IR 05000333/2020001

Integrated Inspection Report 05000333/2020001

ML20119A050
Person / Time
Site:	FitzPatrick
Issue date:	04/28/2020
From:	Erin Carfang NRC Region 1
To:	Bryan Hanson Exelon Generation Co
References
IR 2020001
Download: ML20119A050 (24)

Text

April 28, 2020

SUBJECT:

JAMES A. FITZPATRICK NUCLEAR POWER PLANT - INTEGRATED INSPECTION REPORT 05000333/2020001

Dear Mr. Hanson:

On March 31, 2020, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at James A. FitzPatrick Nuclear Power Plant. On April 23, 2020, the NRC inspectors discussed the results of this inspection with Mr. Pat Navin, Site Vice President, and other members of your staff. The results of this inspection are documented in the enclosed report.

Two findings of very low safety significance (Green) are documented in this report. Two of these findings involved violations of NRC requirements. We are treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.

If you contest the violations or the significance or severity of the violations documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:

Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region I; the Director, Office of Enforcement; and the NRC Resident Inspector at James A. FitzPatrick Nuclear Power Plant.

If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region I; and the NRC Resident Inspector at James A. FitzPatrick Nuclear Power Plant. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely, X /RA/

Signed by: Erin E. Carfang Erin E. Carfang, Chief Reactor Projects Branch 1 Division of Reactor Projects Docket No. 05000333 License No. DPR-59

Enclosure:

As stated

Inspection Report

Docket Number: 05000333 License Number: DPR-59 Report Number: 05000333/2020001 Enterprise Identifier: I-2020-001-0038 Licensee: Exelon Generation Company, LLC Facility: James A. FitzPatrick Nuclear Power Plant Location: Oswego, NY Inspection Dates: January 1, 2020 to March 31, 2020 Inspectors: E. Miller, Senior Resident Inspector D. Beacon, Resident Inspector C. Hobbs, Reactor Inspector D. Merzke, Acting Resident Inspector S. Pindale, Senior Reactor Inspector R. Rolph, Health Physicist A. Turilin, Reactor Inspector Approved By: Erin E. Carfang, Chief Reactor Projects Branch 1 Division of Reactor Projects Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at James A. FitzPatrick Nuclear Power Plant, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

List of Findings and Violations

Failure to Manage Risk and Compensatory Measures during HPCI Testing Cornerstone Significance Cross-Cutting Report Aspect Section Mitigating Green [H.14] - 71111.13 Systems NCV 05000333/2020001-01 Conservative Open/Closed Bias The inspectors identified a Green finding and associated non-cited violation (NCV) of Title 10 of the Code of Federal Regulations (10 CFR) 50.65(a)(4), Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants, when Exelon did not assess and manage the increase in risk for online maintenance activities. Specifically, on November 21, 2019, the inspectors identified during ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test, that Exelon staff failed to evaluate operator compensatory actions associated with the high pressure coolant injection (HPCI) system prior to a change of the base calculation of risk to the station. As a result, the station did not have procedures in place to ensure restoration of the system, if called upon, while the system was out of service for testing.

Fuel Cycle 23 Fuel Leaks Cornerstone Significance Cross-Cutting Report Aspect Section Barrier Integrity Green None (NPP) 71152 NCV 05000333/2020001-02 Open/Closed The inspectors documented a self-revealing Green finding and associated non-cited violation (NCV) of Technical Specification 5.4.1, Procedures, when Exelon did not maintain adequate procedures for check valve maintenance. Specifically, FitzPatricks procedure for reassembly of swing check valves following maintenance did not provide adequate guidance for securing the disc stem nut to the disc stem for condensate system check valves. As a result, condensate booster pump 33P-9C catastrophically failed on June 24, 2016. Failure of this pump introduced foreign material into the reactor coolant system which led to five fuel failures in the following fuel cycle that ended on September 10, 2018.

Additional Tracking Items

None.

PLANT STATUS

FitzPatrick began the inspection period at rated thermal power. On January 31, 2020, FitzPatrick experienced an automatic reactor scram due to a feedwater transient, entering forced outage J1F24. On February 7, 2020, following repairs to the feedwater system, operators commenced a reactor startup. On February 7, 2020, FitzPatrick was synchronized to the grid, ending J1F24. On February 8, 2020, FitzPatrick reached 65 percent power, and later reduced reactor power to 55 percent due to additional feedwater system maintenance. On February 13, 2020, following repairs to the feedwater system, operators continued power ascension and reached 100 percent. On March 16, 2020, operators reduced reactor power to 65 percent to perform condenser waterbox tube leak repairs. On March 17, 2020, following condenser tube repair, operators restored reactor power to 100 percent. FitzPatrick remained at or near rated thermal power for the remainder of the inspection period.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/readingrm/doc-collections/insp-manual/inspection-procedure/index.html.

Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. From January 1 - March 19, 2020, the inspectors performed plant status activities described in IMC 2515, Appendix D, Plant Status, and conducted routine reviews using IP 71152, Problem Identification and Resolution. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

Starting on March 20, 2020, in response to the National Emergency declared by the President of the United States on the public health risks of the coronavirus (COVID-19), resident inspectors were directed to begin telework and to remotely access licensee information using available technology. During this time the resident inspectors performed periodic site visits each week during which they conducted plant status activities as described in IMC 2515, Appendix D, and observed risk significant activities when warranted. In addition, resident and regional baseline inspections were evaluated to determine if all or portions of the objectives and requirements stated in the IP could be performed remotely. If the inspections could be performed remotely, they were conducted per the applicable IP. In the cases where it was determined the objectives and requirements could not be performed remotely, management elected to reschedule the inspection to a later date.

71111.01 - Adverse Weather Protection

Impending Severe Weather Sample (IP Section 03.02) (1 Sample)

(1) The inspectors evaluated the adequacy of the overall preparations to protect risk-significant systems from an impending winter storm on January 17, 2020.

71111.04 - Equipment Alignment

Partial Walkdown Sample (IP Section 03.01) (6 Samples)

The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:

(1) 'A' core spray system on January 25, 2020

(2) 'A' shutdown cooling system on February 3, 2020

(3) High pressure coolant injection system on March 5, 2020

(4) 'B' standby liquid control system on March 17, 2020

(5) 'B' and 'D' emergency diesel generators on March 18, 2020

(6) 71DC-9 temporary 125-volt direct current battery charger on March 24, 2020

71111.05 - Fire Protection

Fire Area Walkdown and Inspection Sample (IP Section 03.01) (5 Samples)

The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:

(1) West cable tunnel, fire area/zone IC/CT-1 on January 15, 2020

(2) Motor generator set room, fire area/zone IA/MG-1 on January 22, 2020

(3) 'A' battery room, 272' elevation, fire area/zone III/BR-1 on March 3, 2020

(4) 'A' battery charger room, 272' elevation, fire area/zone III/BR-2 on March 3, 2020

(5) 'A' and 'B' low pressure coolant injection battery and inverter rooms, 344' elevation, fire area/zone IX/RB-1A on March 3, 2020

71111.06 - Flood Protection Measures

Inspection Activities - Internal Flooding (IP Section 03.01) (1 Sample)

The inspectors evaluated internal flooding mitigation protections in the:

(1) Reactor building east and west crescent (emergency core cooling system pump rooms) on February 11, 2020

Cable Degradation (IP Section 03.02) (1 Sample)

The inspectors evaluated cable submergence protection in:

(1) Underground manhole MH-7A, 115-kilovolt switchyard following sump pump failure, on March 17, 2020

71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance

Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)

(1 Sample)

(1) The inspectors observed and evaluated licensed operator performance in the control room during control rod exercising on January 11, 2020, and reactor downpower and scram activities on January 31, 2020.

Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)

(1) The inspectors observed a simulator evaluation that involved main turbine high vibrations, a loss of a 4.16-kilovolt safety-related bus (10500), a small break loss of coolant accident, and a failure to scram on January 30, 2020.

71111.12 - Maintenance Effectiveness

Maintenance Effectiveness (IP Section 03.01) (2 Samples)

The inspectors evaluated the effectiveness of maintenance to ensure the following structures, systems, and components (SSCs) remain capable of performing their intended function:

(1) Instrument air system on January 28, 2020

(2) Emergency diesel generator bays associated with structural monitoring of safety-related structures on January 29, 2020

71111.13 - Maintenance Risk Assessments and Emergent Work Control

Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)

The inspectors evaluated the accuracy and completeness of risk assessments for the following planned and emergent work activities to ensure configuration changes and appropriate work controls were addressed:

(1) Risk assessment associated with ST-4E, HPCI and SGT Logic System Functional and Simulated Actuation Test on January 7, 2020

(2) 115-kilovolt offsite power source Line 3 during Line 4 outage on January 14, 2020

(3) Elevated risk during B reactor recirculation motor generator set exciter brush replacement on January 22, 2020

(4) 'A' shutdown cooling system while in service on February 4, 2020

(5) 'A' reactor feedwater pump following pump seal failure on February 10, 2020

71111.15 - Operability Determinations and Functionality Assessments

Operability Determination or Functionality Assessment (IP Section 03.01) (5 Samples)

The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:

(1) Reactor water level reference leg '3B' backfill system on January 3, 2020

(2) Containment atmosphere analyzer solenoid operated valves subject to Part 21 on January 29, 2020

(3) Rising trend with suppression pool water level on March 19, 2020

(4) 71EPA-RPS-1B2T, 'B' electrical protection assembly following overvoltage relay trip on March 23, 2020

(5) B containment atmosphere dilution (CAD) sample pump equipment qualification due to missed replacement preventive maintenance on March 26, 2020 71 111.18 - Plant Modifications Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02)

(2 Samples)

The inspectors evaluated the following temporary or permanent modifications:

(1) Permanent Modification: Engineering Change (EC) 630147, Number of Low Pressure Coolant Injection (LPCI) Inverter Fans Allowed Out of Service under Alarm Response Procedure 09-8-3-15, on January 15, 2020

