ML25114A211
| ML25114A211 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  (DPR-029) |
| Issue date: | 05/06/2025 |
| From: | Jason Kozal NRC/RGN-III/DORS/ERPB |
| To: | Rhoades D Constellation Energy Generation, Constellation Nuclear |
| Shared Package | |
| ML25119A217 | List: |
| References | |
| EAF-RIII-2025-0074, 3-2023-013, 3-2023-015 IR 2024403 | |
| Download: ML25114A211 (1) | |
See also: IR 05000254/2024403
Text
EAF-RIII-2025-0074
David P. Rhoades
Senior Vice President
Constellation Energy Generation, LLC
President and Chief Nuclear Officer (CNO)
Constellation Nuclear
4300 Winfield Road
Warrenville, IL 60555
SUBJECT:
QUAD CITIES NUCLEAR POWER STATION - NRC INSPECTION REPORT
NO. 05000254/2024403 AND INVESTIGATION REPORTS 3-2023-013
AND 3-2023-0015
Dear David Rhoades:
On April 16, 2025, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection
at Quad Cities Nuclear Power Station. The purpose of the inspection was to review the
circumstances surrounding a Unit 1 reactor pressure vessel (RPV) drain down event that
occurred on March 28, 2023, during a refueling outage. This letter also refers to investigations
conducted by the NRCs Office of Investigations (OI). The purpose of the investigations was
to determine whether: 1) personnel at the Quad Cities Nuclear Plant who had knowledge
of a human performance error that occurred on March 28, 2023, deliberately took
action to falsify evidence about the event; and 2) whether a senior licensee manager
deliberately entered incomplete and inaccurate information in the Corrective Action Program
(CAP). The investigations were completed on September 11, 2024, and September 18, 2024.
A factual summary of Investigations 3-2023-013 and 3-2023-0015, which substantiated willful
behaviors, is provided as Enclosure 1. The enclosed inspection report presents the results of
the inspection. The inspector discussed the preliminary inspection findings with you and your
staff on April 16, 2025.
Based on the results of this inspection and the investigation, six apparent violations of NRC
requirements were identified and are being considered for escalated enforcement action in
accordance with the NRC Enforcement Policy. The current Enforcement Policy is included on
the NRCs website at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html.
May 6, 2025
D. Rhoades
2
The apparent violations concerned:
1.
Willful failure by a licensed reactor operator (RO) to implement procedure resulting in
RPV drain down
2.
Willful failure to survey and decontaminate personnel sprayed with reactor coolant
3.
Willful failure by a licensed senior reactor operator (SRO) to maintain complete and accurate
records related to RPV drain down event
4.
Failure to document the RPV drain down event in operating logs and CAP
5.
Failure to maintain complete and accurate operating logs associated with RPV drain time
6.
Failure to administer fitness for duty and fatigue testing following an event
The circumstances surrounding these apparent violations, the significance of the issues, and
the need for lasting and effective corrective action were discussed with members of your staff at
the inspection exit meeting on April 16, 2025.
Before the NRC makes its enforcement decision, we are providing you an opportunity
to (1) request a Pre-decisional Enforcement Conference (PEC), or (2) request Alternative
Dispute Resolution (ADR). If a PEC is held, portions not related to the OI investigation will be
open for public observation and the NRC will issue a press release to announce the time and
date of the conference. Please contact Néstor J. Féliz Adorno at 630-829-9739, or
Nestor.Feliz-Adorno@nrc.gov within 10 days of the date of this letter to notify the NRC of
your intended response or request. A PEC should be held within 30 days and an ADR
session within 45 days of the date of this letter.
If you choose to request a PEC, the conference will afford you the opportunity to provide
your perspective on these matters and any other information that you believe the NRC
should take into consideration before making an enforcement decision. The decision to hold a
PEC conference does not mean that the NRC has determined that a violation has occurred, or
that enforcement action will be taken. This conference would be conducted to obtain information
to assist the NRC in making an enforcement decision. The topics discussed during the
conference may include information to determine whether a violation occurred, information to
determine the significance of a violation, information related to the identification of a violation,
and information related to any corrective actions taken or planned.
In lieu of a PEC, you may also request ADR with the NRC in an attempt to resolve this issue.
ADR is a general term encompassing various techniques for resolving conflicts using a neutral
third party. The technique that the NRC has decided to employ is mediation. Mediation is a
voluntary, informal process in which a trained neutral (the mediator) works with parties to
help them reach resolution. If the parties agree to use ADR, they select a mutually agreeable
neutral mediator who has no stake in the outcome and no power to make decisions. Mediation
gives parties an opportunity to discuss issues, clear up misunderstandings, be creative, find
areas of agreement, and reach a final resolution of the issues. Additional information concerning
the NRCs program can be obtained at http://www.nrc.gov/about-
nrc/regulatory/enforcement/adr.html. The Institute on Conflict Resolution (ICR) at Cornell
University has agreed to facilitate the NRCs program as a neutral third party. Please contact
D. Rhoades
3
ICR at 877-733-9415 within 10 days of the date of this letter if you are interested in pursuing
resolution of this issue through ADR.
In addition, please be advised that the number and characterization of apparent violations
described in the enclosed inspection report may change as a result of further NRC review. You
will be advised by separate correspondence of the results of our deliberations on this matter.
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.
If you have any questions concerning this matter, please contact Néstor J. Féliz Adorno or my
staff at 630-829-9739.
Sincerely,
Jason Kozal, Director
Division of Operating Reactor Safety
Docket No. 05000254
License No. DPR-29
Enclosure:
1. Factual Summary of Investigations
3-2023-013 and 3-2023-0015
2. Inspection Report No. 05000254/2024403
cc w/ encl: Distribution via LISTSERV
Signed by Kozal, Jason
on 05/06/25
D. Rhoades
4
Letter to David Rhoades from Jason Kozal dated May 06, 2025.
SUBJECT:
QUAD CITIES NUCLEAR POWER STATION - NRC INSPECTION REPORT
NO. 05000254/2024403 AND INVESTIGATION REPORTS 3-2023-013
AND 3-2023-0015
DISTRIBUTION:
Alejandro Alen Arias
RidsNrrDorlLpl3
RidsNrrPMQuadCities Resource
RidsNrrDroIrib Resource
Eric Brothman
Néstor J. Féliz Adorno
R3-DORS
ADAMS Accession Number: ML25114A211
ADAMS Accession Number (Package): ML25119A217
SUNSI Review
Non-Sensitive
Sensitive
Publicly Available
Non-Publicly Available
OFFICE
RIII/DORS
OE/EB
RIII/EICS
RIII/DORS
NAME
NFéliz
Adorno:anm
JPeralta
DPelton
SKirkwood
DBetancourt
JKozal
DATE
04/29/2025
05/05/2025
05/05/2025
05/02/2025
05/05/2025
05/062025
OFFICIAL RECORD COPY
Enclosure 1
Factual Summary of NRC Office of Investigations Cases No. 3-2023-013 and 3-2023-0015
On August 18, 2023, the U.S. Nuclear Regulatory Commission (NRC), Office of Investigations
(OI), Region III, initiated investigation No. 3-2023-0013 to determine whether personnel at
the Quad Cities Nuclear Plant (Quad Cities or licensee), who had knowledge of a human
performance error that occurred on March 28, 2023, deliberately took action to falsify
evidence about the event. The investigation was completed on September 11, 2024.
On September 5, 2023, investigation No. 3-2023-0015 was initiated to determine whether a
senior licensee manager deliberately entered incomplete and inaccurate information in the
Corrective Action Program (CAP). The investigation was completed on September 18, 2024.
