ML17271A431
| ML17271A431 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 09/27/2017 |
| From: | Troy Pruett NRC/RGN-IV/DRP |
| To: | Halpin E Pacific Gas & Electric Co |
| T. PRUETT | |
| References | |
| EA-16-168 IR 2017008 | |
| Download: ML17271A431 (22) | |
See also: IR 05000275/2017008
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION IV
1600 E. LAMAR BLVD.
ARLINGTON, TX 76011-4511
September 27, 2017
Mr. Edward D. Halpin
Senior Vice President
and Chief Nuclear Officer
Pacific Gas and Electric Company
Diablo Canyon Power Plant
P.O. Box 56, Mail Code 104/6
Avila Beach, CA 93424
SUBJECT:
DIABLO CANYON POWER PLANT - NRC SUPPLEMENTAL INSPECTION
REPORT AND ASSESSMENT FOLLOW-UP LETTER; 05000275/2017008 AND
Dear Mr. Halpin:
On June 15, 2017, the NRC completed the on-site portion of a supplemental inspection using
Inspection Procedure 95001, Supplemental Inspection Response to Action Matrix Column 2
Inputs. On September 21, 2017, the NRC inspection team discussed the results of this
inspection with Mr. J. Welsch and other members of your staff. The results of this inspection
are documented in the enclosed report.
The NRC performed this inspection to review your stations actions in response to a White
finding in the Mitigating Systems cornerstone which was documented in NRC Inspection
Reports 05000275/2016010 and 05000323/2016010, dated October 3, 2016, (Agencywide
Documents Access and Management System (ADAMS) Accession No. ML16277A340), and
finalized in a letter to you from Kriss Kennedy, Regional Administrator, dated December 28,
2016 (ADAMS Accession No. ML16363A429).
On May 3, 2017, you informed the NRC that your station was ready for the supplemental
inspection.
The NRC inspectors did not identify any finding or violation of more than minor significance.
The NRC determined that your staffs cause evaluations were not performed to the depth and
breadth described in Inspection Procedure 95001, Supplemental Inspection Response to
Action Matrix Column 2 Inputs. Your staff did not perform root cause evaluations to a level of
detail commensurate with the significance of the problem (White finding). In particular, the
questioning process concluded prior to the causes identified being beyond your control as
described in Section 03.03.b of Inspection Procedure 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. Had continued questioning occurred, additional
organizational and programmatic causes associated with the failure to provide supervisory
oversight and the failure to provide adequate guidance for developing work instructions would
E. Halpin
2
likely have been identified. The additional organizational and programmatic causes would also
require the development of corrective actions and effectiveness measures. Therefore, the
adequacy of the extent of cause, extent of condition, and corrective actions required to prevent
recurrence cannot be assessed until the depth and breadth of the root cause evaluation is fully
developed.
After reviewing your performance in addressing the White finding, the NRC concluded your
actions did not meet the objectives of Inspection Procedure 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. As a result, in accordance with the guidance in
Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program, the White
finding will be held open and will continue to be considered in assessing plant performance until
you notify the NRC of your readiness for additional inspection on this issue and the NRC
concludes, by inspection, that the objectives of the inspection procedure have been met.
This letter, its enclosure, and your response (if any) will be made available for public inspection
and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document
Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for
Withholding.
Sincerely,
/RA/
Troy W. Pruett, Director
Division of Reactor Projects
Docket Nos. 50-275 and 50-323
License Nos. DPR-80 and DPR-82
Enclosure:
Inspection Report 05000275/2017008 and
w/ Attachment: Supplemental Information
SUNSI Review:
ADAMS:
Non-Publicly Available
Non-Sensitive
By: MSH2/dll
Yes No
Publicly Available Sensitive
OFFICE
RIV/PBD
RIV/PE
BC:DRP/A
RIV/DRP
NAME
CPeabody
CJewett
MHaire
TPruett
SIGNATURE
NON-CONCUR
/RA/
/RA/
/RA/
DATE
08/15/17
08/24/17
08/23/17
9/26/17
SUNSI Review:
ADAMS:
Non-Publicly Available
Non-Sensitive
By: MSH2/dll
Yes No
Publicly Available Sensitive
OFFICE
RIV/PBD
RIV/PE
BC:DRP/A
RIV/DRP
NAME
CPeabody
CJewett
MHaire
TPruett
SIGNATURE
NON-CONCUR
/RA/
/RA/
/RA/
DATE
09/26/17
09/25/17
09/22/17
09/26/17
Enclosure
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket:
05000275; 05000323
License:
Report:
05000275/2017008; 05000323/2017008
Licensee:
Pacific Gas and Electric Company
Facility:
Diablo Canyon Power Plant, Units 1 and 2
Location:
7 1/2 miles NW of Avila Beach
Avila Beach, CA
Dates:
June 12 through September 21, 2017
Inspectors: C. Peabody, Senior Resident Inspector
C. Jewett, Project Engineer
Approved
By:
Troy W. Pruett
Director, Division of Reactor Projects
2
SUMMARY
IR 05000275/2017008, 05000323/2017008; 06/07/2017 - 09/21/2017; Diablo Canyon Power
Plant; Supplemental Inspection - Inspection Procedure 95001
This supplemental inspection was conducted by a senior resident inspector from the Palo Verde
Generating Station and a project engineer from NRCs Region IV office. The NRCs program for
overseeing the safe operation of commercial nuclear power reactors is described in NUREG-
1649, Reactor Oversight Process.
