ML14087A366
| ML14087A366 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 03/28/2014 |
| From: | Boland A Division Reactor Projects III |
| To: | Mccartney E Point Beach |
| References | |
| EA-12-009, EA-13-125 IR-14-007 | |
| Download: ML14087A366 (58) | |
See also: IR 05000266/2014007
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION III
2443 WARRENVILLE RD. SUITE 210
LISLE, IL 60532-4352
March 28, 2014
EA-13-125
Mr. Eric McCartney
Site Vice President
NextEra Energy Point Beach, LLC
6610 Nuclear Road
Two Rivers, WI 54241
SUBJECT: POINT BEACH NUCLEAR PLANT, UNITS 1 AND 2
NRC 95002 SUPPLEMENTAL INSPECTION REPORT
05000266/2014007; 05000301/2014007
Dear Mr. McCartney:
On March 6, 2014, the U.S. Nuclear Regulatory Commission (NRC) completed a follow-up
supplemental inspection pursuant to Inspection Procedure 95002, Supplemental Inspection for
One Degraded Cornerstone or any Three White Inputs in a Strategic Performance Area, at
your Point Beach Nuclear Plant, Units 1 and 2. The enclosed report documents the results of
this inspection, which were discussed at the exit on March 6, 2014, with you and other members
of your staff.
In accordance with the NRC Reactor Oversight Process (ROP), this follow-up supplemental
inspection was performed to assess the White inspection finding for the failure of the Unit 1
Turbine Driven Auxiliary Feedwater Pump (TDAFWP) and the White inspection finding for
external wave run-up flooding. These two White findings both in the Mitigating Systems
Cornerstone placed Point Beach Unit 1 in a degraded cornerstone as of the first quarter of
2013. In addition to these two White findings we requested that you also include in your
assessment the White finding in the Emergency Preparedness (EP) Cornerstone that had been
issued on July 24, 2012. A 95001, Supplemental Inspection for One or Two Inputs in a
Strategic Performance Area, had previously been performed for the White EP finding and the
White TDAFWP finding.
The NRC staff was informed on October 29, 2013, of your readiness, as of that date for us to
conduct this supplemental inspection.
The objectives of this supplemental inspection were to: (1) provide assurance that the root
causes and the contributing causes for the risk significant issues were understood;
(2) independently assess and provide assurance that the extent of condition and extent of cause
of the individual and collective issues were identified; (3) determine if safety culture components
caused or significantly contributed to the individual or collective issues; and (4) provide
assurance that the corrective actions were or will be sufficient to address and preclude
repetition of the root and contributing causes.
E. McCartney -2-
The inspection consisted of an examination of activities conducted under your license as they
related to safety, compliance with the Commissions rules and regulations, and the conditions of
your operating license. The inspectors reviewed selected procedures and records, observed
activities, and interviewed personnel.
Based on the results of the inspection, the NRC determined that Point Beach had performed an
acceptable evaluation of the White EP finding and the White TDAFWP finding but had not
performed an acceptable evaluation of the White flooding finding and had not performed an
acceptable evaluation of the collective White inputs. Taken collectively the issues associated
with the White flooding finding represented a significant weakness, as discussed in Inspection
Procedure (IP) 95002, and your actions to date have not provided the assurance level required
to meet the inspection objectives. The inspection determined that your staff failed to adequately
evaluate the root causes, contributing causes, extent-of-condition, or extent-of-cause of the
safety-significant finding, and take or plan adequate corrective actions to address the root
causes, contributing causes, extent-of-condition, or extent-of-cause and to prevent recurrence
of the safety-significant finding. The White finding associated with Notice of Violation (NOV)05000266/2013002-10 and 05000301/2013002-10 will be held open. Specific items are
discussed in additional detail in each section of the attached inspection report.
When informed of your readiness, a future inspection will be conducted to verify the corrective
actions that your staff has put in place to address and preclude a repetition of the White flooding
finding.
Based on the results of this inspection, three NRC-identified findings of very low safety
significance (Green) that involved violations of NRC requirements were identified. The NRC
identified an additional Green finding that was associated with a Severity Level IV violation of
NRC requirements evaluated through the traditional enforcement process. However, because
of their very low safety significance, and because these issues were entered into your corrective
action program, the NRC is treating these violations as non-cited violations (NCVs) in
accordance with Section 2.3.2 of the NRC Enforcement Policy.
If you contest the subject or severity of these NCVs, you should provide a response within
30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear
Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a
copy to the Regional Administrator, U.S. Nuclear Regulatory Commission - Region III,
2443 Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement,
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector
Office at the Point Beach Nuclear Plant. In addition, if you disagree with the cross-cutting
aspect assigned to any finding in this report, you should provide a response within 30 days of
the date of this inspection report, with the basis for your disagreement, to the Regional
Administrator, Region III, and the NRC Resident Inspector at the Point Beach Nuclear Plant.
As a result of the Safety Culture Common Language Initiative, the terminology and coding of
cross-cutting aspects were revised beginning in calendar year (CY) 2014. New cross-cutting
aspects identified in CY 2014 will be coded under the latest revision to Inspection Manual
Chapter (IMC) 0310. Cross-cutting aspects identified in the last six months of 2013 using the
E. McCartney -3-
previous terminology will be converted to the latest revision in accordance with the
cross-reference in IMC 0310. The revised cross-cutting aspects will be evaluated for
cross-cutting themes and potential substantive cross-cutting issues in accordance with
IMC-0305 starting with the CY 2014 mid-cycle assessment review.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and
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 System (PARS)
component of NRC's Agencywide Documents Access and Management System (ADAMS),
accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public
Electronic Reading Room).
Sincerely,
/RA/
Anne T. Boland, Director
Division of Reactor Projects
Docket Nos. 50-266; 50-301
Enclosure:
IR 05000266/2014007; 05000301/2014007
w/Attachment: Supplemental Information
cc w/encl: Distribution via ListServTM
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket Nos: 05000266; 05000301
Report No: 05000266/2014007; 05000301/2014007
Licensee: NextEra Energy Point Beach, LLC
Facility: Point Beach Nuclear Plant, Units 1 and 2
Location: Two Rivers, WI
Dates: February 3, 2014, through March 6, 2014
Inspectors: B. Bartlett, Project Engineer
J. Beavers, Emergency Preparedness Inspector
R. Elliott, Acting Resident Inspector, Point Beach
J. Jandovitz, Project Engineer
K. Miller, Resident Inspector, Watts Bar
P. Voss, Resident Inspector, Monticello
Approved by: J. Cameron, Chief
Branch 4
Division of Reactor Projects
Enclosure
SUMMARY OF FINDINGS
Inspection Report (IR) 05000266/2014007, 05000301/2014007; 02/03/2014 - 03/06/2014;
Point Beach Nuclear Plant, Units 1 and 2; Supplemental Inspection - Inspection Procedure
(IP) 95002, Supplemental Inspection for One Degraded Cornerstone or any Three White Inputs
in a Strategic Performance Area.
This inspection was conducted by three regional inspectors and three resident inspectors. The
inspectors identified three NRC-identified findings of very low safety significance (Green) that
involved violations of NRC requirements. The NRC identified an additional Green finding that
was associated with a Severity Level IV violation of NRC requirements evaluated through the
traditional enforcement process. The significance of most findings is indicated by their color
(Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, Significance
Determination Process (SDP). Assigned cross-cutting aspects were determined using
IMC 0310, Components Within the Cross-Cutting Areas. Findings for which the SDP does not
apply may be Green or be assigned a severity level after NRC management review. The NRCs
program for overseeing the safe operation of commercial nuclear power reactors is described in
NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006.
Cornerstone: Mitigating Systems
The NRC staff performed this follow-up supplemental inspection in accordance with
Inspection Procedure 95002, Inspection for One Degraded Cornerstone or Any Three
White Inputs in a Strategic Performance Area, to continue to assess the licensees
evaluation of two White inspection findings that affected the Mitigating Systems Cornerstone.
The inspection team determined that the licensee performed an adequate evaluation of some of
the issues, but failed to perform an adequate evaluation of some issues. The inspection team
determined that the root cause evaluation for the Turbine Driven Auxiliary Feedwater Pump
(TDAFWP) appropriately evaluated the root and contributing causes, adequately addressed the
extent of condition and cause, assessed safety culture, and established corrective actions for
the risk significant performance issues. However, the inspection team determined that for the
flooding White finding that the licensee failed to appropriately evaluate the root and contributing
causes, failed to adequately address the extent of condition and cause, failed to adequately
assess safety culture, and failed to establish adequate corrective actions. In addition to
assessing the licensees evaluations, the inspection team independently performed an extent of
condition and extent of cause review of the two findings and a review of the site safety culture
as it related to the root cause evaluations. The team concluded that the licensees root cause
evaluations and corrective actions, both completed and planned, were sufficient to address the
causes and prevent recurrence for the TDAFWP White finding but had significant weaknesses
resulting in failure for the flooding White finding. The licensees implementation of corrective
actions for the TDAFWP will be reviewed during future inspections.
2
A. NRC-Identified and Self-Revealed Findings
- Green. The inspectors identified a finding of very low safety significance and associated
non-citied violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Actions, in
that from March 13, 2013 until February 14, 2014, the licensee failed to assure that for a
significant condition adverse to quality (SQAC), the cause of the condition was
determined and corrective actions were taken to preclude repetition. Specifically, the
licensees corrective actions failed to preclude repetition of an SQAC where Procedure
PC 80 Part 7, Lake Water Level Determination, as implemented, would not protect
safety-related equipment in the turbine building or Circulating Water Pump House
(CWPH). After the licensee had taken corrective actions to improve the wave barrier
procedure in response to an NRC-identified NOV, PC 80 Part 7 and other flood
protection implementing procedures specified inadequate timelines to ensure wave
run-up flood barriers would be installed prior to the lake level at which wave run-up could
impact the site. Corrective actions for this issue included changing the affected
procedures to install the wave barriers at a lower lake level, changing the lake level
determination surveillance from monthly to weekly, and reducing the allowed installation
time for the barriers from 3 weeks to 1 week.
The performance deficiency was screened against the Reactor Oversight Process per
the guidance of lMC 0612, Appendix B, and determined to be more than minor because
the finding was associated with the Mitigating Systems Cornerstone attributes of
Protection Against External Factors (Flood Hazard) and Procedure Quality, and
adversely affected the cornerstone objective to ensure the availability, reliability, and
capability of systems that respond to initiating events to prevent undesirable
consequences (i.e. core damage). Specifically, the licensees failure to correct
procedural deficiencies associated with flood barrier construction timelines, could
challenge the timely installation of the barriers, which could impact the ability of
mitigating systems to respond during an external flooding event. The inspectors
evaluated the finding using IMC 0609, Attachment 0609.04, Tables 2 and 3, and
Appendix A. Based on a review of Appendix A, Exhibit 2, Item 4.B, the inspectors
determined that this issue screened as having very low safety significance (Green).
This finding has a cross-cutting aspect in the area of problem identification and
resolution, because the licensee failed to thoroughly evaluate issues to ensure that
resolutions address causes and extent of conditions commensurate with their safety
significance. (P.2)
- Green. The inspectors identified a finding of very low safety significance and associated
non-citied violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions,
Procedures, and Drawings, in that from January 19, 1996 until November 25, 2013, the
licensee failed to ensure that activities affecting quality were prescribed by documented
procedures of a type appropriate to the circumstances to address external flooding as
described in the Final Safety Analysis Report (FSAR). Specifically, PC 80 Part 7, Lake
Water Level Determination directed advanced installation of concrete barriers to protect
against deep wave action from the lake, which introduced significant unrecognized
blockages in the natural drainage path credited in the FSAR to protect against the
probable maximum precipitation and Turbine Building internal flooding events.
Corrective actions for this issue included changing the procedure and FSAR to include
actions to provide an additional flood relief path through the CWPH building and reliance
on internal flood relief dampers for the affected flooding events.
3
The performance deficiency was screened against the Reactor Oversight Process per
the guidance of lMC 0612, Appendix B, and determined to be more than minor because
the finding was associated with the Mitigating Systems Cornerstone attributes of
Protection Against External Factors (Flood Hazard) and Procedure Quality, and
adversely affected the cornerstone objective to ensure the availability, reliability, and
capability of systems that respond to initiating events to prevent undesirable
consequences (i.e. core damage). Specifically, the licensees failure to procedurally
control external flooding design features to ensure they would not adversely affect the
strategy for other flooding events, could negatively impact mitigating systems ability to
respond during external and internal flooding events. The inspectors evaluated the
finding using IMC 0609, Attachment 0609.04, Tables 2 and 3, and Appendix A, and
determined a detailed risk evaluation was required. Following a detailed risk evaluation,
Region III SRAs determined that the finding had very low safety significance (Green).
This finding has a cross-cutting aspect in the area of problem identification and
resolution, because the licensee failed to take effective corrective actions to address
issues in a timely manner commensurate with their safety significance. (P.3)
- Severity Level IV: The inspectors identified a finding of very low safety significance and
associated Severity Level IV, non-citied violation of 10 CFR 50.59(d)(1), Changes, tests
and experiments, when, on November 25, 2013, the licensee failed to perform an
evaluation against the criteria in 10 CFR 50.59(c)(2) for a change to procedure
PC 80 Part 7 to include actions to maintain functionality of drainage paths during
probable maximum precipitation and turbine building flooding events. Specifically,
PC 80 Part 7, Lake Water Level Determination was changed to include actions to open
the CWPH rollup doors to provide an additional drainage path while wave barriers were
in place, without fully evaluating the viability of reliance on additional flood features not
credited for external flooding in the Current License Basis (CLB). Corrective actions for
this issue included to updating the FSAR to describe the new flood paths, performing a
10 CFR 50.59 screening and 10 CFR 50.59 evaluation for the new drainage path which
had put the site outside of the CLB, revising a related functionality assessment,
controlling external flooding areas to ensure they are clear of debris, and creating a
procedure to install curtains on the CWPH rollup doors during periods when they were
required to be open.
The inspectors determined that the licensees failure to fully evaluate the viability of
newly created flooding drainage paths as required by 10 CFR 50.59(d)(1) was a
performance deficiency. The inspectors evaluated the performance deficiency using
traditional enforcement in conjunction with the SDP because the performance deficiency
had the potential to impact the regulatory process. The performance deficiency was
screened per the guidance of lMC 0612, Appendix B, and determined to be more than
minor because the finding was associated with the Mitigating Systems Cornerstone
attributes of Protection Against External Factors (Flood Hazard) and Design Control, and
adversely affected the cornerstone objective to ensure the availability, reliability, and
capability of systems that respond to initiating events to prevent undesirable
consequences (i.e. core damage). Specifically, the licensee did not fully demonstrate
that the availability, reliability, and capability of mitigating systems would be maintained
during flooding events due to the sites failure to evaluate the viability of alternate flood
drainage paths through the CWPH. The inspectors evaluated the finding using
IMC 0609, Attachment 0609.04, Tables 2 and 3, and Appendix A. Based on a review of
Appendix A, Exhibit 2, Item 4.B, the inspectors determined that this issue screened as
4
having very low safety significance (Green). Additionally, in accordance with
Section 6.1.d.2 of the NRC Enforcement Policy, this violation is categorized as a
Severity Level IV because the resulting conditions were evaluated as having very low
safety significance (Green) by the SDP. This finding has a cross-cutting aspect in the
area of problem identification and resolution, because the licensee failed to thoroughly
evaluate issues to ensure that resolutions address causes and extent of conditions
commensurate with their safety significance. (P.2)
- Green. The inspectors identified a finding of very low safety significance (Green) and
associated non-citied violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions,
Procedures, and Drawings, for the failure to ensure the effectiveness review attributes
for a significant condition adverse to quality would ensure the corrective actions would
eliminate or reduce the recurrence rate.
The inspectors determined that the licensees failure to establish effectiveness review
criteria that would have identified whether the corrective action to prevent recurrence
(CAPRs) had effectively resolved the conditions was a performance deficiency
warranting further review. The inspectors determined that this finding was more than
minor in accordance with IMC 0612, Appendix B, because it was affected the Mitigating
Systems Cornerstone objective to ensure availability, reliability, and capability of
systems that respond to initiating events to prevent undesirable consequences. If left
uncorrected, would the performance deficiency have the potential to lead to a more
significant safety concern? The inspectors evaluated the finding using IMC 0609,
Appendix A. The inspectors determined the finding was of very low safety significance
(Green) because the finding was not a deficiency affecting the design or qualification of
a mitigating structure, system or component and did not result in a loss of operability or
functionality. In addition, the finding did not represent a loss of system or function, did
not represent an actual loss of function of a least a single train for longer than its
technical specification allowed outage time, and did not represent an actual loss of
function of one or more nontechnical specification trains of equipment designated as
high safety-significance.
The finding had a cross cutting aspect in the area of problem identification and
resolution, specifically resolution, because licensee personnel failed to ensure the
corrective actions to prevent recurrence had effective attributes. (P.2)
5
REPORT DETAILS
4. OTHER ACTIVITIES
Cornerstone: Mitigating Systems
4OA4 Supplemental Inspection (95002)
a. Inspection Scope
The NRC staff performed this follow-up supplemental inspection in accordance with
inspection procedure (IP) 95002, Inspection for One Degraded Cornerstone or Any
Three White Inputs in a Strategic Performance Area, to assess the White inspection
finding for the failure of the Unit 1 Turbine Driven Auxiliary Feedwater Pump (TDAFWP)
and the White inspection finding for external wave run-up flooding. In addition to these
two White findings the licensee was requested to also include in their assessment the
White finding in the Emergency Preparedness (EP) Cornerstone that had been issued
on July 24, 2012. A 95001, Supplemental Inspection for One or Two Inputs in a
Strategic Performance Area, had previously been performed for the White EP finding
and the White TDAFWP finding.
The objectives of the supplemental inspection included:
- To provide assurance that the root and contributing causes for the White findings
are understood.