The first issue involves a licensed senior reactor operator (SRO) who knowingly provided
inaccurate and incomplete information about the event. 10 CFR § 50.9(a), Completeness and
Accuracy of Information, requires, in part, that information required by statute or by the
Commissions regulations, orders, or license conditions to be maintained by the applicant or
the licensee shall be complete and accurate in all material respects. The investigation showed
that on March 28, 2023, an (SRO) overseeing Unit 1s outage work activities became aware of
a reactor pressure vessel (RPV) drain down event due to the mispositioning of approximately
177 safety-related hydraulic control units (HCU) accumulator drain valves. Despite this
knowledge, for 10 days, the SRO inaccurately attributed the event to broken hoses and
submitted an inaccurate CAP document (i.e., Work Group Evaluation (WGE)). The SRO did not
rectify this inaccurate information until April 7, 2023. Through the SROs sworn testimony and
admission, he was aware of the facts of what happened on March 28, 2023, and admitted to
investigators that he submitted an incomplete and inaccurate WGE to the licensee. In his
testimony, the individual stated he knew the submitted WGE was false when he sent it. The
SRO said fear of a particular senior managers anger kept him from providing complete and
accurate information.
The second issue pertains to a reactor operators (ROs) reckless disregard for procedural
compliance, which resulted in the RPV drain down event. Technical Specification 5.4.1,
Procedures, requires, in part, that written procedures shall be established, implemented,
and maintained as covered in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978.
Regulatory Guide 1.33, Section 1, Administrative Procedures, covers procedures for
procedure adherence, as well as authorities and responsibilities for safe operation and
shutdown. Section 4, Procedure for Startup, Operation, and Shutdown of Safety-Related BWR
Systems, cover procedures for energizing, filling, venting, draining, startup, shutdown, and
changing modes of operation for the CRD system. The licensee established procedure
QCOP 0500-04, Inserting Manual Scrams, Revision 14, as a continuous use procedure of the
CRD system to provide instructions for inserting a full manual scram when the reactor is
shutdown. Step D.5 states, in part, that Inserting a scram with the CRD drain valves open will
result in a drain path from the vessel. Step F.2.b(3) requires, in part, closing all 177
safety-related HCU accumulator drain valves per Attachment B, which requires either a
concurrent or independent verification that each valve is closed. After reviewing the
investigation, the NRC concluded that a willful (careless disregard) failure of Technical
Specification 5.4.1 (procedure QCOP-0500-04) occurred on March 28, 2023. Specifically,
testimony from the investigation showed that during discussions about procedure
QCOP-0500-04, an (RO) recognized the existence of Attachment B, directed equipment
operators (EOs) not to complete the attachment and acted with reckless indifference as to the
applicability of the requirement to complete the attachment in directing that the attachment not
be completed. This decision resulted in the opening of the HCU accumulator drain valves
without the human performance tools in Attachment B (i.e., concurrent or independent
2
verification), thereby creating multiple drain paths below top of active fuel (TAF) susceptible to a
common mode failure. The resulting drain down led to the loss of approximately 5-6 inches of
RPV inventory. A conservative estimate, one that does not account for simultaneous water
injection sources, indicates that at least 1,200 gallons of reactor coolant were lost over a period
of about 6 minutes.
The third issue involves a radiation protection technician (RPT) reckless disregard for
procedures during the response to personnel contamination following the event. Technical
Specification 5.4.1(a) specifies written procedure shall be established, implemented, and
maintained covering the applicable procedures recommended in Regulatory Guide 1.33,
Revision 2, Appendix A, February 1978. Regulatory Guide 1.33, Revision 2, Appendix A.
Items 7.e(4), Contamination Control, and 7.e(7) Personnel Monitoring, are applicable to this
activity. Licensee procedure NISP-RP-006, Personnel Contamination Monitoring, Revision 1,
implements this requirement. Sections 5 and 6 provide the requirements and process for
responding to portal monitor alarms, including performing surveys and personnel
decontamination as necessary. Steps 5.7 through 5.8.4 require detailed surveys be performed
with a frisker by an RPT before prescribing decontamination activities. Step 5.10 requires
a whole-body count be performed for contamination on the face. Step 6.3.3 requires medical
assistance for decontamination around the eyes. Interviews performed as part of the
investigation showed that on March 28, 2023, at least two personnel were sprayed in the face
with reactor coolant water due to the opening of the HCU accumulator drain valves and alarmed
the radiologically controlled area (RCA) exit monitors. The investigation showed that a willful
(careless disregard) failure of Technical Specification 5.4.1 (procedure NISP-RP-006) occurred.
Specifically, testimony from the investigation showed that the RPT employed by the licensee
recognized the requirements to perform a hand frisk if an individual alarmed twice, to notify the
house RPT if contamination exceeded threshold levels, to conduct a whole-body count for facial
contamination, and to obtain medical assistance for decontamination near the eyes. Rather than
following these requirements, the RPT directed workers to shower repeatedly and take other ad
hoc actions. In so doing, the RPT acted with reckless disregard for what is required by the
procedure.
Enclosure 2
U.S. NUCLEAR REGULATORY COMMISSION
Inspection Report
Docket Number:
05000254
License Number:
Report Number:
Enterprise Identifier:
I-2024-403-0040
Licensee:
Constellation Nuclear
Facility:
Quad Cities Nuclear Power Station
Location:
Cordova, IL
Inspection Dates:
October 14, 2024, to April 15, 2025
Inspectors:
J. Cassidy, Senior Health Physicist
S. Cavanaugh, Physical Security Inspector
N. Egan, Sr. Physical Security Inspector
R. Farmer, Health Physicist
C. Hunt, Senior Resident Inspector
T. Okamoto, Resident Inspector
Approved By:
Néstor J. Féliz Adorno, Chief
Engineering and Reactor Projects Branch
Division of Operating Reactor Safety
2
BACKGROUND
On March 28, 2023, Unit 1 was shut down for a refueling outage during which operators
inserted a manual scram as part of a planned surveillance activity. Prior to the scram, plant
procedures required verification that all 177 safety-related hydraulic control unit (HCU)
accumulator drain valves were closed to prevent a drain path from the reactor pressure vessel
(RPV). This verification step was marked as complete.
Soon after the scram, reactor coolant water was observed discharging from open HCU drain
valves onto the 595-foot elevation of the reactor building. In response, operators reset the
scram and stopped the water flow. The licensee later confirmed that the valves had not been
closed, resulting in an unintended RPV drain down.
The U.S. Nuclear Regulatory Commission (NRC) was initially unaware of the event. The event
was not documented in operating logs, not discussed during daily plant status meetings
regularly attended by NRC inspectors, and not accurately documented in the Corrective Action
Program (CAP). The only CAP report referred to a generic water spill, without identifying the
source or addressing potential radiological contamination. The NRC became aware of the
event on April 5, 2023, when inspectors followed up on information gathered at the site.
This led to a formal investigation by the NRCs Office of Investigations (OI), which concluded
in September 2024, and subsequent NRC inspections, which concluded in April 2025.
SUMMARY
The NRC continued monitoring the licensees performance by conducting an NRC inspection
at Quad Cities Nuclear Power Station, 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
Willful Failure by a Licensed RO to Implement Procedure Results in RPV Drain Down
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.14] -
Conservative
Bias
A self-revealed finding of pending significance and associated AV of TS 5.4.1, Procedures,
and TS 3.5.2, RPV Water Inventory Control, was identified when the licensee willfully failed
to implement procedures associated with the venting of the control rod drive (CRD)
system. Specifically, during a refueling outage, a licensed RO demonstrated careless
disregard for procedure by directing equipment operators to perform valve manipulations
without using the required procedure attachment. As a result, approximately 177 HCU
accumulator drain valves remained open, creating a drain path that led to a 5- to 6-inch drop
in RPV level and placed the Unit in a TS-prohibited condition and in a red shutdown risk
condition without required mitigating controls.
