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05000247/FIN-2018003-042018Q3Indian PointInadequate Procedure for Turbine Startup Caused a Reactor TripA self-revealing Green NCV of TS 5.4.1, Procedures, was identified because Entergy did not provide adequate guidance in 2-SOP-26.4, Turbine Generator Startup, Synchronization, Voltage Control, and Shutdown. Specifically, Entergy did not provide adequate procedural direction to ensure the main turbine control oil stop valve Z was in the correct position. As a result, the steam generator water level exceeded the trip setpoint for the main boiler feed pumps which led the operators to insert a manual reactor trip.
05000247/FIN-2018003-032018Q3Indian PointContainment Fan Cooler 24 Through-Wall Service Water Leak Caused by Inadequate Application of Epoxy Coating Resulting in Corrosion and a Safety System Functional Failure of ContainmentA self-revealing Green NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified when Entergy did not ensure that activities affecting quality were prescribed by documented instructions or procedures, of a type appropriate to the circumstances, and that these activities were accomplished in accordance with these instructions, procedures or drawings. Furthermore, Entergy did not ensure that the instructions or procedures included appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Specifically, Entergy did not ensure that the maintenance procedure for applying the internal EneconTM epoxy coating to the 24 fan cooler main cooler supply line elbow was adequate to ensure proper epoxy coating adherence, and Entergy did not adequately verify the coating adherence prior to placing the elbow in service. This resulted in a through-wall leak and a safety system functional failure of containment.
05000247/FIN-2018003-022018Q3Indian PointContainment Fan Coolers 21 and 24 Motor Cooler Elbow Through-Wall Leaks Due to Excessive Service Water Flow Rates and Safety System Functional Failures of ContainmentA self-revealing Green NCV of 10 CFR Part 50, Appendix B, Criterion III, Design Control, was identified when Entergy did not ensure that measures were established for the selection and review for suitability of application of materials, parts, equipment, and processes that are essential to the safety-related functions of the structures, systems, and components. Specifically, in 1998, when the former license-holder for Unit 2 decided to replace the original-construction large-radius, butt-welded elbow joints in the service water motor cooler return lines from the Unit 2 FCUs with a new design (a short radius, socket-weld fitting), these elbow joints were not properly evaluated for suitability of application. The service water flow velocity through the modified FCU return piping was in excess of the vendor-allowable flow velocity limit, which resulted in the gradual erosion of the motor cooler elbow joints, eventually leading to through-wall leaks on an ASME class III piping system inside containment, leading to breaches of containment integrity and safety system functional failures.
05000247/FIN-2018003-012018Q3Indian PointInadequate Procedural Guidance for Spent Fuel Movement and Storage RequirementsThe inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion V, Procedures, when Entergy did not have appropriate documented instructions or written procedures for spent fuel movement and storage requirements adjacent to potentially degraded Boraflex panels. Specifically, configuration restrictions were not addressed in some cases and, therefore, did not comply with controls to meet the criticality analysis of record (CAOR) in 2016; and the resultant revised guidance did not accurately reflect the modeled supporting analysis
05000286/FIN-2018002-012018Q2Indian PointReactor Pressure Boundary Leakage Due to Weld Failure in Reactor Vessel Head Penetration #3A self-revealing Severity Level IV NCV of Technical Specification (TS) 3.4.13.a, Reactor Coolant System Operational Leakage, was identified when Entergy operated the reactor in Mode 1 with pressure boundary leakage for a period of time longer than the allowable limiting condition of operation. Specifically, a leak in the J-weld around reactor pressure vessel (RPV) head penetration #3 occurred during the last operating cycle and was not identified until after the reactor was shutdown for a refueling outage.
