ML11269A146: Difference between revisions
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
||
Line 18: | Line 18: | ||
{{#Wiki_filter:San Onofre Nuclear Generating Station 2008 End-of-Cycle Plant Safety Performance Summary Assessment Period: January 1, 2008 -December 31, 2008 1. Operatinqc Summary.A. Power Operations | {{#Wiki_filter:San Onofre Nuclear Generating Station 2008 End-of-Cycle Plant Safety Performance Summary Assessment Period: January 1, 2008 -December 31, 2008 1. Operatinqc Summary.A. Power Operations | ||
-Noteworthy Unplanned Operating Events and Forced Outages Unit 2 Power Operations January 18, 2008 Commenced reactor startup January 22 Power at 95 percent and ascending January 23 Power reduced to 65 percent due to emergent maintenance activities January 25 Power returned to 96 percent and ascended to 98 percent February 12 Power reduced to 90 percent for emergent work on second point feedwater heater February 13 Reactor returned to full power April 10 Power reduced to 65 percent to troubleshoot main feedwater pump turbine April 14 Reactor returned to full power May 31 Reactor was shutdown for additional troubleshooting of main transformer insulator replacements June 3 Reactor returned to full power June 5 Reactor was tripped during stator water low flow testing June 10 Reactor returned to full power September 22 Power reduced to 65 percent to repair main feedwater Turbine K005 lube oil pipe flange leak September 26 Reactor returned to full power December 28 Reactor shutdown for a scheduled midcycle outage.Intorifltion ih this record wasdel in accordance with t r Act, exem tion , | -Noteworthy Unplanned Operating Events and Forced Outages Unit 2 Power Operations January 18, 2008 Commenced reactor startup January 22 Power at 95 percent and ascending January 23 Power reduced to 65 percent due to emergent maintenance activities January 25 Power returned to 96 percent and ascended to 98 percent February 12 Power reduced to 90 percent for emergent work on second point feedwater heater February 13 Reactor returned to full power April 10 Power reduced to 65 percent to troubleshoot main feedwater pump turbine April 14 Reactor returned to full power May 31 Reactor was shutdown for additional troubleshooting of main transformer insulator replacements June 3 Reactor returned to full power June 5 Reactor was tripped during stator water low flow testing June 10 Reactor returned to full power September 22 Power reduced to 65 percent to repair main feedwater Turbine K005 lube oil pipe flange leak September 26 Reactor returned to full power December 28 Reactor shutdown for a scheduled midcycle outage.Intorifltion ih this record wasdel in accordance with t r Act, exem tion , | ||
Unit 3 Power Operations February 4, 2008 Power reduced to 65 percent following failure of feed pump turbine speed control February 8 Reactor returned to full power April 16 Reactor was shutdown for a planned midcycle outage May 13 Reactor was returned to 80 percent power May 30 Reactor returned to full power August 14 Power was reduced to 65 percent to repair main feedwater Turbine K006 trip mechanism August 18 Reactor returned to full power September 1 Reactor was shutdown to comply with Technical Specification 3.8.1 limiting condition for operation for an inoperable emergency diesel generator. | Unit 3 Power Operations February 4, 2008 Power reduced to 65 percent following failure of feed pump turbine speed control February 8 Reactor returned to full power April 16 Reactor was shutdown for a planned midcycle outage May 13 Reactor was returned to 80 percent power May 30 Reactor returned to full power August 14 Power was reduced to 65 percent to repair main feedwater Turbine K006 trip mechanism August 18 Reactor returned to full power September 1 Reactor was shutdown to comply with Technical Specification | ||
====3.8.1 limiting==== | |||
condition for operation for an inoperable emergency diesel generator. | |||