- To determine if the licensees corrective actions for risk-significant performance
issues are sufficient to address the root and contributing causes and prevent
recurrence.
- To independently assess the extent of condition and the extent of cause for
individual and collective risk-significant performance issues.
- To assess the safety culture as a possible contributor.
The inspectors reviewed the Root Cause Evaluations (RCE), in addition to other
assessments, evaluations, and corrective action program documentation completed in
support of and, as a result of, the RCEs. The inspectors reviewed corrective actions that
were taken or planned to address the identified causes. The inspectors interviewed
selected station, corporate, and contractor personnel, and held discussions with these
individuals to verify that the root and contributing causes and the contribution of safety
culture components were understood and that corrective actions taken or planned were
appropriate to address the causes and preclude repetition.
For clarity, documentation of each inspection requirement contains subsections for each
of the two White mitigating systems findings. The White EP finding was assessed by the
inspection team only as it related to commonalities to the other White findings and this is
not individually discussed in this report.
Documents reviewed during this inspection are listed in the Attachment.
6
Inspection Results
The four attributes of IP 95002 were reviewed for each of the three White findings plus
the common cause analysis performed by the licensee. Thus there were a total of 16
attributes that were reviewed. The inspectors concluded that for the White EP finding
and the White TDAFWP finding that the licensee understood the root and contributing
causes. In addition, the inspectors performed the independent extent of condition and
extent of causes and assessed the licensees corrective actions for these two White
findings and concluded that the licensees actions were sufficient. Finally, the inspectors
determined that the safety culture aspects for these two White findings were adequate
although there were safety culture components that contributed to the common cause
analysis conclusions and that corrective actions had been taken to address these
conclusions. Thus of the total of 16 attributes, eight were closed. The inspectors
determined that the root causes, extent of condition, extent of cause, corrective actions
and safety culture aspects for the White flooding finding and the common cause analysis
(CCA) were not sufficient and remain open.
.02 Evaluation of the Inspection Requirements
02.01 Problem Identification
a. Determine that the Evaluation Documented Who Identified the Issue (i.e., Licensee-
Identified, Self-Revealing, or NRC-Identified) and Under What Conditions the Issue was
Identified
The inspectors determined that neither of the RCEs for the two White findings nor the
CCA specifically addressed who identified the issues. The RCE for the TDAFWP White
finding had enough information to infer that the finding was self-revealed but the RCE for
the flooding White finding contained only a minimal inference that a NRC finding had
been issued. The CCA had remarks similar to the flooding RCE that stated that NRC
had issued White findings but again the inspectors had to infer how the findings were
identified. There were no statements in any licensee documentation or as a result of
interviews with licensee management indicating the licensee disagreed with the findings.
The licensee clearly stated the conditions under which the issues were identified. The
inspectors considered the failure to clearly state who identified the issue to be a
weakness for the TDAFWP White finding but not significant enough to leave this item
open. For the TDAFWP White finding, this aspect of IP 95002 is closed. The inspectors
concluded that the licensee failed to clearly document who identified the issue for the
White flooding finding and the CCA and this aspect of IP 95002 was not met.
b. Determine that the Evaluation Documented How Long the Issues Existed and Prior
Opportunities for Identification
The licensees evaluation for the TDAFWP White finding documented that pump to
turbine alignment issues had existed for many years and that each time the pump was
determined to be out of alignment it had been restored to within allowable limits. The
inspectors determined that the licensees evaluation was adequate with respect to
identifying how long the issue existed and prior opportunities for identification.
7
The licensees evaluation for the flooding White finding documented that the change to
the methodology of protecting the site from external lake flooding had been done in
January of 1996. The licensees evaluation also documented some prior missed
opportunities to identify; however, the evaluation failed to address other significant prior
opportunities. As discussed further in various sections of the report, the inspectors
observed that licensee personnel implemented corrective actions that significantly
impacted other license basis events but failed to recognize these impacts. Thus, there
were additional opportunities to identify which were not listed or discussed in the
licensees RCE. The inspectors determined that the licensees evaluation was not
adequate with respect to identifying how long the issue existed and prior opportunities
for identification. This aspect of IP 95002 remains open for the flooding White finding.
c. Determine that the Evaluation Documented the Plant Specific Risk Consequences, As
Applicable, and Compliance Concerns with the Issues Both Individually and Collectively
The risk evaluation performed by the licensee in discussions with the NRC Senior
Reactor Analyst (SRA) prior to issuance of the TDAFWP White finding was not the one
utilized by the licensee for the subsequent RCE. The licensees RCE, stated, in part, In
order to quickly evaluate the safety significance of this issue, the Safety Monitor program
was used by the probabilistic risk assessment (PRA) group. The NRC team did not
understand the need to quickly perform a risk assessment since one had previously
been performed and discussed with an NRC SRA. Nevertheless, the licensee chose to
perform one, but selected a program that did not align with standard NRC significance
determination techniques. The licensees Safety Monitor program is used to monitor on
line risk in a moment to moment manner and use of the program to calculate the risk
consequence for the TDAFWP failure was neither accurate nor appropriate. The team
discussed the licensees risk significance with the NRC SRA who performed the original
assessment and the SRA verified that the licensee had understood and agreed with the
original NRC conclusions. The purpose of this reassessment and write-up was not
understood either by the SRA nor the team. The inspectors also determined that the
licensee had issued a Licensee Event Report for the failure of the TDAFWP and
appropriately entered the failure in the Maintenance Rule database and the Performance
Indicators. Based upon the licensees previous demonstrated knowledge and
understanding of the risk significance of this item, the inspectors concluded that the risk
and compliance portion was weak, but that this fundamental aspect of IP95002 had
been met.
The risk evaluation performed by the licensee for the flooding White finding enforcement
conference was not accepted by the NRC although portions of the licensees
assessment was recognized as acceptable and used to ensure the NRC position was
accurate. Nevertheless, the licensee chose to repeat the previously determined
unsatisfactory risk assessment in the flooding White RCE. In the NRC Final Significance
Determination of a White Finding, dated August 9, 2013, Enclosure 2 provided an
analysis of the licensee risk information. In this analysis the NRC disagreed with the
licensees risk assessment in a number of significant ways, yet these disagreements
appeared to not be factored into the licensees subsequent risk assessment documented
in the associated RCE. The inspectors review of the flooding RCE determined that the
licensee did not address possible compliance concerns or reportability.
8
During interviews, individuals directly involved in responding to the finding cited internal
supplemental calculations, and stated that they believed there would not have been any
consequences to the plant as a result of the finding. Interviewees stated that the
findings risk significance came only from significant conservatisms used in the individual
plant examination external events (IPEEE) evaluation, and not from potential plant
consequences. Interviews with individuals not directly involved in addressing the
flooding finding revealed that working level plant personnel were familiar with the
flooding finding, but their awareness was focused more on the regulatory impacts, with
minimal awareness of potential equipment impacts.
The inspectors concluded that the licensee failed to adequately address the plant
specific risk consequences or compliance concerns related to the flooding White finding
and this aspect of IP 95002 was not met.
d. Findings
No findings were identified.
02.02 Root Cause
a. Determine that the Problem was Evaluated Using a Systematic Methodology to Identify
the Root and Contributing Causes
The inspectors reviewed the licensees RCEs, CCA, and other documents related to the
White findings. The licensee identified a total of four root causes and seven contributing
causes using a systematic methodology. In addition, the licensees CCA identified two
common causes and two contributing causes. The licensee utilized support-refute
matrix, change analysis, barrier analysis, a cause and effects diagram, an event and
causal factor chart, and a why staircase during the two root cause assessments and
the CCA. The inspectors determined that the RCE and CCA were conducted to a level
of detail commensurate with the significance of the issues. The licensees evaluations
included details of each item along with supporting data and other information.
The licensees use of systematic methodology to identify the root and contributing
causes was determined to be adequate for the TDAFWP White finding. Due to the
significant weaknesses identified in the licensees corrective actions, extent of condition,
extent of cause, and root cause, the team concluded that this aspect for the flooding
White finding was negatively impacted. This aspect of IP 95002 will remain open for the
flooding White finding.
b. Determine that the Root Cause Evaluation was Conducted to a Level of Detail
Commensurate with the Significance of the Problem
The licensee utilized the systematic methodologies for the CCA discussed above and
determined that the primary root causes were:
- Less than adequate understanding of the design and licensing basis;
- Corrective Action Program items with incorrect priorities;
- Original construction stress riser introduced to the TDAFWP;
9
- Emergency Preparedness group did not perform reviews of federal guidance;
- A lack of or inadequate leadership; and
- Poor technical procedure quality.
The inspectors noted that while the licensee had poor procedure quality as a root cause
for the TDAFWP issue, the knowledge, skills, and abilities (KSA) of the workers was not
considered as a possible root cause. For example, the TDAFWP alignment procedure
did not require the taking of as-found data nor did the procedure require that if the data
was taken that it be reviewed by engineering personnel. Yet, a qualified maintenance
mechanic would have experience with the need to take such data and would know to
pass it along to their supervisor. The inspectors performed a search of the licensees
CAP database to see if a trend of issues with a cause of KSA existed and did not identify
any trends. The licensees RCEs should have discussed this aspect in sufficient detail
so as to demonstrate that this was not a root cause.
Despite the weakness noted above, the inspectors determined that the RCE for the
TDAFWP White finding was conducted to a level of detail commensurate with the
significance of the issues.
For the flooding White finding and the CCA root cause the inspectors observed that
problems with the quality of condition report evaluations and with Functionality
Assessments (FA) were identified but not included as either a root cause or a
contributing cause. The inspectors also noted that an assessment of the licensees CCA
performed prior to the team arriving on site (Quick Hit PBSA-PBNP-13-03) had a similar
observation and a recommendation to clearly articulate this theme. The inspectors
determined that neither a root cause nor a contributing cause was assigned to either
corrective action program quality or CR evaluations. One CAPR was assigned to
improve the quality of FAs. This is discussed in more detail in Section 02.04, below.
While corrective action program evaluation quality was a part of the issues identified, the
failure of the licensee to either include it as a root cause or to justify why it was not a root
cause was a significant weakness.
The inspectors determined that this aspect of the IP 95002 criteria was not met for the
flooding White finding and the CCA.
c. Determine that the Root Cause Evaluation Included a Consideration of Prior
Occurrences of the Problem and Knowledge of Prior Operating Experience
The inspectors determined that the licensees evaluation included a consideration of
prior occurrences of the issues and industry operating experience. The RCE for the
TDAFWP determined that a prior opportunity was missed in early 2011 during the Unit 2
refueling outage when pipe stresses were identified on the opposite unit TDAFWP. The
licensee determined that even though the pipe stresses were identified and corrected
that a CR was not issued and thus the opportunity to apply this information to the next
Unit 1 refueling outage and TDAFWP maintenance activity was missed.
The inspectors concluded that the root cause evaluation included a review of prior and
precursor problems and properly evaluated internal and industry operating experience.
This aspect of the IP 95002 criteria was met for the TDAFWP finding.
10
The RCE for the White flooding finding determined that prior opportunities were missed
to properly correct the deficiency. This included opportunities in 2004, when condition
reports were generated questioning the adequacy of the wave run-up barriers, given the
1996 procedure change. This also included opportunities in 2012 where a functionality
assessment inappropriately contained conclusions regarding the functionality of the
wave barriers on perceived risk. The inspectors noted that these opportunities were
factored into the determination of one of the root causes. The inspectors also noted the
RCE discussion on industry OE and noted several instances where the causes of
industry deficiencies were similar to the causal factors identified for the White flooding
issue
As discussed later in this inspection report unintended consequences were introduced
during the corrective actions to the White flooding finding. The failure to recognize these
consequences represented additional occurrences of the problem. The inspectors
determined that this aspect of the IP 95002 criteria was not met for the flooding White
finding and the CCA.
d. Determine that the Root Cause Evaluation Addresses the Extent of Condition and the
Extent of Cause of the Problem
The licensees RCE included an evaluation of the extent of condition and extent of cause
of the issues. The inspectors determined that the RCE for the TDAFWP issue was
adequate with comments. These comments are discussed in section 02.04 of this
report. The inspectors also noted that during an assessment of the licensees RCE that
was performed prior to the team arriving on site (Quick Hit PBSA-PBNP-13-03) that
deficiencies with the TDAFWP had been identified. For example, the extent of condition
prior to the Quick Hit was limited to rotating couplings of the same make and model as
that which had failed on the Unit 1 TDAFWP. Following a recommendation of the Quick
Hit team, the licensee had expanded the extent of condition to include other make and
model couplings as well as all rotating connections. Based on a review of the RCE and
CCA and discussions with licensee management and staff personnel, the inspectors
concluded that the evaluations for the TDAFWP White finding adequately addressed the
extent of condition and the extent of cause. This aspect of the IP 95002 was not for the
TDAFWP finding.
The inspectors determined that the RCE for the flooding White finding also included an
evaluation of the extent of condition and extent of cause but based on the NRC findings
documented in Section 02.04 of this report the inspectors concluded that this item was
not acceptable. For example, the RCE did not consider possible bypass paths around
the external flooding barrier. During field walk downs, the inspectors identified two
different drain pipes in the concrete near the CWPH which directly communicated with
the lake shore and should have been evaluated as possible bypass paths. The
inspectors concluded that the evaluations for the flooding White finding did not satisfy
this aspect of the IP 95002 criteria.
e. Findings
No findings were identified.
11
02.03 Corrective Actions
a. Determine that Appropriate Corrective Actions are Specified for Each Root and
Contributing Cause or that the Licensee has an Adequate Evaluation for Why No
Corrective Actions are Necessary
The inspectors assessed the corrective actions for the RCEs and the CCA. The
inspectors verified that all root causes had associated CAPRs and that all contributing
causes had associated corrective actions. The inspectors then performed a more
detailed assessment of selected CAPRs and corrective actions. The detailed
assessment included a sample of corrective action program documents, field walk
downs, interviews with selected licensee individuals, and reviews of the design and
licensing basis.
The inspectors concluded that the corrective actions for the TDAFWP finding were
vague and needed additional clarification. As previously noted, the scope of the root
cause was narrowly focused but this had previously been identified by an internal
licensee review. As a result, the scope of the corrective actions had been expanded to
include other rotating equipment connections. Additional corrective actions were
reviewed by the inspectors with no further substantive observations. The inspectors
concluded that the CAPRs and corrective actions for the TDAFWP met the requirements
of IP 95002.
During the reviews of the corrective action program documents, the inspectors noted
that the licensee questioned whether the installation of the flood protection barriers had
introduced unintended consequences. Specifically, the corrective action to install a
more robust wave barrier in lieu of sandbagging efforts failed to restore compliance with
the CLB. While the improved wave barriers provided necessary protection against wave
action, they introduced unrecognized hazards during the probable maximum
precipitation and turbine building internal flooding events. These barriers blocked
natural drainage paths credited for flood relief and rendered these paths nonfunctional
as a result of wave barrier installation. The inspectors noted that this issue was not
recognized by the licensee until November 2013 for one of the flooding events, and
January 2014 for the other event, and thus, the licensees interim corrective actions for
the flooding finding were deficient between March and November 2013 due to procedure
call-up PC 80 Part 7, which remained inadequate during this time. As a result, the
licensee was required to add compensatory actions during wave barrier installation to
provide additional flow paths by opening the CWPH roll-up doors.
When developing the compensatory action to address the deficiency associated with the
new wave barriers, the licensee failed to recognize that the new compensatory
measures required actions outside of the CLB. Specifically, Section 2.5 Hydrology in
the FSAR for the Maximum precipitation flood states, in part, that the topography of
the site results in adequate natural drainage to remove this amount of water and limit
ponding depth to prevent adversely affecting safety related equipment. The
nonfunctional drainage paths following wave barrier installation resulted in the licensee
having to identify an alternate path for flood water drainage flow. As a compensatory
action, the licensee chose to open the CWPH roll-up doors, route flood waters through
the CWPH, and relying on internal flood relief dampers to open and drain the water. The
licensee viewed those compensatory actions as still with its CLB. As a result, the
12
inspectors determined that the licensee failed to properly screen the actions as
compensatory measures under the requirements of 10 CFR 50.59.
The inspectors noted that as a result of the failure to evaluate these actions under
10 CFR 50.59, the licensee did not properly consider several factors associated with the
compensatory actions that should have been evaluated. Some of these factors included
flood water flow rates through the open doors, the impact of debris and slush from
outside being carried into the CWPH and clogging the flood relief dampers, the impact of
the cold temperatures on the equipment in the rooms during the potentially extended
periods of time during which the doors could be open, and security impacts.
In addition, the inspectors noted the licensee failed to recognize that procedure
PC 80 Part 7, failed to account for the time necessary to ensure that the barriers would
be constructed before the lake reached conditions where deep wave action could impact
the site. Specifically, the licensees calculation specified that 8.2 weeks would be
available after Procedure PC 80 Part 7, initiated actions to install the wave barriers
based on lake level.
The inspectors reviewed EC 279455, Time Available to Respond to Threat From Rising
Water, and the licensees lake level determination monthly surveillance, PBF-2124,
PPCS Forebay and Pump Bay Level Alarm Setpoints, and identified several
deficiencies. These deficiencies included non-conservative assumptions when using the
maximum monthly rate of lake level rise, non-conservative assumptions for the lake level
at which the site could be impacted by the waves, a non-conservative allowance to rely
on the previous months data if no lake level data was immediately available, and an
error in an assumption that wave barriers would be installed earlier than PC 80 Part 7,
actually required. When the licensee corrected these inputs, the inspectors noted that
the time available for action was significantly reduced to less than three weeks.