No findings were identified.
Cornerstone: Mitigating Systems
The NRC determined that the licensees cause evaluations were not performed to the depth and
breadth described in Inspection Procedure 95001, Supplemental Inspection Response to
Action Matrix Column 2 Inputs. The licensee did not perform root cause evaluations to a level
of detail commensurate with the significance of the problem (White finding). In particular, the
questioning process concluded prior to the causes identified being beyond the licensees control
as described in Section 03.03.b of Inspection Procedure 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. Had continued questioning occurred, additional
organizational and programmatic causes associated with the failure to provide supervisory
oversight and the failure to provide adequate guidance for developing work instructions would
likely have been identified. The additional organizational and programmatic causes would also
require the development of corrective actions and effectiveness measures. Therefore, the
adequacy of the extent of cause, extent of condition, and corrective actions required to prevent
recurrence cannot be assessed until the depth and breadth of the root cause evaluation is fully
developed.
After reviewing the licensees performance in addressing the White finding, the NRC concluded
the licensees actions did not meet the objectives of Inspection Procedure 95001,
Supplemental Inspection Response to Action Matrix Column 2 Inputs. As a result, in
accordance with the guidance in Inspection Manual Chapter (IMC) 0305, Operating Reactor
Assessment Program, the White finding will be held open and will continue to be considered in
assessing plant performance until the licensee notifies the NRC of its readiness for additional
inspection on this issue and the NRC concludes, by inspection, that the objectives of the
inspection procedure have been met.
3
REPORT DETAILS
4.
OTHER ACTIVITIES
Cornerstones: Initiating Events, Mitigating Systems, Barrier Integrity, Emergency
Preparedness, Public Radiation Safety, Occupational Radiation Safety, and
Security
4OA4 Supplemental Inspection (95001)
.01
Inspection Scope
This inspection was conducted in accordance with Inspection Procedure 95001,
Supplemental Inspection Response to Action Matrix Column 2 Inputs, to assess the
licensees evaluation of a White finding, which affected the Mitigating Systems
Cornerstone in the Reactor Safety Strategic Performance Area. The inspection
objectives included the following:
Assure that the root causes and contributing causes of the significant performance
issues are understood.
Independently assess and assure that the extent of condition and extent of cause of
significant performance issues are identified.
Assure that corrective actions taken to address and preclude repetition of significant
performance issues are prompt and effective.
Assure that corrective plans direct prompt actions to effectively address and preclude
repetition of significant performance issues.
The licensee remained in the Regulatory Response Column (Column 2) of the NRCs
Action Matrix in the second quarter of 2017 as a result of one inspection finding of low to
moderate safety significance (White). The finding was associated with the failure to
establish adequate work instructions for installation of Namco' Snap Lock limit
switches. Specifically, the licensee failed to provide site-specific instructions for limiting
the travel of these external limit switches when installed on safety-related motor
operated valves (MOVs). Consequently, the lever switch actuator for valve
RHR-2-8700B, residual heat removal pump 2-2 suction from the refueling water storage
tank, was operated repeatedly in an over-travel condition resulting in a sheared internal
roll pin that ultimately caused the limit switch to fail. The NRC staff characterized this
issue as having low to moderate safety significance (White), as documented in NRC
Inspection Report 05000275; 05000323/2016010, dated October 3, 2016, (ADAMS
Accession No. ML16277A340), and updated in a letter to E. Halpin from K. Kennedy,
dated December 28, 2016, (ADAMS Accession No. ML16363A429). On May 3, 2017,
the licensee informed the NRC that they were ready for the supplemental inspection.
In preparation for the inspection, the licensee performed root cause evaluation (RCE)
50886801 to address the performance deficiency associated with the White finding. The
licensee provided revision 1A of the report, completed in April 2017, to the inspectors for
review. This evaluation determined two root causes for the White finding. The first root
cause identified that Electrical Maintenance leadership was not ensuring that workers
perform procedures as written. The second root cause identified that guidance for
4
determining Maintenance Verification Testing work instructions in the electrical
maintenance procedures writing process was not sufficient.
