting equipment brought to the scene;

(5) effectiveness of fire brigade leader communications, command, and control;

(6) search for victims and propagation of the fire into other plant areas;

(7) smoke removal operations;

(8) utilization of preplanned strategies;

(9) adherence to the pre-planned drill scenario; and

(10) drill objectives.

These activities constitute completion of one annual fire-protection inspection sample as defined in Inspection Procedure 71111.05-05.

b. Findings

No findings were identified.

1R06 Flood Protection Measures

Main article: IP 71111.06

a. Inspection Scope

The inspectors reviewed the UFSAR, the flooding analysis, and plant procedures to assess susceptibilities involving internal flooding; reviewed the corrective action program to determine if licensee personnel identified and corrected flooding problems; inspected underground bunkers/manholes to verify the adequacy of sump pumps, level alarm circuits, cable splices subject to submergence, and drainage for bunkers/manholes; and verified that operator actions for coping with flooding can reasonably achieve the desired outcomes. The inspectors also inspected the areas listed below to verify the adequacy of equipment seals located below the flood line, floor and wall penetration seals, watertight door seals, common drain lines and sumps, sump pumps, level alarms, and control circuits, and temporary or removable flood barriers. Specific documents reviewed during this inspection are listed in the attachment.

February 14, 2012 spray pond vault water intrusion inspection These activities constitute completion of one bunker/manhole sample as defined in Inspection Procedure 71111.06-05.

b. Findings

No findings were identified.

1R11 Licensed Operator Requalification Program

Main article: IP 71111.11

.1 Quarterly Review of Licensed Operator Requalification Program

a. Inspection Scope

On February 2, 2012, the inspectors observed a crew of licensed operators in the plants simulator during requalification testing. The inspectors assessed the following areas:

Licensed operator performance

The ability of the licensee to administer the evaluations

The modeling and performance of the control room simulator

The quality of post-scenario critiques

Follow-up actions taken by the licensee for identified discrepancies These activities constitute completion of one quarterly licensed operator requalification program sample as defined in Inspection Procedure 71111.11.

b. Findings

No findings were identified.

.2 Quarterly Observation of Licensed Operator Performance

a. Inspection Scope

On February 25, 2012, the inspectors observed the performance of on-shift licensed operators in the plants main control room. At the time of the observations, the plant was in a period of heightened activity due to a downpower to address tube leakage into the condenser hotwell.

In addition, the inspectors assessed the operators adherence to plant procedures, including conduct of operations procedure and other operations department policies.

These activities constitute completion of one quarterly licensed-operator performance sample as defined in Inspection Procedure 71111.11.

b. Findings

No findings were identified.

1R12 Maintenance Effectiveness

Main article: IP 71111.12

a. Inspection Scope

The inspectors evaluated degraded performance issues involving the following risk significant systems:

January 30, 2012, Units 1 and 3, high pressure safety injection systems

February 6, 2012, Units 1, 2 and 3, control element drive mechanism control system The inspectors reviewed events such as where ineffective equipment maintenance has resulted in valid or invalid automatic actuations of engineered safeguards systems and independently verified the licensee's actions to address system performance or condition problems in terms of the following:

Implementing appropriate work practices

Identifying and addressing common cause failures

Scoping of systems in accordance with 10 CFR 50.65(b)

Characterizing system reliability issues for performance

Charging unavailability for performance

Trending key parameters for condition monitoring

Ensuring proper classification in accordance with 10 CFR 50.65(a)(1) or -(a)(2)

Verifying appropriate performance criteria for structures, systems, and components classified as having an adequate demonstration of performance through preventive maintenance, as described in 10 CFR 50.65(a)(2), or as requiring the establishment of appropriate and adequate goals and corrective actions for systems classified as not having adequate performance, as described in 10 CFR 50.65(a)(1)

The inspectors assessed performance issues with respect to the reliability, availability, and condition monitoring of the system. In addition, the inspectors verified maintenance effectiveness issues were entered into the corrective action program with the appropriate significance characterization. Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of two quarterly maintenance effectiveness samples as defined in Inspection Procedure 71111.12-05.

b. Findings

No findings were identified.

1R13 Maintenance Risk Assessments and Emergent Work Control

Main article: IP 71111.13

a. Inspection Scope

The inspectors reviewed licensee personnel's evaluation and management of plant risk for the maintenance and emergent work activities affecting risk significant and safety-related equipment listed below to verify that the appropriate risk assessments were performed prior to removing equipment for work:

January 18, 2012, Unit 2, high pressure safety injection train B and emergency diesel generator B planned maintenance

January 25, 2012, Unit 2, reactor power cut back

February 1, 2012, Units 1, 2, and 3, startup transformer NANX03 maintenance outage

February 25, 2012, Unit 1, reduction in power to address leak into 2A condenser hotwell

March 19, 2012, Unit 3, refueling outage risk assessment The inspectors selected these activities based on potential risk significance relative to the reactor safety cornerstones. As applicable for each activity, the inspectors verified that licensee personnel performed risk assessments as required by 10 CFR 50.65(a)(4)and that the assessments were accurate and complete. When licensee personnel performed emergent work, the inspectors verified that the licensee personnel promptly assessed and managed plant risk. The inspectors reviewed the scope of maintenance work, discussed the results of the assessment with the licensee's probabilistic risk analyst or shift technical advisor, and verified plant conditions were consistent with the risk assessment. The inspectors also reviewed the technical specification requirements and inspected portions of redundant safety systems, when applicable, to verify risk analysis assumptions were valid and applicable requirements were met. Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of five maintenance risk assessments and emergent work control inspection samples as defined in Inspection Procedure 71111.13-05.

b. Findings

.1 Failure to Follow Corrective Action Program Procedure

Introduction.

The inspectors identified a Green non-cited violation of 10 CFR 50, Appendix B, Criteria V, Instructions, Procedures, and Drawings, after Arizona Public Service failed to follow station procedures and enter issues into the corrective action program.

Description.

On January 18, 2012, the licensee removed the Unit 2 high pressure safety injection (HPSI) pump B and emergency diesel generator (EDG) B from service for planned maintenance. The maintenance evolution placed Unit 2 into an elevated (Yellow) Risk Management Action Level (RMAL) for the duration of the maintenance.

During plant walkdowns, the inspectors discovered that maintenance on the HPSI B circuit breaker was delayed due to an incorrect tagging permit. Additionally, the inspectors discovered that the maintenance planned for the EDG fuel oil transfer system could not be completed because an incorrect part was acquired for the activity. The maintenance involved replacing the fuel oil storage tank level indicator and housing.

However, the housing that was obtained was not the correct part. The delay in HPSI maintenance and inability to complete EDG work increased the unavailability time of equipment while Unit 2 was is Yellow RMAL. This contradicted the risk management actions identified in procedure 70DP-0RA05, Assessment and Management of Risk When Performing Maintenance in Modes 1 and 2. The licensee completed maintenance on the HPSI system, restored HPSI pump B and EDG B to service, and exited Yellow RMAL.