3
Willful Failure to Survey and Decontaminate Personnel Sprayed with Reactor Coolant
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Occupational
Radiation Safety
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.12] - Avoid
Complacency
The inspectors identified a finding of pending significance and associated AV of TS 5.4.1,
Procedures, involving the willful failure to follow procedures for performing personnel
contamination surveys and decontamination. Specifically, on March 28, 2023, during the RPV
drain down event, at least two individuals sprayed with reactor coolant water alarmed the
RCA exit monitors. In response, an RPT acted with careless disregard for procedures by
failing to ensure a detailed survey was conducted before prescribing decontamination, did not
require a whole-body count for an individual with facial contamination, and failed to seek
medical assistance for decontaminating a worker who had been sprayed in the eye with
Licensed SRO Deliberately Failed to Maintain Complete and Accurate Records Related
to RPV Drain Down Event
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of
Information, for the failure to maintain complete and accurate information in all material
respects. Specifically, on March 28, 2023, a licensed SRO overseeing Unit 1s outage
work activities became aware of an RPV drain down event due to the mispositioning of the
safety-related HCU accumulator drain valves. Despite this knowledge, for 10 days, the SRO
did not review the event by inaccurately attributing the water spill to broken hoses and willfully
submitted an inaccurate CAP document based on this false pretense on April 6, 2023. The
SRO rectified this inaccurate information on April 7, 2023. This information was material to the
NRC, as it left inspectors unaware of the drain down event and the performance issues
causing it within a timeframe necessary to assess appropriate event response and follow-up
inspection activities.
Failure to Document the RPV Drain Down Event in Operating Logs and CAP
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of Information,
for the failure to maintain complete and accurate information. Specifically, on March 28, 2023,
the licensee failed to log an RPV drain down event due to the mispositioning of safety-related
HCU accumulator drain valves. In addition, the licensee failed to document the Configuration
Control issue into the CAP. These incomplete records were material to the NRC, as they left
4
inspectors unaware of the drain down event within a timeframe necessary to assess
appropriate event response and follow-up inspection activities.
Failure to Maintain Complete and Accurate Operating Logs Associated with RPV Drain Time
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of Information,
for the failure to maintain complete and accurate information. Specifically, since
April 11, 2023, the licensee incorrectly estimated the RPV drain time as 1 to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, when
it was about 15 minutes, after assessing the RPV drain down event that occurred on
March 28, 2023. As a result, they did not fully document the required TS entries and the
change in shutdown risk status from yellow to red. The incomplete and inaccurate information
was used by the NRC when evaluating its regulatory response to the actual RPV drain down
that occurred on March 28, 2023. Had the information been maintained completely and
accurately by the licensee, it would have likely caused the NRC to undertake further
substantial inquiry, such as additional inspection activities, to better understand the
circumstances and significance of the of the activity that led to the RPV drain down.
Failure to Administer Fitness for Duty and Fatigue Testing Following Event
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Security
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.8] -
Procedure
Adherence
The inspector identified a finding of pending significance and associated AV of
10 CFR 26.31(c)(3) and 10 CFR 26.211(a)(3) for the failure to conduct post-event drug and
alcohol testing and fatigue assessments. Specifically, on March 28, 2023, the licensee did not
administer drug and alcohol tests to individuals after they committed human errors that may
have caused, or contributed to, the Unit 1 RPV drain down event. In addition, the licensee did
not perform a fatigue assessment as required in response to events that warrant post-event
drug and alcohol testing.
Additional Tracking Items
Type
Issue Number
Title
Report Section
Status
LER 2024-001-00 for Quad
Cities Nuclear Power
Station, Unit 1, Technical
Specification 3.5.2 Action
Not Performed Due to
Inadequate Procedure
Adherence
Closed
5
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/reading-
rm/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. 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.
OTHER ACTIVITIES - BASELINE
71152A - Annual Follow-up Problem Identification and Resolution
Annual Follow-up of Selected Issues (Section 03.03) (1 Sample)
The inspectors reviewed the licensees implementation of its CAP related to the
following issues:
(1)
The RPV drain down event that occurred on March 28, 2023.
71153 - Follow-Up of Events and Notices of Enforcement Discretion
Event Report (IP Section 03.02) (1 Sample)
The inspectors evaluated the following licensee event reports (LERs):
(1)
LER 05000254/2024-001-00, Technical Specification 3.5.2 Action Not Performed
Due to Inadequate Procedure Adherence (ADAMS Accession No. ML25021A090).
The inspection conclusions associated with this LER are documented in the
Inspection Results Section of this report. This LER is Closed.
INSPECTION RESULTS
Willful Failure by a Licensed RO to Implement Procedure Results in RPV Drain Down
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Initiating
Events
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.14] -
Conservative
Bias
A self-revealed finding of pending significance and associated AV of TS 5.4.1, Procedures,
and TS 3.5.2, RPV Water Inventory Control, was identified when the licensee willfully failed
to implement procedures associated with the venting of the control rod drive (CRD)
system. Specifically, during a refueling outage, a licensed RO demonstrated careless
disregard for procedure by directing equipment operators to perform valve manipulations
without using the required procedure attachment. As a result, approximately 177 HCU
accumulator drain valves remained open, creating a drain path that led to a 5- to 6-inch drop
6
in RPV level and placed the Unit in a TS-prohibited condition and in a red shutdown risk
condition without required mitigating controls.
Description:
The CRD system supplies water at the required pressure to each reactor control rod HCU,
ensuring proper cooling and providing the force needed for control rod insertion and
retraction. Each control rod is supported by its own HCU, with 177 HCUs in total, arranged
into north and south banks. Each HCU includes an accumulator drain valve resulting in
177 drain valves overall.
On March 28, 2023, during a Unit 1 planned outage activity, the licensee prepared to
implement procedure QCOP 0500-04, Inserting Manual Scrams, Revision 14, to
depressurize the CRD accumulators for surveillance testing. This procedure was designated
as continuous use, governed by HU-AA-104-101, Procedure Use and Adherence,
Revision 7. When using a continuous use procedure, HU-AA-104-101 required performers
to read each step before performing it, execute steps in sequence, and apply placekeeping
before proceeding to the next step. It also directed performers to review the procedure upon
completion to confirm that all steps were performed and documented.
Section 2.5 of HU-AA-104-101 defined placekeeping as physically marking procedure
steps to prevent omission or duplication. Sections 3.2.2(1) and 4.3.1 required supervisors
to provide direction on placekeeping and mandated its application to continuous use
procedures. Section 4.3.2 further specified that performers must mark completion before
proceeding to the next step. Section 4.1.7 required final review of the document to confirm
that all steps were performed and documented.
QCOP 0500-04 included steps that open penetration flow paths below top of active fuel
(TAF). Per QCAP 0260-03, Screening for Reactor Pressure Vessel Water Inventory Control,
Revision 17, these steps qualified as water inventory control activities if they reduced RPV
drain time to less than 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />. The licensees TS defined drain time as the time it would
take for the water inventory in and above the RPV to drain to TAF at the limiting drain rate.
This rate was the larger of (1) the drain rate through a single highest flow penetration or
(2) the combined rate through multiple paths susceptible to a common mode failure, such as
a single human error, for all penetration flow paths below the TAF. TS exceptions included
flow paths that were isolated, connected to intact systems, or isolable before reaching TAF
under specified conditions. TS assumed instantaneous flow path opening, no makeup water,
and realistic drain rates.
QCAP 0260-03 defined a single human performance error as any incorrect or omitted action
not immediately recoverable or preventable by peer or concurrent review. Step D.4.g required
drain time evaluation for multiple penetration flow paths below TAF susceptible to a common
mode failure, including a single human performance error that opened multiple flow paths
below TAF, which was explicitly listed as an example. The procedure also required that if
drain time was projected to be less than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, the actions of LCO 3.5.2 Condition D must
be met prior to activity start and prohibited planned evolutions resulting in a drain time of less
than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />.