In addition, the licensee performed RCE 50870357 to address why a probabilistic risk
assessment (PRA)-significant component failure was not recognized in a timely manner.
The licensee provided revision 2 of RCE 50870357, completed in October 2016, to the
inspectors for review. There were two root causes and one contributing cause identified
for RCE 50870357. The first root cause involved a non-industry standard design feature
of the emergency core cooling system (ECCS) interlocks which resulted in a failure
mechanism that was not immediately recognizable. Specifically, Diablo Canyon utilizes
external limit switches to provide feedback to the ECCS pump suction interlocks,
whereas it is more common for nuclear power plants to use the limit switches internal to
the valves motor operator. Having a separate external limit switch provides additional
separation and redundancy in the design, but warrants additional testing and verification
beyond the normal MOV testing to ensure that the external limit switch is functioning
properly. The second root cause identifieded that the external limit switch was not
identified as requiring additional post-maintenance testing to verify proper operation. A
similar contributing cause identified that the external limit switches were not identified as
requiring additional monitoring which could eliminate missed opportunities to identify
degraded conditions.
The inspectors reviewed the licensees two RCE reports and supporting evaluations.
The inspectors reviewed corrective actions that were taken or planned to address the
identified causes. The inspectors also interviewed licensee personnel to determine
whether the root and contributing causes were understood, and whether corrective
actions taken or planned were appropriate to address the causes and preclude
repetition.
.02
Evaluation of the Inspection Requirements
02.01 Problem Identification
a. Determine that the evaluation documented who identified the issue and under what
conditions the issue was identified.
The RHR-2-8700B valve failure event of May 16, 2016, was self-revealing. The initial
licensee corrective actions in response to the event failed to identify the performance
deficiencies associated with the inadequate level of guidance provided by the
maintenance work instructions that constituted the White finding. The NRC inspection
effort identified the performance deficiency independently of the efforts of the licensees
corrective action program.
This 95001 inspection requirement is closed.
b. Determine the evaluation documented how long the issue existed and prior opportunities
for identification.
The limit switch failed sometime after the last successful stroke test of interlocked valves
2-RHR-8982A and 2-RHR-8982B during the Unit 2, fall 2014 refueling outage. The
condition can be reasonably determined to have been introduced at the last
maintenance interval during the Unit 2, spring refueling outage of 2013. The
misalignment which caused the limit switch to over-travel was not detected during the
5
post-maintenance testing of 2-RHR-8700B. The misaligned switch repeatedly over-
traveled during quarterly stroke testing.
RCE 50886801 determined that the quarterly stroke testing and other maintenance
activities performed on 2-RHR-8700B were missed opportunities to visually identify the
misaligned external limit switch. In recognition of the safety significance of the interlocks
associated with the external limit switch, involved personnel missed the opportunity to
visually inspect the valve and limit switch travel during quarterly stroke testing as a
means of validating proper switch alignment. The inspectors noted the licensee also
missed opportunities to confirm interlock circuit continuity during valve testing. However,
since there was not adequate guidance to include additional procedural direction to
check this separate external limit switch or the ECCS interlock circuitry, the deficiency
was not identified. The licensees corrective actions included direction to visually inspect
the valve and limit switch travel and circuit continuity during quarterly stroke testing as a
means of validating proper switch alignment. Both RCE 50886801 and RCE 50870357
concluded that the physical positioning of the switch adjacent to the building wall,
combined with the lack of indication of switch position for the external limit switch and
ECCS interlock, made the degradation and failure of the switch unlikely to be identified
during quarterly testing of 2-RHR-8700B without the additional guidance to specifically
observe operation.
This 95001 inspection requirement is closed.
c. Determine that the evaluation documented significant plant-specific consequence, as
applicable, and compliance concerns associated with the issue.
The licensee conducted RCE 50886801 to address the White finding and
RCE 50870357 to address their failure to timely recognize a PRA-signficant component
failure. RCE 50870357 addressed plant specific consequences by using PRA
information to compile a list of components with elevated failure consequences. These
components were flagged in the corrective action program system so that future
conditions adverse to quality identified on these components will prompt automated
notifications, instructing the initiators to take corrective action in the timeliest manner
possible.
RCE 50886801 addressed the White finding and restoration of compliance. RCE
50886801 corrective actions (as outlined in Section 02.03.a below) added procedural
guidance to ensure the external limit switches are operating correctly and surveillance
monitoring of the ECCS interlock circuitry.
This 95001 inspection requirement is closed.
02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation
a. Determine that the problem was evaluated using a systematic methodology to identify
the root and contributing causes.