On the following day, the inspectors searched the corrective action program and identified that PVARs had not been created for the issues. Procedure 01DP-0AP12, Palo Verde Action Request Processing, Appendix D, states, in part, that a breakdown or degradation in the control of maintenance is an example of a condition adverse to quality and should be documented in a PVAR.

The licensee entered the issue into the corrective action program as Condition Report Disposition Request (CRDR) 4078014 and also identified another example of failure to initiate a PVAR as required. Specifically, on November 29, 2011, maintenance personnel attempted to replace the EDG B fuel oil storage tank level indicator and identified that the housing could not be removed and the maintenance could not be completed. This activity led to the scheduled maintenance on January 18, 2012. The licensee has initiated corrective actions to conduct training on the requirements to enter issues into the corrective action program.

Analysis.

The inspectors concluded that the failure of plant personnel to enter issues into the corrective action program in accordance with plant procedures was a performance deficiency. The inspectors concluded the performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.

The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I -

Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding:

(1) is not a design or qualification issue;

(2) did not represent an actual loss of safety function of the system or train;

(3) did not result in the loss of one or more trains of non-technical specification equipment; and

(4) did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of human performance associated with the component of work practices because the licensee failed to define and effectively communicate expectations to maintenance department personnel regarding the prompt initiation of PVARs into the corrective action program H.4(b).

Enforcement.

Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings. Procedure 01DP-0AP12, Palo Verde Action Request Processing, Revision 16, provided guidelines and instructions for entering issues into the corrective action program. Contrary to the above, between November 29, 2011 and January 18, 2012, plant personnel failed to accomplish an activity affecting quality in accordance with the prescribed instructions, procedures, and drawings. Specifically, plant personnel failed to follow Procedure 01DP-0AP12 and enter issues into the corrective action program associated with incomplete and delayed maintenance activities. The licensee initiated corrective actions to train maintenance department personnel on procedural requirements and station expectations for entering issues into the corrective action program. The licensee entered the issue into the corrective action program as Condition Report Disposition Request (CRDR) 4078014 and is evaluating further corrective actions. Because this finding is of very low safety significance and was entered into the corrective action program as Condition Report Disposition Request 4078014, this violation is being treated as a non-cited violation in accordance with Section 2.3.2 of the Enforcement Policy: NCV 05000529/2012002-01, Failure to Follow Corrective Action Program Procedure.

.2 Failure to Assess and Manage Risk Prior to Troubleshooting 4.16 kV Bus Supply

Breaker Hand Switch

Introduction.

The inspectors reviewed a self-revealing Green non-cited violation of 10 CFR 50.65 a(4), for the licensees failure to assess and manage an increase in risk prior to planned maintenance activities. Specifically, on January 25, 2012, the licensee failed to include the potential to interrupt energized equipment in the nearby work area in the risk assessment.

Description.

On January 25, 2012, the licensee performed tool pouch troubleshooting on the control room hand switch for the non-class 1E 4.16 kV bus normal supply breaker E-NBN-S02 to assess indication problems under work order 4035861. During the work, the licensee experienced a loss of the non-class 1E 4.16 kV bus which resulted in the loss of main feedwater pump A and a reactor power cut back from 100 percent to 48 percent power.

The licensees investigation identified, as a result of reviewing the sequence of events, that maintenance electricians were checking the tightness of hand switch 2ENBNHSS02A with an insulated screwdriver. Although insulated, the screwdrivers uninsulated tip was of greater length than the distance between two adjacent contact terminals on the hand switch, terminals 2 and 4. The licensee determined that an electrical short occurred across the hand switch contact terminals, which energized the trip circuit for the normal supply breaker, E-NBN-S02. The opening of this breaker resulted in a loss of condensate pump C and heater drain pump A which led to the tripping of main feedwater pump A on low suction pressure.

The inspector reviewed the licensees procedures that implement the requirements of 10 CFR 50.65, including procedures 02DP-RS01, Operational Risk Management, Rev. 0, 40DP-9RS01, Online Risk Management Modes 1 and 2, Rev. 0, and 70DP-0RA05, Assessment and Management of Risk when Performing Maintenance in Modes 1 and 2, Rev. 18. The inspectors reviewed the licensees investigation and determined the licensee followed the procedures, however, the procedures did not provide detailed guidance for assessing and managing risk during fix-it-now maintenance activities.

The licensees corrective actions included the suspension of all tool pouch work on energized equipment, completion of a root cause evaluation, human performance stand downs, crew briefs, and a revision of procedure 01DP-9ZZ01, "Systematic Troubleshooting. The procedure change will include work instructions for performing maintenance on energized equipment. The licensee also identified a need for developing guidance for determining operational risk assessments. The licensee documented this deficiency in PVAR 4036588.

Analysis.

The performance deficiency associated with this finding involved the licensees failure to assess and manage an increase in risk prior to planned maintenance activities as required by 10 CFR 50.65 a(4). The performance deficiency was more than minor, and therefore a finding, because it affects the equipment performance attribute of the Initiating Events Cornerstone and its objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. The inspectors determined that the licensee does not maintain a probabilistic risk analysis model that incorporates fix-it-now maintenance activities because they are neither scheduled nor emergent. An incremental core damage probability cannot be estimated for the plant conditions that existed at the time of the performance deficiency. For this reason, the inspectors determined that Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, Flowchart 2, could not be used to determine the risk significance of the finding. Using the qualitative review process of Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, the finding is determined to have very low safety significance (Green) because the finding did not result in any additional loss of defense in depth systems, and based on the judgment of the senior reactor analyst, the increase in risk was very small. This finding had a cross-cutting aspect in the area of human performance associated with the resources component because the licensee failed to ensure complete and accurate procedures and work packages are adequate to assure nuclear safety H.2(c).

Enforcement.

Title 10 CFR 50.65 a(4), states in part, before performing maintenance activities, the licensee shall assess and manage the increase in risk that may result from the proposed maintenance activities. Contrary to the above, the licensee did not assess nor manage an increase in risk that resulted from proposed maintenance activities.

Specifically, on January 25, 2012, the licensee failed to perform a risk assessment prior to commencing tool pouch troubleshooting on the normal non-class 1E 4.16 kV supply breaker hand switch in the control room. The failure to assess and manage the risk for the planned activities resulted in a plant transient due to a hot short which tripped the normal supply breaker that supplies power to pumps that provide suction pressure for main feedwater pump A. The licensee will revise procedures, as a corrective action, to develop and implement a structured operational risk assessment process for use by the senior reactor operator when authorizing un-scheduled work to commence in the field.

Because this finding is of very low safety significance and has been entered into the licensees corrective action program as PVAR 4036588, this violation is being treated as an NCV, consistent with section 2.3.2 of the NRC Enforcement Policy: NCV 05000529/2012002-02, Failure to Assess and Manage Risk Prior to Troubleshooting on 4.16 kV Bus Supply Breaker Hand Switch.