September 11 Following emergency diesel generator repairs, commenced reactor startup September 13 Reactor at full power September 17 Power reduced to 98 percent due to a tripped heater drain pump September 20 Power reduced to 75 percent to alleviate an extraction steam line bellow leak and to accommodate condenser tube leak repairs.October 12 Reactor shutdown for refueling outage December 15 Commenced reactor start up December 20 Reactor reaches 65 percent were it remained due to restrictions caused by a main feedwater pump being out of service December 24 Reactor at full power B. Planned Outages -Noteworthy Unplanned Outage Events Unit 2 Planned Outages -Reactor was shutdown on December 28, 2008 for a planned midcycle outage. This outage was to perform weld overlays of piping in accordance with industry guidance. | September 11 Following emergency diesel generator repairs, commenced reactor startup September 13 Reactor at full power September 17 Power reduced to 98 percent due to a tripped heater drain pump September 20 Power reduced to 75 percent to alleviate an extraction steam line bellow leak and to accommodate condenser tube leak repairs.October 12 Reactor shutdown for refueling outage December 15 Commenced reactor start up December 20 Reactor reaches 65 percent were it remained due to restrictions caused by a main feedwater pump being out of service December 24 Reactor at full power B. Planned Outages -Noteworthy Unplanned Outage Events Unit 2 Planned Outages -Reactor was shutdown on December 28, 2008 for a planned midcycle outage. This outage was to perform weld overlays of piping in accordance with industry guidance. | ||
Unit 3 Planned Outages -Reactor was shutdown on October 12, 2008 for refueling outage 3R15. The unit started up on December 15, 2008.Upcoming RFOs Unit 2 -2R16: October 2, 2009 -January 20, 2010 2. Safety Performance Overview A. Previous Assessment Results 1st Qtr 2008 2 nd Qtr 2008 3 rd Qtr 2008 Action Matrix Licensee Response Licensee Response Licensee Response Column Basis All findings and Pi's All findings and Pl's All findings and Pl's were Green. were Green. were Green.Summary of results from Previous Mid-Cycle Letter Plant performance from the Mid-Cycle assessment period was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).B. Proposed 2008 End-of-Cycle Assessment Plant performance for the most recent quarter for Unit 2 was in the Regulatory Response Column of the NRC's Action Matrix, based on one inspection finding being classified as having low to moderate safety significance (White) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green). On August 4, 2008, the NRC commenced a special inspection at Southern California Edison to inspect activities associated with deficient electrical connections with the potential to adversely affect the safety function of multiple safety systems used for accident mitigation. | Unit 3 Planned Outages -Reactor was shutdown on October 12, 2008 for refueling outage 3R15. The unit started up on December 15, 2008.Upcoming RFOs Unit 2 -2R16: October 2, 2009 -January 20, 2010 2. Safety Performance Overview A. Previous Assessment Results 1st Qtr 2008 2 nd Qtr 2008 3 rd Qtr 2008 Action Matrix Licensee Response Licensee Response Licensee Response Column Basis All findings and Pi's All findings and Pl's All findings and Pl's were Green. were Green. were Green.Summary of results from Previous Mid-Cycle Letter Plant performance from the Mid-Cycle assessment period was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).B. Proposed 2008 End-of-Cycle Assessment Plant performance for the most recent quarter for Unit 2 was in the Regulatory Response Column of the NRC's Action Matrix, based on one inspection finding being classified as having low to moderate safety significance (White) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green). On August 4, 2008, the NRC commenced a special inspection at Southern California Edison to inspect activities associated with deficient electrical connections with the potential to adversely affect the safety function of multiple safety systems used for accident mitigation. |
Revision as of 18:17, 13 October 2018
ML11269A146 | |
Person / Time | |
---|---|
Site: | San Onofre ![]() |
Issue date: | 09/23/2011 |
From: | - No Known Affiliation |
To: | Office of Information Services |
References | |
FOIA/PA-2011-0159 | |
Download: ML11269A146 (20) | |
Text
San Onofre Nuclear Generating Station 2008 End-of-Cycle Plant Safety Performance Summary Assessment Period: January 1, 2008 -December 31, 2008 1. Operatinqc Summary.A. Power Operations