The inspectors observed that PC 80 Part 7, granted three weeks allowance for activities
to be scheduled and performed to install the wave barriers. The inspectors concluded
that the deficiencies in the licensees timelines left them vulnerable in that actions may
not have been initiated soon enough to protect the site from the wave run-up design
basis event. The inspectors determined that this aspect of IP 95002 was not met for the
flooding White finding.
b. Determine that the Corrective Actions Have Been Prioritized with Consideration of Risk-
Significance and Regulatory Compliance
The inspectors assessed the licensees timeliness of corrective actions for the RCEs and
CCA associated with the risk significant issues. The inspectors noted that there were no
formal tracking mechanisms or documentation for several of the corrective actions that
had been previously taken prior to the completion of the RCEs and CCA. Formalized
tracking measures would assure the actions are satisfactorily completed and allow for
documentation of the basis for closure.
The inspectors concluded that an appropriate schedule had been established for
implementing and completing the corrective actions for the TDAFWP White finding. This
aspect for the flooding White finding will remain open pending the inspectors review of
the additional corrective actions the licensee will need to perform.
13
c. Determine that a Schedule has been Established for Implementing and Completing the
Corrective Actions
As discussed in Section 02.03.b, above, the inspectors determined that the licensee had
established an appropriate schedule for implementing the corrective actions for the
TDAFWP White finding. The aspect for the flooding White finding will remain open
pending the inspectors review of the additional corrective actions that the licensee will
need to perform.
d. Determine that Quantitative or Qualitative Measures of Success Have Been Developed
for Determining the Effectiveness of the Corrective Actions to Prevent Recurrence
The inspectors review of the effectiveness review (EFR) plan identified a number of
weaknesses. The inspectors determined that these weaknesses rose to the level of a
finding and that the weaknesses were broad and deep enough to conclude that this
section did not meet the requirements of IP 95002. As the TDAFWP finding occurred
first and there had been additional time the EFR had already been substantially
performed for this issue. The interim assessments, combined with the general quality of
the RCE led the inspectors to conclude that this section is complete for the TDAFWP
finding but remains open for the flooding White finding and the CCA.
e. Determine that the Corrective Actions Planned or Taken Adequately Address a Notice of
Violation that was the Basis for the Supplemental Inspection, if Applicable
For the TDAFWP White finding, the licensee did not respond to the initial NOV because
the corrective actions taken and planned to be taken to correct the violation, and the
date when full compliance was achieved was already addressed on the docket in NRC
Inspection Report 05000266/2012009. As part of the 95002 inspection, the team
members performed a sampling of the immediate corrective actions and determined the
full compliance had been restored. The team considered that the IP 95002 requirements
were met for the TDAFWP White finding.
For the flooding White finding, the licensee did not respond to the initial NOV because
the corrective actions taken and planned to be taken to correct the violation, and the
date when full compliance was achieved was already addressed on the docket in
NRC Inspection Report 05000266/2013002 and 05000301/2013002 and in the
licensees submittals dated July 10, 15, and 29, 2013. As part of the 95002 inspection,
the team members performed a sampling of the immediate corrective actions and
determined the full compliance had been restored. However, as stated above, the
inspectors noted that the corrective actions resulted in unintended consequences. In
addition, as noted previously, the inspectors identified a deficiency where insufficient
corrective action was taken to correct PC 80 Part 7, in order to preclude repetition of the
original significant condition adverse to quality. Thus the team concluded that the
requirements of IP 95002 were not met for the flooding White finding.
f. Findings
(1) Failure to Take Corrective Actions to Address External Flooding Procedure Deficiencies
Introduction: The inspectors identified a finding of very low safety significance and an
associated non-citied violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective
14
Actions, in that from March 13, 2013 until February 14, 2014, the licensee failed to
assure that for a significant condition adverse to quality (SCAQ), the cause of the
condition was determined and corrective actions were taken to preclude repetition.
Specifically, the licensees corrective actions failed to preclude repetition of an SCAQ
where Procedure PC 80 Part 7, Lake Water Level Determination, as implemented,
would not protect safety-related equipment in the turbine building or CWPH. After the
licensee had taken corrective actions to improve the wave barrier procedure in response
to an NRC-identified NOV, PC 80 Part 7, and other flood protection implementing
procedures specified inadequate timelines to ensure wave run-up flood barriers would
be installed prior to the lake level at which wave run-up could impact the site.
Description: The inspectors reviewed procedures associated with flooding as part of
their independent extent of condition and extent of cause, and review of corrective
actions to prevent recurrence. The inspectors noted the licensee failed to recognize that
procedure, PC 80 Part 7, did not grant adequate timelines to ensure that the barriers
would be constructed before the lake reached conditions where deep wave action could
impact the site. Specifically, the licensees calculation specified that 8.2 weeks would be
available after Procedure PC 80 Part 7, initiated actions to install the wave barriers
based on lake level. The inspectors observed that based on these timelines,
PC 80 Part 7 granted three weeks allowance for activities to be scheduled and
performed to install the wave barriers. Specifically, PC 80 Part 7, stated, in part,
IF corrected mean level is greater than or equal to +0.5 ft., THEN PERFORM the
following: NOTIFY maintenance to generate on demand PM (PMRQ 00059608-02) to
INSTALL barriers and sandbags as required to be completed within three weeks.
The inspectors reviewed EC 279455, Time Available to Respond to Threat From Rising
Water, and the licensees lake level determination monthly surveillance, PBF-2124,
PPCS Forebay and Pump Bay Level Alarm Setpoints, and found several deficiencies.
These deficiencies included non-conservative assumptions when using the maximum
monthly rate of lake level rise, non-conservative assumptions for the lake level at which
the site could be impacted by the waves, non-conservative allowances to rely on the
previous months data if no lake level data was immediately available, and an error in an
assumption that wave barriers would be installed earlier than PC 80 Part 7 actually
dictated. Inspectors noted that the procedure had no barriers to prevent the previous
months data from being used during multiple subsequent months. When the licensee
corrected these inputs, the inspectors noted that the time available to fully implement the
provisions of PC 80 Part 7 significantly reduced to less than the three weeks called for in
the procedure.
The inspectors concluded that these deficiencies in the licensees timelines left them
vulnerable in that actions may not be initiated soon enough to protect the site from the
wave run-up design basis event. The inspectors noted that these deficiencies
represented a failure of the licensees corrective action to preclude repetition of an
SQAC where Procedure PC 80 Part 7, Lake Water Level Determination, as
implemented, would not protect safety-related equipment in the turbine building or
CWPH.
In addition, to the PC 80 Part 7 issues associated with the timelines for barrier
installation, the inspectors found additional procedural deficiencies that should have
been identified and corrected as part of the corrective actions taken to address the
flooding NOV. PC 80 Part 7 procedural deficiencies included error traps where steps
15
could be performed out of sequence (i.e. barriers installed before CWPH doors open),
and a failure to include CWPH doors in robust tag-out process to ensure their open
position was controlled. PBF-2124 procedural inadequacies included direction to install
jersey barriers rather than the more robust barriers associated with the licensees RCE
corrective actions. Inspectors noted that this reference to the jersey barriers referred to
the previous wave run-up flooding response strategy. The inspectors identified that the
same +0.5ft. installation threshold error was made in PBF-2124, as well as the licensees
external flooding abnormal procedure, AOP 13C.
Licensee procedure PI-AA-204, Condition Identification and Screening Process,
Section 2.45 defines a Significant Condition Adverse to Quality (SCAQ) as, Failures,
malfunctions, deficiencies, deviations, defective items, abnormal occurrences, non-
conformances, or out-of control processes that significantly threatens or has
compromised nuclear safety or radiological safety, as well as any significant reportable
industrial safety or environmental (e.g., OSHA, State, etc.) issues. SCAQ issues require
corrective actions to prevent recurrence. Condition Report 01883633 identified the
White flooding finding and associated performance deficiency as an SQAC.
The inspectors also noted that the licensee completed an interim action to improve the
wave barrier and associated procedure on March 13, 2013, and a final corrective action
CAPR 01883633-22 on November 30, 2013 to implement a plant modification to
strengthen the physical external flood protection measures associated with a high lake
level wave run-up and associated procedure guidance and design documentation. The
inspectors observed that this action was credited in the licensees RCE as an action to
prevent recurrence of the original SQAC. As a result, the inspectors determined that the
licensee failed to take corrective actions to preclude repetition of an SCAQ where
Procedure PC 80 Part 7, as implemented, would not protect safety-related equipment in
the turbine building or CWPH.
Analysis: The inspectors determined that the licensees failure to take corrective actions
to address the inadequate flooding procedure was a performance deficiency, because it
was the result of the failure to meet the requirements of 10 CFR Part 50, Appendix B,
Criterion XVI; the cause was reasonably within the licensees ability to foresee and
correct; and it should have been prevented. The inspectors determined that the finding
had a cross-cutting aspect in the area of problem identification and resolution, because
the licensee failed to thoroughly evaluate issues to ensure that resolutions address
causes and extents of condition commensurate with their safety significance (P.2).
Specifically, the licensee failed to fully evaluate issues with the flooding procedure to
ensure the corrective actions they took would assure that robust protection from wave
run-up would be installed prior to reaching a lake level where deep wave action could
present a threat to the site.
The inspectors screened the performance deficiency in accordance with IMC 0612,
Power Reactor Inspection Reports, Appendix B, and determined that the issue was
more than minor because the finding was associated with the Mitigating Systems
Cornerstone attributes of Protection Against External Factors (Flood Hazard) and
Procedure Quality, and adversely affected the cornerstone objective to ensure the
availability, reliability, and capability of systems that respond to initiating events to
prevent undesirable consequences (i.e. core damage). Specifically, the licensees
failure to procedurally control external flooding design features, to ensure they would not
adversely affect the strategy for other flooding events, could negatively impact mitigating
16
systems ability to respond during an external flooding event. The inspectors evaluated
the finding using IMC 0609, Attachment 0609.04, Tables 2 and 3, and Appendix A.
Based on a review of Appendix A, Exhibit 2, Item 4.B, the inspectors determined that this
issue screened as having Very low safety significance (Green).
Enforcement: Title 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Actions,"
requires, in part, that Measures shall be established to assure that conditions adverse
to quality, such as failures, malfunctions, deficiencies, deviations, defective material and
equipment, and non-conformances are promptly identified and corrected. In the case of
significant conditions adverse to quality, the measures shall assure that the cause of the
condition is determined and corrective action taken to preclude repetition. Contrary to
this requirement, from March 13, 2013 until February 14, 2014, the licensee failed to
assure that for a significant condition adverse to quality, the cause of the condition was
determined and corrective actions were taken to preclude repetition. Specifically, the
licensees corrective actions failed to preclude repetition of an SCAQ where Procedure
PC 80 Part 7, Lake Water Level Determination, as implemented, would not protect
safety-related equipment in the turbine building or CWPH. After the licensee had taken
corrective actions to improve the wave barrier procedure in response to an NRC-
identified NOV, PC 80 Part 7 and other flood protection implementing procedures
specified inadequate timelines to ensure wave run-up flood barriers would be installed
prior to the lake level at which wave run-up could impact the site. Specifically, the
licensee completed an interim action to improve the wave barrier and associated
procedure on March 13, 2013, and a final corrective action CAPR 01883633-22 on
November 30, 2013, to implement a plant modification to strengthen the physical
external flood protection measures associated with a high lake level wave run-up and
associated procedure guidance and design documentation. These actions failed to
preclude repetition of the original SCAQ. Corrective actions for this issue included
changing the affected procedures to install the wave barriers at a lower lake level,
changing the lake level determination surveillance from monthly to weekly, and reducing
the allowed installation time for the barriers from 3 weeks to 1 week. Because the
violation was of very low safety significance and was entered into the licensees
corrective action program (CR 01940739), this violation is being treated as an NCV,
consistent with Section 2.3.2 of the NRC Enforcement Policy.
(NCV 05000266/2014007-01; 05000301/2014007-01; Failure to Take Corrective
Actions to Address External Flooding Procedure Deficiencies)
(2) Failure to Maintain External Flooding Procedure to Address All Possible CLB Floods
Introduction: The inspectors identified a finding of very low safety significance and
associated non-citied violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions,
Procedures, and Drawings, in that from January 19, 1996 until November 25, 2013, the
licensee failed to ensure that activities affecting quality were prescribed by documented
procedures of a type appropriate to the circumstances to address external flooding as
described in the Final Safety Analysis Report (FSAR). Specifically, PC 80 Part 7, Lake
Water Level Determination directed advanced installation of concrete barriers to protect
against deep wave action from the lake, which introduced significant unrecognized
blockages in the natural drainage path credited in the FSAR to protect against the
probable maximum precipitation and Turbine Building internal flooding events.
17
Description: The inspectors reviewed the licensees procedures and corrective action
documents and noted an important deficiency associated with procedure PC 80 Part 7.
Specifically, CR 01932698, 95002 Wave run-up protection may conflict with other
floods, was generated a few days prior to the 95002 inspection teams arrival onsite.
This condition report described the concern that while wave barriers were installed near
the CWPH, the probable maximum precipitation and turbine building flooding events
could result in several feet of water at the CWPH and turbine building rollup doors due to
the wave barriers blocking natural site drainage paths. The inspectors noted that this
deficiency traced back to the original inappropriate action cited in the White Flooding
finding, where in 1996, the licensee inappropriately deleted an AOP directing use of
sandbags at plant doorways and substituted a wave barrier installation strategy without
recognizing the adverse impacts of the change.
The inspectors noted that the immediate corrective actions for the Flooding Apparent
Violation that were taken in March 2013 to improve the wave barrier described in
PC 80 Part 7, failed to address all deficiencies that were created when sand bagging
actions were changed to wave barrier installation in 1996. While the improved wave
barriers provided necessary protection against wave action, they failed to address
unrecognized hazards during the probable maximum precipitation and turbine building
internal flooding events. These barriers blocked natural drainage paths credited for flood
relief and rendered these paths nonfunctional as a result of wave barrier installation.
The Inspectors determined that procedure PC 80 Part 7 was inadequate until actions
were taken to modify it to provide additional flow paths for flood relief. The inspectors
noted that this issue was not recognized by the licensee until November 2013 for the
turbine building flooding event, and late January 2014 for the PMP event.
The inspectors concluded that the licensee did not adequately address the flooding
finding barrier deficiencies described in the original white flooding finding. This was
evident in the licensees interim corrective actions taken in March 2013, when the
licensee failed to restore full compliance, and did not recognize the need for providing an
additional drainage path. However, the inspectors noted that the licensee had not
implemented final corrective actions for wave barrier modification and flooding procedure
changes until November 2013, at which point steps were added to PC 80 Part 7 that
created a compensatory drainage path. As a result, the inspectors concluded that the
issue was most appropriately characterized as a failure to ensure that activities affecting
quality were prescribed by documented procedures of a type appropriate to the
circumstances to address external flooding in accordance with 10 CFR 50 Appendix B,
Criterion V. The inspectors also noted that this issue should have been readily identified
as a direct outcome of reviewing the NRC-identified finding, and it was not the result of a
thorough RCE which resulted in hidden issues surfacing.
Analysis: The inspectors determined that the licensees failure to maintain an external
flooding procedure appropriate to the circumstances to ensure the site was not
adversely impacted during CLB flooding events was a performance deficiency, because
it was the result of the failure to meet the requirements of 10 CFR Part 50, Appendix B,
Criterion V; the cause was reasonably within the licensees ability to foresee and correct;
and it should have been prevented. The inspectors determined that the finding has a
cross-cutting aspect in the area of problem identification and resolution, because the
licensee failed to take effective corrective actions to address issues in a timely manner
commensurate with their safety significance (P.3). Specifically, licensee personnel failed
to take appropriate interim corrective actions in March of 2013 when correcting a SCAQ
18
in that the interim action plan posed additional hazards to the site during design basis
floods.
The inspectors screened the performance deficiency in accordance with IMC 0612,
Power Reactor Inspection Reports, Appendix B, and determined that the issue was
more than minor because the finding was associated with the Mitigating Systems
Cornerstone attributes of Protection Against External Factors (Flood Hazard) and
Procedure Quality, and adversely affected the cornerstone objective to ensure the
availability, reliability, and capability of systems that respond to initiating events to
prevent undesirable consequences (i.e. core damage). Specifically, the licensees
failure to procedurally control external flooding design features to ensure they would not
adversely affect the strategy for other flooding events, could negatively impact mitigating
systems ability to respond during external and internal flooding events.
The inspectors evaluated the finding in accordance with IMC 0609, Significance
Determination Process, Attachment 0609.04, Initial Characterization of Findings. The
inspectors determined that the finding affected the Mitigating Systems Cornerstone and
evaluated the finding using Appendix A, The Significance Determination Process for
Findings At-Power, Exhibit 2, for the Mitigating Systems Cornerstone. In the Mitigating
Systems Cornerstone, the inspectors answered "Yes" to the screening question Does
the finding represent a loss of system and/or function? because an assumed turbine
building (TB) internal flooding event in a condition with the jersey barriers installed due to
high lake water level could ultimately result in the loss of emergency diesel generators
and other safety-related equipment. Therefore, the finding required a detailed risk
evaluation.
The probability of the jersey barriers being installed was evaluated based on the fact that
the jersey barriers have not been installed during the 18 years (since 1996) that the
jersey barriers were available for installation if high lake water level was encountered.
Using a statistical Bayesian update with a Jeffreys non-informative prior, the probability
that the jersey barriers could have been installed was determined to be 2.63E-2.
The risk evaluation was performed by Region III Senior Reactor Analysts (SRAs). The
increase in core damage frequency (CDF) was calculated assuming scenarios
involving internal turbine building flooding events. The exposure time assumed was one
year which is the maximum allowed by the significance determination process.
For the evaluation of the risk significance, the SRAs considered TB flooding events with
three plant systems that have basically an unlimited system volume if the flooding event
is not terminated. These systems are the fire protection (FP) system, the circulating
water (CW) system, and the service water (SW) system.