TS 3.5.2, RPV Water Inventory Control, required, in part, that drain time to TAF be greater
than or equal to 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> in Modes 4 and 5. If drain time was less than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, Condition D
required operators to, in part, immediately initiate action to verify that one standby gas
treatment subsystem was capable of being placed in operation. If Condition D was not met,
7
or if drain time was less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, Condition E required operators to immediately initiate
action to restore drain time to greater than or equal to 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />.
QCOP 0500-04 precaution D.5 warned that inserting a scram with CRD drain valves open
would create an RPV drain path. Step F.2.b(3) required closing all 177 HCU accumulator
drain valves per Attachment B, which required either concurrent or independent verification
to mitigate the risk of human error. HU-AA-101, Human Performance Tools and Verification
Practices, Revision 14, stated that both concurrent and independent verifications must be
documented upon completion.
Attachment B, HCU Drain Valve Position Verification, contained a two-person verification
process for closing and confirming all 177 drain valves. This process mitigated the risk of a
single human performance error opening multiple drain paths below TAF and ensured the
activity did not meet the criteria for common mode failure per QCAP 0260-03.
During the refueling outage, operations were organized into system coordination teams per
OP-AA-117-1001, Operations Refueling Outage Readiness and Execution, Revision 9.
Each team coordinated the removal, testing, and return to service of assigned systems.
On March 28, 2023, the CRD system coordination team (Group 2) held a pre-job briefing
led by the licensed RO overseeing QCOP 0500-04. The RO discussed precaution D.5 of
QCOP 0500-04 and prior operating experience involving inadvertently open HCU drain valves
that led to an RPV drain down at the site.
Later in the pre-job briefing, the RO directed the two teams of two EOs each not to complete
Attachment B of QCOP 0500-04. Under the procedure, each EO was required to
independently verify and sign off on valve closures. Instead, the RO instructed the teams to
informally check each others work, citing a desire to reduce time in the field and thereby
minimize radiological dose. Although the procedural method requires more field time, it
serves as a control to prevent valve mispositioning. One team was assigned roughly half the
valves, the other team the rest, with neither completing the required verifications.
Based on interviews, including those from the licensees root cause evaluation, the pre-job
brief led to a miscommunication. The RO assumed the EOs understood that they were to
perform QCOP 0500-04 up to step F.2.b(3), but without completing Attachment B. However,
the EOs understood they were to pause after step F.2.b(2), which directed them to open the
valves, because step F.2.b(3) required Attachment B, which they had been directed not to
implement.
Following fieldwork, one EO team returned without Attachment B because it had been
contaminated. The second EO team returned with an attachment that was not filled out. The
RO asked each team if all required steps were complete but did not specify which steps were
being referenced. After receiving verbal confirmation, the RO signed off step F.2.b(3) without
verifying that Attachment B had been completed and then notified the control room they were
ready to insert a scram.
The control room operators inserted a manual scram per step F.2.d of QCOP 0500-04.
Minutes later, they noted slower-than-expected RPV level recovery. In response, a control
room operator manually adjusted feedwater flow to restore RPV water level, which had
dropped below the control band. Field reports soon indicated water spraying from HCU drain
connections. Realizing the RPV was draining to the reactor building, control room operators
reset the scram to isolate the drain path.
8
The ROs decision to bypass the required human performance tools replaced a verified
method that would have required hundreds of independent errors to misposition
approximately 177 valves with an unauthorized approach vulnerable to a single error. As a
result, the projected RPV drain time to TAF was reduced from over 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> to approximately
15 minutes. This condition violated TS 3.5.2 and procedure OU-AA-103, Shutdown Safety
Management Program, Revision 23. Step 4.4.2.4 of OU-AA-103 states that a plant overall
safety status of red shall not be planned or scheduled. The ROs decision to informally plan
the implementation of QCOP 0500-04 without completing Attachment B led to an
unrecognized drain time of less than one hour, a condition corresponding to red shutdown
safety status as defined in Attachment 1 of OU-QC-104, Shutdown Safety Management
Program Quad Cities Annex, Revision 23. Per the TS Bases, a drain time under 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />
may not allow sufficient operator response to prevent inventory from reaching TAF.
Corrective Actions: The licensees action to reset the scram signal approximately 6 minutes
after initiation halted the inadvertent drain down that occurred on March 28, 2023. The event
was not initially documented in the CAP. It was not until 14 days later, on April 11, 2023,
that the licensee entered the issue into the CAP as AR 04669057 and initiated a causal
evaluation.
Corrective Action References: AR 04669057, Configuration Control During QCOP 0500-04
Execution
Performance Assessment:
Performance Deficiency: The failure to implement procedure QCOP 0500-04 was contrary to
Technical Specification 5.4.1 and was a performance deficiency.
Screening: The inspectors determined the performance deficiency was more-than-minor
because it was associated with the Configuration Control attribute of the Initiating Events
cornerstone and adversely affected the cornerstone objective to limit the likelihood of events
that upset plant stability and challenge critical safety functions during shutdown, as well as
power operations. Specifically, the failure to implement QCOP 0500-04 resulted in multiple
drain paths from the RPV below the TAF, resulting in an inadvertent drain down of the RPV.
Significance: The inspectors assessed the significance of the finding using IMC 0609
Appendix G, Shutdown Operations Significance Determination Process. The safety
significance of this issue is pending the final enforcement decision.
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. Specifically,
the RO directed EOs not to complete Attachment B of QCOP 0500-04 to reduce field dose,
without considering the safety or regulatory impact. This replaced a verified method that
would have required hundreds of independent errors to misposition approximately 177 valves
with an unauthorized approach vulnerable to a single error. The RO did not determine the
action was safe before proceeding.
9
Enforcement:
The ROPs significance determination process does not specifically consider willfulness in
its assessment of licensee performance. Therefore, it is necessary to address this violation
which involves willfulness using traditional enforcement to adequately deter non-compliance.
Severity: The NRC has not made an enforcement decision regarding the severity level of this
AV yet.
Violation: TS 5.4.1, Procedures, required, in part, that written procedures shall be
established, implemented, and maintained as covered in Regulatory Guide 1.33, Revision 2,
Appendix A, February 1978. Regulatory Guide 1.33, Section 1, Administrative Procedures,
covered procedures for procedure adherence, as well as authorities and responsibilities for
safe operation and shutdown. Section 4, Procedure for Startup, Operation, and Shutdown of
Safety-Related BWR Systems, covered procedures for energizing, filling, venting, draining,
startup, shutdown, and changing modes of operation for the CRD system.
The licensee established procedure QCOP 0500-04, Inserting Manual Scrams, Revision 14,
as a continuous use procedure for the CRD system. The procedure provided instructions for
inserting a full manual scram when the reactor is shut down. Step F.2.b(3) required closing all
177 safety-related HCU accumulator drain valves per Attachment B, which included either
concurrent or independent verification that each valve was closed. The use of continuous use
procedures, including the requirement to perform steps in sequence, apply placekeeping, and
verify completion before proceeding, was governed by HU-AA-104-101, Procedure Use and
Adherence, Revision 7. The concurrent and independent verification methods required by
Attachment B were further governed by HU-AA-101, Human Performance Tools and
Verification Practices, Revision 14.
Contrary to the above, on March 28, 2023, the licensee failed to implement written
procedures covering the applicable procedures recommended in Regulatory Guide 1.33.
Specifically, a licensed RO directed EOs to not complete Attachment B of QCOP 0500-04,
contrary to step F.2.b(3). As a result, the EOs neither performed, nor verified the closure of
the valves. The RO then signed off step F.2.b(3) as complete and proceeded with the next
steps without ensuring Attachment B had been completed and that all appropriate steps were
performed in accordance with HU-AA-104-101 and HU-AA-101. Instead, the RO relied on
verbal confirmation from the EOs that their assigned tasks were complete. This led to
inadvertently establishing multiple drain paths from the Unit 1 RPV, resulting in a water level
drop of approximately 5 to 6 inches.