-Noteworthy Unplanned Operating Events and Forced Outages Unit 2 Power Operations January 18, 2008 Commenced reactor startup January 22 Power at 95 percent and ascending January 23 Power reduced to 65 percent due to emergent maintenance activities January 25 Power returned to 96 percent and ascended to 98 percent February 12 Power reduced to 90 percent for emergent work on second point feedwater heater February 13 Reactor returned to full power April 10 Power reduced to 65 percent to troubleshoot main feedwater pump turbine April 14 Reactor returned to full power May 31 Reactor was shutdown for additional troubleshooting of main transformer insulator replacements June 3 Reactor returned to full power June 5 Reactor was tripped during stator water low flow testing June 10 Reactor returned to full power September 22 Power reduced to 65 percent to repair main feedwater Turbine K005 lube oil pipe flange leak September 26 Reactor returned to full power December 28 Reactor shutdown for a scheduled midcycle outage.Intorifltion ih this record wasdel in accordance with t r Act, exem tion ,
Unit 3 Power Operations February 4, 2008 Power reduced to 65 percent following failure of feed pump turbine speed control February 8 Reactor returned to full power April 16 Reactor was shutdown for a planned midcycle outage May 13 Reactor was returned to 80 percent power May 30 Reactor returned to full power August 14 Power was reduced to 65 percent to repair main feedwater Turbine K006 trip mechanism August 18 Reactor returned to full power September 1 Reactor was shutdown to comply with Technical Specification
3.8.1 limiting
condition for operation for an inoperable emergency diesel generator.
September 11 Following emergency diesel generator repairs, commenced reactor startup September 13 Reactor at full power September 17 Power reduced to 98 percent due to a tripped heater drain pump September 20 Power reduced to 75 percent to alleviate an extraction steam line bellow leak and to accommodate condenser tube leak repairs.October 12 Reactor shutdown for refueling outage December 15 Commenced reactor start up December 20 Reactor reaches 65 percent were it remained due to restrictions caused by a main feedwater pump being out of service December 24 Reactor at full power B. Planned Outages -Noteworthy Unplanned Outage Events Unit 2 Planned Outages -Reactor was shutdown on December 28, 2008 for a planned midcycle outage. This outage was to perform weld overlays of piping in accordance with industry guidance.
Unit 3 Planned Outages -Reactor was shutdown on October 12, 2008 for refueling outage 3R15. The unit started up on December 15, 2008.Upcoming RFOs Unit 2 -2R16: October 2, 2009 -January 20, 2010 2. Safety Performance Overview A. Previous Assessment Results 1st Qtr 2008 2 nd Qtr 2008 3 rd Qtr 2008 Action Matrix Licensee Response Licensee Response Licensee Response Column Basis All findings and Pi's All findings and Pl's All findings and Pl's were Green. were Green. were Green.Summary of results from Previous Mid-Cycle Letter Plant performance from the Mid-Cycle assessment period was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).B. Proposed 2008 End-of-Cycle Assessment Plant performance for the most recent quarter for Unit 2 was in the Regulatory Response Column of the NRC's Action Matrix, based on one inspection finding being classified as having low to moderate safety significance (White) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green). On August 4, 2008, the NRC commenced a special inspection at Southern California Edison to inspect activities associated with deficient electrical connections with the potential to adversely affect the safety function of multiple safety systems used for accident mitigation.
In Inspection Report 2008013, the NRC issued a violation of low to moderate safety significance (White) for the failure to establish appropriate instructions for performing maintenance activities on a safety-related 125 Vdc station battery breaker. The NRC will be conducting Supplemental Inspection 95001,"Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area." Plant performance for the most recent quarter for Unit 3 was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).Therefore, we plan to conduct reactor oversight process (ROP) baseline inspections.