To evaluate this finding, the Senior Reactor Analysts (SRAs) determined the frequency
of a pipe break (or expansion joint failure) using Electric Power Research Institute
(EPRI) Report 302000079, Pipe Rupture Frequencies for Internal Flooding Probabilistic
Risk Assessments, Revision 3. The pipe breaks of interest were determined to be
those between approximately 20,000 gpm and 36,000 gpm. The lower value of
20,000 gpm is based on the drainage capacity at the eight foot level (which is the ground
floor elevation in the TB) provided by a combination of gaps in the metal siding of the
circulating water pump house (CWPH) walkway and the storm drains still available even
with the jersey barriers installed. Pipe breaks of less than 20,000 gpm would not result
19
in water accumulation on the lowest level of the TB and thus would not imperil risk
significant equipment. The upper value of 36,000 gpm is based on calculation
2008-0024, Auxiliary Feedwater Pump Room Flood, which determined that for a
36,000 gpm TB flood rate, the TB rollup door(s) would fail at a level of 18 inches and
allow a flow of up to 36,000 gpm while maintaining the TB flood level at less than
18 inches. For the risk evaluation, a maximum TB flood rate of 36,000 gpm was thus
used to represent the delta risk associated with the finding, since this is the maximum
drainage flow through the failed TB rollup door(s). Any TB flood rate greater than
36,000 gpm would cause the TB water level to exceed 18 inches if the break flow was
not immediately terminated regardless of whether the jersey barriers were installed or
not. It was conservatively assumed that exceeding 18 inches level in the TB would
result in a core damage event (i.e., a conditional core damage probability (CCDP) of 1.0)
due to the loss of risk significant plant equipment.
Fire Protection System
The FP system was screened because of the relatively low maximum flood rates that
can occur with a break in the FP system. The capacity of the two fire water pumps
together is approximately 6,800 gpm, which is well below the drainage capacity of
approximately 20,000 gpm at the eight foot level.
The SRAs evaluated the delta risk associated with a break in the Circulating Water (CW)
system with the jersey barriers installed. Two different failure causes were available on
the CW system which could result in a break of greater than 20,000 gpm: (1) a CW
system expansion joint (EJ) failure, or (2) a CW system piping break. Each of these
failures was evaluated separately.
Circulating Water System Expansion Joints
In the EPRI report, the failure rate of an EJ per year was given for flood rates greater
than 10,000 gpm. This value was conservatively used to represent the failure rate of an
EJ for a flood greater than 20,000 gpm (i.e., a flood rate that would exceed the drainage
capacity at the eight foot level). There are eight EJs on the CW system in the TB. From
the EPRI report, the frequency of a major flood with from a CW system EJ with a flood
rate of greater than 10,000 gpm is 6.08E-6/yr/EJ. With eight EJs per Unit, the frequency
of an EJ failure is 4.86E-5/yr.
Without the jersey barriers installed, the flood water would drain out toward the CWPH
and down towards the lake with an essentially open path (i.e., essentially an unlimited
drainage rate outside the TB). With the jersey barriers installed, the drainage capacity
would be approximately 20,000 gpm at the eight foot level provided by a combination of
gaps in the metal siding of the CWPH walkway and the storm drains near the CWPH.
The drainage capacity provided by the gaps in the metal siding of the CWPH walkway
would increase as the height of the water level outside the Turbine Building increased
and would represent the majority of the drainage flow above the eight foot level. Using
the TB floor volume, the outside volume up to the jersey barriers, and the drainage rate
outside the TB (as a function of height), the licensee estimated that there was
approximately 31 minutes available to secure the CW pumps to terminate the break flow
20
before exceeding a level of 18 inches in the TB. A CW system flooding event would
require the operators to enter AOP-13A, Circulating Water System Malfunction.
Securing the CW pumps on a CW system flood event is Step 1 of the AOP. The SRAs
used the SPAR-H method (per NUREG/CR-6883) to calculate a human error probability
(HEP) for the failure of the operators to terminate a CW flood event. Using SPAR-H an
HEP for the failure of the operators to secure the CW pumps before exceeding 18 inches
level in the TB was calculated to be 0.2. This calculation assumed high stress for both
diagnosis and action and poor ergonomics for diagnosis (since a local operator would be
required to identify the flood location).
Using an HEP value of 0.2 for the probability that the operators would secure the CW
pumps before exceeding 18 inches in the TB, and the probability of 2.63E-2 that the
jersey barriers would be installed, the result was a delta core damage frequency (CDF)
of 2.56E-7/yr for an event involving a CW expansion joint failure in the turbine building.
Circulating Water System Pipe Breaks
To evaluate the CDF for CW system piping breaks, the length of large diameter CW
piping in the TB (obtained from the Point Beach PRA 7.1, Internal Flooding Notebook)
was used. For the CW piping random failure event, the frequency of a major flooding
event was conservatively estimated to be 7.95E-7/yr/ft, from the EPRI report. This is the
failure rate based on a flood rate of greater than 2000 gpm and was conservatively used
to represent the failure rate of a flood greater than 20,000 gpm. Based on this piping
failure rate per unit length and the lengths of CW piping obtained from the Point Beach
PRA 7.1, Internal Flooding Notebook, the frequency of a major flood event in the TB due
to a random CW pipe failure was evaluated to be 2.39E-5/yr. Using an HEP of 0.2
(as described above) for the failure of the operators to secure the CW pumps before
exceeding 18 inches level in the TB, and the probability of 2.63E-2 that the jersey
barriers would be installed, the result was a CDF of 1.25E-7/yr. for an event involving a
random CW system piping failure in the turbine building.
Service Water System Pipe Breaks
To evaluate the CDF for SW system piping breaks, the length of large diameter
(greater than 4 inches) SW piping in the TB was obtained from the Point Beach
PRA 7.1, Internal Flooding Notebook. From the EPRI report, a failure rate of
3.57E-7/yr/ft. was obtained for SW piping with a diameter between 4 and 10 inches,
and a failure rate of 6.44E-8/yr/ft. was obtained for SW piping with a diameter greater
than 10 inches. The length of SW piping in the TB with a diameter between 4 and
10 inches, and the length of SW piping in the TB with a diameter of greater than
10 inches was obtained from the Point Beach PRA 7.1, Internal Flooding Notebook.
The piping failure rate for a major flood event in the EPRI report is based on a flood rate
of greater than 2000 gpm. This failure rate was conservatively used to represent the
failure rate of a flood greater than 20,000 gpm. Based on these piping failure rates per
unit length and the lengths of SW piping obtained from the Point Beach PRA 7.1,
Internal Flooding Notebook, the frequency of a flood event in the TB due to a random
SW pipe failure was evaluated to be 4.40E-4/yr.
21
The pipe breaks of interest for the SW system were determined to be those between
approximately 20,000 gpm and 27,000 gpm. The lower value of 20,000 gpm is based as
stated before on the drainage capacity at the eight foot level. The upper value of 27,000
gpm is based on the flow rate for three SW pumps at run-out flow per the Point Beach
PRA 7.1, Internal Flooding Notebook. Based on a maximum SW break of 27,000 gpm,
the maximum TB flood level would be approximately 14 inches. This level would
correspond to the steady-state level at which the drainage capacity outside provided by
the gaps in the metal siding of the CWPH walkway and the storm drains near the CWPH
would equal the assumed 27,000 gpm flood rate.
The Point Beach Standardized Plant Analysis Risk (SPAR) model version 8.22 and
Systems Analysis Programs for Hands on Integrated Reliability Evaluations version
8.0.9.0 software was used to obtain a delta Conditional Core Damage Probability
(CCDP) for the event. A loss of service water (LOSW) initiating event was assumed.
Using the licensees evaluation of equipment that is lost as a function of level, all
equipment in the TB that would be submerged at or below 17 inches was assumed to fail
to bound failure of equipment at 14 inches. The 1P53 Auxiliary Feedwater Pump was
also assumed to fail as a surrogate to represent the loss of the power supply for the
Unit 2 motor-driven AFW pump 2P53 during a Unit 2 flooding event because the SPAR
model replicates Unit 1. The result was a CCDP of 1.68E-2.
Based on the probability of 2.63E-2 that the jersey barriers would be installed, and the
CCDP of 1.68E-2 for an event if the jersey barriers were installed, the result was a
CDF of 1.94E-7/yr. for an event involving a random SW system piping failure in the
turbine building.
Total CDF for Internal Events
The total CDF for internal events caused by random failures of piping and CW
expansion joints is the sum of the individual delta risk values or 5.76E-7/yr.
External Event Risk Contribution
Since the resultant internal event CDF is greater than 1.0E-7/yr., an evaluation of
external event contributions was obtained. Due to the nature of the performance
deficiency, no fire-induced floods were credible. However, a seismic-induced flooding
event was considered. Using guidance from NRCs Risk Assessment Standardization
Project (RASP) handbook, only the Bin 2 seismic events were assumed to represent a
CDF. Bin 2 was defined in the RASP handbook as seismic events with intensities
greater than 0.3g, but less than 0.5g. Earthquakes of lesser severity are unlikely to
result in large pipe failures and earthquakes of a larger magnitude could result in major
structural damage throughout the plant, which would not be representative of a
differential risk. The initiating event frequency of an earthquake in Bin 2 for
Point Beach was estimated to be 1.3E-5/yr. using Table 4A 1 of Section 4 of the RASP
handbook.
To estimate the seismic capacity of the CW piping and the CW EJs, an evaluation of the
seismic capacity for a similar Westinghouse plant was referenced. For this plant, it
stated that the CW piping and the CW EJs had high seismic capacity, and a flooding
assessment due to seismic concerns was screened from the assessment.
22
For the SW piping in the TB, making the conservative assumption that the high
confidence of low probability of failure (HCLPF) capacity for the SW piping is 0.3g, a
failure probability of 3.9E-2 was obtained for the SW system. It was conservatively
assumed that every SW system piping failure resulted in the maximum flooding rate of
27,000 gpm. Similar to the earlier evaluation of random SW piping failure due to internal
events, the licensees evaluation of equipment that is lost as a function of level was
used. All equipment in the TB with a flood level of less than or equal to 17 inches was
assumed to fail. The 1P53 Auxiliary Feedwater Pump was also assumed to fail as
discussed earlier. A dual unit loss of offsite power (LOOP) initiating event was assumed
to occur as a result of the seismic event, and it was conservatively assumed that the
operators would fail to recover off-site power for at least 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. Also, the SW pumps
were assumed to fail-to-run. The result was a CCDP of 0.37. The CDF for a seismic
event was estimated to be 1.84E-7/yr.
Total CDF For This Issue
The total CDF associated with the finding was obtained as the sum of the CDF for the
internal events random failures of piping and CW expansion joints, and the CDF for a
seismic event or 7.6E-7/yr. The dominant sequence was associated with a random
CW system expansion joint failure in the TB that results in flooding that renders risk
significant equipment unavailable.
Large Early Release Frequency Risk Contribution
Since the total estimated change in core damage frequency was greater than 1.0E-7/yr.,
IMC 0609 Appendix H, Containment Integrity Significance Determination Process was
used to determine the potential risk contribution due to large early release frequency
(LERF). Point Beach is a 2-loop Westinghouse Pressurized Water Reactor (PWR) with
a large dry containment. Sequences important to LERF include steam generator tube
rupture events and inter-system loss-of-coolant-accident (LOCA) events. These were
not the dominant core damage sequences for this finding.
Therefore, based on the detailed risk evaluation, the SRAs determined that the finding
was of very low safety significance (Green).
Enforcement: Title 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures,
and Drawings," requires, in part, that activities affecting quality shall be prescribed by
documented instructions, procedures, or drawings, of a type appropriate to the
circumstances and shall be accomplished in accordance with these instructions,
procedures, or drawings. Contrary to this requirement, from January 19, 1996 until
November 25, 2013, the licensee failed to ensure that activities affecting quality were
prescribed by documented procedures of a type appropriate to the circumstances to
address external flooding as described in the FSAR. Specifically, PC 80 Part 7, Lake
Water Level Determination directed advanced installation of concrete barriers to protect
against deep wave action from the lake, which introduced significant unrecognized
blockages in the natural drainage path credited in the FSAR to protect against the
probable maximum precipitation and Turbine Building internal flooding event. Corrective
actions for this issue included changing the procedure and FSAR to include actions to
provide an additional flood relief path through the CWPH building and reliance on
internal flood relief dampers for the affected flooding events. Because the violation was
23
of very low safety significance and was entered into the licensees corrective action
program (CR 01932698), this violation is being treated as an NCV, consistent with
Section 2.3.2 of the NRC Enforcement Policy. (NCV 05000266/2014007-02;
05000301/2014007-02; Failure to Maintain External Flooding Procedure to Address
All Possible CLB Floods)
(3) Failure to Perform a Required 10 CFR 50.59 Evaluation
Introduction: The inspectors identified a finding of very low safety significance and
associated Severity Level IV, non-citied violation, of 10 CFR 50.59(d)(1), Changes,
tests and experiments, when, on November 25, 2013, the licensee failed to perform an
evaluation against the criteria in 10 CFR 50.59(c)(2) for a change to procedure
PC 80 Part 7 to include actions to maintain functionality of drainage paths during
probable maximum precipitation and turbine building flooding events. Specifically,
PC 80 Part 7, Lake Water Level Determination was changed to include actions to open
the CWPH rollup doors to provide an additional drainage path while wave barriers were
in place, without evaluating the viability of reliance on additional flood features not
credited for external flooding in the CLB.
Description: When developing the procedural actions to address the deficiency
associated with the new wave barriers, the licensee failed to recognize that these
actions were outside the CLB. Specifically, procedure PC 80 Part 7 was revised on
November 25, 2013 to include direction to ENSURE Maintenance has raised the North
and South CWPH Roll-up doors approximately two feet to provide flooding relief. These
actions were directed to be performed in advance of the installation of the wave run-up
barriers, to ensure that while the barriers were installed, an additional flow path would be
created because the credited flow paths for the PMP external and turbine building
internal flooding events would be blocked during this time.
Final Safety Analysis Report Section 2.5 Hydrology regarding for the maximum
precipitation flood event states, in part, that the topography of the site results in
adequate natural drainage to remove this amount of water and limit ponding depth to
prevent adversely affecting safety related equipment. Contrary to these statements, the
newly created actions which were developed to compensate for the nonfunctional
natural drainage paths during wave barrier installation required use of additional features
not credited for external flooding events. Specifically, the actions included opening the
CWPH roll-up doors and routing flood waters through the CWPH and relying on internal
flood relief dampers to open and drain the water. The inspectors noted that the
10 CFR 50.59 screening documentation for Revision 6 of PC 80 Part 7, the revision
which added CWPH door actions to the procedure, did not include any discussion of the
actions to open the CWPH doors to provide a flood water flow path. The inspectors
observed that due to the licensees position that this action was in accordance with the
CLB, licensee personnel failed to screen or evaluate these actions under the
requirements of 10 CFR 50.59.
The inspectors noted that as a result of the failure to evaluate these actions under
10 CFR 50.59, the licensee failed to properly consider several factors associated with
the newly created drainage path that should have been evaluated. Some of these
factors included flood water flow rates through the open doors, the impact of debris and
slush from the outdoors being carried into the CWPH room and clogging the flood relief
dampers, the potential for substitution of unintended manual actions in place of passively
24
credited actions in the CLB, the impact of the cold temperatures on the equipment in the
rooms during the potentially extended periods of time during which the doors could be
open, and security impacts.
Analysis: The inspectors determined that the licensees failure to fully evaluate the
viability of newly created flooding drainage paths as required by 10 CFR 50.59(d)(1) was
a performance deficiency, because it was the result of the failure to meet the
requirements of 10 CFR 50.59; the cause was reasonably within the licensees ability to
foresee and correct; and it should have been prevented. The inspectors determined that
this finding has a cross-cutting aspect in the area of problem identification and
resolution, because the licensee failed to thoroughly evaluate issues to ensure that
resolutions address causes and extent of conditions commensurate with their safety
significance (P.2). Specifically, the licensee failed to fully evaluate a deficiency found in
PC 80 Part 7 associated with wave barriers blocking natural drainage paths, to ensure
that the corrective actions adequately addressed the problem.
The performance deficiency was screened in accordance with the guidance of
lMC 0612, Appendix B, and determined to be more than minor because the finding was
associated with the Mitigating Systems Cornerstone attributes of Protection Against
External Factors (Flood Hazard) and Design Control, and adversely affected the
cornerstone objective to ensure the availability, reliability, and capability of systems that
respond to initiating events to prevent undesirable consequences (i.e. core damage).
Specifically, the licensee did not fully demonstrate that the availability, reliability, and
capability of mitigating systems would be maintained during flooding events due to the
sites failure to evaluate the viability of alternate flood drainage paths through the CWPH.
The inspectors evaluated the finding using IMC 0609, Attachment 0609.04, Tables 2
and 3, and Appendix A. Based on a review of Appendix A, Exhibit 2, Item 4.B, the
inspectors determined that this issue screened as having very low safety significance
(Green).
Because this issue involved the failure to perform a written evaluation pursuant to
10 CFR 50.59, Changes, Tests, and Experiments, it, by definition, impacted the
regulatory process. As a result, the traditional enforcement process was determined to
be applicable. In determining the severity level of the traditional enforcement aspect of
the issue, the inspectors identified that Subsection d.2 of Section 6.1, Reactor
Operations, of the NRC Enforcement Policy lists a 10 CFR 50.59 violation that results in
conditions evaluated by the SDP as having very low safety significance as an example
of a Severity Level IV violation. Because the associated finding was determined to be of
very low safety significance, this issue was determined to represent a Severity Level IV
violation under the traditional enforcement process.
Enforcement: Title 10 CFR 50.59(d)(1) requires, in part, that the licensee shall maintain
records of changes in the facility, of changes in procedures, and of tests and
experiments made pursuant to paragraph (c) of this section. These records must
include a written evaluation which provides the bases for the determination that the
change, test, or experiment does not require a license amendment pursuant to
paragraph (c)(2) of this section. Title 10 CFR 50.59(c)(2) lists several examples and
states, in part, that a licensee shall obtain a license amendment pursuant to
10 CFR 50.90 prior to implementing a proposed change, test, or experiment if the
change, test, or experiment would meet the description of any of the listed examples.