The White finding RCE 50886801 used Comparative Timeline©, Event and Causal
Factors Analysis, and a Barrier Analysis. The undetected failure RCE 50870357 used
Factor Tree Analysis and ABS Consulting Root Cause MapTM. These cause evaluation
tools provided a systematic methodology that can be used to identify the root and
contributing causes of the event.
6
No deficiencies were noted with the licensees selection of root cause methods. This
95001 inspection requirement is closed.
b. Determine that the root cause evaluation was conducted to a level of detail
commensurate with the significance of the problem.
The NRC determined that the licensees cause evaluations were not performed to the
depth and breadth described in Inspection Procedure 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. The licensee did not perform root cause
evaluations to a level of detail commensurate with the significance of the problem (White
finding). In particular, the questioning process concluded prior to the causes identified
being beyond the licensees control as described in Section 03.03.b of Inspection
Procedure 95001, Supplemental Inspection Response to Action Matrix Column 2
Inputs.
This 95001 inspection requirement will remain open.
c. Determine that the root cause evaluation included a consideration of prior occurrences
of the problem and knowledge of prior operating experience.
Both RCEs included a thorough review of internal and external operating experience to
search for previous occurrences. No identical failures of ECCS interlocks resulting from
external limit switches were identified. There were two instances from early refueling
outages in the fall of 1988 and fall of 1989 that identified maintenance difficulties in
setting the external limit switches, but no identical service failures were identified. There
were six industry operating experience events for over-travel failure of Namco' external
limit switches in low safety applications such as plant process systems or alarm and
indication functions, but none in applications related to safety system interlocks. As a
result of the low safety significance of these operating experience items, the six industry
events were characterized as broke/fix conditions rather than formally evaluated under
the respective licensees corrective action program.
This 95001 inspection requirement will remain remain open pending completion of a re-
assessment of the licensees root cause to satisfy Section 02.02.b, above. In particular,
the licensee should consider whether there are organizational and programmatic
concerns associated with how the licensee dispositions low risk operating experience
from other sites that may have risk significance at Diablo Canyon.
d. Determine that the root cause evaluation addressed the extent of condition and the
extent of cause of the problem.
Both RCEs identified the extent of condition as the population of risk significant valves
containing Namco' external limit switches which provided input into ECCS or other
engineered safety features actuation system (ESFAS) interlocks. The extent of
condition identified 8 ECCS valves on each unit, 16 in total, that met this criteria.
Extent of condition and extent of cause cannot be fully evaluated at this time because of
the determination that the root cause evaluations were not conducted to sufficient depth
and breadth. Of particular concern is whether or not organizational and programmatic
deficiencies involving management oversight of work activities, operating experience,
and guidance documents existed and corrective actions that may be warranted. This
95001 inspection requirement will remain open.
7
e. Determine that the root cause, extent of condition, and extent of cause evaluation
appropriately considered the safety culture traits in NUREG-2165, Safety Culture
Common Language, referenced in IMC 0310, Aspects within Cross-Cutting Areas.
Both RCEs contained a safety culture analysis. The White finding RCE 50886801
identified seven safety culture attributes associated with the White Finding. The RCE
identified H.2 Field Presence and H.8 Procedure Adherences as safety culture attributes
associated with the leadership oversight root cause. RCE 50886801 also identified X.5
Leader Behaviors, X.6 Standards, and X.10 Expectations as supplemental cross cutting
aspects associated with the leadership oversight root cause. In addition,
RCE 50886801identified H.1 Resources and H.7 Documentation as safety culture
attributes associated with the inadequate work instructions root cause. The undetected
failure RCE 50870357 identified the H.1 and H.7 assafety culture attributes associated
with the inadequate test requirements root cause and the inadequate monitoring
contributing cause.
No deficiencies were noted in this area, however further revisions of the RCEs could
introduce additional safety culture attributes that would require NRC review. This 95001
inspection requirement will remain remain open.
f. Examine the common cause analyses for potential programmatic weaknesses in
performance when a licensee has a second white input in the same cornerstone.
Not applicable; there was not a second White input in the affected cornerstone.
02.03 Corrective Actions Taken
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.
Immediate corrective actions were taken under Notification 50852345 to walk down and
visually inspect all of the accessible affected MOVs in the extent of condition population
for physical signs of damage to the external limit switch assemblies.
Corrective actions taken in response to the White finding RCE 50886801 included the
following actions:
(1) Establishment of supervisory observation signoffs for maintenance verification
testing on Namco' external limit switches.
(2) Revision of the Nuclear Procedure Writers Manual to include specific guidance for
establishing maintenance verification testing in electrical procedures.