(2) Permanent Modification: OP-27A, Reactor Water Level Reference Leg Backfill System Change to Out of Service Time Determination, on January 21, 2020

71111.19 - Post-Maintenance Testing

Post-Maintenance Test Sample (IP Section 03.01) (12 Samples)

The inspectors evaluated the following post maintenance test activities to verify system operability and functionality:

(1) B emergency diesel generator turbocharger lubricating oil pump following breaker corrective maintenance on January 15, 2020

(2) 66AOV-100B, reactor building ventilation inlet isolation valve following solenoid replacement on January 15, 2020

(3) 02-2MOV-53B, 'B' reactor water recirculation discharge isolation valve motor replacement on February 4, 2020

(4) 12MOV-15, reactor water cleanup inboard isolation valve following repair on February 4, 2020

(5) 29BPV-3, bypass valve #3 following electro-hydraulic fluid leak repair on February 4, 2020

(6) 34FWS-4A, 'A' feed water pump discharge check valve repairs following failure on February 6, 2020

(7) 'A' service air compressor following compressor maintenance on February 19, 2020

(8) 94P-2(M), turbine lube oil emergency bearing oil pump motor following control circuit fuse installation on March 9, 2020

(9) 31P-7B(M), B reactor feedwater turbine emergency lube oil pump motor following control circuit fuse installation on March 11, 2020

(10) 71EPA-RPS1B2T, B reactor protection system electrical protection assembly following over-voltage protection relay replacement on March 12, 2020

(11) 94P-13(M), hydrogen seal oil emergency pump motor following control circuit fuse installation on March 17, 2020

(12) 31P-7A(M), A reactor feedwater turbine emergency lube oil pump motor following control circuit fuse installation on March 18, 2020

71111.20 - Refueling and Other Outage Activities

Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)

(1) Forced outage J1F24 from January 31, 2020 - February 7, 2020

(2) Refuel outage J1R24 risk planning on March 27, 2020 (Partial)

71111.22 - Surveillance Testing

The inspectors evaluated the following surveillance tests:

Surveillance Tests (other) (IP Section 03.01)

(1) ST-9BB, B and D Emergency Diesel Generator Test, on January 7, 2020

(2) ISP-22-1, RCIC Turbine Exhaust Diaphragm High Pressure Instrument Functional Test/Calibration, on February 25, 2020

(3) ISP-150B, RCIC Auto Isolation Instrument Functional Test/Calibration, on

February 25, 2020 Inservice Testing (IP Section 03.01) (1 Sample)

(1) ST-24J, RCIC Flow Rate and Inservice Test (IST), on February 24, 2020

Containment Isolation Valve Testing (IP Section 03.01) (1 Sample)

(1) ST-39B-X14, Type C Leak Rate Test of RWCU Suction Line VLVS (IST), on February 5,

71124.04 - Occupational Dose Assessment

Source Term Characterization (IP Section 03.01) (1 Sample)

(1) The inspectors evaluated licensee performance as it pertains to radioactive source term characterization.

External Dosimetry (IP Section 03.02) (1 Sample)

(1) The inspectors evaluated licensee performance as it pertains to external dosimetry that is used to assign occupational dose.

Internal Dosimetry (IP Section 03.03) (1 Sample)

The inspectors evaluated the following internal dose assessments for actual internal exposures:

(1) The inspectors reviewed air sample results for work on reactor water cleanup valve 12MOV-15. All workers wore powered air purifying hood respirators and no dose was assigned. The highest air sample activity was 1.674 DAC for air sample 20028.

Special Dosimetric Situations (IP Section 03.04) (1 Sample)

The inspectors evaluated the following special dosimetric situations:

(1) The dose assessment for three declared pregnant workers.

OTHER ACTIVITIES - BASELINE

===71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:

IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) ===

(1) January 1, 2019 - December 31, 2019 IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)

(1 Sample)

(1) January 1, 2019 - December 31, 2019

IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03) (1 Sample)

(1) January 1, 2019 - December 31, 2019

71152 - Problem Identification and Resolution

Annual Follow-up of Selected Issues (IP Section 02.03) (1 Sample)

The inspectors reviewed the licensees implementation of its corrective action program related to the following issues:

(1) FitzPatrick Fuel Cycle 23 Fuel Leaks (IR 4097375, ACE CR-JAF-2016-02246)

71153 - Followup of Events and Notices of Enforcement Discretion Event Followup (IP Section 03.01)

(1) Planned downpower to 65 percent to perform waterbox repairs on March 16,

INSPECTION RESULTS

Failure to Manage Risk and Compensatory Measures During HPCI Testing Cornerstone Significance Cross-Cutting Report Aspect Section Mitigating Green [H.14] - 71111.13 Systems NCV 05000333/2020001-01 Conservative Open/Closed Bias The inspectors identified a Green finding and associated NCV of 10 CFR 50.65(a)(4),

Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants, when Exelon did not assess and manage the increase in risk for online maintenance activities. Specifically, on November 21, 2019, the inspectors identified during ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test, that Exelon staff failed to evaluate operator compensatory actions associated with the high pressure coolant injection (HPCI) system prior to a change of the base calculation of risk to the station. As a result, the station did not have procedures in place to ensure restoration of the system, if called upon, while the system was out of service for testing.