25
Contrary to the above, on November 25, 2013, the licensee failed to perform an
evaluation against the criteria in 10 CFR 50.59(c)(2) for a change to procedure
PC 80 Part 7 to include actions to maintain functionality of drainage paths during
probable maximum precipitation and turbine building flooding events. Specifically,
PC 80 Part 7, Lake Water Level Determination was changed to include actions to open
the CWPH rollup doors to provide an additional drainage path while wave barriers were
in place, without evaluating the viability of reliance on additional flood features not
credited for external flooding in the CLB. Corrective actions for this issue included
actions to update the FSAR to describe the new flood paths, performing a 10 CFR 50.59
screening and 10 CFR 50.59 evaluation for the new drainage path which had put the site
outside of the CLB, revising a related functionality assessment, controlling external
flooding areas to ensure they are clear of debris, and creating a procedure to install
curtains on the CWPH rollup doors during periods when they were required to be open.
Because this violation was of very low safety significance and because the issue was
entered into the licensees corrective action program (CR 01946330), this violation is
being treated as a Severity Level IV NCV, consistent with Section 2.3.2 of the NRCs
Enforcement Policy. (NCV 05000266/2014007-03; 05000301/2014007-03; Failure to
Perform a Required 10 CFR 50.59 Evaluation)
The associated finding for this issue was evaluated separately from the traditional
enforcement violation; and therefore, the finding is being assigned a separate Tracking
Number. (FIN 05000266/2014007-04; 05000301/2014007-04; Failure to Perform a
Required 10 CFR 50.59 Evaluation)
(4) Failure to Establish EFR Attributes to Assess the Effectiveness of Corrective Actions
Introduction: The inspectors identified a finding of very low safety significance (Green)
and associated non-citied violation of 10 CFR Part 50, Appendix B, Criterion V,
Instructions, Procedures, and Drawings, for the failure to ensure the effectiveness
review attributes for a significant condition adverse to quality would ensure the corrective
actions would eliminate or reduce the recurrence rate.
Description: The licensee performed a common cause analysis (CCA) of the two White
findings documented in NRC Inspection Reports 05000266/2012-009 and 2013-012.
The CCA was documented in CR 01896156. Each of the two white findings had a root
cause analysis (RCA) performed and the CCA determined whether common causes
from the RCAs existed. The licensee identified two CCAs. CCA 1 was Leadership has
not consistently driven the organization to identify risk significant conditions and evaluate
those conditions to ensure timely resolution. CCA 2 was Several examples of technical
procedure quality issues have led to workers applying knowledge based decision making
during activities resulting in additional risk to the station.
The CCA and the RCAs were performed in accordance with licensee procedure
PI-AA-100-1005 and as required by this procedure the licensee also established an EFR
plan. The purpose of the EFR was to outline the attributes needed to assess the
effectiveness of the corrective actions to prevent recurrence (CAPRs). The EFRs were
not limited to just CAPRs but could also apply to corrective actions when necessary.
26
The inspectors reviewed the EFRs established by the licensee for the two CCAs
identified in CR 01896156. The EFRs were to be performed six months following CAPR
implementation. The inspectors noted that of the five success criteria established by the
licensee three of them relied entirely upon NRC feedback. Common Cause Analysis 1,
criteria 1, required positive NRC Resident Inspector feedback regarding issue resolution
and timeliness. Common Cause Analysis 1, criteria 2, required zero findings with a
crosscutting aspect of H.1(a) [Decision Making - Systematic Process], and CCA 2,
criteria 1, required zero findings with a H.2(b) crosscutting aspect [training]. Discussions
with licensee personnel and a review of the CCA determined that use of H.2(b) was a
typographical error and that H.2(c) [Procedure Quality] was intended to be used.
The inspectors challenged the licensee regarding the use of NRC inspector findings as
one of the few measures of how effective their corrective actions had been implemented.
The inspectors were concerned with the use of performance measures that were not
under the licensees control, were informal, and had a zero tolerance.
The main focus of the inspectors concerns was that the licensee had originally failed to
identify the weakness and violations noted above and had not recognized the need to
correct them until the NRC observations. The inspector noted that this approach was
not proactive and that waiting to see if the NRC found any new items in the next six
months would neither demonstrate the problems had been corrected nor identify that
they had not been corrected. The inspectors concluded that the EFRs were not
effective.
Analysis: The inspectors determined that the licensees failure to establish EFR criteria
that would have identified whether the CAPRs had effectively resolved the conditions
was a performance deficiency warranting further review.
The inspectors determined that this finding was more than minor in accordance with
IMC 0612, Appendix B, because it was affected the Mitigating Systems Cornerstone
objective to ensure availability, reliability, and capability of systems that respond to
initiating events to prevent undesirable consequences.
The inspectors evaluated the finding using IMC 0609, Appendix A. The inspectors
determined the finding was of very low safety significance (Green) because the finding
was not a deficiency affecting the design or qualification of a mitigating structure, system
or component and did not result in a loss of operability or functionality. In addition, the
finding did not represent a loss of system or function, did not represent an actual loss of
function of a least a single train for longer than its technical specification allowed outage
time, and did not represent an actual loss of function of one or more nontechnical
specification trains of equipment designated as high safety-significance.
The finding had a cross cutting aspect in the area of problem identification and
resolution, specifically resolution, because licensee personnel failed to ensure the
corrective actions to prevent recurrence had effective attributes. (P.2)
Enforcement: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures,
and Drawings, requires, in part, that activities affecting quality be prescribed by
procedures of a type appropriate to the circumstances and shall be accomplished in
accordance with these procedures. Licensee procedure PI-AA-100-1005, Revision 8,
27
Root Cause Analysis, had been written and established in accordance with
10 CFR Part 50, Appendix B, Criterion V.
Step 4.11.2.B, of PI-AA-100-1005, required, in part, The effectiveness review plan
outlines attributes to verify, responsibility and due dates. The attributes of effectiveness
are the critical elements from those improvements that will guarantee success.
Contrary to the above, on February 7, 2014, the NRC inspectors identified that some of
the EFR attributes for CCA 1 and CCA 2, of CR 01896156 would not have assessed the
critical elements of the CAPRs and thus the verification that the corrective actions were
effective would not have been performed as required by PI-AA-100-1005.
This violation is being treated as an NCV, consistent with Section 2.3.2 of the
Enforcement Policy, because it was of very low safety significance (Green) and was
entered into the CAP as CR 01938326. (NCV 05000266/2014007-05;
05000301/2014007-05, Failure to Establish EFR Attributes to Assess the
Effectiveness of Corrective Actions).
02.04 Independent Assessment of Extent of Condition and Extent of Cause
As directed by IP 95002, the inspectors independently assessed the validity of the
licensees conclusions regarding the extent of condition and extent of cause of the
issues. The objective of this requirement was to independently sample performance, as
necessary, within the key attributes of the cornerstones that were related to the subject
issues and to provide assurance that the licensees evaluations regarding the extent of
condition and extent of cause were sufficiently comprehensive. The extent of condition
review differs from the extent of cause review in that the extent of condition review
focuses on the actual condition and its existence in other places. The extent of cause
review should focus more on the actual root causes (RC) of the condition and on the
degree that these RCs have resulted in additional weaknesses.
.1 Extent of Condition
a. Inspection Scope
The inspectors conducted an independent extent of condition review of the (1) White
NOV for the Turbine Driven Auxiliary Feedwater Pump (TDAFWP) issue; (2) the White
Flooding issue; and (3) and the Common Cause Evaluation of both issues. The
inspectors review focused on the conditions identified in the primary root causes
associated with the above issues.
The inspectors interviewed station personnel, and reviewed program and process
documentation, maintenance procedures, and corrective action documents. In addition,
the inspectors conducted field walk downs of safety related equipment that involved
possible alignment requirements such as pumps and motor-operated valves (MOVs).
The inspectors looked for installation conditions that may challenge alignment of rotating
equipment, as was the case with the TDAFWP. The inspectors also performed walk
downs of plant areas that could be impacted by the wave run-up design basis flooding
event. Walk down activities included evaluation of the locations where the wave run-up
barriers would be constructed, and assessment of the physical flood barriers and sand
bags that would be utilized to respond to a wave run-up event.
28
b. Assessment
The inspectors assessed the licensees extent of condition evaluation through their own
independent extent of condition review. However, this assessment was only possible
due to changes the licensee made to the initial extent of condition evaluation.
Additionally, significant actions still remained to be defined by the licensee to determine
with high confidence their corrective actions would be effective.
TDAFWP White Finding
The licensee defined the condition in RCE 10768931, TDAFWP Coupling Degradation
During IT 08 Run, as the 1 P-29 TDAFWP coupling degraded due to misalignment. The
setup condition was the misalignment exceeded the coupling vendor's specification. The
same-same condition would be any other identical couplings on the 1P-29 TDAFWP,
which there are none, and the coupling on the 2P-29 TDAFWP being misaligned. The
same-similar condition would be other pumps with the same model coupling and have
alignment problems. No other pumps at Point Beach used the Thomas 54 Size 262
flexible disc coupling. The similar-similar condition would be other pumps that use
Thomas flexible disc couplings and have alignment problems which identified seven
other sets of pumps, the only safety related pumps being the containment spray pumps.
The licensees CCA 1896156; Degraded Cornerstone - Mitigating Systems, Two
White Findings, conducted an in-depth review of the AFW degraded coupling root
cause analysis report and identified that the extent of condition performed under
RCE 01768931 only considered what other equipment used Thomas Flexible disc
couplings to ensure alignment criteria was specified in alignment procedures. The CCA
concluded a more appropriate extent of condition would have considered all rotating
equipment that has alignment criteria specified.
As a result, the CCA initiated actions 26 through 29 to have the system engineers for all
mitigating system pumps, review and revise assembly procedures to incorporate
TDAFWP pump lessons learned. However, CCA action 15 was to expand the extent of
condition assessment to include all rotating equipment that has alignment criteria
specified. This action was not yet defined or started and therefore its scope or
effectiveness could not be assessed.
The inspectors independent extent of condition review considered all safety related
rotating equipment where alignment may be needed to ensure expected operation and
reliability. Therefore, the inspectors selected a sample of pumps and MOVs. The
inspectors verified installation procedures for the pumps included in the action items
mentioned above were changed appropriately.
The inspectors performed a walk down of one set of Emergency Core Cooling Pumps
and a variety of plant configurations of MOVs with system engineers and maintenance
personnel. The inspectors did not identify any conditions that would challenge alignment
of these components during installation. The inspectors found that alignment of MOVs
was not required by vendor or licensee procedures as the MOVs should be inherently
aligned through the valve yoke. If alignment issues were to result from installation, they
were expected to be discovered through the as-left MOV testing. A small number of
MOVs had attached supports. Condition Report 01938749 was initiated to evaluate the
29
need to do MOV testing after installation of supports on MOVs to ensure installation of
the supports did not affect valve performance.
The inspectors reviewed a sample of the CAP and found the following condition reports
that contained concerns with equipment alignment. Condition Report 01216019
discussed cracking of a valve yoke in 1999 due to actions taken to alleviate a yoke
alignment issue. Condition Report 01660763 discussed a large amount of pipe strain
when installing pump 2P-73B in 2011 (similar to the issue with the TDAFWP). Condition
Report 01202954 discussed alignment issues with 2P-11B where the base has to be cut.
Condition Report 01879455 discussed alignment issues due to bearing housing fit-up.
Condition Report 01808901 discussed an alignment issue with the Emergency Diesel
Generator, G-01, circulation oil pump due to excessive pipe strain.
As discussed above, the licensees expanded extent of condition evaluation, CCA action
item 15, to include all rotating equipment that requires alignment had not been further
defined, but based on the inspectors review of previous CAP issues and walk downs, the
scope should include pumps, valves, fans, and diesels as a minimum. The evaluation
may conclude the condition does not exist in these components or that existing
processes adequately address alignment of the components.
The inspectors concluded the extent of condition was initially too narrowly defined, which
would not have been acceptable, but was subsequently expanded in the CCE. Based
on the walk downs, which did not identify challenges to alignment during installation, the
actions taken to revise the installation procedures for the mitigating system pumps and
expanded action to evaluate additional rotating equipment, the inspectors assessed this
aspect of IP 95002 was met for the TDAFWP White finding.
White Flooding Finding
The licensee described the condition for the White flooding finding as procedure
PC 80 Part 7, did not prescribe adequate barriers to implement external flooding wave
run-up protection features. The licensees extent of condition addressed other
external flood protection measures as well as additional external hazard protection
measures and commitments. The inspectors performed an independent extent of
condition by performing plant walk downs, interviewing personnel, reviewing corrective
action programs generated for site identified external flooding issues, and assessing
selected plant procedures.
During walk downs of the plant areas where flood barriers would be built, the inspectors
questioned plant personnel regarding possible bypass mechanisms around the flood
protection features. Specifically, the inspectors questioned whether storm drains outside
the CWPH that communicated directly with the lakeshore could present a wave barrier
bypass hazard. Licensee personnel stated they had only briefly considered these drains
but had rejected them as a possible bypass path without performing an analysis or any
follow-up. Following a request from the NRC inspectors for information regarding these
drain lines and the potential wave barrier bypass paths, the licensee performed an
engineering calculation to review the impacts. The calculation determined that the drain
paths did not in fact represent a significant threat to having high lake water bypass the
flood protection features. The inspectors determined that the calculation was neither
simple nor straightforward and should have been performed as part of the licensees
extent of condition.
30
During a review of the licensees corrective action program the inspectors observed that
licensee personnel had identified that the installation of the more robust flood protection
barriers would introduce an unintended consequence of blocking the natural flow path of
rain water and snow melt. The licensee had identified this unintended consequence
while performing Fukushima external threat calculations and not due to the extent of
condition review for the White flooding finding. This issue represented a flaw in the
licensees initial corrective action which was first put in place in March 2013 as an
immediate action to restore compliance. Inspectors noted that this issue should have
been identified prior to installation and represented another missed opportunity to
identify for their extent of condition. Instead, the inspectors noted that this left the site in
a position where they were still in discovery when the IP 95002 inspection team arrived
onsite.
Inspectors also noted a corrective action document generated several months after
completion of the RCE, and approximately one week prior to the inspection teams
arrival onsite, regarding conflicting AOP procedures. Specifically, the inspectors noted a
CR that stated the High Winds AOP was in conflict with the External Flooding AOP, in
that the former required CWPH roll up doors to be open and the latter required them to
be closed. The inspectors observed that invoking both procedures at the same time
could easily be required depending on weather conditions. The inspectors noted that
this was another example of late discovery, which represented an additional missed
opportunity for the licensee to have identified the issue during their RCE extent of
condition.
The inspectors review of external flooding procedures to ensure that the procedure was
adequately corrected to ensure protection of equipment during a design basis flood
yielded several deficiencies. These deficiencies are described in more detail in the
findings section of the report. Specifically, during the inspectors review of PC 80 Part 7
and PBF-2124 the inspectors identified a number of issues resulting in the determination
that both procedures were flawed and would not have accomplished their intended
function.
PC 80 Part 7 procedural deficiencies included error traps where steps can be performed
out of sequence (i.e. barriers installed before CWPH doors open); failure to include
CWPH doors in robust tag-out process to ensure their open position was controlled;
and direction to install barriers at +0.5 ft. plant elevation, which was not early enough in
accordance with the licensees timeline calculation. PBF-2124 procedural inadequacies
included a note that allowed them to rely on last months data for lake level if the current
months data was not readily available, direction to install barriers at the incorrect
threshold of +0.5 ft. plant elevation, and direction to install jersey barriers rather than the
more robust barriers associated with the licensees RCE corrective actions (reference to
the jersey barriers referred to the previous flooding strategy). The inspectors identified
that the same +0.5 ft. installation threshold error was made in the licensees external
flooding abnormal procedure, AOP 13C.
The licensees extent of condition did not extend to non-external event design basis
items because as stated in the RCE separate and rigorous processes already in
place to ensure site documentation is up to date and accuratefor instance, AOPs are
reviewed (and validated) on a regular basis to ensure quality and accuracy of the
procedure. Yet during the inspectors review it was observed that procedure technical
quality was determined by the licensee to be a root cause for the TDAFWP White
finding. The inspectors also noted that it would have been appropriate for the licensee
to more thoroughly evaluate the modification 10 CFR 50.59 process during their extent
31
of condition review, due to the integral role that the inadequate 10 CFR 50.59 review
played in the original performance deficiency. This may have also been appropriate in
light of the licensees failure to properly utilize the 10 CFR 50.59 process during
development of the modification to correct the performance deficiency, as discussed in
the findings section of this report.
The team concluded that the requirements of IP 95002 for the extent of condition were
not met for the flooding White finding.
c. Findings
No findings were identified.
.2 Extent of Cause
a. Inspection Scope
TDAFWP
The inspectors conducted an independent extent of cause reviewed based on the root
and contributing causes identified by the licensee in RCE 10768931, TDAFWP Coupling
Degradation During IT 08 Run. Licensee personnel identified the Root Cause as the
TDAFWP exhaust steam piping was not installed properly during original construction to
eliminate stresses on the turbine per vendor recommendations resulting in cold piping
spring and coupling misalignment. Contributing Cause 2 (CC2) was determined to be
that as-found alignment data was classified as information-only, resulting in no
evaluation of out-of-tolerance conditions and the procedures lacked acceptance criteria.
Contributing Cause 3 (CC3) was determined to be that the TDAFWP and turbine were
not aligned during original construction using vendor recommended dowels allowing
subsequent movement of equipment.
The inspectors determined that the root cause was narrowly focused and not a good
candidate to perform an independent extent of cause. In fact, most aspects of the root
cause were included in the extent of condition discussed above. Instead the inspectors
selected CC2 and CC3 to perform the independent extent of cause.
The inspectors reviewed the licensees extent of cause evaluations to assess whether
they were of sufficient breadth and depth to accurately capture the extent of the causes.