The ROs decision to not complete the attachment caused the licensee to place Unit 1 in
a condition prohibited by TS 3.5.2, which required, in part, that RPV drain time to TAF be
greater than or equal to 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> in Modes 4 and 5. Immediate TS actions were required if
drain time fell below 8 or 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. Because the decision to informally plan the implementation
of QCOP-0500-04 without completing Attachment B resulted in a drain time of about
15 minutes, the plant also entered a red shutdown safety level, which was not permitted by
procedure OU-AA-103, Shutdown Safety Management Program, Revision 23.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
10
Willful Failure to Survey and Decontaminate Personnel Sprayed with Reactor Coolant
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Occupational
Radiation
Safety
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.12] - Avoid
Complacency
The inspectors identified a finding of pending significance and associated AV of TS 5.4.1,
Procedures, involving the willful failure to follow procedures for performing personnel
contamination surveys and decontamination. Specifically, on March 28, 2023, during the
RPV drain down event, at least two individuals sprayed with reactor coolant water alarmed
the RCA exit monitors. In response, an RPT acted with careless disregard for procedures by
failing to ensure a detailed survey was conducted before prescribing decontamination, did not
require a whole-body count for an individual with facial contamination, and failed to seek
medical assistance for decontaminating a worker who had been sprayed in the eye with
Description:
During the March 28, 2023, RPV drain down event, at least two contract workers were
sprayed with reactor coolant and subsequently triggered alarms on the RCA personnel
contamination monitors (PCMs).
Transcripts from the NRC Office of Investigations interviews indicate that the licensee failed
to assess and quantify contamination levels on the affected individuals. The workers were
sprayed with reactor coolant water over large portions of their bodies, including the face, and
were instructed to wash off the contamination before any measurements were taken using a
frisker. One individual reported being sprayed in the ear, eye, and mouth. Despite these
exposures, the licensee did not perform whole-body counts to evaluate potential internal dose
and did not seek medical assistance for decontaminating the individual who experienced
contamination involving the eye.
Procedure NISP-RP-006, Personnel Contamination Monitoring, Revision 1, governed the
required response to PCM alarms. It included provisions for hand frisking if an individual
alarms twice and mandated additional notifications when contamination levels exceeded
threshold limits. However, the RPT directed the workers to repeatedly shower without first
conducting the required surveys.
In interviews, the RPT acknowledged awareness of the procedural requirements outlined in
NISP-RP-006, including the need for frisking and notification protocols following PCM alarms.
Despite this, the technician directed decontamination actions inconsistent with procedural
requirements.
Following the event, surveys of areas affected by the reactor coolant release identified
contamination levels as high as 440,000 disintegrations per minute.
Corrective Actions: The affected workers removed the contamination using soap and water
before exiting the radiologically controlled area. All individuals subsequently passed
whole-body contamination monitors prior to leaving the RCA and again prior to exiting the
site. These monitors are designed to ensure that no radioactive material is inadvertently
11
transported beyond the site boundary. Based on radiological data collected before and after
decontamination of the work area, along with successful screening results from both the
PCMs and portal monitors, it was reasonably concluded that the failure to implement
procedural requirements did not result in unaccounted-for exposures or internal intakes that
would exceed established regulatory thresholds. In addition, the licensee plans to investigate
the cause of this failure to follow procedure.
Corrective Action References: AR04857728, NRC ID: Failure to Survey in Event in
IR45650406
Performance Assessment:
Performance Deficiency: The licensees failure to perform personnel contamination surveys
and decontamination following PCM alarms was contrary to procedure NISP-RP-006, and
was a performance deficiency
Screening: The inspectors determined the performance deficiency was more-than-minor
because it was associated with the Program & Process attribute of the Occupational
Radiation Safety cornerstone and adversely affected the cornerstone objective to ensure
the adequate protection of the worker health and safety from exposure to radiation from
radioactive material during routine civilian nuclear reactor operation. Specifically, the failure to
perform personnel contamination surveys and decontamination following PCM alarms did not
ensure the workers sprayed with reactor coolant water over large portions of their bodies,
including the face, were adequately protected.
Significance: The inspectors assessed the significance of the finding using IMC 0609
Appendix C, Occupational Radiation Safety SDP. The safety significance of this issue is
pending the final enforcement decision.
Cross-Cutting Aspect: H.12 - Avoid Complacency: Individuals recognize and plan for the
possibility of mistakes, latent issues, and inherent risk, even while expecting successful
outcomes. Individuals implement appropriate error reduction tools. Specifically, the RPT at
the RCA exit control point failed to recognize the risk of known exposures. Instead of
adhering to procedures, the RPT assumed the workers could successfully exit the RCA with
minimal effort.
Enforcement:
The ROPs significance determination process does not specifically consider willfulness in
its assessment of licensee performance. Therefore, it is necessary to address this violation
which involves willfulness using traditional enforcement to adequately deter non-compliance.
Severity: The NRC has not made an enforcement decision regarding the severity level of
this AV yet.
Violation: TS 5.4.1, Procedures, required, in part, written procedure to be established,
implemented, and maintained, covering the applicable procedures recommended in
Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Regulatory Guide 1.33,
Section 7.e(4) covered Contamination Control and Section 7.e(7) covered Personnel
Monitoring.
The licensee established procedure NISP-RP-006, Personnel Contamination Monitoring,
Revision 1, to address contamination control and personnel monitoring. Sections 5 and 6
12
provided the requirements and process for responding to portal monitor alarms, including
performing surveys and personnel decontamination as necessary. Steps 5.7 through 5.8.4
required detailed surveys be performed with a frisker by an RPT before prescribing
decontamination activities. Step 5.10 required a whole-body count be performed for
contamination on the face. Step 6.3.3 required medical assistance for decontamination
around the eyes.
Contrary to the above, on March 28, 2023, the licensee failed to implement written
procedures covering the applicable procedures recommended in Regulatory Guide 1.33.
Specifically, when at least two workers who had been sprayed with reactor coolant water
alarmed the RCA exit monitors, the licensee did not perform surveys and decontamination
activities in accordance with NISP-RP-006, Sections 5 and 6. An RPT failed to: 1) perform
detailed surveys using a frisker before prescribing decontamination activities; 2) conduct a
whole-body count for contamination on the face; and 3) ensure decontamination of the eye
was performed with medical assistance.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
Licensed SRO Deliberately Failed to Maintain Complete and Accurate Records Related to
RPV Drain Down Event
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not
Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not
Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of
Information, for the failure to maintain complete and accurate information in all material
respects. Specifically, on March 28, 2023, a licensed SRO overseeing Unit 1s outage
work activities became aware of an RPV drain down event due to the mispositioning of the
safety-related HCU accumulator drain valves. Despite this knowledge, for 10 days, the SRO
inaccurately assessed the event by attributing the water spill to broken hoses and willfully
submitted an inaccurate CAP document based on this false pretense on April 6, 2023. The
SRO rectified this inaccurate information on April 7, 2023. This information was material to
the NRC, as it left inspectors unaware of the drain down event and the performance issues
causing it within a timeframe necessary to assess appropriate event response and follow-up
inspection activities.
Description:
On March 28, 2023, during a Unit 1 planned outage, EOs depressurized the CRD
accumulators for surveillance testing using procedure QCOP 0500-04, Inserting Manual Scrams, Revision 14. The EOs did not close the HCU accumulator drain valves after
opening them, contrary to the procedure. Subsequently, control room operators inserted a
manual scram as directed by the procedure, inadvertently initiating a reactor coolant drain
path from the RPV through the open valves. Soon after, field personnel reported water
spraying from HCU drain connections. Upon realizing that the RPV was draining to the
reactor building, control room operators reset the scram, thereby isolating the drain path.