1R15 Operability Evaluations and Functionality Assessments

Main article: IP 71111.15

a. Inspection Scope

The inspectors reviewed the following issues:

January 25, 2012, Unit 1, emergency diesel generator, train B

February 21, 2012, Units 1, 2 and 3, atmospheric dump valve full open position requirements

February 28, 2012, Unit 1, 2, and 3, reactor coolant pump oil collection system

March, 23, 2012, Units 1, 2, and 3, misadjusted auxiliary feedwater pump constant level oilers The inspectors selected these potential operability issues based on the risk significance of the associated components and systems. The inspectors evaluated the technical adequacy of the evaluations to ensure that technical specification operability was properly justified and the subject component or system remained available such that no unrecognized increase in risk occurred. The inspectors compared the operability and design criteria in the appropriate sections of the technical specifications and UFSAR to the licensee personnels evaluations to determine whether the components or systems were operable. Where compensatory measures were required to maintain operability, the inspectors determined whether the measures in place would function as intended and were properly controlled. The inspectors determined, where appropriate, compliance with bounding limitations associated with the evaluations. Additionally, the inspectors also reviewed a sampling of corrective action documents to verify that the licensee was identifying and correcting any deficiencies associated with operability evaluations. Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of four operability evaluations inspection samples as defined in Inspection Procedure 71111.15-05.

b. Findings

Failure to Obtain NRC Approval for a Change Adverse to Safe Shutdown

Introduction.

The inspectors identified a Severity Level IV non-cited violation of License Conditions 2.C.7, 2.C.6, and 2.F, for Palo Verde Units 1, 2, and 3 respectively, for the licensees failure to maintain the reactor coolant pumps (RCP) in compliance with fire protection requirements. Specifically, the licensee failed to evaluate changes to maintenance procedures to address any impacts and conditions adverse to safe shutdown.

Description.

On March 28, 2009, operations documented a question in PVAR 3305719 addressing a potential nonconformance with fire protection requirement 10 CFR 50, Appendix R, section III.O. Operations identified through review of operator training material that a technical document and work permit allows an addition of 30 gallons of oil to be added to the kenett unit, which is part the RCP oil collection system. Based on the question, there was no immediate concern and no evidence of nonconformance. The licensee concluded that the system remained functional but needed further evaluation as tracked in associated condition report disposition record (CRDR) 3308336. On March 29, 2009, operations determined that the question of concern did not constitute a degradation of the oil collection system. On April 3, 2009, the action request review committee categorized the CRDR 3308336 as evaluate.

On February 14, 2012, the licensee amended the PVAR and CRDR, and reclassified the CRDR as Adverse-Evaluate which resulted in 12 corrective maintenance tasks and Engineering Work Order 4055552. On February 16, 2012, the licensee completed engineering evaluation WO 4055552, which provided evidence that the system has the potential to be overfilled due to an excess amount of oil contained in the system. On February 27, 2012, the inspectors reviewed PVAR 3305719, adverse CRDR 3308336, Engineering Work Order 4055552, and various license documents and determined that the licensee failed to maintain compliance with fire protection requirements for the RCP oil collection system.

The inspectors discussed the issue with engineering and operations personnel and concluded that if a catastrophic failure of the RCP thrust bearing occurred, a maximum of 29 gallons of oil could spill over the top of the kenett unit. The inspectors determined, that should the kennet unit become overfilled, the excess oil could leak onto heated components and create the potential for an unevaluated fire hazard in containment. The inspectors discussed the potential to over fill the oil collection system with the licensee and determined that two maintenance procedures, 31MT-9RC23, Reactor Coolant Pump Sulzer Bingham Seal Replacement, Rev. 30, and 31MT-9RC24, Reactor Coolant Pump Thrust Bearing Maintenance, Rev. 17 contained instructions to add 35 gallons of oil to the kenett unit. The inspectors identified that changes in maintenance procedures were made without the required fire protection evaluation. The inspectors identified that the licensee failed to maintain compliance because of the failure to follow the procedure change process which introduced the step of adding an additional 35 gallons into the procedure.

Analysis.

The performance deficiency associated with this finding involved the failure to obtain NRC approval prior to making a change which was adverse to safe shutdown.

Specifically, the licensee made a change to maintenance procedures, which permitted an excess amount of oil in the reactor coolant pumps oil collection system. The performance deficiency is more than minor, and therefore a finding, because the failure to obtain NRC approval prior to making a change adverse to fire protection affects the protection against external factors attribute of the Initiating Events Cornerstone and its objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations.

Violations of program changes adverse to fire protection are dispositioned using the traditional enforcement process instead of the significance determination process (SDP)because they are considered to be violations that potentially impede or impact the regulatory process. However, the associated finding is evaluated under the SDP to determine the significance of the violation. In this case, the inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase I - Initial Screening and Characterization of Findings, Table 3b. The inspectors determined the finding degraded the fire protection defense-in-depth strategies. Therefore, screening under IMC 0609, Appendix F, Fire Protection Significance Determination Process, was required. Using IMC 0609 Appendix F, Fire Protection Significance Determination Process, the inspectors determined that the condition represented a low degradation of the fire protection program element of fire prevention through control of combustible materials.

In accordance with Section 6.1.d.2 of the NRC Enforcement Policy, dated July 12, 2011, this violation is categorized as Severity Level IV because the resulting changes were evaluated by the SDP as having very low safety significance (Green).

Enforcement.

Arizona Public Services Palo Verde Nuclear Generating Station Licensee Conditions 2.C.7, 2.C.6, and 2.F for Units 1, 2, and 3 respectively, state, in part, that APS shall implement and maintain in effect all provisions of the approved fire protection program as described in the Final Safety Analysis Report for the facility, as supplemented and amended, and as approved in the SER through Supplement 11, subject to the following provision: APS may make changes to the approved fire protection program without prior approval of the Commission only if those changes would not adversely affect the ability to achieve and maintain safe shutdown in the event of a fire. Contrary to the above, the licensee failed to obtain Commission approval for a change to the approved fire protection program which adversely affected the ability to achieve and maintain safe shutdown in the event of a fire. Specifically, from approximately 2006 to February 2012, the licensee failed to evaluate a change to the maintenance procedure which allowed an excess amount of oil in the reactor coolant pumps oil collection system. The excess amount of oil degraded the oil collection system and caused the non-conformance with 10 CFR 50, Appendix R, Section III.O.

This could lead to an overspill which has the potential to cause a fire in containment.

Because this issue is of very low safety significance, was not repetitive or willful, and was entered into the licensees corrective action program as PVAR 3305719, the violation is being treated as a non-cited violation (NCV) consistent with Section 2.3.2 of the NRC Enforcement Policy, and is designated as NCV 05000528; 05000529;05000530/2012002-03, Failure to Obtain NRC Approval for a Change Adverse to Safe Shutdown.