The inspectors independent extent of cause evaluation involved in-plant walk downs
and observation of work activities, interviews with station management and staff, reviews
of program implementing procedures, reviews of program monitoring and station
improvement efforts, and comprehensive searches of the corrective action program.
White Flooding Finding
The inspectors performed an independent extent of cause based on the root and
contributing causes in the licensees RCE. The inspectors focused their review on the
licensees two identified root causes, as well as the two contributing causes identified in
the RCE. The root causes identified by the licensee included inadequate identification
and understanding of the external flooding CLB (RC1), and inappropriate prioritization of
flood protection deficiencies in the corrective action program based on
conditional/immediate station risk perceptions (RC2). The contributing causes the
licensee identified included a lack of clear supporting detail in station documents for
32
external events combined with a lack of use and understanding of license basis (CC1),
and a lack of formality and rigor regarding the stations follow-up and resolution of NRC
concerns (CC2).
The inspectors reviewed the licensees extent of cause evaluations to assess whether
they were of sufficient breadth and depth to accurately capture the extent of the causes.
The inspectors interviewed licensee management and personnel, reviewed program and
process documentation, performed plant walk downs, reviewed licensee program
monitoring and improvement efforts, and reviewed corrective action documents.
b. Assessment
TDAFWP
The inspectors determined that the extent of cause evaluations conducted by the
licensee for the TDAFW issues were narrowly focused. The extent of each cause
evaluations conducted by the inspectors broadly considered other programs and
components that may be affected by similar causes. The limited sampled performed by
the inspectors did not identify significant issues to concluded the cause would be
applicable in those areas. Therefore, based on the actions taken so far, and with the
additional actions entered into the licensees corrective action program, overall, the
inspectors concluded that Extent of Cause objectives of the 95002 inspection procedure
were met for the TDAFWP finding. The inspectors noted a number of licensee actions
are yet to be defined or completed as discussed below. Specific results of the
inspectors review of the causes and program areas are discussed below.
CC2: RMP 9044-1 Identified As-Found Alignment Data as Information Only Resulting In
No Evaluation of Out-of-Tolerance Conditions and Lacked Acceptance Criteria
The inspectors determined that the vibration monitoring and In-service Test (IST)
procedures require reviews by appropriate departments, including operations and
engineering. The procedures do not discuss information only data. Personnel involved
with these programs stated all data taken was reviewed by engineering. The review of
the corrective action program only identified the following issues.
Condition Report 019118667 described a condition found during review of the 1P-11A
coupling setting. It was identified that the as found coupling gap was recorded as 0.046
inch. The procedural requirement in RMP 9006-2A, required the gap to be 0.125 inches
per the OEM installation requirements for the Falk Model 1080T20 coupling. A review of
the last performed pump work on 1P-11A in 2010 under WO 392829, which included
procedure RMP 9006-2A, recorded the coupling back of hub to back of hub dimension
as 7.035 inches and did not record the actual gap, as the coupling was not removed.
The as found coupling back of hub to back of hub dimension under the current work was
7.034 inches with a gap of 0.046. Based on this information and that the coupling hubs
have not been replaced, the as found coupling appears to have been set incorrectly
since the coupling was last removed in 2007 under WO 188114.
33
Another CR 01895229 stated that during the previous TDAFW Pump 95001, the NRC
identified that routine maintenance procedures lack acceptance criteria.
During this review, some instances were found where as-found alignment data is now
being evaluated. The inspectors did not identify instances where vibration or IST data
was not evaluated.
The licensees extent of cause evaluation for CC2 considered as-found Thomas Series
54 Size 262 coupling alignment data that was being treated as information-only. It found
this cause only applied to procedure RMP 9044-1 because the P-29 turbine-pump
combination is the only equipment that utilizes the Thomas Series 54 Size 262 coupling.
The licensee determined RMP 9044-1 needed to be revised to include acceptance
criteria for the critical parameters of the Thomas Series 54 Size 262 coupling that could
affect operability, and included formal evaluation by engineering if any of these criteria
are exceeded. No other corrective actions were required.
The licensee evaluation also included other Thomas flexible disc pack coupling
alignment data and determined as-found data that is not evaluated applied to
procedures or work orders associated with the following equipment:
- P-028 Main Feedwater Pumps (Series 51 Size 450)
- P-007 Monitor Tank Pumps (Series DBZ-A Size 101)
- P-014 Containment Spray Pumps (Series DBZ-A Size 101)
- P-099 SGFP Seal Water Injection Pumps (Series DBZ-C Size 126)
- P-004 Boric Acid Transfer Pumps (Series DBZ-C Size 126)
- W-001 Containment Accident Recirculation Fans (375SN)
- W-004 Containment Reactor Cavity Cooling Fans (Series AMR)
The licensee action was to review the procedures or work orders for the above
equipment and revise them as necessary to include acceptance criteria for the critical
parameters.
The inspectors found the licensee extent of condition to be narrowly focused on either
the specific Thomas Series 54 Size 262 coupling or other Thomas flexible disc pack
couplings and did not consider other alignment procedures or procedures and programs
where as-found or information-only date may be taken and not evaluated. However, the
inspectors only found a few instances in the CAP where this weakness existed and
therefore could not conclude the cause identified extended into other equipment and
programs and therefore concluded this aspect requirements of IP 95002 was adequately
met for CC2.
CC3: 1 P-29 Pump and Turbine Were Not Aligned During Original Installation Using
Vendor Recommended Dowels Allowing Subsequent Movement of Equipment
Through review of a sample of vendor manuals, the inspectors did not identify any
vendor guidance concerning alignment that should have been incorporated into licensee
procedures. However, there were some issues identified in the corrective action
program that the inspectors considered representative of CC3.
34
For instance, CR 01920659, dated November 14, 2013, found that the 1P-029 as-found
alignment checks were outside the acceptance criteria of RMP 9044-1, Auxiliary
Feedwater Pump Terry Turbine Overhaul. The acceptance criteria for horizontal
alignment (offset) is -0.002 to 0.002 and, the as-found results were -0.0037 for horizontal
alignment. The as-found vertical alignment was satisfactory. The 1P-029-T was
realigned per RMP 9044-1 as part of the contingency work plan. Although the 2P-029
was doweled in accordance with vendor manual instructions, there was no mention of
doweling in this procedure.
Condition Report 01217509 dated June 8, 2000, states the post maintenance test
(PMT) for WO 9925677 indicated a probable alignment problem with P-132. Work
Order 9927144 was created to perform a "hot" alignment on P-132. The term "hot"
alignment is more commonly referred to in vendor manuals as a "final" alignment. The
vendor manual for all Goulds 3196 pumps calls for an initial alignment to be performed
when a pump is installed or reinstalled. The manual then calls for a final alignment to be
performed "after the unit has been run under actual operating conditions for a sufficient
length of time to bring the unit up to operating temperature." The manual goes on to say
that the final alignment should be checked after approximately one week of operation.
The manual also states that "the final alignment procedure......must be followed". Based
on the inspectors review, final alignments described in the Goulds pumps' manual are
not performed at Point Beach Nuclear Plant. These final alignments should be
performed as they are specifically called for by the pump manufacturer. Pump
misalignment could cause premature failure of critical pump parts such as bearings and
seals.
Another CR 01195885, dated April 17, 2001, stated that oil analysis shows evidence of
bearing wear for a safety injection pump motor. During alignment, the motor shaft was
apparently not at the mechanical center as recommended by the manufacturer. It was
mis-positioned such that contact was made at the inboard bearing thrust face with the
coupling compressed.
The inspectors also identified current observations by oversight organizations that are
indicative of conflicts with vendor manual instructions. Point Beach Daily Quality
Summary, dated October 16, 2012, discussed an observed activity for AF-00109,
P-38A Auxiliary Feed Pump Discharge Check Valve Inspection. It noted that the work
instructions were minimal and lacked warnings to avoid cocking the bonnet during
disassembly and reassembly that were stated in the vendor technical manual (VTM).
The scope in the WO instructions was written from the lift check valves vendor technical
manual and is different from what is listed in the Engineering technical basis. This
observation also indicates possible alignment issues with this check valve that supports
the need to consider valves during evaluation of the extent of cause for CC2.
Another observation, Point Beach Daily Quality Summary for 2P-29 TDAFW Pump
Assembly, dated November 19, 2012, noted that CR 01824455, Functional Criteria Not
Met, was initiated by Maintenance for the failure of the inboard bearing clearance to
meet the functional criteria. The System Engineer provided additional information to
CR 01824455 on November 17, 2012 stating that the functional criteria from preceding
Step 5.23.17 should have replaced the current criteria. The system engineer initiated
PCR 01825115 to put the correct criteria into the procedure. In light of the alignment
35
issues with this pump, the inspectors were concerned the licensee process did not
account for the latest vendor guidance to be entered into the applicable procedures.
After completion of the independent extent of cause for CC3, the inspectors reviewed
the licensees extent of cause for CC3. The licensee justified not doing an extent of
cause on CC3 base on it being unique to the TDAFWPs. Justification was based on the
following:
Since the piping misalignment issue has been resolved on 2P-29 and it is
not experiencing the governor valve chugging problem, no extent of cause
is required for this maintenance activity. The Terry turbine and pump are
unique in design compared to other driven pumps or components. Most
pumps and other pieces of equipment are driven with an electric motor. In
the normal configuration, the pump is considered the fixed point due to
being hard piped with suction and discharge pipe and is doweled once set.
The motor is moved as needed to obtain the required alignment tolerances
and is not doweled. Moving the motor to obtain proper alignment is being
restrained by hold down bolts. Slight movement of the motor to
accomplish proper alignment is permitted since only the connection to the
motor is the flexible power source conduit. For the AFW turbine and the
pump, both are hard piped, which is a significant challenge during
alignment. In addition, both the turbine and pump are to be doweled per
their respective vendor manuals, which is unique compared to other
rotating pieces of equipment. This condition of no dowels has existed
since startup and is considered an original which included procedure RMP
9006-2A construction deficiency of which the cause will not be determined.
Therefore no extent of cause is justified for this.
With a relatively small sample the inspectors found issues that had been identified
previously by the licensee that indicated CC3 may extend to other equipment with
vendor manual information. Therefore, the inspectors concluded the licensees extent of
cause evaluation for CC3 was narrowly focused and may not capture other vendor
guidance into licensee procedures. Condition Report 1939217 was initiated for this
observation. The recommended corrective action was to review a sample of vendor
recommendations contained in VTMs for safety related equipment to determine whether
there are broader issues associated with implementation of vendor recommendations.
While the inspectors determined the licensees extent of cause evaluation was narrowly
focused, other than the doweling guidance, no instances were identified where vendor
guidance was not appropriately incorporated into licensee procedures. Based on this
and the licensee action referenced above, the inspectors concluded the 95002
procedure requirements were satisfied.
White Flooding Finding
The inspectors determined that the extent of cause evaluations conducted by the
licensee for the External Flooding deficiencies were narrowly focused. Each of the
inspectors independent extent of cause evaluations broadly considered other programs,
procedures, functional areas that may be affected by similar causes. The limited sample
performed by the inspectors identified a few notable issues which are documented in
36
detail in the findings section of this report and the section below. Based on the actions
taken so far, the inspectors concluded that Extent of Cause objectives of the 95002
inspection procedure were not met for the Flooding finding. Areas of concern will be
reviewed as part of a future inspection. Specific results of the inspectors review of the
causes are discussed below.
RC1: Inadequate Identification and Understanding of the External Flooding CLB
The inspectors reviewed the licensees extent of cause evaluation for the first root cause
identified, RC1. Specifically, RC1 was identified as less than adequate identification
and understanding of the external flood protection design and licensing basis resulted in
loss of high lake level protection measures in 1996 when AOP 13B was cancelled.
Inspectors reviewed corrective action programs from the preceding 2-year period,
external events program controls, and general procedures in the areas of High winds,
Tornados, High Energy Line Breaks, Internal Flooding, and External Flooding, and
walked down related plant areas to independently assess whether the licensee had
appropriately identified deficiencies in understanding and identification of the design and
license basis.
No significant issues were identified. However, inspectors noted examples described in
the findings section of the report, where the licensee had failed to fully recognize impacts
of the wave run up barriers during the probable maximum precipitation (PMP) and
turbine building flooding event until the 95002 inspection team arrived onsite. The
inspectors noted that given the topography of the site and associated drainage
characteristics, this issue should have been more readily identified as part of the extent
of condition and extent of cause evaluations.
In addition, as noted in the findings section of this report, the licensee failed to recognize
that the conflict with the barriers resulted in a failure to comply with the CLB and the
need to open the CWPH roll-up doors constituted a compensatory action that needed to
be reviewed in accordance with 10 CFR 50.59. The inspectors noted that this issue was
served as an example where licensee personnel still demonstrated a lack of
understanding of the CLB, which served as evidence that the extent of cause for this
root cause have not been fully probed and deficiencies corrected.
RC2: Inappropriate Prioritization of Flood Protection Deficiencies in the Corrective
Action Program Based on Conditional/Immediate Station Risk Perceptions
The inspectors reviewed the licensees extent of cause evaluation for the second root
cause identified, RC2. Specifically, RC2 was identified as the degraded function of high
lake level protection measures for wave run-up identified in the corrective action
program were inappropriately prioritized based on conditional/immediate station risk
perceptions rather than compliance with license commitments resulting in untimely
resolution of the issues.
During review of RC2, inspectors interviewed plant personnel to evaluate general
understanding of the flooding deficiencies, recognition of associated risks, and
effectiveness of site communication campaigns. As previously noted, inspectors
observed that broader issues with risk recognition may still exist, based on discussion
with site personnel.
37
The inspectors assessed the extent of cause relative to the licensees failure to
characterize the wave barrier as nonfunctional and thus failed to properly prioritize
fixing the deficient strategy due to the lack of risk recognition. The inspectors noted that
of the 11 functionality assessments (FA) that the licensee sampled as part of their extent
of cause, and including an additional FA, excluded from the licensees sample because
the NRC had already found it deficient, half were found to be deficient in their
conclusions or logic. The inspectors observed that no action was taken to correct these
deficiencies, as the CR written on the results of the review was closed to no action. In
addition, no action was taken to learn from the results of the review, or probe these
results more deeply due to reliance on some procedural changes being made to the FA
process.
The inspectors noted that the sites focus on the perception that these deficient FA
conclusions were non-consequential had parallels to the White flooding finding root
cause. Specifically, the licensee had drawn the wrong FA conclusion, but plant
personnel had determined that it did not matter as long as the correct action was
ultimately taken. The inspectors observed that in the case of the original White Flooding
finding, site personnel had not properly addressed the deficiency even though there was
a belief that the correct action had been taken. The inspectors noted that the licensee
would have been driven to correct the deficiency more promptly if the FA conclusion had
been correctly classified as non-functional. This highlights the importance of drawing the
correct functionality conclusion. The inspectors concluded that to ensure correction of
the deficiencies associated with these FAs, and as an extension, the root cause that
drove them to perform the functionality assessment sample, it may have been
appropriate to enact more robust corrective actions to arrest the trend.
The inspectors learned during the functionality assessment review, as documented in
CR 01924763, FA errors & less than adequate corrective action program threshold, an
individual had discovered deficiencies in the conclusions of several FAs, and chose not
to write a CR because they felt that initiation of a new CR would constitute low value
work. The inspectors noted that this example served as a data point of an individual that
may still be focused on what they believe is or is not significant, without looking at the
bigger picture, and failing to write a CR to ensure that risks could be evaluated.
Inadequate corrective action program threshold and risk recognition were common to the
flooding root cause and common cause evaluations. The inspectors questioned whether
this might be an indication that the workforce has not been fully reached by licensee
communications focused on fixing licensee personnels lack of risk recognition, and
instilling them with the objective to prove that something is safe.
The inspectors noted that in response to the CR 01924763, less than adequate
corrective action program threshold this CR was closed to no action, with a note that
stated that coaching was provided. Inspectors noted that without any review of the
behavior documented in the CR, it would be difficult for the licensee to determine
whether this behavior was a single isolated incident, or more of a wide spread problem.
Inspectors noted that it may have been appropriate for the licensee to take action to
make this determination so that more robust corrective actions than coaching could be
taken, if necessary.
38
The inspectors also noted that because the extent of cause was not extended from the
FA process to a similar process, the Operability Determination process, the licensee
missed an opportunity to implement robust corrective actions to address deficiencies in
the operability determination process. The inspectors noted that within the previous
2 years, there had been approximately five NRC findings associated with inadequate
operability determinations. The licensee noted that they had adopted a new operability
determination process procedure in August of 2013, and had taken actions as a result of
an April 2013 Condition Evaluation to perform one-time trainings for Operations and
Engineering to improve operability determination process knowledge. The inspectors
noted that Condition Evaluations serve as lower level evaluations that do not generally
probe deeply into issues, and may not reveal all aspects of a complex issue. Inspectors
also noted that actions to perform one-time trainings may not be robust enough to
ensure sustainable improvement. The inspectors concluded that given the critically
important function that operability evaluations serve, it may have been appropriate to
enact more robust corrective actions to ensure improvement in this area.
CC1: Lack of Clear Supporting Detail in Station Documents for External Events
Combined with a Lack of Use and Understanding of License Basis
The inspectors reviewed the licensees extent of cause evaluation for the first
contributing cause identified, CC1. Specifically, CC1 was identified as deficiency in
having clear supporting detail in station documents for external events combined with a
lack of use and understanding of license basis resulted in the FSAR requirements
remaining unmet.
Inspectors reviewed corrective action programs from the preceding 2-year period,
external events program controls, and general procedures in the areas of High winds,
Tornados, High Energy Line Breaks, Internal Flooding, and External Flooding, and
walked down related plant areas to independently assess whether the licensee had
appropriately identified deficiencies in clear supporting detail in station documents
associated with the license basis.