Description:

On November 21, 2019, Exelon staff performed ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test, Revision 58. This test is performed once every 2 years, and involves opening breakers associated with nine HPCI valves and two standby gas treatment (SGT) system valves to prevent operation during testing. The inspectors identified that performance of this test historically would result in reclassification of station risk to an elevated condition due to HPCI not being available.

However, the station attempted to reclassify station risk to the normal baseline during performance of the test by briefing an equipment operator on which HPCI valves would need to be restored if the HPCI system was called upon for a design basis event.

WC-AA-101-1006, Online Risk Management and Assessment, Revision 3, Section 4.3.2 provides direction for making changes to the base calculation of configuration risk for the station. The inspectors noted there was no documentation for the change in risk determination, and approvals were not obtained as required by section 4.3.2. Procedure WC-AA-101, Online Work Control Process, Revision 29, Attachment 5 provides guidance to make a system available through operator action. The guidance directs an evaluation to take into consideration the number of actions required, and the environment conditions are expected. The inspectors found that by not having an approved evaluation and procedure containing restoration actions, the elevated risk condition had not been properly mitigated. The inspectors determined that HPCI may trip when called upon, if not restored in a specific sequence that would allow the system to start up and operate properly.

Corrective Actions: The station entered this condition into the corrective action program as IR 04313552. The station updated the model work order to have a dedicated operator briefed, stationed and with no other concurrent duties. The station also shared an operations crew learning update regarding the event, and guidance regarding the importance of having adequate compensatory actions associated with risk mitigation actions.

Corrective Action References: IR 04313552

Performance Assessment:

Performance Deficiency: The inspectors determined that the failure to assess and manage the increased risk for online maintenance activity associated with ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test was contrary to 10 CFR 50.65(a)(4), Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants.

Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Procedure Quality attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, on November 21, 2019, the inspectors identified during ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test, that Exelon staff failed to evaluate operator compensatory actions associated with the HPCI system prior to a change of the base calculation of risk to the station. As a result, the station did not have procedures in place to ensure restoration of the system, if called upon, while station risk was assumed to be very low (Green). Additionally, this issue is similar to Example 8.d of Inspection Manual Chapter 0612 Appendix E, Examples of Minor Issues, issued January 1, 2020, because the overall risk assessment would result in a higher licensee-established risk category, and because the credited function would not have been maintained due to the failure to identify proper sequence of risk mitigative compensatory actions.

Significance: The inspectors assessed the significance of the finding using Appendix K, Maintenance Risk Assessment and Risk Management SDP. The inspectors used Flowchart 1, Assessment of Risk Deficit, to analyze the finding and calculated incremental core damage probability, and because the incremental core damage probability deficit was less than 1E-6, this finding was determined to be of very low safety significance (Green).

Cross-Cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices that emphasize prudent choices over those that are simply allowable. A proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop. The inspectors determined that the finding had a cross-cutting aspect of Conservative Bias within the cross-cutting area of Human Performance because Exelon staff attempted to place the station in a very low risk condition without evaluating risk and establishing procedures as compensatory measures.

Enforcement:

Violation: The inspectors identified a violation of 10 CFR 50.65(a)(4), which states, in part, that, the licensee shall assess and manage the increase in risk that may result from the proposed maintenance activities. Exelon procedure WC-AA-101-1006, Online Risk Management and Assessment, Revision 3, section 4.3.2 provides direction for making changes to the base calculation of configuration risk for the station and for obtaining station approval. Procedure WC-AA-101, Online Work Control Process, Revision 29, Attachment 5 provides guidance to make a system available through operator action. Contrary to the above, on November 21, 2019, the inspectors identified that Exelon did not assess and manage the increase in risk for online maintenance activities during ST-4E, HPCI and SGT Logic System Functional and Simulated Automatic Actuation Test." Specifically, Exelon staff failed to evaluate risk and operator compensatory actions in accordance with WC-AA-1010-1006 and WC-AA-101 prior to a change of the base calculation of risk to the station. As a result, the station did not have procedures in place to ensure restoration of the HPCI system, if called upon, while station risk was assumed to be very low (Green).

Enforcement Action: This violation is being treated as an NCV, consistent with Section 2.3.2 of the Enforcement Policy.

Fuel Cycle 23 Fuel Leaks Cornerstone Significance Cross-Cutting Report Aspect Section Barrier Integrity Green None (NPP) 71152 NCV 05000333/2020001-02 Open/Closed The inspectors documented a self-revealing Green finding and associated NCV of Technical Specification 5.4.1, "Procedures," when Exelon did not maintain adequate procedures for check valve maintenance. Specifically, FitzPatricks procedure for reassembly of swing check valves following maintenance did not provide adequate guidance for securing the disc stem nut to the disc stem for condensate system check valves. As a result, condensate booster pump 33P-9C catastrophically failed on June 24, 2016. Failure of this pump introduced foreign material into the reactor coolant system which led to five fuel failures in the following fuel cycle that ended on September 10, 2018.