(3) Revision of MOV maintenance procedures that set and test external limit switches to
provide explicit instructions for switch configuration control, as well as switch travel
setting and testing.
(4) Development and implementation of a dynamic learning activity for Electrical
Maintenance MOV crews. Revision of the Pre-outage Just in Time Training module
offered to MOV technicians to include operating experience on this event.
8
(5) Revision of the MOV Sizing, Switch Setpoint Determination and Test Evaluation
procedure to include the Namco' vendor total travel limits and parameters, as well
as associated testing criteria.
(6) Education of the Diablo Canyon Power Plants extended leadership team on this
event and recent related human performance events in accordance with the Diablo
Canyon Power Plants Human Performance Reinforcement policy.
Corrective actions taken in response to the undetected failure RCE 50870357 included
the following actions:
(1) Development of a routine check to verify interlock circuit continuity for the
RHR 8700A/B valves and their associated external limit switches on a quarterly basis
in conjunction with the quarterly valve stroke surveillance.
(2) Revision of applicable maintenance procedures to specify direction as appropriate:
(a) Inclusion of external limit switch operation data.
(b) Specific evaluation of external limit switch and geared limit switch settings.
(c) Provide instructions for standardized assembly, configuration, and adjustment of
external limit switches.
(d) Provide inspection of external limit switch configuration against a set of
standardized criteria.
(e) Perform visual inspections of the external limit switch with each quarterly valve
stroke surveillance test.
(f) Apply position indication lamacoids on the 16 extent of condition valves.
The actions taken have restored compliance. The revised maintenance procedure work
instructions contain adequate and specific guidance to ensure confidence of operability
to the affected extent of condition valve population. Subsequent visual inspections and
electrical testing of the affected ECCS interlocks has confirmed operability.
No deficiencies were noted in this area, however further revisions of the RCEs could
introduce additional corrective action items that would require NRC review. This 95001
inspection requirement will remain open.
b. Determine that the corrective actions have been prioritized with consideration of
significance and regulatory compliance.
The licensees corrective actions have been prioritized with consideration of significance
and regulatory compliance. All corrective actions for the White finding RCE 50886801
are completed.
There is one remaining corrective action planned for the undetected failure
RCE 50870357. This action is to implement a design change to remove the external
limit switches associated with the ECCS MOV interlocks. Plans to modify the system to
remove the external limit switches will take until Spring 2019 to analyze and implement
in order to ensure the modification is conducted in accordance with 10 CFR 50.59 and
9
50.90. In the interim, the licensee added test requirements to electrically verify the
condition of the ECCS interlock when valves are stroked quarterly for surveillance
testing. During the quarterly stroke tests, the licensee also added visual field inspections
of the valve stroke by qualified MOV engineers. As the actions were implemented at the
first reasonable opportunity following the White finding, the inspector concluded that the
actions were prioritized.
No deficiencies were noted in this area, however further revisions of the RCEs could
introduce additional corrective action items that would require NRC review to assess
prioritization. This 95001 inspection requirement will remain remain open.
c. Determine that corrective actions taken to address and preclude repetition of significant
performance issues are prompt and effective.
Corrective actions to prevent recurrence (CAPR) of the White finding RCE 50886801
included the following:
(1) Establishment of supervisory observation signoffs for maintenance verification
testing on Namco' external limit switches.
(2) Revision of the Nuclear Procedure Writers Manual to include specific guidance for
establishing maintenance verification testing in electrical procedures.
(3) Revision of MOV maintenance procedures that set and test external limit switches to
provide explicit instructions for switch figure configuration control and switch travel
setting and testing.
Corrective actions to prevent recurrence of the undetected failure RCE 50870357
included the following actions:
(1) Development of a routine check to verify interlock circuit continuity for the
RHR 8700A/B valves and their associated external limit switches on a quarterly
basis; which was performed concurrent with the quarterly valve stroke surveillance.
(2) Revision of applicable maintenance procedures to specify direction as appropriate:
(a) Inclusion of external limit switch operation data.
(b) Specific evaluation of external limit switch and geared limit switch settings.
(c) Provide instructions for standardized assembly, configuration, and adjustment of
external limit switches.
The corrective actions taken to address and preclude repetition of significant
performance issues were prompt and effective. All but one CAPR is completed, and that
action has a corresponiding interim CAPR to monitor the interlock directly. The CAPRs
implemented have restored regulatory compliance and demonstrated operability for the
affected ECCS interlocks.
No deficiencies were noted in this area, however further revisions of the RCEs could
introduce additional CAPR items that would require NRC review to assess effectiveness.
This 95001 inspection requirement will remain remain open.
10
d. Determine that each Notice of Violation (NOV) related to the supplemental inspection is
adequately addressed, either in corrective actions taken or planned.