ý(b)(5)3. Inspection and Performance Indicator Results A. Results by Cornerstones Initiating Events Inspection Findings:
Six green NCV's and two green findings were evaluated by inspectors during this assessment period.1) Green FIN -Maintenance personnel failed to adequately adjust bearing oil pressure to a Unit 2 main feedwater pump, causing the main feedwater pump to trip and leading to an unplanned power reduction (HP, IR 2008002-01, PIM# 79196)2) Green NCV -Licensee failed to have adequate procedures in place to ensure troubleshooting associated with a proportional heater bank would not adversely impact plant stability, resulting in a pressurizer pressure transient (HP, IR 2008003-02, PIM#79215)3) Green NCV -Licensee failed to understand, monitor and perform a Unit 2 reactivity manipulation in accordance with procedural requirements, resulting in overfeeding of both steam generators and an inadvertent addition of positive reactivity during a planned startup (HP, IR 2008003-03, PIM# 79216) sO "ive te / i9e0e io~!Jnf ýatiý4) Green NCV -Licensee failed to implement procedural guidance to ensure a Unit 2 power reduction was properly performed, resulting in the reduction of secondary power faster than that of primary power, leading to a steam generator low pressure pre-trip annunciator (HP, IR 2008003-06, PIM# 79219)5) Green NCV -Licensee failed to follow procedures for nuclear fuel movement in the spent fuel pool, resulting in the placement of spent fuel assemblies into storage locations different from those evaluated and approved by the procedure (HP, IR 2008004-01, PIM# 79227)6) Green NCV -Licensee failed to consider the risk associated with the increased likelihood of an initiating event during emergent work on energized safety-related 125 Vdc battery breakers (HP, IR 2008013-04, PIM# 79232)7) Green NCV -Licensee took ineffective corrective actions to address blended flow evolutions, resulting in multiple reactivity excursions occurring in the plant over the past two years (PI&R, IR 2008010-07, PIM# 79246)8) Green Finding -Licensee failed to perform an adequate inspection of a main generator stator water pump discharge check valve, resulting in an unrecognized degraded condition that caused a main generator trip and subsequent reactor trip (PI&R, IR 2008005-01, PIM# 79252)Performance Indicators:
All performance indicators were Green throughout the assessment period.Mitigating Systems Inspection Findings:
Nineteen NCV's, one severity level IV violation and one white violation were evaluated by inspectors during this assessment period.1) Green NCV -Failure to meet operability determination procedural requirements following unexplained load swings on emergency diesel generator (PI&R, IR 2008006-01, PIM# 79210)2) Green NCV -Failure to provide adequate guidance for evaluating momentary transients while performing emergency diesel generator surveillance testing (HP, IR 2008006-02, PIM# 79211)3) Green NCV -Licensee failed to follow procedure for saltwater cooling system alignments.
An air equalizing supply valve was not secured closed contrary to procedural requirements (PI&R, IR 2008003-01, PIM# 79214)4) Green NCV -Licensee failed to follow procedures and adequately evaluate the operability of the Unit 2 component cooling water system when unexpected, rapid heat exchanger fouling occurred during low tide conditions (HP, IR 2008003-04, PIM# 79217)
M s iti nIr Pe esna or o 5) Green NCV -Licensee failed to have adequately pre-planned procedures in place to ensure valve maintenance would not adversely impact plant performance and reliability.