Description:

On June 24, 2016, operators initiated a manual scram which caused the 'C' condensate booster pump (33P-9C) to trip, as expected. Shortly after the trip, operators heard a loud noise coming from 33P-9C and noted that the pump was spinning backwards. Additionally, bearing temperatures on the pump and motor spiked, and the 'C' condensate booster pump and motor catastrophically failed. Upon disassembly and inspection of 33P-9C internals, foreign material was found lodged between the pump impeller and cast iron pump casing. The foreign material was identified as the disc nut and part of the threaded disc nut stem missing from the 'C' condensate booster pump discharge check valve (33CND-28C). Before the check valve failed in 2016, it was disassembled and inspected three times since 1990. Each time, the integrity of the valve assembly was found in poor condition. Tack or spot welds were placed between the disc stem and disc stem nut to prevent the nut from backing off the stem. The tack welds holding the disc nut in place were either degraded and cracked, or failed, allowing the nut to back completely off the stem and become loose in the system. From 2007 to 2016, the tack welds retaining the disc nut to disc stem on all three condensate booster pump check valves were found either cracked or broken.

FitzPatrick resumed power operations on July 7, 2016, shutdown for a refueling outage on January 14, 2017, and then returned to power operation following reactor startup on February 25, 2017. On May 8, 2017, there was an increase in radiochemistry isotope levels that were consistent with a new fuel leak, and on May 12, 2017, power suppression testing (PST) was performed to identify and suppress the fuel defect. The PST results indicated a defect in a fuel assembly located in the area of control cells 06-27 and 06-31. Control rods 06-27 and 06-31 were fully inserted to suppress the local power around the location of the fuel leaks and minimize further degradation during the fuel cycle. Immediate corrective actions included instituting an adverse condition monitoring plan (ACMP), which specified actions to be taken if chemistry sample data increased beyond specific limits for certain isotopes. In addition, a failed fuel monitoring team (FFMT) was convened to meet routinely throughout the fuel cycle to discuss trends and actions associated with the fuel defects.

Three additional power suppressions were performed on August 15, 2017, November 5, 2017, and December 19, 2017, due to suspected leaking fuel bundles.

Following the final power suppression on December 19, 2017, FitzPatrick operated the remainder of the fuel cycle with five control rods fully inserted.

On September 10, 2018 operators commenced a reactor shutdown for a planned refueling and maintenance outage (RFO23). During the refueling outage, a comprehensive inspection of the reactor fuel was performed through in-mast sipping of fuel assemblies and vacuum-can sipping. Two of the three assemblies containing fuel defects identified through PST during the operating cycle were confirmed and identified through in-mast sipping. The third fuel defect plus two additional unknown defects were identified through more sensitive vacuum-can sipping for a total of five confirmed fuel leaks during fuel cycle 23. All fuel assemblies with identified leaks were discharged into the spent fuel pool and not re-used in the current FitzPatrick fuel cycle (fuel cycle 24). Additional corrective actions taken during the refueling outage included a full core offload and inspection of all fuel assemblies from the core for foreign material, an inspection of all discharged fuel assemblies residing in the spent fuel pool for foreign material, development of a foreign material exclusion (FME) improvement plan that included focused walkdowns of the refueling floor, and a reactor fuel bundle nose cleaning using an underwater vacuum to remove debris from all fuel assemblies that would be re-used in the next fuel cycle. Hot cell debris collected from the fuel bundle nose cleanings was sent for analysis to Canadian Nuclear Laboratories and Exelon Power labs.

FitzPatrick completed a root cause investigation of the fuel defects under IR 4097375 following the FME analysis conducted by offsite specialists in February 2020. The root cause investigation determined the cause of the fuel bundle leaks was debris fretting due to foreign material residing in the reactor vessel in the vicinity of the fuel bundles. The most probable source of the foreign material came from the catastrophic failure of 'C' condensate booster pump, as a result of the failure of 'C' condensate booster pump discharge check valve in June 2016. This failure resulted in debris being transported to the reactor vessel via feedwater injection and entering the reactor fuel.

Corrective Actions: On September 12, 2018, MP-059.12, Swing Check Valves Without Operators (ISI), was revised under IR 4097375, to specify that for future maintenance work, a seal weld will be used to attach the disc stem nut to the disc stem for check valves in the condensate system. A seal weld provides better structural support for the disc nut than tack welds and a cotter pin. Installing cotter pins into the valves potentially introduces a foreign material source because the cotter pins would have the potential to break or come loose within the system.