05000247/FIN-2017003-012017Q3Indian PointComponent Misalignments for Nuclear Instrumentation P6 Permissive and AFW Flow Transmitter FI-1201 Following Scheduled MaintenanceA self-revealing Green NCV of Technical Specification (TS) 5.4.1, Procedures, with two examples was identified when Entergy failed to implement procedures to ensure correct system alignment for the nuclear instrumentation permissive interlock, P6, and auxiliary feedwater (AFW) flow transmitter, FI-1201. Entergy promptly corrected the alignment issues and entered them into their corrective action program (CAP) as condition report (CR)-IP2-2017-02193 for the P6 permissive interlock and CR-IP2-2017-02150 for the AFW flow transmitter. This performance deficiency is more than minor because it affects the configuration control attribute of the Mitigating System cornerstone to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, in both cases, the instrumentation was left disabled following maintenance such that they could not perform their safety functions required by TSs. Additionally, the first example was similar to IMC 0612, Appendix E, example 2.g, because Entergy changed plant modes from Mode 5 to Mode 2 without ensuring P6 was operable. The second example was similar to IMC 0612, Appendix E, examples 5.a and 5.b, because Entergy failed to return the AFW flow transmitter to service after the refueling outage. The inspectors assigned a cross-cutting aspect in the area of Human Performance, Work Management, because both examples demonstrated a failure in the planning, control, and execution of work, and a lack of coordination between work groups to ensure quality.(H.5)
05000293/FIN-2017002-012017Q2PilgrimFailure to Follow Procedure Requirements for the Control of a Flood Protection BarrierAn NRC-identified Green finding was identified because Entergy personnel did not follow Procedure 1.3.135, Control of Doors, to adequately control a condenser bay flood protection door. Specifically, on May 22, 2017, Entergy personnel failed to control door 25A, which is designed to mitigate condenser bay flooding to preclude adversely impacting the important to safety instrument air system. Entergys short-term corrective actions included closing the door and providing additional operator training. This issue was entered into the CAP as CR 2017-5746. The performance deficiency is more than minor because it is associated with the configuration control attribute of the Mitigating Systems cornerstone and affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding was evaluated using IMC 0609, Appendix A, Exhibit 4, External Events Screening Questions, issued June 19, 2012, with respect to the degraded safety function of the flood barrier door. The finding was determined to be of very low safety significance (Green) because the failure of the flood door was determined to not degrade the instrument air system ability to support the feedwater injection function or the alternate injection through the control rod drive system. This is because the backup diesel driven compressor was available to be started locally and supply the instrument air headers. The finding also did not involve the total loss of any safety function. The finding has a cross-cutting aspect in the area of Human Performance - Procedure Adherence, because Entergy personnel did not follow processes, procedures, and work instructions. Specifically, Entergy personnel did not follow procedural requirements to adequately control flood protection door 25A. (H.8)
05000293/FIN-2017002-022017Q2PilgrimReporting of Unplanned Scrams with Complications Performance Indicator for Feedwater Regulating Valve ScramThe inspectors identified an unresolved item (URI) associated with Entergys reporting of Unplanned Scrams with Complications PI data for the third quarter of 2016. Description. On September 6, 2016, PNPS operators initiated a manual reactor scram based on oscillating feed flow as a result of a malfunction with feedwater regulating valve (FRV) A. As a result of high reactor vessel water level, all of the reactor feed pumps tripped, the HPCI and RCIC systems isolated, and a Group 1 isolation signal was present, initiating closure of the MSIVs. In order to maintain pressure control of the reactor, SRV 3B was manually cycled. This event was reported under Licensee Event Report (LER) 05000293/2016-007-00. During the scram response, PNPS operators were required to use an SRV to maintain reactor pressure control, but Entergys submittal of PI data for the third quarter of 2016 does not count the scram as an Unplanned Scram with Complications, which is required by EN-LI-114, Regulatory Performance Indicator Process. This URI is being opened to determine if a performance deficiency exists pending resolution of the differing interpretation of guidance contained in NEI Document 99-02, Regulatory Assessment Performance Indicator Guidance, Revision 7, at the next scheduled Reactor Oversight Process Working Group Meeting. (URI 05000293/2017002-02, Reporting of Unplanned Scrams with Complications Performance Indicator for Feedwater Regulating Valve Scram)
05000293/FIN-2017002-082017Q2PilgrimLicensee-Identified Violation10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires in part, that activities affecting quality shall be accomplished in accordance with documented procedures. Entergy Procedure EN-OP-104, Operability Determination Process, requires that operators have a reasonable expectation of operability when determining the operability of a component. On April 15, 2017, operators did not have a reasonable expectation of operability, as required by EN-OP-104, and incorrectly declared the B SRM operable without reasonable assurance. This resulted in a violation of TS 3.10.B, Core Alterations, which requires, during core alterations, when fuel is in the vessel, at least 2 SRMs shall be operable, one in the quadrant where fuel or control rods are being moved and one in an adjacent quadrant. Entergy entered this issue into the CAP as CRs 2017-3541, 2017-3952, 2017-5294, and 2017-6724. Entergy repaired the B SRM, and performed a causal evaluation on the equipment failure that includes the late inoperability determination by the operators. The inspectors evaluated this finding using IMC 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix G, Attachment 1, Exhibit 3, Mitigating Systems Screening Questions. The inspectors determined that the finding was of very low safety significance (Green) because the finding did not affect the design or qualification of a system, and did not represent a loss of safety function of a train or system, and did not degrade a functional auto-isolation of RHR on low reactor vessel level.