Corrective actions taken thus far have restored compliance with Technical
Specification 5.4.1.a., Procedures. The licensee has made applicable and appropriate
revisions to the maintenance procedures pertaining to VIO 05000323/2016010-01. The
licensee has taken steps to ensure that there are no additional failures in the extent of
condition valve population. As outlined above, surveillance testing of the affected valves
has been enhanced to provide additional means of verification, including visual testing of
proper external limit switch operation and electrical circuit verification of the associated
ECCS interlock function.
This 95001 inspection requirement is closed.
02.04 Corrective Action Plans
a. Determine that appropriate corrective action plans are specified for each root and
contributing cause or that the licensee has an adequate evaluation for why no corrective
actions are necessary. Determine that the corrective action plans have been prioritized
with consideration of significance and regulatory compliance.
All corrective actions for the White finding RCE 50886801 are completed.
There is one remaining corrective action planned for the undetected failure
RCE 50870357. This action is to implement a design change to remove the external
limit switches associated with the ECCS MOV interlocks. This design change is
expected to be implemented during the respective unit refueling outages in the
spring 2018 and the spring 2019.
Corrective actions taken thus far have been appropriate. Corrective actions taken and
planned have been prioritized with consideration of safety significance and regulatory
compliance. The interim actions to verify the design basis of the ECCS interlocks and
Namco' external limit switches provide a reliable means of maintaining safety and
regulatory compliance.
This 95001 inspection requirement will remain remain open pending completion of a re-
assessment of the licensees root cause to satisfy Section 02.02.b, above.
b. Determine that corrective plans direct prompt actions to effectively address and preclude
repetition of significant performance issue.
All corrective actions to prevent recurrence under White finding RCE 50886801 are
completed. The remaining actions planned for the undetected failure RCE 50870357 to
modify the system by removing the external limit switches have corresponding interim
actions in place to verify the ECCS interlocks associated with the Namco' external limit
switches are functioning properly.
This 95001 inspection requirement will remain remain open pending completion of a re-
assessment of the licensees root cause to satisfy Section 02.02.b, above.
11
c. Determine that appropriate quantitative or qualitative measures of success have been
developed for determining the effectiveness of planned and completed corrective
actions.
The White finding RCE 50886801 specified the following effectiveness evaluations:
(1) Procedure use and adherence - Targeted supervisory observations during outages
and online; review of station and department level events for procedure use and
adherence as a causal factor; and quick hit self-assessments.
(2) Procedure writers guide changes - 100 percent review of maintenance procedure
revisions, as well as interviews with maintenance procedure writers to confirm
understanding of the writers guide changes.
The undetected failure RCE 50870357 specified the following effectiveness evaluations:
(1) Design verification testing and return to service following the design change
modification to remove the external limit switches from the ECCS interlocks.
(2) During outages 1R20 and 2R20, satisfactory verifications of the setting, testing, and
adjustment of affected Namco' external limit switches.
(3) Satisfactory testing of the interlock circuit continuity testing during the quarterly
surveillance testing.
The success measures for RCE 50886801 were appropriate and provide qualitative
measures of success of the corrective actions taken. RCE 50870357 effectiveness
measures are satisfactory; the second and third criteria provide appropriate
effectiveness measures until the modifications associated with the first criteria are
implemented.
This 95001 inspection requirement will remain remain open pending completion of a re-
assessment of the licensees root cause to satisfy Section 02.02.b, above.
d. Determine that each Notice of Violation (NOV) related to the supplemental inspection is
adequately addressed in corrective actions taken or planned.
As discussed in Section 02.03.d (above), the corrective actions have restored
compliance with Technical Specification 5.4.1.a., Procedures. for which the NOV was
issued associated with the White finding.
This 95001 inspection requirement is closed.
02.05 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues.
Not applicable; the performance deficiency associated with the White finding does not
warrant treatment as an old design issue.
This 95001 inspection requirement is closed.
12
03.00 Inspection Results Summary
The NRC determined that the licensees cause evaluations were not performed to the
depth and breadth described in Inspection Procedure 95001, Supplemental Inspection
Response to Action Matrix Column 2 Inputs. The licensee did not perform root cause
evaluations to a level of detail commensurate with the significance of the problem (White
finding). In particular, the questioning process concluded prior to the causes identified
being beyond the licensees control as described in Section 03.03.b of Inspection
Procedure 95001, Supplemental Inspection Response to Action Matrix Column 2
Inputs. Had continued questioning occurred, additional organizational and
programmatic causes associated with the failure to provide supervisory oversight and
the failure to provide adequate guidance for developing work instructions would likely
have been identified. The additional organizational and programmatic causes would
also require the development of corrective actions and effectiveness measures.