Corrective Action References: IR 4097375, ACE CR-JAF-2016-02246

Performance Assessment:

Performance Deficiency: The inspectors determined that FitzPatrick did not maintain adequate procedural guidance for maintenance of swing check valves in the condensate system. This was a performance deficiency that was within FitzPatricks ability to foresee and correct and should have been prevented. Specifically, quality-related maintenance procedure MP-059.12, did not provide adequate guidance for securing the disc stem nut to the disc stem for condensate check valves which led to the catastrophic failure of the 'C' condensate booster pump check valve and introduction of metal debris into the reactor vessel in June 2016.

Screening: The inspectors determined the performance deficiency was more than minor because it was associated with the Procedure Quality attribute of the Barrier Integrity cornerstone and adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases caused by accidents or events. Specifically, on June 24, 2016, the 'C' condensate booster pump discharge check valve (33CND-28C) failed to seat and introduced foreign material into the reactor vessel, due to inadequate guidance for maintenance and repair of condensate system check valves, which resulted in fuel clad damage and fuel leaks that increased the possibility of adversely impacting nuclear safety.

Significance: The inspectors assessed the significance of the finding using Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Question 1 of Exhibit 3 was answered no to the question of did the finding involve control manipulations that unintentionally added positive reactivity that challenged fuel cladding integrity. Question 2 was also answered no to the question of did the finding result in a mismanagement of reactivity by operators that challenged fuel cladding integrity. Question 3 was answered no to the question of did the finding result in the mismanagement of foreign material exclusion or reactor coolant chemistry control program that challenged fuel cladding integrity (e.g., loose parts, material controls). Specifically, the fuel defects of 2017 and 2018 did not place the plant in an unanalyzed condition, adversely impact any fundamental assumptions regarding fuel failure used in the accident analysis (such as fuel failure temperature or oxidation rate)or result in reactor coolant specific activity exceeding any TS 3.4.6 limits. Therefore, the inspectors determined the fuel cladding integrity was not significantly challenged and that the finding is of very low safety significance (Green).

Cross-Cutting Aspect: Not Present Performance. No cross-cutting aspect was assigned to this finding because the inspectors determined the finding did not reflect present licensee performance.

Enforcement:

Violation: Technical Specification (TS) 5.4.1, Procedures, states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33, Appendix A, November 1972. Regulatory Guide 1.33, Appendix A,Section I, Procedures for Performing Maintenance, states that maintenance that can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances.

Contrary to this requirement, prior to September 12, 2018, Exelon did not adequately establish, implement, and maintain written procedures covering an applicable procedure recommended in Appendix A of Regulatory Guide 1.33, November 1972, in that maintenance on the 'C' condensate booster pump check valve that could affect the performance of safety-related equipment such as the reactor fuel, was not preplanned and performed in accordance with a written procedure appropriate to the circumstances.

Specifically, on three occasions, between 1990 and 2016, the 'C' condensate booster pump check valve was disassembled and inspected in accordance with quality related maintenance procedure MP-059.12. Each time, the integrity of the valve assembly was found in poor condition, and, in accordance with the procedure, tack welds were used between the disc stem and disc stem nut to prevent the nut from backing off the stem. However, this procedural direction was not appropriate to correct the condition, because the tack welds were continually found to be degraded and broken.

On June 24, 2016, the welds failed, allowing the nut to back completely off the stem. This resulted in a catastrophic failure of condensate booster pump 33P-9C, and the introduction of foreign material from the pump and discharge check valve into the safety related reactor coolant system, leading to five fuel leaks in the following fuel cycle that ended on September 10, 2018.

Enforcement Action: This violation is being treated as an NCV, consistent with Section 2.3.2 of the Enforcement Policy.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

• On April 23, 2020, the inspectors presented the integrated inspection results to Mr. Pat Navin, Site Vice President, and other members of the licensee staff.

• On February 12, 2020, the inspectors presented the health physicist inspection results to Mr. Joseph Pacher, Site Vice President, and other members of the licensee staff.

• On April 1, 2020, the inspectors presented the FitzPatrick fuel cycle 23 fuel leaks inspection results to Mr. Richard Sullivan, Regulatory Assurance Manager, and other members of the licensee staff.

DOCUMENTS REVIEWED

Inspection Type Designation Description or Title Revision or

Procedure Date

71111.04 Drawings FM-17A Flow Diagram Radwaste System 20 44

FM-17B Flow Diagram Radwaste System 20 50

FM-19A Flow Diagram Fuel Pool Cooling & Clean-up 45

FM-20A Flow Diagram Residual Heat Removal System 10 72

FM-23A Flow Diagram Core Spray System 14 49

FM-25A Flow Diagram High Pressure Coolant Injection System 23 75

Miscellaneous DBD-014 Design Basis Document for the Core Spray System 014 10

Procedures OP-13D RHR Shutdown Cooling 34

OP-14 Core Spray System 40

OP-17 Standby Liquid Control System 52

OP-22 Diesel Generator Emergency Power 68

ST-4N HPCI Quick Start, Inservice, And Transient Monitoring Test 73

(IST)