05000293/FIN-2017002-062017Q2PilgrimSecondary Containment Testing not performed per Technical SpecificationsAn NRC-identified Green NCV of 10 CFR Part 50, Appendix B, Criterion XI, Test Control, and TS 4.7.C, Containment Systems Secondary Containment, was identified when Entergy performed a surveillance test requiring a refueling outage while online. Specifically, Entergy performed Procedure 8.7.3, Secondary Containment Leak Rate Test, TS Surveillance Requirement (SR) 4.7.C from February 27, 1997, to April 5, 2017. As corrective actions, Entergy re-performed the test during the April 2017 refueling outage prior to refueling. This issue was entered into the CAP as CR 2017-2900. The performance deficiency is more than minor because it is associated with the configuration control attribute of the Barrier Integrity cornerstone and adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protects the public from radionuclide releases caused by accidents or events. Specifically, Entergy intentionally removed the safety function of standby gas and secondary containment for operational convenience and did not comply with the requirements of TS SR 4.7.C which requires the test to be performed during a refueling outage before refueling. In accordance with IMC 0609.04, Initial Characterization of Findings, issued October 7, 2016, and Exhibit 3 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, issued June 19, 2012, the inspectors determined that the finding was of very low safety significance (Green), because the finding only represented a degradation of the radiological barrier function provided for the SBGTS. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance - Conservative Bias, in that Entergy personnel did not use decision making-practices that emphasize prudent choices over those that are simply allowable. Specifically, operators did not refer to the TSs to understand the required conditions for a secondary containment surveillance test. Operators followed an inadequate site procedure for the plant conditions at the time and did not question why removal of a safety function for operational convenience was acceptable. (H.14)
05000293/FIN-2017002-052017Q2PilgrimDamper Failure Causes Loss of Secondary ContainmentA self-revealing Green NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, and TS 3.7.C.2, Containment Systems Secondary Containment, was identified because Entergy did not establish an appropriate interval to overhaul the secondary containment isolation dampers. As a result, the refueling floor supply isolation dampers were operated beyond the recommended overhaul interval and subsequently failed. Entergys corrective actions included cleaning, lubricating, and post-work testing the failed refueling floor supply isolation dampers. This issue was entered into the CAP as CR 2017-0494. The performance deficiency is more than minor because it is associated with the SSC and barrier performance attribute of the Barrier Integrity cornerstone and adversely affected the cornerstone objective of providing reasonable assurance that physical design barriers (containment) protect the public from radionuclide releases caused by accidents or events. Specifically, Entergys preventative maintenance (PM) for the refueling floor supply isolation dampers was inadequate to ensure the availability and reliability of SSCs required to maintain secondary containment operable. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 3 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, the inspectors determined that this finding was of very low safety significance (Green) because the performance deficiency only represented a degradation of the radiological barrier function provided by the reactor building and standby gas treatment system (SBGTS). The finding has a cross-cutting aspect in the area of Problem Identification and Resolution - Resolution, in that Entergy personnel did not take effective corrective actions to address issues in a timely manner. Specifically, in 2016, Entergy personnel identified there were deficiencies in the PM program with technical justifications for deferring PMs. Entergy reasonably had the opportunity to identify which PMs were not performed within recommended guidelines and make appropriate changes as needed. (P.3)
05000293/FIN-2017002-042017Q2PilgrimImproper System Restoration Results in Suppression Pool InoperabilityA self-revealing Green NCV of TS 5.4.1.a, Procedures, was identified on March 31, 2017, when operators did not follow procedures and caused an inadvertent increase in the suppression pool water level. The inspectors determined that the operators did not restore the core spray system valve line-up as prescribed in Attachment 11 of Entergy Procedure 2.2.20, Core Spray, and the maintenance safety tag clearance sheet. Operator implementation of these documents is directed by Entergy Procedure EN-OP-102, Protective Caution Tagging, section 5.19(4)(b). As corrective actions, Entergy performed additional management oversight of control room operations and performed a root cause evaluation (RCE). This issue was entered into the CAP as CR-2017-2785. The performance