On September 11, 2024, the NRC Office of Investigations finalized its report, Quad Cities 1
Licensee Failed to Document an Operational Event (Case No.: 3-2023-013), concluding that
13
a licensed SRO deliberately sought to conceal information about the operational event.
While overseeing outage activities, the SRO became aware of the RPV drain down caused
by the mispositioning of the safety-related HCU accumulator drain valves. However, from
March 28 to April 7, 2023, the SRO knowingly and falsely attributed the event to failed hoses.
The SRO was assigned to perform a work group evaluation (WGE) causal analysis in
accordance with licensee procedure PA-AA-125, Corrective Action Program (CAP)
Procedure, Revision 8. Step 4.3.5.1 required the SRO to document the problem that resulted
in the issue, and step 4.3.5.2 directed the SRO to state the cause by explicitly answering the
question, why did the issue occur? On April 6, 2023, the SRO knowingly submitted an
inaccurate WGE to their supervisor, which included corrective actions to replace the hoses.
On April 7, 2023, the SRO revised the WGE and informed their supervisor that the event had
actually been caused by mispositioned HCU drain valves. Subsequently, the licensee created
a new issue report under AR 4669057, documenting the Configuration Control event and the
associated inadvertent RPV drain down.
Corrective Actions: The licensee canceled the WGE under AR 4565406 and performed a root
cause evaluation under AR 4669057.
Corrective Action References: AR 4669057, Configuration Control During QCOP 0500-04
Execution
Performance Assessment: None
Enforcement:
The ROPs significance determination process does not specifically consider willfulness in its
assessment of licensee performance. Therefore, it is necessary to address this violation
which involves willfulness using traditional enforcement to adequately deter non-compliance.
Severity: The NRC has not made an enforcement decision regarding the severity level of
this AV yet.
Violation: Title 10 CFR 50.9, Completeness and Accuracy of Information, stated,
Information provided to the Commission by an applicant for a license or by a licensee or
information required by statute or by the Commissions regulations, orders, or license
conditions to be maintained by the applicant or the licensee shall be complete and accurate in
all material respects.
Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings,
stated, Activities affecting quality to 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.
The licensee-established procedure OP-AA-106-101-1001, Event Response Guidelines,
Revision 32, provided instructions for responding to significant plant issues and events.
Step 4.4.2, stated, Review the event to determine if the event is significant and if a prompt
investigation is necessary. Significant equipment failures and human performance events
require equal consideration for prompt investigations.
Contrary to the above, from March 28, 2023, to April 7, 2023, the licensee failed to maintain
accurate information required to be maintained by the Commissions regulations in all
material respects. Specifically, on March 28, 2023, an SRO overseeing Unit 1s outage
14
work activities became aware of an RPV drain down event due to the mispositioning of the
safety-related HCU accumulator drain valves. Despite this knowledge, the SRO deliberately
failed to accurately evaluate or report the event for a period of 10 days. Instead, the SRO
knowingly misattributed the water spill to broken hoses and willfully submitted an inaccurate
WGE on April 6, 2023, based on that false explanation. The SRO did not correct the record
until April 7, 2023.
This information was material to the NRC because it resulted in inspectors being unaware of
the drain down event and the associated performance issues within a timeframe necessary to
assess appropriate event response and determine the need for follow-up inspection activities.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
Failure to Document the RPV Drain Down Event in Operating Logs and CAP
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not
Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not
Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of
Information, for the failure to maintain complete and accurate information. Specifically, on
March 28, 2023, the licensee failed to log an RPV drain down event due to the mispositioning
of safety-related HCU accumulator drain valves. In addition, the licensee failed to document
the Configuration Control issue into the CAP. These incomplete records were material to the
NRC, as they left inspectors unaware of the drain down event within a timeframe necessary
to assess appropriate event response and follow-up inspection activities.
Description:
On March 28, 2023, during a planned Unit 1 outage, EOs depressurized the CRD
accumulators for surveillance testing using procedure QCOP 0500-04, Inserting Manual Scrams, Revision 14. Contrary to the procedure, the EOs did not close the HCU accumulator
drain valves after opening them. Shortly afterward, control room operators inserted a manual scram as directed by the procedure, inadvertently initiating a reactor coolant drain path from
the RPV through the open valves.
Field personnel soon reported water spraying from HCU drain valves. Control room operators
recognized that the RPV was draining to the reactor building and responded by resetting the
scram, which isolated the drain path.
The licensees procedures required documentation of this event. Specifically,
OP-AA-111-101, Operating Narrative Logs and Records, Revision 19, required control room
operators to maintain logs at a level of detail sufficient to reconstruct shift activities without
face-to-face turnover. Section 4.3 contained examples of information to be included in the
control room logs, such as abnormal plant configurations. Additionally, OP-AA-106-101-1001,
Event Response Guidelines, Revision 32, required Configuration Control events to be
documented in the CAP through an issue report. OP-AA-108-112, Plant Status
Configuration, Revision 13, defined Configuration Control events as those involving
mispositioned plant components.
15
On October 15, 2024, following a review of the licensees causal evaluation and interviews
conducted by the NRCs Office of Investigations, inspectors determined that control room
operators recognized the RPV drain down was caused by an abnormal plant configuration.
However, they did not document the event in the control room narrative logs. Inspectors also
found that multiple licensee personnel involved in the incorrect execution of QCOP 0500-04,
and the subsequent recovery actions, were aware that the HCU accumulator drain valves had
been mispositioned, but they did not initiate an issue report.
Corrective Actions: On April 11, 2023, the licensee documented the Configuration Control
event under AR 04669057 and updated the control room logs to reflect the occurrence of the
drain down.
Corrective Action References: AR 04669057, Configuration Control During QCOP 0500-04
Execution
Performance Assessment: None
Enforcement:
The ROPs significance determination process does not specifically consider the regulatory
process impact in its assessment of licensee performance. Therefore, it is necessary to
address this violation which impedes the NRCs ability to regulate using traditional
enforcement to adequately deter non-compliance. Specifically, failures to log the event and
document the Configuration Control issue in the CAP resulted in incomplete licensee records
for activities affecting quality. These incomplete records were material to the NRC, as they
delayed inspectors awareness of the drain down event, hindering timely assessment of event
response and appropriate follow-up inspections.
Severity: The NRC has not made an enforcement decision regarding the severity level of this
AV yet.
Violation: Title 10 CFR 50.9(a), Completeness and Accuracy of Information, stated
Information provided to the Commission by an applicant for a license or by a licensee or
information required by statute or by the Commissions regulations, orders, or license
conditions to be maintained by the applicant or the licensee shall be complete and accurate
in all material respects.
Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings,
stated Activities affecting quality to 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.
The licensee established procedure OP-AA-111-101, Operating Narrative Logs and
Records, Revision 19, as the governing procedure for log entries. Section 4.1 stated, in part,
Maintain records at a level of detail that will allow reconstruction of shift activities by
oncoming personnel that do not have the benefit of a face-to-face discussion of the shift.
Records are a useful aid in troubleshooting and tracking problems that may arise during the
shift. Include as much information as possible for this purpose. Section 4.3 contained
examples of information to be recorded in operations logs, including abnormal plant
configurations.
The licensee-established procedure OP-AA-106-101-1001, Event Response Guidelines,
Revision 32, provided guidance for responding to significant plant issues and events. Step
16
4.4.1, stated, Ensure an IR [issue report] is written for the event. Step 4.4.2 stated, Review
the event to determine if the event is significant and if a prompt investigation is necessary.
Significant equipment failures and human performance events require equal consideration for
prompt investigations. Step 4.4.2 clarified that examples of a significant event include a level
1, 2, or 3 Configuration Control event.