1R19 Post Maintenance Testing

Main article: IP 71111.19

a. Inspection Scope

The inspectors reviewed the following post maintenance activities to verify that procedures and test activities were adequate to ensure system operability and functional capability:

February 8, 2012, Unit 3, atmospheric dump valves ADV-179 and ADV-184

March 5, 2012, Unit 2, engineered safety feature actuation system BC matrix power supply replacement The inspectors selected these activities based upon the structure, system, or component's ability to affect risk. The inspectors evaluated these activities for the following (as applicable):

The effect of testing on the plant had been adequately addressed; testing was adequate for the maintenance performed

Acceptance criteria were clear and demonstrated operational readiness; test instrumentation was appropriate The inspectors evaluated the activities against the technical specifications, the UFSAR, 10 CFR Part 50 requirements, licensee procedures, and various NRC generic communications to ensure that the test results adequately ensured that the equipment met the licensing basis and design requirements. In addition, the inspectors reviewed corrective action documents associated with post maintenance tests to determine whether the licensee was identifying problems and entering them in the corrective action program and that the problems were being corrected commensurate with their importance to safety. Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of two post-maintenance testing inspection samples as defined in Inspection Procedure 71111.19-05.

b. Findings

No findings were identified.

1R22 Surveillance Testing

Main article: IP 71111.22

a. Inspection Scope

The inspectors reviewed the UFSAR, procedure requirements, and technical specifications to ensure that the surveillance activities listed below demonstrated that the systems, structures, and/or components tested were capable of performing their intended safety functions. The inspectors either witnessed or reviewed test data to verify that the significant surveillance test attributes were adequate to address the following:

Preconditioning

Evaluation of testing impact on the plant

Acceptance criteria

Test equipment

Procedures

Jumper/lifted lead controls

Test data

Testing frequency and method demonstrated technical specification operability

Test equipment removal

Restoration of plant systems

Fulfillment of ASME Code requirements

Updating of performance indicator data

Engineering evaluations, root causes, and bases for returning tested systems, structures, and components not meeting the test acceptance criteria were correct

Reference setting data

Annunciators and alarms setpoints The inspectors also verified that licensee personnel identified and implemented any needed corrective actions associated with the surveillance testing.

January 22, 2012, Unit 2, engineered safety feature actuation system train B subgroup relay functional test

February 8, 2012, Unit 2, diesel fuel oil transfer pump, train A

February 14, 2012, Unit 2, essential spray pond pump inservice test, train B

March 1, 2012, Unit 3, containment purge isolation valve CPA-UV-2B

March 7, 2012, Unit 3, reactor cavity sump reactor coolant system leakage detection instrumentation calibration

March 19, 2012, Unit 3, diesel generator and integrated safeguards train A testing Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of surveillance testing inspection samples as defined in Inspection Procedure 71111.22-05.

b. Findings

No findings were identified.

Failure in the Choice of Protective Actions Consistent with Federal Guidance

Introduction.

The inspectors identified a Green non-cited violation of 10 CFR 50.47(b)(10) for the licensees failure to develop and have in place guidelines for the choice of protective actions during an emergency that were consistent with federal guidance. Specifically, the licensees Procedure EP-0905, Protective Actions, Revision 2, did not implement the guidance of EPA-400-R-92-001, Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, which states, in part, that evacuation is rarely justified when the projected dose does not exceed 1 rem (TEDE).

Procedure EP-0905, Revision 2, defaults to plant conditions and extends existing protective action recommendations into additional geographical areas of the emergency planning zone under conditions of changing wind vectors, even when valid dose assessments are available and do not exceed protective action guidelines.

Description.

The licensee conducted four table top drills in December 2011 which included wind changes. Even though dose assessment reports showed doses in the additional sectors affected by the wind change were less than applicable protective action guides in the 2 to 5 mile distance the licensee recommended evacuation. During the February 9, 2011, pre-exercise drill, the licensee issued a protective action recommendation to evacuate 5 miles around the site and 5 to 10 miles in the down-wind affected sectors based on plant conditions; however, the applicable dose assessment did not exceed protective action guides at 5 miles. During the March 1, 2011, Biennial Exercise, the licensee issued an upgraded protective action recommendation of 5 to 10 miles in the down-wind affected sectors per plant procedures; however, the applicable dose assessment did not exceed protective action guides at 5 miles. The inspectors determined the licensees procedure for recommending protective action to offsite authorities was not consistent with federal guidance during emergency scenarios which included core damage and wind shifts. In these scenarios, even though valid dose assessments were available, the procedure required the licensee to recommend protective action that was beyond that recommended in federal guidance. Federal guidance for the choice of protective actions during an emergency is described in EPA-400-R-92-001, Manual of Protective Action Guides and Protective Actions for Nuclear Incidents, which states, in part, that evacuation is seldom justified when doses are less than protective action guides. The licensees automatic practices in extending protective action for plant conditions and during wind shift scenarios without consideration of valid dose assessments resulted in unnecessary evacuation recommendations and may expose members of the public to unjustified risks. Although the licensee identified this issue in November 2009, and a condition report was written identifying the non-compliance with federal guidance; no corrective action had been enacted as of the time of this inspection.

Analysis.

The licensees automatic process that extended protective action during plant conditions and changes in wind direction without considering radiation dose was identified as a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affects the Emergency Preparedness Cornerstone objective of implementing adequate measures to protect the health and safety of the public in the event of a radiological emergency, and is associated with the cornerstone attributes of emergency response organization performance and procedure quality. The finding was determined to be of very low safety significance (Green) because it was a failure to comply with NRC requirements, was associated with risk significant planning standard 10 CFR 50.47(b)(10), and was not a risk significant planning standard functional failure or a planning standard degraded function. The finding was not a functional failure or degraded planning standard function because appropriate protective action recommendations for the public would have been made for all areas where protective action guides were exceeded. This issue is documented in the licensees corrective action program as CRDR 3403829. The finding has a cross-cutting aspect in the area of problem identification and resolution, corrective action program component because the licensee failed to take appropriate corrective actions to address the safety issue in a timely manner P1.d].

Enforcement.

Title 10 of the Code of Federal Regulations, 50.47(b)(10) states, in part, that guidelines for the [licensees] choice of protective actions during an emergency, consistent with federal guidance, are developed and in place. Contrary to the above, the licensees choice of protective actions during an emergency was not consistent with federal guidance. Specifically, the licensees procedure for protective action recommendation determinations EP-0905, Protective Actions, Revision 2, is inadequate in that it defaults to plant conditions to issue protective action recommendations. This practice extends existing protective action recommendations into additional geographical areas of the emergency planning zone for plant conditions and during wind shift scenarios without consideration of valid dose assessments which resulted in unnecessary evacuation recommendations and may expose members of the public to unjustified risks. Because this finding is of very low safety significance and has been entered into the licensees corrective action program, this violation is being treated as an NCV, consistent with Section 2.3.2 of the NRC Enforcement Policy: NCV 05000528;05000529;05000530/2012002-04, Failure in the Choice of Protective Actions Consistent with Federal Guidance

1EP6 Drill Evaluation

Main article: IP 71114.06

Emergency Preparedness Drill Observation

a. Inspection Scope

The inspectors evaluated the conduct of a routine licensee emergency drill on February 29, 2012, to identify any weaknesses and deficiencies in classification, notification, and protective action recommendation development activities. The inspectors observed emergency response operations in the technical support center to determine whether the event classification, notifications, and protective action recommendations were performed in accordance with procedures. The inspectors also attended the licensee drill critique to compare any inspector-observed weakness with those identified by the licensee staff in order to evaluate the critique and to verify whether the licensee staff was properly identifying weaknesses and entering them into the corrective action program. As part of the inspection, the inspectors reviewed the drill package and other documents listed in the attachment.