Therefore, the adequacy of the extent of cause, extent of condition, and corrective
actions required to prevent recurrence cannot be assessed until the depth and breadth
of the root cause evaluation is fully developed.
The status of the inspection requirements of Inspection Procedure 95001 have been
categorized below. Requirements held open in entirety by this inspection will require a
full re-evaluation by NRC inspectors at a later date. Requirements held open for
changes only are those for which no deficiencies were noted during this inspection but
may be impacted, and therefore require additional review, as a result of revisions to the
licensees RCEs. In this instance, only the changes added by future revisions of the
RCEs will have to be evaluated by NRC inspectors at a later date. Requirements closed
by this inspection effort will require no additional inspection effort.
03.01 Inspection Requirements Held Open in Entirety
02.02b
Determine that the root cause evaluation was conducted to a level of detail
commensurate with the significance of the problem
02.02d
Determine that the root cause evaluation addressed the extent of condition
and the extent of cause of the problem
03.02 Inspection Requirements Held Open for Changes Only
02.02c
Determine that the root cause evaluation included a consideration of prior
occurrences of the problem and knowledge of prior operating experience
02.02e
Determine that the root cause, extent of condition, and extent of cause
evaluation appropriately considered the safety culture traits in NUREG-
2165, Safety Culture Common Language, referenced in IMC 0310,
Aspects within Cross-Cutting Areas
02.03a
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
02.03b
Determine that the corrective actions have been prioritized with
consideration of significance and regulatory compliance
13
02.03c
Determine that corrective actions taken to address and preclude repetition
of significant performance issues are prompt and effective
02.04a
Determine that appropriate corrective action plans are specified for each
root and contributing cause or that the licensee has an adequate evaluation
for why no corrective actions are necessary. Determine that the corrective
action plans have been prioritized with consideration of significance and
regulatory compliance
02.04b
Determine that corrective plans direct prompt actions to effectively address
and preclude repetition of significant performance issue
02.04c
Determine that appropriate quantitative or qualitative measures of success
have been developed for determining the effectiveness of planned and
completed corrective actions
03.03 Inspection Requirements Closed
02.01a
Determine that the evaluation documented who identified the issue and
under what conditions the issue was identified
02.01b
Determine the evaluation documented how long the issue existed and prior
opportunities for identification
02.01c
Determine that the evaluation documented significant plant-specific
consequence, as applicable, and compliance concerns associated with the
issue
02.02a
Determine that the problem was evaluated using a systematic methodology
to identify the root and contributing causes
02.02f
Examine the common cause analyses for potential programmatic
weaknesses in performance when a licensee has a second white input in
the same cornerstone
02.03d
Determine that each Notice of Violation (NOV) related to the supplemental
inspection is adequately addressed, either in corrective actions taken or
planned
02.04d
Determine that each Notice of Violation (NOV) related to the supplemental
inspection is adequately addressed in corrective actions taken or planned
02.05
Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues
14
4OA6 Meetings, Including Exit
Exit Meeting Summary
On September 21, 2017, the inspectors presented the inspection results to Mr. J. Welsch, Site
Vice President, and other members of the licensee staff. The licensee acknowledged the issues
presented. The licensee confirmed that any proprietary information reviewed by the inspectors
had been returned or destroyed.