Contrary to the above, from March 28, 2023, through April 11, 2023, the licensee failed to
maintain complete information required to be maintained by the Commissions regulations
in all material respects. Specifically, the licensee did not maintain the operating logs at a level
of detail sufficient to reconstruct shift activities related to the RPV drain down event, an
activity affecting quality, that occurred on March 28, 2023. Furthermore, the licensee did not
ensure an issue report was written, also an activity affecting quality, upon discovering that the
event involved the mispositioning of the safety-related HCU accumulator drain valves. This
event was later classified as a level 3 Configuration Control event. Due to the lack of issue
report, the licensee did not assess whether the event was significant and required prompt
investigation.
These incomplete records were material to the NRC, as they left inspectors unaware of the
drain down event within a timeframe necessary to assess appropriate event response and
follow-up inspection activities.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
Failure to Maintain Complete and Accurate Operating Logs Associated with RPV Drain Time
Cornerstone
Severity
Cross-Cutting
Aspect
Report
Section
Not
Applicable
Apparent Violation
Open
EAF-RIII-2025-0074
Not
Applicable
The inspectors identified an AV of 10 CFR 50.9, Completeness and Accuracy of
Information, for the failure to maintain complete and accurate information. Specifically,
since April 11, 2023, the licensee incorrectly estimated the RPV drain time as 1 to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />,
when it was about 15 minutes, after assessing the RPV drain down event that occurred on
March 28, 2023. As a result, they did not fully document the required TS entries and the
change in shutdown risk status from yellow to red. The incomplete and inaccurate information
was used by the NRC when evaluating its regulatory response to the actual RPV drain down
that occurred on March 28, 2023. Had the information been maintained completely and
accurately by the licensee, it would have likely caused the NRC to undertake further
substantial inquiry, such as additional inspection activities, to better understand the
circumstances and significance of the of the activity that led to the RPV drain down.
Description:
TS 3.5.2, RPV Water Inventory Control, required, in part, that the drain time of RPV water
inventory to TAF be greater than or equal to 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> in Modes 4 and 5. If drain time was less
than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, Condition D required operators to, in part, immediately initiate action to verify
one standby gas treatment subsystem was capable of being placed in operation. If Condition
D was not met or drain time was less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, Condition E required immediate action to
restore drain time to at least 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />.
17
On March 28, 2023, during a planned Unit 1 outage, an RO informally replaced a previously
approved method for depressurizing the HCU accumulators with an unapproved approach
that introduced a single-point vulnerability. The approved method required multiple
independent errors per valve, making widespread valve mispositioning highly unlikely.
In contrast, the unauthorized method allowed for the mispositioning of up to 177
safety-related HCU accumulator drain valves through a single human error. This configuration
reduced the projected RPV drain time to TAF from greater than 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> to approximately
15 minutes.
Due to the informal nature of the change, the licensee did not evaluate the resulting
configuration using procedure QCAP 0260-03, Screening for Reactor Pressure Vessel
Water Inventory Control, Revision 17, and did not enter the applicable TS 3.5.2 conditions.
The ROs decision ultimately resulted in an RPV drain down event.
On April 11, 2023, following its assessment of the event, the licensee made a late entry in the
control room narrative log indicating that TS 3.5.2, Condition D, applied on March 28, 2023,
because the RPV drain time was less than 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> but greater than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. The log claimed
that all TS required actions had been satisfied and concluded there was no impact to
shutdown safety.
On October 15, 2024, inspectors determined that the April 11 log entry contained incomplete
and inaccurate information. Specifically, when inspectors requested the calculation
supporting the RPV drain time estimate, the licensee could not provide documentation for
the original calculation. Upon re-performing the calculation, the licensee determined the
actual RPV drain time was approximately 15 minutes, also requiring entry into Condition E
of TS 3.5.2.
Despite this revised calculation, the licensee incorrectly concluded that Condition D did not
apply concurrently with Condition E. Further inspector engagement led the licensee to
recognize the applicability of both conditions. However, the licensee erroneously concluded
that all actions required under both conditions were satisfied and that they maintained
compliance with TS 3.5.2.
Additionally, the licensee did not assess and log the impact of the drain time miscalculation
on shutdown risk. Specifically, the ROs decision to informally plan the implementation of
QCOP 0500-04 without completing Attachment B led to an unrecognized drain time of less
than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, a condition corresponding to red shutdown safety status as defined in
Attachment 1 of OU-QC-104, Shutdown Safety Management Program Quad Cities Annex,
Revision 23. Per the TS Bases, a drain time under 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> may not allow sufficient operator
response to prevent inventory from reaching TAF.
This inaccurate and incomplete information was material to the NRC because it hindered the
agencys ability to timely evaluate the March 28, 2023, event and its significance. Had the
information been complete and accurate, the NRC would have likely undertaken further
substantial inquiry, such as additional inspection activities, to better understand the
circumstances and significance of the activity that led to the RPV drain down.
Corrective Actions: The licensee entered the issue into the CAP to perform a causal
evaluation. As of April 9, 2025, inspectors observed that the inaccurate control room narrative
log entry made on April 11, 2023, had not been corrected. The licensee subsequently entered
this observation into the CAP to initiate correction of the log entry.
18
Corrective Action References: AR 4810186, Wrong Tech Spec Condition Entered In Logs
on 4/11/23; AR 4855057, NRC ID: Log Entry Required for IRs 4810186 and 4819173
Performance Assessment: None
Enforcement:
The ROPs significance determination process does not specifically consider the regulatory
process impact in its assessment of licensee performance. Therefore, it is necessary to
address this violation which impedes the NRCs ability to regulate using traditional
enforcement to adequately deter non-compliance. Specifically, had the information been
maintained completely and accurately by the licensee, it would have likely caused the NRC
to undertake further substantial inquiry, such as additional inspection activities, to better
understand the circumstances and significance of the of the activity that led to the RPV
drain down.
Severity: The NRC has not made an enforcement decision regarding the severity level of
this AV yet.
Violation: Title 10 CFR 50.9(a), Completeness and Accuracy of Information, stated
Information provided to the Commission by an applicant for a license or by a licensee or
information required by statute or by the Commissions regulations, orders, or license
conditions to be maintained by the applicant or the licensee shall be complete and accurate in
all material respects.
TS 5.4.1, Procedures, stated that written procedures shall be established, implemented, and
maintained, covering the applicable procedures recommended in Regulatory Guide 1.33,
Revision 2, Appendix A, dated February 1978. Regulatory Guide 1.33, Quality Assurance
Program Requirements (Operation), Appendix A, Section 1, Administrative Procedures,
covered procedures for, in part, log entries.
The licensee established procedure OP-AA-111-101, Operating Narrative Logs and
Records, Revision 19, as the administrative procedure for log entries. Section 4.1 states, in
part, Maintain records at a level of detail that will allow reconstruction of shift activities by
oncoming personnel that do not have the benefit of a face-to-face discussion of the shift.
Section 4.3 contained examples of information to be recorded in operations logs, including
technical specification action statements entered or exited unless logged on short duration
time clock logs and changes in online, shutdown, and dry cask storage risk color.
Contrary to the above, since April 11, 2023, the licensee failed to maintain complete and
accurate information required to be maintained by the Commissions regulations in all
material respects. Specifically, after assessing the March 28, 2023, drain down event,
the licensee determined that it involved multiple drain paths below TAF susceptible to a
common mode failure. As a result, RPV drain time needed to be evaluated for compliance
with TS 3.5.2. However, the licensee incorrectly determined that drain time was between
1 and 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, when the correct drain time was approximately 15 minutes. Consequently,
on April 11, 2023, the licensee recorded in the operating logs that Condition D of TS 3.5.2
should have been entered on March 28, 2023. However, they failed to record that Condition E
was also applicable and did not record the resulting change in shutdown safety status from
yellow to red due to the incorrect drain time.