This resulted in a replaced saltwater cooling butterfly valve not being properly aligned and not performing post-maintenance testing to verify the proper function of the valve prior to return to service. (HP, IR 2008003-05, PIM# 79218)6) Green NCV -Licensee failed to follow procedures after notification that Battery 2B008 terminal voltage was less than required Technical Specification value, resulting in more than a two hour delay in entering the required 2-hour technical specification action statement (HP, IR 2008013-01, PIM# 79233)7) Green NCV -Licensee failed to follow procedures, resulting in troubleshooting activities that were performed without a maintenance order and control room authorization (HP, IR 2008013-02, PIM# 79234)8) Green NCV -Licensee failed to follow procedures, resulting in commencing work to correct the identified degraded electrical condition prior to having the appropriately authorized maintenance order (HP, IR 2008013-03, PIM# 79235)9) White Violation
-Licensee failed to establish appropriate instructions for performing maintenance activities on safety-related 125 Vdc breaker, resulting in an electrical connection whose integrity was inadequate to ensure the equipment would be able to perform its safety function (HP, IR 2008013-05, PIM# 79236)10) SL-IV NCV -Licensee failed to submit a required Licensee Event Report within 60 days after discovering an event requiring a report, specifically safety-related 125 Vdc battery 2B008, which had been inoperable for greater than the technical specification allowed outage time (PI&R, IR 2008013-06, PIM# 79237)11) Green NCV -Licensee failed to establish measures to assure that deficient electrical connections were promptly identified and corrected (PI&R, IR 2008013-08, PIM# 79238)12) Green NCV -Licensee failed to provide procedural guidance to operations personnel to combat and recover from a loss or degradation of a Class 1 E 125 Vdc bus (IR 2008013-09, PIM# 79239)13) Green NCV -Licensee had no procedures to verify periodic heat treatments of intake tunnel and structure was consistent with historical data, resulting in the design basis calculation and operating instructions not ensuring the capability of the heat exchangers to perform their design function during anomalous conditions (IR 2008010-01, PIM# 79241)14) Green NCV -Licensee failed to consider and analyze the voltage drop that occurs in control circuit elements that could result in considerably lower voltage at the devices than is available at the corresponding distribution panels (IR 2008010-02, PIM# 79242)
- 15) Green NCV -Licensee failed to recognize, evaluate, or write an action request when the performance test for a station battery was terminated early due to test equipment issues (IR 2008010-04, PIM# 79245)16) Green NCV -Licensee failed to follow procedures while performing battery performance tests, resulting in the performance tests for one station battery being terminated early instead of continuing the tests until reaching one of the test termination criteria (HP, IR 2008010-05, PIM# 79243)17) Green NCV -Licensee had inadequate procedures that did not identify the deleterious effects of 480 Volt AC system grounds on connected equipment (IR 2008010-06, PIM# 79244)18) Green NCV -Licensee failed to have adequate procedures, resulting in an inadvertent electrical ground on a safety-related electrical distribution bus (HP, IR 2008012-01, PlM# 79248)19) Green NCV -Licensee failed to properly evaluate a degraded relay that affected the operability of Unit 3 Train A emergency diesel generator (HP, IR 200801.2-02, PIM#79249)20) Green NCV -Licensee failed to consider the impact to the auxiliary feedwater pump room's heat load design basis calculation for the most limiting scenario (IR 2008012-03, PIM# 79250)21) Green NCV- Licensee failed to resolve degraded or nonconforming conditions at the first available opportunity or appropriately justify a longer completion schedule (PI&R, IR 2008005-02, PIM# 79253)Performance Indicators:
All performance indicators were Green throughout the assessment period.Barrier Integrity Inspection Findings:
One green NCV was evaluated by inspectors during this assessment period.1) Green NCV -Licensee did not properly implement procedural controls to adequately evaluate or repair a degraded source handling tool used in the spent fuel, resulting in the tool being returned to service still in a degraded condition (PI&R, IR 2008005-03, PIM#79254)Performance Indicators:
All performance indicators were Green throughout the assessment period.
Emergency Preparedness Inspection Findings:
No findings were evaluated by inspectors during this assessment period.Performance Indicators:
All performance indicators were Green throughout the assessment period.Occupational Radiation Safety Inspection Findings:
No findings were evaluated by inspectors during this assessment period.Performance Indicators:
All performance indicators were Green throughout the assessment period.Public Radiation Safety Inspection Findings:
No findings were evaluated by inspectors during this assessment period.Performance Indicators:
All performance indicators were Green throughout the assessment period.4. Adverse Trends in Cross-cutting areas A. SCWE- Allegations Received Between January, 2008 -December 21, 2008 or NRC letters to Licensee Twenty-eight allegations were received and/or closed during the past twelve months.The NRC has not sent any letters to Southern California Edison regarding SCWE. The following lists the concerns associated with SCWE.1. Alleger believes that (s)he was discriminated against for raising various safety concerns.