No significant issues were identified. However, inspectors identified several deficiencies
with the licensees failure to ensure clear supporting detail existed in station documents
associated with internal flooding. Specifically, inspectors noted that although during a
design basis turbine building flooding event, the site was crediting tripping the circulating
water pumps to mitigate the flood with a short specified amount of time, i.e. 34 minutes
or less, the site failed to evaluate and control this action under the time critical operator
action procedure. In addition, inspectors noted that the site had chosen to credit failure
of the turbine building roll up door during the same internal flooding event. Inspectors
identified that the site had failed to upgrade this door to an augmented quality
classification, despite the fact that they had taken action to credit the door in the design
basis to perform the safety related function of flood relief.
The inspectors also noted that reliance on the failure of the turbine building door for the
internal turbine building flooding event was not clearly articulated in changes the
licensee made to the FSAR, in that the TDAFW pump rooms noted that the door was
credited for flood relief, but the EDGs did not contain the same statement despite a
similar reliance on the same door. These issues were entered into the licensees
corrective action program. The inspectors determined that these issues could be related
39
to CC1, in that station documents did not clearly define and control features that were
credited to mitigate internal flooding scenarios.
CC2: Lack of Formality and Rigor Regarding the Stations Follow-Up and Resolution of
NRC Concerns
The inspectors reviewed the licensees extent of cause evaluation for the second
contributing cause identified, CC2. Specifically, CC2 was identified as stations rigor for
follow up on NRC concerns lacks formality and as a result the CR written for the
1Q2012 URI was not validated for accuracy, nor contained the necessary action, thus
contributing to the untimely resolution of potentially degraded flood protection
measures.
During review of CC2, inspectors identified that the licensees extent of cause was
narrow, and should have focused more broadly. Specifically, the licensees evaluations
focused only on improvements and deficiencies associated with the tracking and
resolution of NRC concerns. The inspectors questioned whether the site should have
looked across the organizations at similar processes and interactions with other external
stakeholders. Specifically, the inspectors noted that tracking and resolution of nuclear
oversight, corporate nuclear review boards, management review board, and
independent site evaluations may have similarities to the NRC issue tracking and
resolution processes. The inspectors noted that the site missed an opportunity to
identify improvements in these processes. The inspectors did not identify any instances
where the site had not appropriately tracked or resolved issues associated with these
groups, but inspectors also recognized that deficiencies in these areas may not be
readily identifiable due to the nature of these interactions.
The inspectors concluded the 95002 procedure requirements for the flooding White
finding were not satisfied.
c. Findings
No findings were identified
02.05 Safety Culture Consideration
a. Inspection Scope
As part of the current 95002 inspection, the inspectors independently confirmed that a
number of safety culture components that contributed to the risk significant issues that
were the subject of this inspection were identified in the licensees RCEs. The licensees
root cause evaluations included a discussion of the applicable safety culture
components described in Regulatory Issue Summary 2006-013, Information on the
Changes Made to the Reactor Oversight Process to More Fully Address Safety Culture,
(ADAMS Accession No. ML061880341) as they applied to the violations and findings.
The licensee determined that weaknesses in decision making (conservative
assumptions and systematic process), resources (procedures/work instructions), work
practices (oversight), work control (planning), and the corrective action process
(low threshold and evaluations) were the most prevalent safety culture attributes. The
licensee also included the results of a 2013 station nuclear safety culture self-
assessment and employees concern program site pulsing surveys. For each of the
40
identified prevalent and contributing safety culture components, the inspectors confirmed
that the licensee established corrective actions to address the issues.
Assessment
The inspection team independently confirmed a sample of other safety culture
components which contributed to the issue(s) that were also identified in the root cause
analysis. These additional safety culture components included weaknesses in the CAP
and resources. For each of the identified prevalent and contributing safety culture
components, the inspection team confirmed that the licensee established appropriate
corrective actions to address the issues. Some corrective actions are complete, but
pending corrective actions and effectiveness of those actions has not been confirmed to
a point where the NRC has confidence that the licensees actions are sufficient to
address and correct the causes and issues. During the course of interviews with
licensee personnel, the inspection team asked interviewees questions related to safety
conscience work environment (SCWE) to determine if the licensees staff were reluctant
to raise safety concerns or if fear of retaliation existed for raising safety concerns. The
inspection team did not identify concerns related to SCWE.
The inspection team confirmed that the licensees root cause, extent of condition, and
extent of cause evaluations appropriately considered the safety culture components as
described in IMC 0305, Operating Reactor Assessment Program.
The inspectors observed that the previously cited example of a failure to initiate a CR, as
described in CR 01924763, FA errors & less than adequate CAP threshold, was an
important data point from a safety culture and CR initiation standpoint. This CR
documented an individuals failure to write a CR to document deficiencies in the
conclusions of several functionality assessments. The inspectors noted that while the
issue itself was just one data point, the licensees failure to act to determine the extent to
which those behaviors were prevalent onsite was an additional data point in the area of
safety culture. The inspectors noted that the licensee had instead closed the CR to no
action, and noted that coaching had been provided. The inspectors determined that
investigative actions may have been appropriate to assist in the licensees assessment
of whether their RCE corrective actions to improve CR initiation and risk recognition had
adequately reached the working level staff. This may have especially been appropriate
given the fact that similar inappropriate CAP threshold issues played a role in the
common cause for the greater than green findings being evaluated during the 95002
inspection.
Inspectors noted that the O.2a safety culture component may not have been adequately
considered during the licensees safety culture evaluation. Specifically, O.2a is focused
on ensuring that appropriate training and knowledge transfer was in place to ensure
technical competency of staff. The inspectors noted that the licensee marked this
aspect as not applicable. The inspectors observed that this safety culture aspect may
have played a role in the licensees root cause associated with licensee staffs failure to
understand the CLB. Mainly, the inspectors noted that training and knowledge transfer
could have increased licensee personnels understanding of the CLB. The inspectors
observed that at the least, this training and knowledge transfer could have prompted the
identification of vague requirements in the design basis or licensee staffs lack of full
understanding of the CLB. The inspectors noted that this could have driven resolution of
questions on requirements.
41
The inspectors noted that subject matter experts at the site who were charged with
ownership and knowledge of the external flooding program and other functional areas,
did not have any qualification cards or required subject matter trainings to ensure their
competency. This remained unchanged after the finding. The inspectors noted that
corrective actions to provide general external events training and to develop a formal
external events program may have appropriately addressed concerns about subject
matter experts training adequacy, as the procedure consolidated requirements into
controlling program procedures. However, the inspectors concluded that more
specialized training could have increased defense in depth in the training and knowledge
transfer areas.
The inspectors concluded the 95002 procedure requirements were satisfied for the
TDAFWP finding but not for the White flooding finding.
b. Findings
No findings were identified
02.06 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues
The licensee did not request credit for self-identification of an old design issue.
Consequently, the subject risk significant issues were not evaluated against the
IMC 0305 criteria for treatment of an old design issue.
4OA5 Other Activities
The inspectors utilized other inspection procedures as part of the assessment of the
licensees performance. The following inspection samples were completed as part of
this inspection.
- 71111.01 - External Flooding - 1 sample
- 71111.06 - Internal Flooding - 1 sample
- 71111.15 - Operability Evaluations - 1 sample
- 71152 - Problem Identification and Reporting - Annual Follow-Up
of Selected Samples - 1 sample
4OA6 Management Meeting
Exit Meeting Summary
On March 6, 2014, the inspectors presented the inspection results to
Mr. E. McCartney, Site Vice President, and other members of the licensee staff. The
licensee acknowledged the issues presented. The inspectors confirmed that none of the
potential report input discussed was considered proprietary.
ATTACHMENT: SUPPLEMENTAL INFORMATION
42
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
E. McCartney, Site Vice President
R. Wright, Plant General Manager
R. Weber, Operations Director
M. Millen, Licensing Manager
K. Longston, Acting EP Manager
J. Atkins, Systems Engineering Manager
B. Beltz, Assistant Operations Manager
F. Hennessy, Performance Improvement Manager
J. Pruitt, Site Quality Manager
R. Welty, Radiation Protection Manager
R. Harrsch, Engineering Director
D. Lauterbur, Training Manger
P. Wild, Design Engineering Manager
L. Christensen, Licensing Project Manager
B. Scherwinski, Engineering Analyst II
T. Schneider, Licensing
F. Huber, Projects Manager
S. Cassidy, Communications Manager
C. Trezise, Director Special Projects
M. Ley, Civil/Mechanical Engineering Supervisor
T. Lesniak, Mechanical Maintenance Department Head
M. Maertens, Business Operations Manager
R. Clark, Licensing
S. Ruesch, Employee Concerns Program Manager
J. Petro, Licensing Director
A. Gustafson, Training
K. Locke, Licensing
Nuclear Regulatory Commission
A. Boland, Director, Division of Reactor Projects
J. Cameron, Chief, Branch 4, Division of Reactor Projects
K. Barclay, Acting Senior Resident Inspector Point Beach
R. Elliott, Acting Resident Inspector Point Beach
1 Attachment
LIST OF ITEMS OPENED, CLOSED AND DISCUSSED
Opened
05000266/2014007-01 NCV Failure to Take Corrective Actions to Address External
05000301/2014007-01 Flooding Procedure Deficiencies05000266/2014007-02 NCV Failure to Maintain External Flooding Procedure to
05000301/2014007-02 Address All Possible CLB Floods05000266/2014007-03 NOV Failure to Perform a Required 10 CFR Part 50.59
05000301/2014007-03 Evaluation
05000266/2014007-04 FIN Failure to Perform a Required 10 CFR Part 50.59
05000301/2014007-04 Evaluation
05000266/2014007-05 NCV Failure to Establish EFR Attributes to Assess the
05000301/2014007-05 Effectiveness of Corrective Actions
Closed
05000266/2014007-01 NCV Failure to Take Corrective Actions to Address External
05000301/2014007-01 Flooding Procedure Deficiencies05000266/2014007-02 NCV Failure to Maintain External Flooding Procedure to
05000301/2014007-02 Address All Possible CLB Floods05000266/2014007-03 NOV Failure to Perform a Required 10 CFR Part 50.59
05000301/2014007-03 Evaluation
05000266/2014007-04 FIN Failure to Perform a Required 10 CFR Part 50.59
05000301/2014007-04 Evaluation
05000266/2014007-05 NCV Failure to Establish EFR Attributes to Assess the
05000301/2014007-05 Effectiveness of Corrective Actions
2
LIST OF DOCUMENTS REVIEWED
The following is a partial list of documents reviewed during the inspection. Inclusion on this list
does not imply that the NRC inspectors reviewed the documents in their entirety, but rather that
selected sections or portions of the documents were evaluated as part of the overall inspection
effort. Inclusion of a document on this list does not imply NRC acceptance of the document or
any part of it, unless this is stated in the body of the inspection report.
Corrective Action Documents
CR 01195739, CCW Pump Vibration
CR 01195885, Oil Analysis Shows Evidence of Bearing Wear on Safety Injection Pump Motor
CR 01196175, G-02 Exhibited High Axial Impact-Type Acceleration
CR 01200210, RMP For Reactor Coolant Pump Uncoupling Questioned
CR 01200598, Refueling Water Storage Tank Throttle Valve Difficult To Operate
CR 01202954, 2P-11B Alignment Problems
CR 01208186, G-01 EDG Bearing Vibration
CR 01208318, RCS Piping Stress
CR 01212030, Service Water Pump Gland Follower Improperly Aligned
CR 01215799, Inadequacies Identified In SI Pump Routine Maintenance Procedure
CR 01216019, Potential for Cracking In MSB Lift Yoke
CR 01217509, P-132 BDE Distillate Pump Alignment
CR 01390003, License Renewal Exam of STP-00014 has Minor Indication
CR 01610365, P-032C SW Pump Shaft Vibration Trending High
CR 01633548, NOS Identified IER1 11-1, Flood Barrier Door Inspection
CR 01639502, Jacking Bolt Broken For Motor Alignment
CR 01655812, 2P-10B Bearing Housing Bracket Jack Bolt Holding Alignment
CR 01660763, P-73A/B Suction And Discharge Pump Piping Misalignment
CR 01678709, NRC Issues Position on Missile Protection For G-01/02 Exhaust
CR 01691196, Operability Determination Issues Across Fleet
CR 01723755, Safe Shutdown Fire Dampers No Inspected
CR 01726015, FSAR Questions Regarding Cross Over Steam Dump Testing
CR 01727221, Plant Safe Shutdown Equipment Exposed To Tornados
CR 01736062, High Energy Line Break Door Issues
CR 01748940, Tornado Hazard
CR 01757131, Potential Violation RSPS Degraded Function
CR 01760171, G-01 and G-02 EDGs Declared Inoperable
CR 01762122, Design Basis Docs On Tornado Missiles
CR 01768931, 1P-29 Turbine Driven Auxiliary Feedwater Pump Degraded Coupling
CR 01771762, Green Finding - Weld Design Deficiency in the EDG Missile Protection Barriers
CR 01779635, Green Finding - Failure to Incorporate WOG ERG, Revision 2 into the EOPs
CR 01780474, G05 Control System Does Not Control Well
CR 01799222, 1P-28B, MFW Pump, High Vibration As-Found Alignment Data
CR 01801696, Quarterly DQS of a Licensing Topic
CR 01804588, Inadequate Scoping of Non-Safety Related System into Maintenance Rule
CR 01805402, Procedure PC 80 Part 7 Lake Water Level Determination Issues
CR 01806402, Procedure PC 80 Part 7 Lake Water Determination Issues
CR 01806545, Inconsistent Application of IPEEE Information in CLB
CR 01807841, Sand Bags Erroneously Eliminated From PB Flood Contingencies
CR 01807866, WR - Obtain Hot and Cold Pump And Motor Growth Readings
CR 01808661, Failure to Implement Risk Management Actions During Emergent Work Activities
3
CR 01808901, Coupling Misalignment On 0P-217A G-01 Circulation Oil Pump
CR 01809095, Deficiencies In PC 80 Part 7, Lake Level Determination
CR 01816327, Missing Appendix R Calculations
CR 01824582, PC 80 Part 7 CA 01809095 Due July 31, 2013
CR 01826212, Generator to Engine Coupling Is Degraded
CR 01826753, Coupling on Turbine Has Minor Damage
CR 01833683, Green Finding - Failure to Update the Fire Emergency Plan
CR 01845168, CMP for EN-AA-203-1001 Revision 10 (OD/FA) Implementation
CR 01847140, G-05 Functionality During Severe Weather
CR 01849522, G01/G02 Missile Shield Impact on External Flooding
CR 01850776, 2P-028A High Vibration At Drive End Bearing
CR 01851639, Green Finding - Failure to Submit LER Within 60 Days
CR 01853775, Basis for Flood Barriers Not Referenced In FSAR
CR 01853779, Current Licensing Basis for External Flooding Not Changed
CR 01855615, Resident NRC Inspector Roof Inspection Questions
CR 01856318, FSAR Not Updated for External Flooding Features
CR 01856322, Failure to Establish Adequate Procedures to Respond to PMP Event
CR 01856327, Failure to Maintain Features to Address Max Wave Run Up
CR 01860140, Prior to Starting Work Problems Found With TDAFWP Work Package
CR 01861967, Recent Issues Related to Operability/Functionality, April 1, 2013
CR 01863557, FSAR Errors Identified in Self-Assessment
CR 01863560, High Energy Line Break Door Issue Trending
CR 01875052, Electrical Short Circuit Protection Issues
CR 01875056, Electrical Short Circuit Protection Issues
CR 01877254, G-05 Excessive Hunting at Peak Load
CR 01879455, 2P-011B Pump OB Bearing Doweling Issue
CR 01878130, 2013 CAP FSA - CR Initiation Sensitivity