deficiency is more than minor because it is associated with the equipment reliability attribute of the Mitigating Systems cornerstone objective 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, the out of specification conditions on March 31, 2017, impacted suppression pool reliability because the suppression pool was not maintained within parameters required to ensure operability. Additionally, significant analysis was necessary to show the suppression pool and associated supports remained functional when TS requirements were not met. Using IMC 0609, Appendix A, Exhibit 2, issued June 19, 2012, The Significance Determination Process for Findings At-Power, the inspectors determined the finding was of very low safety significance (Green) because the finding did not affect the design or qualification of a mitigating structure, system, or component (SSC), the finding did not represent a loss of system and/or function, the finding did not represent an actual loss of a function of a single train for greater than the TS allowed outage time (AOT), and the finding did not represent an actual loss of a function of one or more non-TS trains of equipment. Specifically, the suppression pool, including downcomers and supports, remained functional following the influx of water. The finding has a cross-cutting aspect in the area of Human Performance - Procedure Adherence, because Entergy personnel did not follow processes, procedures, and work instructions. Specifically, Entergy personnel did not follow procedures and work instructions during the restoration of the core spray system. (H.8)
05000293/FIN-2017002-032017Q2PilgrimInaccurate Suppression Pool Water Level Instrument not Identified during Post-event Prompt InvestigationAn NRC-identified Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion XVI, Corrective Action, was identified because Entergy staff did not identify and correct a condition adverse to quality related to suppression pool water level indication when the A suppression pool wide range instrument provided inaccurate level indication during the inadvertent suppression pool water level increase event on March 31, 2017. As corrective actions, Entergy entered Technical Specification (TS) 3.2.F, Protective Instrumentation - Surveillance Information Readouts, and repaired the instrument. This issue was entered into Entergys corrective action program (CAP) as condition report (CR) 2017-2965. The performance deficiency is more than minor because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, inaccurate level indication during off-normal changing level conditions in the suppression pool could result in operator actions not warranted by plant conditions. The finding is also associated with the Initiating Events cornerstone. Using IMC 0609, Appendix A, Exhibit 1, issued June 19, 2012, The Significance Determination Process for Findings At-Power, the inspectors determined the finding was of very low safety significance (Green) because the finding did not cause a reactor trip and a loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. This finding has a cross-cutting aspect in the area of Problem Identification and Resolution - Identification, because the Entergy organization did not demonstrate an appropriately low threshold for entering problems into their CAP. Specifically, Entergys prompt investigation of the inadvertent suppression pool level increase event did not identify that the A suppression pool wide range level instrument was not indicating properly and required corrective maintenance. (P.1)
05000293/FIN-2017002-072017Q2PilgrimUntimely 10 CFR 50.72 Notification of a Secondary Containment System Functional FailureAn NRC-identified SL IV NCV of 10 CFR 50.72, Immediate Notification Requirements for Operating Nuclear Power Reactors, was identified because both trains of the SBGTS were made inoperable during surveillance testing, and the condition was not reported to the NRC within eight hours of the occurrence, as required by 10 CFR 50.72(b)(3)(v), Event or Condition that Could Have Prevented Fulfillment of a Safety Function. Specifically, on April 5, 2017, while performing TS SR 4.7.C, trains A and B of the SBGTS were made inoperable leading to the inoperability of the Secondary Containment System (SCS). As a corrective action, Entergy personnel performed a causal evaluation. This issue was entered into the CAP as CR 2017-7446. The inspectors evaluated this performance deficiency in accordance with the traditional enforcement process because the issue impacted the regulatory process, in that a condition that could have prevented a safety function was not reported to the NRC within the required timeframe, thereby delaying the NRCs opportunity to review the matter. Using Example 6.9.d.9 from the NRC Enforcement Policy (the failure of a licensee to make a report as required by 10 CFR 50.72 or 10 CFR 50.73), the inspectors determined that the violation was a SL IV violation. Because this violation involves the traditional enforcement process and does not have an underlying technical violation, inspectors did not assign a cross-cutting aspect, in accordance with IMC 0612, Appendix B.