71111.05 Corrective Action 04312077

Documents

Resulting from

Inspection

Fire Plans PFP-PWR02 West Cable Tunnel/Elev 258' Fire Area/Zone IC/CT-1 05

PFP-PWR04 Battery Room Complex/Elev. 272, 282 Fire Area/Zone 02

III/BR-1, III/BR-2, IV/BR-3, BR-4, XVI/BR-5

PFP-PWR23 Motor Generator Set Room/Elev. 300' Fire Area/Zone 05

IA/MG-1

PFP-PWR27 Reactor Building/Elev. 344 Fire Area/Zone IX/RB-1A 04

71111.06 Corrective Action 04326657

Documents

Work Orders 04326657

71111.11Q Procedures OP-27 Recirculation System 085

OP-65 Startup and Shutdown Procedure 126

ST-20C Control Rod Operability for Fully Withdrawn Control Rods 31

71111.12 Corrective Action 04194506

Documents 04208557

Inspection Type Designation Description or Title Revision or

Procedure Date

220158

Miscellaneous JAF-RPT-07- Maintenance Rule Structural Monitoring Report Multiple

00006 Revisions

Procedures EN-DC-150 Condition Monitoring of Maintenance Rule Structures 12

ER-AA-450 Structures Monitoring 8

71111.13 Procedures OP-AA-108-117 Protected Equipment Program 5

OU-AA-103 Shutdown Safety Management Program 21

ST-4E HPCI and SGT Logic System Functional and Simulated 58

Automatic Actuation Test

WC-AA-101 On-Line Work Control Process 29

WC-AA-101-1006 On-Line Risk Management and Assessment 3

Work Orders 04650507

71111.15 Corrective Action 04305671

Documents 04312098

Miscellaneous QDR 71.01 EXO Sensor H2 & O2 Monitoring System, Model 115D211 2

TM100-11 Technical Manual Solenoid Operating Valve PN 1015005-3 February

PN 1015005-2 1983

Procedures OP-27A Reactor Water Level Reference Leg Backfill System 14

OP-AA-108-115 Operability Determinations (CM-1) 22

ST-1CA Outside Primary Containment Isolation Valve Exercise Test 002

(IST)