The incomplete and inaccurate information was used by the NRC when evaluating its
regulatory response to the actual RPV drain down that occurred on March 28, 2023. Had the
19
information been maintained completely and accurately by the licensee, it would have likely
caused the NRC to undertake further substantial inquiry, such as additional inspection
activities, to better understand the circumstances and significance of the of the activity that
led to the RPV drain down.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
Failure to Administer Fitness for Duty and Fatigue Testing Following Event
Cornerstone
Significance/Severity
Cross-Cutting
Aspect
Report
Section
Security
Pending
Apparent Violation
Open
EAF-RIII-2025-0074
[H.8] -
Procedure
Adherence
The inspector identified a finding of pending significance and associated AV of
10 CFR 26.31(c)(3) and 10 CFR 26.211(a)(3) for the failure to conduct post-event drug and
alcohol testing and fatigue assessments. Specifically, on March 28, 2023, the licensee did not
administer drug and alcohol tests to individuals after they committed human errors that may
have caused, or contributed to, the Unit 1 RPV drain down event. In addition, the licensee did
not perform a fatigue assessment, as required in response to events that warrant post-event
drug and alcohol testing.
Description:
On March 28, 2023, the licensee experienced a Configuration Control event caused by
human error. This resulted in a significant reduction in RPV drain time, as calculated in
accordance with TS requirements. The condition led to an RPV drain down event without the
TS controls intended to mitigate such an event and, therefore, constituted a potential
substantial degradation of plant safety.
On approximately October 2024, inspectors noted that the licensee did not perform
post-event drug and alcohol testing, as required by 10 CFR 26.31(c)(3) and
10 CFR 26.211(a)(3). These requirements apply to events involving human error by
individuals subject to Part 26, where the error may have caused or contributed to the event.
The purpose of post-event testing is to determine whether drug or alcohol use played a role.
Applicable events include those resulting in an actual or potential substantial degradation of
plant safety. The licensee established SY-AA-102-202, Testing for Cause, Revision 21, to
implement the Fitness for Duty Program.
Corrective Actions: On April 16, 2025, the licensee captured this issue in their CAP after the
inspectors informed them of the issue. The licensee planned to perform an investigation to
determine the cause of this issue.
Corrective Action References: AR04857727, NRC ID: Failure to Administer FFD and Fatigue
Assessment
20
Performance Assessment:
Performance Deficiency: The failure to conduct post-event fitness for duty testing following
the RPV drain down event, which involved human error, was contrary to 10 CFR 26.31(c)(3)
and 26.211(a)(3), and was a performance deficiency.
Screening: The inspectors determined the performance deficiency was more-than-minor
because if left uncorrected, it would have the potential to lead to a more significant safety
concern. Specifically, the failure to conduct post-event drug and alcohol testing and fatigue
assessments would have the potential to allow individuals who were not trustworthy or
reliable to continue performing risk-significant duties without detection.
Significance: The inspectors assessed the significance of the finding using IMC 0609
Appendix E, Part I, Baseline Security SDP for Power Reactors. The safety significance of
this issue is pending the final enforcement decision.
Cross-Cutting Aspect: H.8 - Procedure Adherence: Individuals follow processes, procedures,
and work instructions. Specifically, as addressed by other violations in this report, the
licensee did not follow their event response and CAP procedures following the RPV
drain down event. As a result, the event was not formally recognized, leading to the failure to
conduct post-event fitness for duty testing following the RPV drain down event.
Enforcement:
The ROPs significance determination process does not specifically consider the regulatory
process impact in its assessment of licensee performance. Therefore, it is necessary to
address this violation which impedes the NRCs ability to regulate using traditional
enforcement to adequately deter non-compliance.
Severity: The NRC has not made an enforcement decision regarding the severity level of
this AV yet.
Violation: 10 CFR 26.31(c)(3) stated, in part, that licensees and other entities shall administer
drug and alcohol tests as soon as practical after an event involving a human error that was
committed by an individual who was subject to this subpart, where the human error may have
caused or contributed to the event. It also stated that the individuals who committed the
human errors shall be tested if the event resulted in actual or potential substantial
degradations of the level of safety of the plant.
10 CFR 26.211(a)(3) stated, in part, that post-event, a fatigue assessment must be
conducted in response to events requiring post-event drug and alcohol testing as specified in
10 CFR 26.31(c). Licensees may not delay necessary medical treatment in order to conduct
fatigue assessment.
The licensee established SY-AA-102-202, Testing for Cause, Revision 21, as the
implementing procedure. Section 4.3.6, required, in part, that a fatigue assessment and a
for-cause evaluation be conducted as soon as practical after an event where individual
human error may have caused or contributed to the event if the event resulted in actual or
potential substantial degradation of the plants safety level.
Contrary to the above, on March 28, 2023, the licensee failed to administer drug and alcohol
tests to individuals as soon as practical after an event involving human error they committed,
21
where the human error may have caused or contributed to the event. In addition, the licensee
failed to conduct a fatigue assessment in response to events requiring post-event drug and
alcohol testing. Specifically, the licensee did not administer drug and alcohol tests to
personnel who committed human errors leading to the Unit 1 RPV drain down event, nor did
they perform a fatigue assessment as soon as practical.
Enforcement Action: This violation is being treated as an apparent violation pending a final
significance (enforcement) determination.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
On April 16, 2025, the inspectors presented the NRC inspection results to
David Rhoades, Senior Vice President, and other members of the licensee staff.
22
DOCUMENTS REVIEWED
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Corrective Action
Documents
Unplanned Spread of Contamination - RB1 595'
03/28/2023
Corrective Action
Documents
Configuration Control During QCOP 0500-04 Execution
04/11/2023
Corrective Action
Documents
Resulting from
Inspection
Wrong Tech Spec Condition Entered In Logs on 4/11/23
10/17/2024
Corrective Action
Documents
Resulting from
Inspection
NRC ID: Violation of TS 3.5.2
11/22/2024
Corrective Action
Documents
Resulting from
Inspection
NRC ID: Log Entry Required for IRs 4810186 and 4819173
04/06/2025
Corrective Action
Documents
Resulting from
Inspection
NRC ID: Failure to Administer FFD and Fatigue Assessment
04/16/2025
Corrective Action
Documents
Resulting from
Inspection
NRC ID: Failure to Survey in Event in IR 4565406
04/16/2025
Miscellaneous
Control Room
Unified Log
March 28, 2023, Through April 11, 2023
Procedures
Human Performance Tools and Verification Practices
14
Procedures
Procedure Use and Adherence
7
Procedures
Roles and Responsibilities of On-shift Personnel
13
Procedures
OP-AA-106-101-
1001
Event Response Guidelines
32
Procedures
Plant Status and Configuration
13
23
Inspection
Procedure
Type
Designation
Description or Title
Revision or
Date
Procedures
OP-AA-108-112-
1001
Response to Identified Component Mispositionings
5
Procedures
Operating Narrative Logs and Records
19
Procedures
Operations Refueling Outage Readiness and Execution
10
Procedures
Shutdown Safety Management Program
23
Procedures
OU-QC-104
Shutdown Safety Management Program Quad Cities Annex
23
Procedures
Corrective Action Program (CAP) Procedure
8
Procedures
QCAP 0260-03
Screening For Reactor Pressure Vessel Water Inventory
Control
17
Procedures
QCOP 0500-04
Inserting Manual Scrams
14
Procedures
Testing For Cause
21
Procedures
SY-AA-102-202-
F-01
For Cause Test Evaluation
0
Procedures
Access Authorization Program
17
Corrective Action
Documents
Resulting from
Inspection
Wrong Tech Spec Condition Entered in Logs on 4/11/23
10/14/2024
Corrective Action
Documents
Resulting from
Inspection
NRC ID: Violation of TS 3.5.2
11/22/2024
Miscellaneous
Control Room
Unified Log
March 28, 2023, Through April 11, 2023
Procedures
QCAP 0260-03
Screening For Reactor Pressure Vessel Water Inventory
Control
17