Attachment
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
T. Baldwin, Director, Nuclear Site Services
J. Cheek, MOV Program Engineer
D. Evans, Director, Security & Emergency Services
M. Fraunheim, Manager Nuclear Performance Improvement
P. Gerfen, Senior Director Plant Manager
M. Ginn, Manager, Emergency Planning
E. Halpin, Sr. Vice President, Chief Nuclear Officer Generation
H. Hamzehee, Manager, Regulatory Services
A. Heffner, NRC Interface, Regulatory Services
J. Hinds, Director, Quality Verification
L. Hopson, Director Maintenance Services
T. Irving, Manager, Radiation Protection
K. Johnston, Director of Operations
M. McCoy, NRC Interface, Regulatory Services
J. Morris, Senior Advising Engineer
C. Murry, Director Nuclear Work Management
J. Nimick, Senior Director Nuclear Services
A. Peck, Director, Nuclear Engineering
R. Walthos, Nuclear Engineering Specialist, Principal
J. Welsch, Site Vice President
NRC Personnel
C. Newport, Senior Resident Inspector
J. Reynoso, Resident Inspector
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Discussed 05000323/2016010-01 VIO
Failure to Establish Adequate Work Instructions for Installation
of Namco' Snap Lock Limit Switches (Section 4OA4)
LIST OF DOCUMENTS REVIEWED
Section 4OA4: Supplemental Inspection (95001)
Procedures
Number
Title
Revision
AD1
Administrative Controls Program
17
AD1.ID1
Nuclear Generation Procedure Writers Manual
30
A-2
Procedures
Number
Title
Revision
AD7.ID12
Work Management Process
6
AD7.ID15
On-Line Maintenance Outrage Window Execution
3
AD7.ID16
Tool Pouch and Minor Maintenance
4
AD7.ID2
Daily Notification Review Team (DRT) & Standard Plant
Priority Assignment Scheme
27
AD7.ID4
On-line Maintenance Scheduling
25
AWP E-027
Motor Operated Valve Sizing, Switch Setpoint Determination
and Test evaluation
4
MA1.DC58
Troubleshooting Evidence Preservation and Forensic
Analysis
1
MP E-53.10A
Preventive Maintenance of Limitorque Motor Operators
41
MP E-53.10A1
Low Impact External Inspections of Limitorque Motor
Operators
2
MP E-53.10R
Augmented Stem Lubrication for Limitorque Operated
Valves
9
MP E-53.10S
Limitorque Swap-Out and Switch Settings
14
MOV Diagnostic Testing
18
OM15.ID8
Human Performance Error Prevention Tools
7
OM7.ID1
Problem Identification and Resolution
49A
OM7.ID3
Root Cause Evaluation
45
OM7.ID4
Cause Determinations
36
OM7.ID7
Emerging Issue and Event Investigations
18A
OP1.DC18
Authorization of Test Equipment Operation, Maintenance,
and Testing
11
OP2.ID1
Clearances
39
PEP V-7B
Test of ECCS Valve Interlocks
10
PRA 17-02
1
STP V-2B2
Exercising and Position Verification of Valves 9003A and
9003B Unit 2
0
STP V-2B2
Exercising and Position Verification of Valves 9003A and
9003B Unit 1
16
STP V-2D2A
Exercising and Position Verification of Valve 8700A Unit 2
0
STP V-2D2A
Exercising and Position Verification of Valve 8700A Unit 1
3
A-3
Procedures
Number
Title
Revision
STP V-2D2B
Exercising and Position Verification of Valve 8700B Unit 2
0
STP V-2D2B
Exercising and Position Verification of Valve 8700B Unit 1
3
STP V-2O6
Exercising and Position Verification of Valves 8982A and
8982B Unit 2
1
STP V-2O6
Exercising and Position Verification of Valves 8982A and
8982B Unit 1
10
STP V-2V1
Exercising and Position Verification of Valves 8804A and
8804B Unit 2
0
STP V-2V1
Exercising and Position Verification of Valves 8804A and
8804B Unit 1
11
TP V-3M5
Exercising Valves RHR-8701 and RHR-8702, Reactor
Coolant Loop 4 to RHR Pump Suction
16
Notifications
50852345
50870357
50923338
50923339
50857553
50874911
50886801
50871499
50910294
50908100
50915340
50891772
50906150
50906119
50915775
50893249
50874463
50875300
50866497
50872919
50913951
50891005
50910293
50891005
Miscellaneous Documents
Number
Title
Revision /
Date
Cause Determination Manual
May 18, 2017
2016 Maintenance Audit
November 7, 2016
HUJITDC055
JITT Validating Assumptions
April 20, 2017
HUJITDC050
Confined Space DLA
February 16, 2017
HUJITIS041
Human Performance Training
March 29, 2016
JITTEM1604
April 19, 2017
1R20 Supervisor Stand Down
May 1, 2017
R165C11
Task Training: Nuclear Operators
0
Program and Process Codes
May 2, 2013
Cause Codes
A-4
Miscellaneous Documents
Number
Title
Revision /
Date
Site Standards Handbook
WG-24
NRC Administrative Support
7
WG-7
Reportability Reviews
8
2017-S009-001
Undetected ECCS Interlock Failure
April 18, 2017
50870357
Root Cause Evaluation Report Undetected ECCS
Interlock Failure
2
50886801
Root Cause Evaluation Report DCPP Inadequate
NAMCO Procedure
1A
50913375 95-001 Pre-Inspection Assessment
May 3, 2017
130100011
Work Order Preparation
January 28, 2013
150360043
Assessment of 1Y19
February 5, 2015
163620001
2017 Fire Protection Audit
1
9000035423
Motor Operated Valve Sizing and Switch Setting
Calculations
September 30, 2013
Work Orders
60098575
60098576
60098577
60098578
60094730
60094731
60090383
64090172
60100131
64065079
LIST OF ACRONYMS
Agencywide Document Access and Management System
corrective action to prevent recurrence
CFR
Code of Federal Regulations
engineered safety features actuation system
motor-operated valve
Root Cause Evaluation