These activities constitute completion of one sample as defined in Inspection Procedure 71114.06-05.

b. Findings

No findings were identified.

The inspectors sampled licensee submittals for the Alert and Notification System performance indicator for the period from the first quarter 2011 through the fourth quarter 2011. To determine the accuracy of the performance indicator data reported during those periods, performance indicator definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 5, was used. The inspectors reviewed the licensees records associated with the performance indicator to verify that the licensee accurately reported the indicator in accordance with relevant procedures and the Nuclear Energy Institute guidance. Specifically, the inspectors reviewed licensee records and processes including procedural guidance on assessing opportunities for the performance indicator and the results of periodic alert notification system operability tests. The specific documents reviewed are described in the attachment to this report.

These activities constitute completion of the alert and notification system sample as defined in Inspection Procedure 71151-05.

During a review of items entered in the licensees corrective action program, the inspectors recognized a corrective action item that warranted a further scrutiny.

January 3, 2012, Units 1, 2 and 3, essential chilled water system gas intrusion

January 31, 2012, Unit 1, Technical Specification 3.0.3 entry during cold-leg boration

February 14, 2012, Units 1, 2, and 3, safety-related building roof drainage capability The inspectors considered the following during the review of the licensee's actions: (1)complete and accurate identification of the problem in a timely manner;

(2) evaluation and disposition of operability/reportability issues;

(3) consideration of extent of condition, generic implications, common cause, and previous occurrences;

(4) classification and prioritization of the resolution of the problem;

(5) identification of root and contributing causes of the problem;

(6) identification of corrective actions; and

(7) completion of corrective actions in a timely manner.

Specific documents reviewed during this inspection are listed in the attachment.

These activities constitute completion of three in-depth problem identification and resolution samples as defined in Inspection Procedure 71152-05.

b. Findings

.1 Failure to Promptly Identify and Correct a Condition Adverse to Quality Associated with

Essential Chilled Water System Gas Accumulation

Introduction.

The inspectors reviewed a self-revealing Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct a condition adverse to quality associated with essential chilled water system gas accumulation in all three units. The condition adverse to quality involved ineffective monitoring following a chemistry strategy change, which failed to ensure no unintended consequences occurred. Specifically, more frequent biocide additions to the essential chilled water systems resulted in significant bacterial off gassing and voiding in the systems in all three units.

Description.

On August 18, 2011, Unit 2 operators responded to a surge tank high pressure alarm for the essential chilled water (EC) system A train. During system venting, operators observed surge tank level to rise, indicating possible air voids in the system. On August 21, 2011, Unit 2 operators declared EC train A inoperable based on calculated void size. On August 23, 2011, Unit 1 operators received a surge tank high pressure alarm for EC A train. During system venting, operators also observed surge tank level to rise and declared EC A train inoperable based on calculated void size. On August 27, 2011, Unit 3 operators declared EC A train inoperable based on void size calculated during extent of condition reviews. Operators in all three units subsequently performed venting of the systems to reduce void sizes to acceptable levels and initiated regular void testing and venting to maintain system operability.

Plant personnel initiated a root cause evaluation under Condition Report Disposition Request 3850945 and concluded the voiding was caused by bacterial off gassing. In March 2009, plant personnel had revised system chemistry specifications to perform preventive maintenance additions of glutaraldehyde to the EC system every 6 months instead of on an as-needed basis. This change occurred as a corrective action following the licensees evaluation of slime buildup in the essential cooling water (EW) system which identified that the EC system did not have a preventive chemistry program.

Glutaraldehyde is added to reduce the amount of Adenosine Tri Phosphate (ATP) in the EC system. ATP levels represent the amount of bacterial growth in the system. The licensees evaluation concluded that the frequent biocide additions resulted in surplus amounts of glutaraldehyde that would quickly break down due to the pH of the system and produce carbon for bacteria that was resistant to glutaraldehyde. The increased growth of denitrifying bacteria resulted in the generation of nitrous oxide gas and voiding in the EC system. Additionally, the licensee completed an evaluation that concluded the EC systems were still capable of performing their safety functions with the amount of voiding discovered.

The root cause evaluation also identified that during 2009 and 2010, operators received more frequent surge tank pressure and level alarms and chemistry samples revealed that system ATP levels were higher than before the program changes were made. The licensee failed to recognize the adverse trends in both ATP levels and recurring alarms.

The licensee initiated corrective actions to revise its chemistry controls program and conduct additional training to both Chemistry and Operations Department personnel.

Analysis.

The inspectors determined the failure of the licensee to promptly identify and correct a condition adverse to quality associated with essential chilled water system gas accumulation in all three units was a performance deficiency. The performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding:

(1) is not a design or qualification issue;

(2) did not represent an actual loss of safety function of the system or train;

(3) did not result in the loss of one or more trains of non-technical specification equipment; and

(4) did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to trend and assess information from the corrective action program and other assessments to identify this common cause problem P.1(b).

Enforcement.

10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, states, in part, that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. Contrary to the above, the licensee failed to promptly identify and correct the adverse condition of gas accumulation in the essential chilled water systems of all three units. Specifically, between July 2009 and August 2011, plant operators received numerous surge tank high pressure alarms and chemistry sampling revealed increased levels of Adenosine Tri Phosphate. However, the licensee failed to recognize that more frequent biocide additions resulted in the gas accumulation and failed take prompt corrective action to resolve the issue. The licensee subsequently implemented corrective actions to vent the systems and monitor for gas accumulation, and is implementing additional corrective actions for control of biological growth.

Because this finding is of very low safety significance and was entered into the corrective action program as Condition Report Disposition Request 3850945, this violation is being treated as a non-cited violation in accordance with Section 2.3.2 of the Enforcement Policy: NCV 05000528;05000529;05000530/2012002-05, Failure to Promptly Identify and Correct a Condition Adverse to Quality Associated with Essential Chilled Water System Gas Accumulation.

.2 Failure to Provide an Adequate Operating Procedure for Cold-Leg Boration

Introduction.

The inspectors reviewed a self-revealing Green non-cited violation of 10 CFR 50 Appendix B, Criterion V, for the failure of the licensee to provide an adequate operating procedure that resulted in Unit 1 operators exceeding allowed pressure of the low pressure safety injection system during cold-leg boration of the safety injection piping.