71111.18 Calculations93-033 Steady-State Design Operation of Backfill System A

JSED-93-0719, James A. FitzPatrick Nuclear Power Plant Out-of-Service 0

C.D.I. Technical Time Analysis for the Reactor Water Level Backfill System

Note No. 93-16

Corrective Action 04301611

Documents

Engineering EC 630147 Technical Evaluation for Increasing the Number of Fans

Evaluations Allowed Out of Service for LPCI Inverters

Miscellaneous Vendor Manual GUTOR Model PDW 3400-400/600-EA Inverter 001

G953-0002

Procedures ARP-09-8-3-15 LPCI MOV IPS A 71INV-3A Minor Alarm Trouble 8

MST-071.29 LPCI Charger-Inverter Performance Surveillance Test 15

Inspection Type Designation Description or Title Revision or

Procedure Date

ODSO-17 Operator Plant Tour and Operating Logs 89

OP-27A Reactor Water Level Reference Leg Backfill System 15

71111.19 Corrective Action 04314634

Documents 04314832

04315093

CR-JAF-2009-

2166

CR-JAF-2012-

06590

Drawings FM-24A Flow Diagram Reactor Water Cleanup System 12 72

Engineering 630560 Valve 12MOV-15 Manual Backseat 0

Changes 630580 12MOV-15 Seal Weld 0

Miscellaneous Valve Packing Datasheet: 12MOV-15 2

A391-0057 Anchor/Darling Valve Company Installation Operation and 8

Maintenance Manual Double Disc Gate Valve

SEP-APJ-007 James A. FitzPatrick Nuclear Power Plant Primary 10

Containment Leakage Rate Testing (Appendix J) Program

Section

Procedures MP-059.41 Limitorque Motor Operator Model SB/SMB-0-4 Corrective 32

and Overhaul Maintenance Requirements

MP-059.51 Limitorque Actuators Inspection and Lubrication 38

MP-059.77 Nozzle Check Valve Maintenance 5

OP-39 Breathing, Instrument, and Service Air System 39

ST-39B-X14 Type C Leak Test of RWCU Suction Line VLVS (IST) 15

Work Orders 04722380

04822818

04879739

04938652

05005014

05016658

80390629

80424890

80454311

Inspection Type Designation Description or Title Revision or

Procedure Date

71111.20 Corrective Action 04319690

Documents

Corrective Action 04314611

Documents

Resulting from

Inspection

Procedures AOP-31 Loss of Condenser Vacuum 25

ARP 09-6-1-30 SJAE STM PRESS LO 4

ARP 09-6-4-11 RFPT A VIB HI 9

CY-AB-120-100 Reactor Water Chemistry 20

OP-2A Feedwater System 81

OP-65 Startup and Shutdown Procedure 126

OU-JF-103-101 JAF Reactor Pressure Vessel Water Inventory Control 0

RAP-7.3.16 Plant Power Changes 57

ST-26J Heatup and Cooldown Temperature Checks 24

71111.22 Procedures ARP 93ECP-B-2 Low Lube Oil Pressure 4

ISP-150B RCIC Auto Isolation Instrument Functional Test /Calibration 42

(ATTS)**

ISP-22-1 RCIC Turbine Exhaust Diaphragm High Pressure Instrument 38

Functional Test/Calibration

ST-24J RCIC Flow Rate and Inservice Test (IST) 53

ST-9BB EDG B and D Full Load Test and ESW Pump Operability 16

Test

71124.04 Corrective Action 04222261

Documents 04226421

231538

268514

274778

292222

292348

04316312

Miscellaneous 2019 Landauer InLight Audit Report 2/6/2019

Landauer NVLAP Certification 01/01/2020 -

Inspection Type Designation Description or Title Revision or

Procedure Date

2/31/2020

GEL Laboratories Environmental Laboratory Quarterly April 15,

Quality Assurance Report 2019

GEL Laboratories Environmental Laboratory Quarterly July 31,

Quality Assurance Report 2019

GEL Laboratories Environmental Laboratory Quarterly October 30,

Quality Assurance Report 2019

GEL Laboratories Environmental Laboratory Quarterly February 7,

Quality Assurance Report 2020

Procedures RP-AA-203 Exposure Control and AUthorization 5

RP-AA-203-1003 Restriction for Individuals Receiving Medical Radioactive 1

Isotope Treatments

RP-AA-210 Dosimetry Issue, Usage, and Control 29

RP-AA-210-1004 Shallow Dose Equivalent Program Review 0

RP-AA-211 Personnel Dosimetry Performance Verification 14

RP-AA-215 Calculating and Crediting Dose from Noble Gas Exposure 1

RP-AA-216 Dose Assessment for Contaminated Wounds 0

RP-AA-220 Bioassay Program 14

RP-AA-220-1001 Collection and Handling of in-vitro Bioassay Samples 2

RP-AA-221 Review, Correction, and Analysis of Whole Body Count Data 3

RP-AA-222 Methods for Estimating Internal Exposure from in-VIVO and 6

in-VITRO Bioassay Data

RP-AA-224 CEDE Dose Tracking Using Lapel Air Samplers 4

RP-AA-250 External Dose Assessments from Contamination 8

Radiation 20003 General Area Air Sample Dry Well 268' 2/2/2020

Surveys 0425-0435

20008 Breathing Zone Air Sample 2/2/2020

20011 Breathing Zone Air Sample 2/3/2020

20012 General Area Air Sample Machine Shop 12 MOV 15 2/3/2020

1155-1210

20016 Breathing Zone Air Sample 2/3/2020

20017 Breathing Zone Air Sample 2/4/2020

20018 Breathing Zone Air Sample 2/4/2020

Inspection Type Designation Description or Title Revision or

Procedure Date

20023 General Area Air Sample Dry Well 292' 12 MOV 15 2/5/2020

205-1217

20026 Breathing Zone Air Sample 2/5/2020

20028 General Area Air Sample Dry Well 292' 2/2/2020

0130-0140

20029 General Area Air Sample Outside Dry Well Entrance 2/2/2020

25-0435

20034 General Area Air Sample Dry Well 268' 2/3/2020

25 -

2/4/2020

240

20035 General Area Air Sample Dry Well 292' 2/3/2020

25 -

2//4/2020

240

20036 General Area Air Sample Dry Well 292' 2/5/2020

1730 -

2/6/2020

0310

20037 General Area Air Sample Dry Well 268' 2/5/2020

1737 -

2/6/2020

0312

20039 General Area Air Sample Dry Well 292' 2/2/2020

0514-0524

20040 Breathing Zone Air Sample 2/6/2020

20045 General Area Air Sample Dry Well 292' 2/5/2020

1019-1027

71151 Miscellaneous NEI 99-02 Regulatory Assessment Performance Indicator Guideline 07

71152 Corrective Action CR-JAF-2016- Apparent Cause Evaluation - 33CND-28C (Condensate

Documents 02246 Booster Pump C Discharge Check Valve) Failed to Isolate

Following Reactor Scram.

IR 4097375 Root Cause Investigation for FitzPatrick Cycle 23 Fuel

Defects

Inspection Type Designation Description or Title Revision or

Procedure Date

Drawings FM-33A Flow Diagram of Condensate System 33 64

FM-33C Flow Diagram of Condensate System 33 29

FM-34A Flow Diagram of Feedwater System 34 74

Procedures EN-MA-118 Foreign Material Exclusion - Entergy 10

ER-AA-400-1001 Check Valve Monitoring and Preventive/Predictive 14

Maintenance Program

MA-AA-716-008 Foreign Material Exclusion Program - Exelon 14

MA-AA-716-008- Definitions and Measurements of FME Events - Exelon 6

1000

MP-059.12 Swing Check Valves Without Operators (ISI) 25

MP-059.47 Anchor Darling Swing Check Valves with Air Actuators (IST) 7

Work Orders 449263

449327

449329

71153 Corrective Action 04314313

Documents 04316427

Procedures OP-AA-108-114 Post Transient Review 13

Work Orders 04647475

21