05000293/FIN-2016009-012016Q2PilgrimFailure to Correct a Condition Adverse to Quality Associated with the Salt Service Water SystemThe inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion XVI, Corrective Action, because Entergy did not ensure that an identified condition adverse to quality related to maintenance work on the salt service water (SSW) pumps was corrected. Specifically, Entergy did not implement a procedure change to require installation of additional anti-rotation pins. This procedure change was specified as a corrective action in an equipment apparent cause evaluation (E-ACE) (condition report (CR)-2015-09189), and addressed the assembly of a pump component relied upon to maintain operability of the SSW system. As immediate corrective action, Entergy captured this issue in their CAP as CR-2016-02401, CR-2016-02446, and CR-2016-02454. Additionally, Entergy implemented the necessary procedure change and ensured additional anti-rotation pins were installed during the most recent rebuilds of the A and B SSW pumps. The finding was more than minor because it was associated with the procedure quality attribute of the Mitigating Systems cornerstone, and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the absence of additional anti-rotation pins contributed to the failure of the spider bearings, which led Entergy to declare the A SSW pump inoperable on November 7, 2015. Absent a procedure change identified as a corrective action for this condition that required installation of additional anti-rotational pins, this vulnerability continued to exist, which could contribute to subsequent spider bearing failure, thereby rendering a SSW pump inoperable. In accordance with IMC 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, the inspectors determined that this finding was of very low safety significance (Green) because the performance deficiency was not a design or qualification deficiency, and did not involve an actual loss of a safety function of a single train for greater than its technical specification allowed outage time. The inspectors determined that this finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Resolution, because Entergy failed to ensure that established corrective actions adequately resolved and corrected the identified issues in a manner commensurate with their safety significance. Specifically, Entergy did not ensure that the corrective action taken adequately captured the intent of the corrective action as prescribed in the E-ACE. Furthermore, four CR closeout barriers within Entergys CAP failed to recognize and correct the issue.
05000443/FIN-2016002-012016Q2SeabrookAutomatic Initiation of Emergency Feedwater Resulting from Performance of Procedural Steps in a Manner Prohibited by Documented InstructionsA self-revealing Green NCV of 10 CFR, Appendix B, Criterion V, Instructions Procedures, and Drawings, was identified, because NextEra did not ensure that activities affecting quality were accomplished in accordance with documented instructions. Specifically, while implementing a procedure following a plant trip that occurred on March 2, 2016, NextEra staff performed steps of a procedure in a manner that was prohibited by a departmental instruction, leading to an automatic initiation of emergency feedwater (EFW) to maintain adequate steam generator (SG) level. NextEra entered this issue into their corrective action program (CAP) and subsequently initiated a root cause evaluation to determine the factors which contributed to the event. Additionally, NextEra took corrective actions (C/As) to provide additional training and guidance for their staff and to resolve issues with existing procedures, which were determined to have been contributing factors during the event. The inspectors determined that this performance deficiency was more than minor because it was associated with the Human Performance attribute of the Initiating Events cornerstone, and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability (loss of FW) and challenge critical safety functions during shutdown as well as power operations. In accordance with IMC 0609, Attachment 4, Initial Characterization of Findings, and IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, the inspectors determined that this finding was of very low safety significance (Green) because the performance deficiency did not cause the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance, Challenge the Unknown, because NextEra did not ensure that individuals stopped when faced with uncertain conditions. Specifically, the individuals involved did not adequately challenge the basis for a decision to disregard a department instruction.
05000443/FIN-2016002-022016Q2SeabrookMultiple Letdown Isolations Resulting from an Inadequate Procedure and the Performance of Steps Not Prescribed by Established ProceduresA self-revealing Green NCV of 10 CFR, Appendix B, Criterion V, Instructions Procedures, and Drawings, was identified because NextEra did not ensure that activities affecting quality were prescribed by documented procedures of a type appropriate to the circumstances and that these activities were accomplished in accordance with these procedures. Specifically, a procedure associated with the testing of safety-related containment isolation functions did not contain sufficient instruction to ensure proper control of plant configuration; thus implementation of this procedure resulted in an inadvertent letdown isolation. Additionally, while attempting to perform this test on a subsequent occasion, individuals performed additional steps not prescribed in the associated procedure; the execution of these additional steps resulted in an additional inadvertent letdown isolation. NextEra entered these issues into their CAP and subsequently performed apparent cause evaluations for the two events, made necessary changes to the associated procedure, and provided coaching to NextEra staff. The inspectors determined that this performance deficiency was more than minor because it was associated with the Procedure Quality and Human Performance attributes of the Initiating Events cornerstone and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability (letdown isolation) during power operations. In accordance with IMC 0609, Attachment 4, Initial Characterization of Findings, and IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, the inspectors determined that this finding was of very low safety significance (Green) because the performance deficiency did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance, Procedural Adherence, because NextEra failed to ensure that individuals followed processes and procedures appropriately.
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