Description.

On November 19, 2011, Unit 1 operators were utilizing operating procedure 40OP-9SI02, Recovery from Shutdown Cooling to Normal Operating Lineup, Section 5.0, which provides directions to borate the cold-leg injection piping by running a HPSI pump on recirculation. Step 5.3.19 of the procedure instructs operators to adjust valve SIA-V218, mini-flow recirculation orifice bypass valve, until HPSI discharge pressure is 1400 to 1500 psig as read on pressure instrument SIN-PI-308. Additionally, a note in the procedure states, Header pressure greater than 1525 psig as read on SIN-PI-319/339 makes the associated LPSI pump(s) inoperable. Step 5.3.20 directs operators to initiate cold-leg boration by opening four HPSI injection valves. Upon performing this step, operators received a high pressure alarm and identified that header pressures exceeded 1525 psig in all four headers. Operators declared both LPSI trains inoperable and entered Technical Specification LCO 3.0.3. Operators subsequently lowered header pressure below 1525 psig, declared both LPSI trains operable, and exited LCO 3.0.3.

The licensee entered the issue into the corrective action program as Condition Report Disposition Request 3989295. The evaluation identified that the pressure indication used to establish HPSI discharge pressure in Step 5.3.19 would indicate less that an actual discharge pressure when the mini-flow recirculation orifice bypass valve is opened due to the position of the pressure instrument in the piping. A 2009 engineering evaluation, EWR 3332883, identified that this lineup could result in measurement errors.

Additionally, an engineering evaluation, EWR 3989294, subsequently concluded that both LPSI trains would have been able to perform their safety functions given the header pressures identified during the event. The licensee initiated corrective actions to perform a hydraulic analysis to determine the correct header pressures and limits to use to perform cold-leg boration and revise the operating procedure as necessary.

Analysis.

The inspectors concluded that the failure of the licensee to provide an adequate operating procedure was a performance deficiency. The performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding:

(1) is not a design or qualification issue;

(2) did not represent an actual loss of safety function of the system or train;

(3) did not result in the loss of one or more trains of non-technical specification equipment; and

(4) did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of problem identification and resolution associated with the corrective action program component because the licensee failed to thoroughly evaluate a problem such that the resolution addressed cause and extent of condition.

Specifically, the 2009 engineering evaluation identified the pressure instrument inaccuracies but did not consider the extent of condition and potential impact on plant operating procedures P.1(c).

Enforcement.

10 CFR 50 Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances. Contrary to this, on November 19, 2011, the licensee completed an activity affecting quality that was prescribed by a procedure that was not appropriate to the circumstances. Specifically, Unit 1 operators performed cold-leg boration of safety injection piping in accordance with operating procedure 40OP-9SI02, Recovery from Shutdown Cooling to Normal Operating Lineup, that failed to account for pressure instrument inaccuracies. As a result, operators exceeded the operability limits for both low pressure safety injection trains as defined by the procedure and entered Technical Specification Limiting Condition for Operation 3.0.3. Operators subsequently reduced header pressure and exited Technical Specification Limiting Condition for Operation 3.0.3. Because this finding is of very low safety significance and was entered into the corrective action program as Condition Report Disposition Request 3989295, this violation is being treated as a non-cited violation in accordance with Section 2.3.2 of the Enforcement Policy: NCV 05000528/2012002-06, Failure to Provide an Adequate Operating Procedure for Cold-Leg Boration.

.3 Failure to Perform Functionality Assessment for Safety-Related Buildings

Introduction.

The inspectors identified a Green non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations and engineering personnel to follow station procedures to provide a technical justification for continued operation of a degraded structure, system, or component.

Specifically, after identifying a potential for insufficient drainage for safety-related building roofs and no supporting documentation, plant personnel failed to perform a functional assessment and assess the nonconforming condition to the current licensing basis.

Description.

On October 26, 2011, the licensee surveyed safety-related seismic Category I buildings to verify external event screening criteria as part of a Regulatory Guide 1.200 compliance project. On November 4, 2011, engineering personnel who performed the survey documented in the corrective action program under PVAR 3952605 that it was their judgment there was inadequate drainage for the roof to maintain less than 6 inches of ponding with respect to the probable maximum precipitation (PMP) event and no documentation was found to verify the drainage capacity of the roofs. Procedure 40DP-9OP26, Palo Verde Action Request Processing and Operability Determination/Functional Assessment, Appendix K, section 3.3.1 states that missing or deficient documentation that could affect the operability of a structure, system, or component should be treated as a loss of qualification. Operations personnel who reviewed the corrective action document dismissed the concern and failed to perform a functional assessment of the safety-related seismic Category I buildings as required.

On November 7, 2011 inspectors identified that a functional assessment had not been performed and informed the licensee of the issue. The licensee entered this issue into the corrective action program as PVAR 3958463. A functional assessment was performed and requested an engineering work request to validate assumptions made in the assessment. Inspectors reviewed the functional assessment and its supporting documentation and challenged the technical justification used to verify functionality of the safety-related seismic Category I buildings. The assessment failed to compare the condition to the design basis PMP as it was thought to be excessive. Inspectors determined that this methodology was non-conservative and did not meet basic design requirements as defined in the current licensing basis. Subsequent revisions of the evaluation were challenged by inspectors to address non-conservative assumptions in the draining of water from the building roofs and the use of margin in the assessment of structural integrity of the roofs.

On February 15, 2012, the evaluation was revised to incorporate all necessary information and ponding was found to be 10.73 inches, well beyond the design of six inches as described in the UFSAR. The licensee credited additional rebar which was added during construction but not accounted for in the original design in demonstrating that the safety-related buildings would not fail under the additional loading due to the increased ponding on the roofs. Inspectors have independently reviewed the licensees conclusions and determined the issue did not result in a loss of functionality of the safety-related seismic Category I buildings.

Analysis.

The inspectors concluded that the failure of the operations and engineering personnel to evaluate the operability of a safety-related structure, system, or component was a performance deficiency. The inspectors concluded the performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding is a design or qualification issue confirmed not to result in the loss of operability or functionality. The inspectors determined this finding has a cross-cutting aspect in the area of human performance associated with the component of decision making because the licensee failed to use conservative assumptions in decision making and adopts a requirement to demonstrate that the proposed action is safe in order to proceed rather than a requirement to demonstrate that it is unsafe in order to disapprove the action H.1(b).

Enforcement.

Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings. Procedure 40DP-9OP26, Operations PVAR Processing and Operability Determination/Functional Assessment, Revision 31, provided guidelines and instructions for evaluating the operability of safety-related structures, systems, or components, when degraded conditions were identified. Contrary to the above, from November 4, 2011 through February 15, 2012, operations and engineering personnel failed to accomplish an activity affecting quality in accordance with the prescribed instructions, procedures, and drawings. Specifically, plant personnel failed to follow Procedure 40DP-9OP26 and provide a timely technical justification for continued operation of all safety related seismic Category I buildings. The licensee performed the functional assessment when notified one needed to be preformed and revised the assessment to incorporate all relevant information to as corrective action to restore compliance. Because this finding is of very low safety significance and has been entered into the licensees corrective action program as PVARs 3958463 and 3952605, this violation is being treated as a non-cited violation in accordance with Section 2.3.2 of the Enforcement Policy: NCV 05000528;05000529;05000530/2012002-07, Failure to Perform Functionality Assessment for Safety-Related Buildings.

.4 Failure to Translate Design Basis Into Drawings and Calculations for Safety-related Roof

Drainage Capability

Introduction.

The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the failure of the licensee to translate the safety-related roof drainage capability design basis into drawings and calculations.

Specifically, the licensee could not provide design documentation to support the as built roof drainage capacity.

Description.

During the inspectors review of an engineering evaluation of the structural integrity of the safety-related seismic Category I buildings in the event of a design basis PMP event, described in further detail in Section 4OA2.3, inspectors identified that design basis information was not readily available to support the review. Specifically, there were no calculations or drawings available to support the adequacy of safety-related seismic Category I buildings roof drainage due to ponding in the event of a design basis PMP event. Inspectors walkdown of the building roofs confirmed that the building configuration was as shown in plant drawings but did not include roof drains as described in the UFSAR. Inspectors reviewed calculation 13-CC-ZV-0061 Power Block Area Drainage Revision 3, and confirmed that the use of roof drains was not included for safety related building roof runoff. On February 15, 2012, the licensee revised its evaluation of the safety related building drainage capacity to incorporate all necessary design basis information and ponding was found to be 10.73 inches, well beyond the design of six inches as described in the UFSAR. The licensee credited additional building strength from rebar that was added during construction but not accounted for in the original design. This demonstrated that the safety-related buildings would not fail under the additional loading due to the increased ponding on the roofs. Inspectors have independently reviewed the licensees conclusions and determined the issue did not result in a loss of functionality of the safety-related seismic Category I buildings.

Analysis.

The inspectors concluded that the failure of the licensee to translate design basis documentation for safety-related building roof drainage into drawings and specifications was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affected the design control attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the design control issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Phase I - Initial Screening and Characterization of Findings, and concluded the finding was of very low safety significance (Green) because the finding is a design or qualification issue confirmed not to result in the loss of operability or functionality. No cross-cutting aspect was assigned because the performance deficiency was not indicative of current performance.

Enforcement.

Title 10 Appendix B, Criterion III, Design Control, requires, in part, that measures shall be established to assure that the design basis shall be correctly translated into specifications, drawings, procedures, and instructions. Contrary to the above, prior to February 15, 2012, the licensee did not correctly translate the design basis for roof drainage capabilities to minimize ponding below six inches during a design basis probable maximum precipitation event into specifications, drawings, procedures and instructions. Consequently, the licensee failed to construct safety-related buildings with adequate drainage as described in the Updated Final Safety Analysis Report. The licensee has performed an engineering evaluation to support the structural integrity of the safety-related buildings in the event of a design basis probable maximum precipitation event and is evaluating further corrective action. Because this finding is of very low safety significance and has been entered into the licensees corrective action program as PVARs 3958463 and 3952605, this violation is being treated as a non-cited violation in accordance with Section 2.3.2 of the Enforcement Policy: NCV 05000528; 05000529;05000530/2012002-08, Failure to Translate Design Basis Into Drawings and Calculations for Safety-related Roof Drainage Capability.

4OA3 Follow-up of Events and Notices of Enforcement Discretion

Main article: IP 71153

.1 (Closed) LER 05000528,05000529,05000530/2011-003-00 and LER

05000528,05000529,05000530/2011-003-01, Control Room Essential Filtration Misalignment Resulting in Condition Prohibited by Technical Specifications On April 13, 2011, control room essential filtration system (CREFS) outside air intake (OSA) dampers were found to be in the normally closed position instead of the normally open position stipulated in the updated final safety analysis report. This incorrect configuration was the result of procedure changes made in 1986. Upon identification, Unit I and Unit 3 entered Technical Specification (TS) 3.3.9, condition A when both channels of CREFAS (Control Room Essential Filtration Actuation System) were determined to be inoperable. In response, both units placed an operable train of CREFS into operation per required action A.1. Unit 2 was defueled and irradiated fuel assemblies were not being moved; therefore, TS 3.3.9 was not applicable to Unit 2 at the time this condition was identified. The licensee originally screened this condition as not reportable. The inspectors challenged this conclusion and after a subsequent review completed on July 5, 2011, the licensee determined the condition was reportable as a condition prohibited by TS. The inspectors dispositioned this issue as NCV 05000528, 529, 530/2011003-03, Failure to Submit an LER for a Condition Prohibited by the Plants Technical Specifications.

Additionally, the inspectors identified an issue with the licensees classification and evaluation of this condition. The inspectors dispositioned this issue as NCV 05000528;05000529;05000530/2011004-01, Failure to Adequately Classify and Evaluate Conditions Adverse to Quality.

The licensee issued LER 2011-003-01 as a supplement. After further review of the event, the licensee determined that this event also constituted a common cause inoperability of an independent train. Since the plant configuration was inconsistent with the design configuration and the safety analysis for the CREFAS assumes the trains to be independent, this condition represented a common cause inoperability for independent trains. The licensee entered this second issue into the corrective action program.

The inspectors reviewed the LERs and did not identify any additional concerns. Both LERs are closed.

.2 (Closed) Licensee Event Report 05000530/2010-002-00, Condition Prohibited by

Technical Specification Resulting from Containment Spray Nozzle Obstruction On October 13, 2010, during a Unit 3 refueling outage, the licensee identified seven obstructed containment spray nozzles during a scheduled surveillance test. The nozzles were obstructed for a period greater than allowed by Technical Specification 3.6.6. The licensee concluded the obstruction was caused by boric acid residue and borated water that remained in the containment spray headers from prior overfill events. The licensee also determined that the boric acid deposits were friable and easily removed using a pipe cleaner, and that the deposits would dissolve if an actual containment spray event occurred. The licensee subsequently cleaned the obstructed nozzles and successfully completed the surveillance test. The inspectors dispositioned this issue as a licensee-identified violation in Section 4OA7 of NRC Integrated Inspection Report 05000528/2010005, 05000529/2010005, and 5000530/2010005.

The inspectors reviewed the LER and did not identify any additional concerns. This LER is closed.

.3 (Closed) Unit 2 Reactor Power Cut Back Following A Loss of Main Feedwater Pump A

On January 25, 2012, the licensee performed troubleshooting on the control room hand switch for the non-class 1E 4.16 kV bus normal supply breaker to assess indication problems. During the work, the licensee experienced a loss of the non-class 1E 4.16 kV bus which resulted in the loss of main feedwater pump A and a reactor power cut back.