CR 01880011, Calculation 2005-0053, Revision 1 Presents Appendix R Issues
CR 01883633, Flooding Root Cause Evaluation; Revision 3
CR 01886923, Determine If An Issue Was a Missed Opportunity - Flooding
CR 01889400, Condition Evaluation Did Not Evaluate Scope Identified in Parent CR 01763937
CR 01889518, Final Effectiveness Review Prompt Operability Determinations and
CR 01892543, Interim Actions Were Not Fully Effective (EFR 1889518)
CR 01894831, 95001 Inspection AR Screened as CAQ
CR 01894925, NRC 95001 RCE 01768931 Enhancement
CR 01895229, Routine Maintenance Procedures Lack a Specific Standard for Alignment Data
CR 01896156, Degraded Cornerstone - Mitigating Systems Two White Findings
CR 01900061, Functionality Assessment CA1806402-01 Conclusion Questioned
CR 01901996, ACE for Green Finding for Probable Maximum Precipitation Event Controls
CR 01902111, Validate That AOP-13C Will Meet Station Blackout Requirements
CR 01907036, 95002 VSGR Door Gaps Documentation Potential Deficiency
CR 01907864, 95002 Preps: Difference in Annual Snowfall Levels in FSAR
CR 01912749, Subsoil Drainage System is Blocked
CR 01914914, 2-P11A Pump Alignment Challenges
CR 01917384, Unable To Obtain Acceptable Alignment On G-03 Lube Oil Circulation Pump
CR 01918667, 1P-11A As-found Coupling Gap Below RMP Requirements
CR 01919077, Adverse Trend - Engineering CAP Backlog
CR 01920608, Adverse Trend - Engineering CAP Backlog
CR 01920659, 1P-029 As-found Alignment Checks Were Outside the Acceptance Criteria of
RMP 9044-1
4
CR 01920783, During Performance of WO# 40241255 Checking Alignment on the Terry turbine
CR 01921089, Recent Decline In Operations Performance
CR 01922342, Increase In Initiation Rate of Anonymous and NSC ARs
CR 01924763, FA Errors & Less Than Adequate CAP Threshold
CR 01927436, 2P-11B Loose Hold Down Bolts And As-Found Alignment
CR 01932698, 95002 Wave Run-Up Protection May Conflict With Other Floods
CR 01936250, Employee Behavior Not Aligning With Expectations
CR 01936497, Conflict Between AOP-13C High Winds And PC 80 Part 7 Barrier
CR 01937027, 95002 Revise NP 7.5.2 and Form PBF-9178 to Address Flooding
CR 01937424, PBSA-ENG-15-01 External Events Program Quick Hit Assessment
CR 01938711, NRC 95002 Inspection - RCE 1883633 EOCA for CC2
NRC Identified CRs
CR 01938106, Incomplete Disposition of AR 01860140 On Unit 1 TDAFWP
CR 01938122, During NRC Walk Down Black Putty and Dry Boric Acid Was Noted on the Base
Plate of the Unit 2 Train B Containment Spray Pump
CR 01938271, Snow Was on the Barrier Installation Pads As Well As A Power Cable
CR 01938314, Visible Dimple Noted Near Jacking Bolt
CR 01938317, During Walk Down Dried Boric Acid Noted on The Unit 2 Train B RHR
Pump Seal
CR 01938326, Final Effectiveness Reviews for Common Cause 1 and 2 Were Inappropriately
Reliant Upon NRC Input
CR 01938384, Alignment Issue With Valve 2RH-823B Reach Rod
CR 01938501, Maximum Precipitation and Wave Run Up Not Assessed Simultaneously
CR 01938670, Root Cause Reports Were Not Aligned with the 95002 Procedure
CR 01938711, Scope for the Extent of Cause of Contributing Cause 2 From the Flooding RCE
Is Limited to NRC Concerns Only
CR 01938749, Attachment of Spring Cans to the MOVs After All As Left Testing Completed
CR 01938706, Formal Aggregate Review of all Flooding Related CRs
CR 01938825, Potential Storm Drain Bypass of Wave Run Up Barriers Not Assessed
CR 01938861, Risk Analysis Sections in Root and Common Causes Narrowly Focused
CR 01939011, Expand FSAR Section on Probable Maximum Precipitation Event
CR 01939095, VTM Dowling Recommendation Not Incorporated Into Procedures
CR 01939217, TDAFWP Root Cause Did Not Implement a Vendor Recommendation
CR 01939345, No Corrective Actions Initiated for Flooding Barriers During Cold Weather
CR 01939362, Functionality Assessments Found Issues But No Corrective Actions Taken
CR 01939389, Needed Enhancement to FSAR Appendix A.7, Internal Flooding
CR 01939838, Remove Door 349 When Wave Run Up Barriers Are Installed
CR 01940082, Procedure PC 80 Part 7, Revision 6 50.59 Screen Error
CR 01940118, Procedure PC 80 Part 7, Revision 4 50.59 Screen Error
CR 01940511, Errors Identified in Surveillance PBF-2124
CR 01940562, Poor CAP Product Quality
CR 01940606, Errors Identified in Procedure PC 80, Part 7
CR 01940621, FSAR Revision Required
CR 01940739, Unintentional Change to PC 80 Part 7 Identified
CR 01941022, Additional Errors Found in PBF-2124
CR 01941085, Potential Licensing Basis Questions Identified
CR 01941262, Quality Level of Flood Related Doors in Error
CR 01941902, Readiness for Inspection Letter Sent the Same Day as it Was Identified That the
Site was Not Ready for the Inspection
5
CR 01942059, Another Error Found In PBF-2124
CR 01942315, Several Drawing Errors Identified
CR 01942317, Error Identified On ARB C01 B1-1
CR 01942343, Error Identified In AOP-13C
CR 01943803, Use of Wrong NRC Cross Cutting Code in Effectiveness Review Criteria
CR 01946330, Severity Level IV Violation for 50.59 - Use of Roll-Up Doors
Drawings
M-1, Equipment Location Plan Containment Operating Floor Unit 1, Revision 19
M-3, Water Intake Facility General Arrangement Plan B-B, Revision, November 17, 1967
M-4, Water Intake Facility General Arrangement Plan C-C and D-D, November 17, 1967
M-15, Water Intake Facility Piping Section F-F, November 4, 1969
M-16, Circulating Water Pump House Piping, Revision 13
M-2007, Equipment Location Plan Ground Floor North, Revision 22
M-2009, Equipment Location Plan Sections H-H and K-K, Revision 9
M-2010, Equipment Location Miscellaneous Section, Revision 5
C-1, Site Plan, Revision 19
6704-E-121001, Plant Key Plan, Drawing, Index and Specification Numbers, Revision 4
6704-E-121102, Diesel Generator Building Floor and Roof Plan, Revision 5
6704-E-151001, Diesel Generator Building Yard Area Grading Plan, Revision 3
M-165, Turbine Building Floor & Equipment Drainage Area No 3 - Plan at EL. 8.0, Revision 6
Licensee Procedures
AD-AA-103, Nuclear Safety Culture Program, Revision 5
EN-AA-203-1001, Operability Determinations/Functionality Assessments, Revision 7
EN-AA-203-1001, Operability Determinations/Functionality Assessments, Revision 11
EN-AA-203-1001, Operability Determinations/Functionality Assessments, Revision 12
EN-AA-203-1001, Operability Determinations/Functionality Assessments, Revision 15
RMP 9044-1, Auxiliary Feedwater Pump Terry Turbine Overhaul, Revision 35
RMP 9376-1, Limitorque MOV Removal, Installation, SWAP, and Testing for Gate and
RMP 9376-2, Limitorque MOV Static/DP Testing for Gate and Globe Valves
RMP 9376-3, Limitorque MOV Removal, Installation, and Adjustment for Butterfly Valves
RMP 9376-4, Limitorque Motor Operator Model SMB-000 Disassembly, Inspection Repair,
and Re-Assembly
RMP 9376-5, Limitorque Motor Operator Model SMB-0 Through SMB-4 Disassembly,
Inspection, Repair, and Re-Assembly
RMP 9376-6, Limitorque Motor Operator Model SMB-00 Disassembly, Inspection, Repair, and
Re-Assembly
RMP 9008-1, RHR Pump Removal and Installation
RMP 9005-2, SI Pump Overhaul
Vendor Manual 0501, Pacific Pumps, Inc.
AOP-13C; Abnormal Operating ProcedureSevere Weather Conditions, Revision 32
NP 7.5.2; PBNP Owner Controlled Area Temporary Structure Limitations, Revision 12
NA-AA-200, Employees Concern Program Process Description, Revision 5
PI-AA-01, Corrective Action Program and Condition Reporting, Revision 3
PI-AA-204, Condition Identification and Screening Process, Revision 22
PI-AA-205, Condition Evaluation and Corrective Action, Revision 23
PI-AA-100-1005, Root Cause Analysis, Revision 8
6
PI-AA-100-1006, Common Cause Evaluation, Revision 6
PI-AA-100-1007, Apparent Cause Analysis, Revision 7
PI-AA-100-1008, Condition Evaluation, Revision 5
PI-AA-101-1001, Quick Hit Assessments, Revision 5
MA-AA-203-1001, Work Order Planning, Revision 1
PDM 1.0, Vibration Monitoring Program
Procedure IT 02, High Head Safety Injection Pumps and Valves Train B, Unit 2
Procedure IT 03, Low Head Safety Injection Pumps and Valves Train A, Unit 1
Procedure IT 06, Containment Spray Pump and Valves
Procedure IT 12, 1P-11B, Component Cooling Water Pumps and Valves Unit 1
Procedure IT-07D, Service Water Pump (Quarterly) Surveillance
PC 80 Part 7, Lake Water Level Determination, Revision 3
PC 80 Part 7, Lake Water Level Determination, Revision 4
PC 80 Part 7, Lake Water Level Determination, Revision 5
PC 80 Part 7, Lake Water Level Determination, Revision 6
PC 80 Part 7, Lake Water Level Determination, Revision 7
PC 80 Part 7, Lake Water Level Determination, Revision 8
PC 80 Part 7, Lake Water Level Determination, Revision 9
PC 80 Part 7, Lake Water Level Determination, Revision 10
CL 11A G-02, G-02 Diesel Generator Checklist, Revision 29
NP 7.2.29; External Events Program, Revision 0
Root Cause Reports
RCE 01757131, Potential Violation Due to a Degraded Emergency Planning Risk Significant
Planning Standard Function, Revision 4
RCE 01768931, Unit 1 Turbine Driven Auxiliary Feedwater Pump 1P-29 Coupling Degraded
During IT-08A Run, Revision 5
RCE 01883633, Potential Greater Than Green Finding Flooding, Revision 3
RCE 01896156, Degraded Cornerstone - Mitigating Systems Two White Findings, Revision 1
Calculations
FPL-076-CALC-017, Maximum Precipitation Analysis for Past Reportability, Revision 0
CALC 2008-0024, AFWP Room Flood Basis CalculationJanuary 23, 2014, Revision 1
CALC 2009-0008, Circulating Water Pump House Internal Flooding, Revision 1
FPL-076-CALC-016, Flow Depth Sensitivity to Openings with Wave BarriersFebruary 6, 2014,
Revision 0
FPL-076-CALC-003, Point Beach DELFT3D Surge and Wave Model, Revision 0
EC 279455, Time Available to Respond to Threat From Rising Water, June 24, 2013
FPL-076-CALC-014, PBNP Precipitation and Snow Intensity Determination and Roof Drainage
Evaluation - December 18, 2013, Revision 0
FPL-076-CALC-015, Maximum Precipitation Flood Effects - January 7, 2014, Revision 0
CALC 2014-0002, Effects on Safety Equipment of Bypassing the Installed Wave Run-Up
Barriers Through The Storm Drains - February 11, 2014, Revision 0
Miscellaneous Documents
List of Technical Procedure Revisions for 2013
Presentation for Outage Review Board Team Meeting, February 4, 2014
Corrective Action Review Board Package for February 4, 2014
7
PBSA-PBNP-13-013, Quick Hit Assessment Report for the 95002 Mock Inspection for
Degraded Cornerstone, October 29, 2013
PBSA-ENG-07-13, 2008 Component Design Basis Inspection Preparations, March 10-20, 2008
PBSA-ENG-10-20, Focused Self-Assessment of Flooding Program, September 20-23, 2010
PBSA-ENG-11-01, Component Design Basis Inspection Preparations, January 17-27, 2011
PBSA-ENG-06-02, SA Preparation for Design Basis Inspection Based on 71111.21,
January 16 - February 2, 2006
PBSA-ENG-12-20, Quick Hit Assessment ReportFlooding Program, April 15 - May 24, 2013
PBSA-PBNP-13-02, CR 01908740, Quick Hit Assessment Report Station Nuclear Safety
Culture, September 23 through October 4, 2013
PBSA-PBNP-12-02, Quick Hit Assessment Report Station Nuclear Safety Culture
September 17 through 20, 2012
MOR 2013-23, Missed Opportunity ReviewPotential Greater Than Green FindingFlooding,
July 9, 2013
NOS Daily Quality Summary Related to Flooding MORGas Accumulation Management
Program, April 24, 2013
CEI Independent Evaluation, Point Beach Root Cause Evaluation for NRC White Performance
IndicatorFlooding, September 20, 2013
EC 280223, Review of Flooding Vulnerability Report for Possible CLB Encroachment,
October 22, 2013
NEE 05-PR-003, Flooding Vulnerability Report, Revision 0
EN-AA-203-1001 Operations TrainingOperability Determinations/Functionality Assessment
Training Materials, August 28, 2013
EN-AA-203-1001 Engineering Lesson PlanOperability Determinations/Functionality
Assessments, July 3, 2013
SCR 2013-0213, 50.59 Screening Form FSAR Sect 2.5 PMP FloodJanuary 28, 2014,
Revision 1
Monthly Weather ReviewThe Prediction of Surges in the Southern Basin of Lake Michigan;
May 1965
NPC98-00509, Harza Preliminary Hydrologic and Hydraulic Studies for Nuclear Power Plant
Site Selection, March 18, 1966
NOS Observations, October 30, 2008, November 20, 2009, August 16, 2010, April 23, 2011,
November 19, 2011
Point Beach Daily Quality Summary - 1P-29 Turbine Driven Auxiliary Feedwater Pump,
January 27, 2012
Point Beach Daily Quality Summary - Initial Auxiliary Feedwater Pump and Terry Turbine
Alignment, June 22, 2012
Point Beach Daily Quality Summary - Terry Turbine Oil Change and Sampling, July 02, 2012
PBN 12-010, Nuclear Oversight Report: Maintenance-Corrective and Preventative,
July 12, 2012
Point Beach Daily Quality Summary - 1/2 P-38 AFW Pump October 16, 2012
PBN-12-014, Nuclear Oversight Report: System Engineering, November 19, 2012
Point Beach Daily Quality Summary - 2P-29 TDAFW Pump Assembly, November 19, 2012
PBN-13-003 Nuclear Oversight Report: Engineering Design, March 8, 2013
Point Beach Daily Quality Summary - Fire Protection Walkdown P-53 Motor Driven Auxiliary
Feed Pump Rooms, October 2, 2013
MOR 2013-09 Missed Opportunity Review, 1-29-T, Auxiliary Feed Water Pump Turbine
Coupling Failure, CR 1846183, February 7, 2014
WO 383111-01, STP-00014; Inspect for License Renewal per LR-TR-519, May 17, 2010
WO 40188994-09, Simulate PC 50 Part 7 Draft with New Barriers (PMT), November 21, 2013
WO 40188994-04, Verify Ability to Place and Secure Jersey Barriers (PMT), July 10, 2013
8
Fleet Daily Quality Summary ReportFukushima, November 22, 2011
Point Beach Daily Quality Summary ReportFlooding Related, April 4, 2012
Point Beach Nuclear Oversight ReportFire Protection and Flood Doors, October 7, 2010
Point Beach Nuclear Oversight ReportISFSI Environmental Impacts Audit, July 14, 2011
Point Beach Nuclear Oversight ReportReview of OE Related to Flooding and Actions Taken,
March 8, 2013
Point Beach Nuclear Oversight ReportReview of CommitmentsFlooding Walk Downs,
March 30, 2013
Fleet Daily Quality Summary ReportFlooding Underground Cables, January 21, 2008
WO 40220319-01, PC 80 Part 7 Install CWPH Concrete Block Barriers, February 4, 2014
Pictures of Wave Barriers Constructed, November 26, 2013
9
LIST OF ACRONYMS USED
ADAMS Agencywide Document Access Management System
AR Action Request
CAPR Corrective Action to Prevent Recurrence
CC Contributing Cause
CCA Common Cause Analysis
CCDP Conditional Core Damage Probability
CDF Core Damage Frequency
CFR Code of Federal Regulations
CLB Current License Basis
CR Condition Report
CW Circulating Water
CWPH Circulating Water Pump House
CY Calendar Year
DRP Division of Reactor Projects
EFR Effectiveness Review
EJ Expansion Joint
EPRI Electric Power Research Institute
FP Fire Protection
FSAR Final Safety Analysis Report
gpm Gallons per Minute
HCLPF High Consequence of Low Probability of Failure
HEP Human Error Probability
IMC Inspection Manual Chapter
INPO Institute of Nuclear Power Operations
IP Inspection Procedure
IPEEE Individual Plant Examination External Events
IR Inspection Report
IST In-service Test
KSA Knowledge Skills and Abilities
LERF Large Early Release Frequency
LOCA Loss of Coolant Accident
LOOP Loss of Off-Site Power
MOV Motor Operated Valve
N/A Not Applicable
NCV Non-Cited Violation
NOV Notice of Violation
NRC U.S. Nuclear Regulatory Commission
OEM Original Equipment Manufacturer
OSHA Occupational Safety Health and Safety
PARS Publicly Available Records
PC Procedure Call-Up
PMP Probable Maximum Precipitation
PMT Post Maintenance Test
PRA Probabilistic Risk Assessment
PWR Pressurized Water Reactor
RASP Risk Assessment Standardization Project
10
RC Root Cause
RCE Root Cause Evaluation
ROP Reactor Oversight Process
SCWE Safety Conscience Work Environment
SDP Significance Determination Process
SME Subject Matter Expert
SPAR Standardized Plant Analysis Risk
SQAC Significant Condition Adverse to Quality
SRA Senior Reactor Analyst
TDAFWP Turbine Driven Auxiliary Feedwater Pump
TB Turbine Building
TS Technical Specification
URI Unresolved Item
VTM Vendor Technical Manual
Yr Year
E. McCartney -3-
previous terminology will be converted to the latest revision in accordance with the
cross-reference in IMC 0310. The revised cross-cutting aspects will be evaluated for
cross-cutting themes and potential substantive cross-cutting issues in accordance with
IMC-0305 starting with the CY 2014 mid-cycle assessment review.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and
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 System (PARS)
component of NRC's Agencywide Documents Access and Management System (ADAMS),
accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public
Electronic Reading Room).
Sincerely,
/RA/
Anne T. Boland, Director
Division of Reactor Projects
Docket Nos. 50-266; 50-301
Enclosure:
IR 05000266/2014007; 05000301/2014007
w/Attachment: Supplemental Information
cc w/encl: Distribution via ListServTM
Distribution:
See next page
DOCUMENT NAME: PB 2014 007
Publicly Available Non-Publicly Available Sensitive Non-Sensitive
To receive a copy of this document, indicate in the concurrence box "C" = Copy without attach/encl "E" = Copy with attach/encl "N" = No copy
OFFICE RIII RIII RIII RIII
NAME BBartlett:mt/rj JCameron
BBartlett for
DATE 04/27/14 04/27/14
OFFICIAL RECORD COPY
Letter to Eric McCartney from Ann Boland dated March 28, 2014
SUBJECT: POINT BEACH NUCLEAR PLANT, UNITS 1 AND 2
NRC 95002 SUPPLEMENTAL INSPECTION REPORT
05000266/2014007; 05000301/2014007
DISTRIBUTION:
RidsNrrDorlLpl3-1 Resource
RidsNrrPMPointBeach
RidsNrrDirsIrib Resource
Cynthia Pederson
DRPIII
DRSIII
Patricia Buckley
ROPassessment.Resource@nrc.gov