This transient rapidly reduced power from 100 percent to 48 percent power. Inspectors responded to the control room to observe operator performance and reviewed the licensees actions in response to the event. Inspectors reviewed one self-revealing finding associated with this event documented in Section 1R13 of this report.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On January 27, 2012, regional inspectors presented the onsite emergency preparedness inspection results to Mr. R. Bement, Senior Vice President, Site Operations, and other members of the licensees staff. The licensee acknowledged the issues presented. The inspector asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

On April 6, 2012, the resident inspectors presented the quarterly inspection results to Mr. R.

Bement, Senior Vice President, Site Operations, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspector asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

4OA7 Licensee-Identified Violations

The following violation of very low safety significance Green was identified by the licensee and is a violation of NRC requirements which meet the criteria of the NRC Enforcement Policy for being dispositioned as a non-cited violation.

.1 Technical Specification 3.1.7 requires, in part, that regulating CEAs groups shall be

limited to insertion limits specified in the core operating limits report and the associated time restraints. Palo Verde Nuclear Generating Station Unit 2s core operating limits report, Figure 3.1.7-1, states that the fully withdrawn position is defined as greater than 147.75 in. as indicated on the pulse counter. Contrary to the above, on January 25, 2012, the licensee failed to meet the insertion limits specified in the core operating limits report and the associated time restraints. Specifically, on January 25, 2012, the licensee failed to ensure that group 3 assemblies were fully withdrawn to 147.75 in. and failed to shutdown as required, when the limiting condition of operations of technical specification 3.1.7 could not be met. The licensee took immediate corrective actions to fully withdraw rods and restore compliance when the non-compliance was identified. The licensee has submitted LER 05-529/2012-001-00 to document the condition prohibited by technical specifications. The licensee plans to modify procedures as corrective actions documented under PVAR 4037346.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

R. Barnes, Director, Regulatory Affairs

R. Bement, Senior Vice President, Site Operations

B. Berryman, Plant Manager, Plant Operations

J. Cadogan, Director, Plant Engineering

K. Chavet, Consultant, Nuclear Regulatory Affairs

E. Dutton, Director, Nuclear Assurance Department

M. Fallon, Director, Communications

M. Lacal, Vice President, Operations Support

F. Lake, Director, Performance Improvement Department

M. McGhee, Department Leader, Nuclear Regulatory Affairs

D. Mims, Vice President, Nuclear Regulatory Affairs/Oversight

M. Powell, Director, Nuclear Fuel Management

M. Ray, Director, Emergency Preparedness/Security

M. Shea, Director, Safety Culture

J. Waid, Director, Nuclear Training

NRC Personnel

M.A. Brown, Senior Resident Inspector

M. Baquera, Resident Inspector

D. Bradley, Project Engineer

A. Fairbanks, Reactor Inspector

D. Reinert, Reactor Inspector

E. Uribe, Reactor Inspector

G. Warnick, Senior Resident Inspector

Attachment

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

Failure to Follow Corrective Action Program

05000529/2012002-01 NCV Procedure (Section 1R13)

Failure to Assess and Manage Risk Prior to

05000529/2012002-02 NCV Troubleshooting on 4.16 kV Bus Supply Breaker Hand Switch (Section 1R13)

05000528; Failure to Obtain NRC Approval for a Change NCV

05000529;05000530/2012002-03 Adverse to Safe Shutdown (Section 1R15)

05000528; Failure in the Choice of Protective Actions Consistent NCV

05000529;05000530/2012002-04 with Federal Guidance (Section 1EP5)

Failure to Promptly Identify and Correct a Condition

05000528; NCV Adverse to Quality Associated with Essential Chilled

05000529;05000530/2012002-05 Water System Gas Accumulation (Section 4OA2)

Failure to Provide an Adequate Operating Procedure

05000528/2012002-06 NCV for Cold-Leg Boration (Section 4OA2)

05000528; Failure to Perform Functionality Assessment for NCV

05000529;05000530/2012002-07 Safety-Related Buildings (Section 4OA2)

Failure to Translate Design Basis Into Drawings and

05000528; NCV Calculations for Safety-related Roof Drainage

05000529;05000530/2012002-08 Capability (Section 4OA2)

Closed

Control Room Essential Filtration Misalignment

05000528,

05000529,

05000530/2011-

LER Resulting in Condition Prohibited by Technical 003-00 Specifications (Section 4OA3)

Control Room Essential Filtration Misalignment

05000528,

05000529,

05000530/2011-

LER Resulting in Condition Prohibited by Technical 003-01 Specifications (Section 4OA3)

Condition Prohibited by Technical Specification

05000530/2010-002-00 LER Resulting from Containment Spray Nozzle Obstruction (Section 4OA3)

Attachment

LIST OF DOCUMENTS REVIEWED

IR 05000528/2012002

Text

SUBJECT:

Dear Mr. Edington:

Enclosure:

SUMMARY OF FINDINGS

NRC-Identified Findings and Self-Revealing Findings

Cornerstone: Initiating Events

Cornerstone: Mitigating Systems

Cornerstone: Emergency Preparedness

Licensee-Identified Violations

REPORT DETAILS

Summary of Plant Status

REACTOR SAFETY

1R04 Equipment Alignment

a. Inspection Scope

b. Findings

1R05 Fire Protection

.1 Quarterly Fire Inspection Tours

a. Inspection Scope

b. Findings

.2 Annual Fire Protection Drill Observation

a. Inspection Scope

b. Findings

1R06 Flood Protection Measures

a. Inspection Scope

b. Findings

1R11 Licensed Operator Requalification Program

.1 Quarterly Review of Licensed Operator Requalification Program

a. Inspection Scope

b. Findings

.2 Quarterly Observation of Licensed Operator Performance

a. Inspection Scope

b. Findings

1R12 Maintenance Effectiveness

a. Inspection Scope

b. Findings

1R13 Maintenance Risk Assessments and Emergent Work Control

a. Inspection Scope

b. Findings

.1 Failure to Follow Corrective Action Program Procedure

Introduction.

Description.

Analysis.

Enforcement.

.2 Failure to Assess and Manage Risk Prior to Troubleshooting 4.16 kV Bus Supply

Introduction.

Description.

Analysis.

Enforcement.

1R15 Operability Evaluations and Functionality Assessments

a. Inspection Scope

b. Findings

Introduction.

Description.

Analysis.

Enforcement.

1R19 Post Maintenance Testing

a. Inspection Scope

b. Findings

1R22 Surveillance Testing

a. Inspection Scope

b. Findings

Cornerstone: Emergency Preparedness

1EP2 Alert Notification System Testing

a. Inspection Scope

b. Findings

1EP3 Emergency Response Organization Augmentation Testing

a. Inspection Scope

b. Findings

1EP5 Correction of Emergency Preparedness Weaknesses and Deficiencies

a. Inspection Scope

b. Findings

Introduction.

Description.

Analysis.

Enforcement.

1EP6 Drill Evaluation

a. Inspection Scope

b. Findings