(2008-A-0035)
- 2. Two individuals separately contacted the NRC claiming that they had been subjected to discrimination after raising safety concerns.
(2008-A-0062)
- 3. An individual was yelled at, intimidated, and questioned as to why this individual raised a safety concern. (2008-A-083)
- 4. Allegation received 06/22/2008 associated with safety culture. (2008-A-0089)
- 5. Discrimination for raising safety concerns.
(2008-A-01 11)6. Employees discouraged from raising concerns.
(2008-A-01 14)7. Schedule pressure to violate procedures.
(2008-A-0128)
- 8. Alleger believes that (s)he was discriminated against for raising various concerns.(2008-A-0141)
- 9. Operators intimidated to work unfit for duty., (2008-A-0152)
- 10. Allegation is associated with a chilled environment.
(2008-A-0163)
The following is a list of all allegations received and/or closed in the past twelve months: 1. Procedural requirements were not being met. (2007-A-01 33)2. Licensed operator inattentive to duty. (2007-A-0134)
- 3. Employee discrimination for raising safety concerns.
(2007-A-0150)
- 4. Individuals signed for inspections they did not perform. (2008-A-0024)
- 5. Operator was inattentive to duty. (2008-A-0032)
- 6. Employee discrimination for raising safety concerns.
(2008-A-0035)
- 7. HP manipulated barrier to allow workers through area. (2008-A-0037)
- 8. Employee discrimination for raising safety concerns.
(2008-A-0062)
- 10. Safety culture allegation.
(2008-A-0089)
- 11. Failing to display ID at gate. (2008-A-0099)
- 12. Employee knowingly made non-code repairs. (2008-A-0105)
- 13. Unescorted access concerns.
(2008-A-0109)
- 14. Emergent work performed outside process. (2008-A-01 10)15. Discrimination for raising safety concerns.
(2008-A-01 11)16. SWC pump replacement not performed per procedures.
(2008-A-0113)
- 17. Employees discouraged from raising concerns.
(2008-A-0114)
- 18. Potential willful violation of battery surveillance procedure.
(2008-0117)
- 19. Inadequate HP survey. (2008-A-0118)
- 20. Excessive overtime.
(2008-A-0127)
- 21. Schedule pressure to violate procedures.
(2008-A-0128)
- 22. Inadequate paint prep for SWC valves. (2008-A-0141)
- 23. Potential willful violation of operator FFD rules. (2008-A-01 50)24. Weld rods stored improperly.
(2008-A-0151)
- 25. Operators intimidated to work unfit for duty. (2008-A-01 52)26. Overtime concern, potential SCWE. (2008-A-0156)
- 27. Radon and alpha exposure not accounted for. (2008-A-0157).
- 28. ERO qualification status not tracked. (2008-A-0163)
Conclusion Though there are a few allegations on the subject of SCWE, no trends have been identified.
Licensee plans to conduct a safety culture assessment in March 2009.B. Human Performance-PIM Entries Between January 1, 2008 -December 31, 2008 Conclusion
--- --- (b)(5)
(b)(5)Details Three of the sixteen findings in the cross-cutting area of human performance were within the resources component.
All three had the common theme of not providing complete, accurate and up-to-date design documentation and procedures (H.2(c)), one finding was safety significant (White). This contributing cause was first noticed in the second quarter of the 12-month inspection cycle and continued throughout the wiod ith two new findings in this aspect occurring during the most recent quarter.!(b)(5)Six of the sixteen findings in the cross-cutting area of human performance were within the work practices component.
Of the six, five had the common theme of not using human error prevention techniques and proceeding in the face of uncertainty (H.4(a)).This contributing cause was first noticed in the first quarter of the 12 month inspection cycle and continued throughout th~eperiod with two new findings in this aspect occurring during the most recent quarter.i -(b)(5)"\
Table 1.0 -Cross Cutting Area -Human Performance Decision-Making Component
.....Documented Cornerstone Finding Contributing Cause Licensee did not Mitigating Licensee failed to follow procedures and adequately make safety- Systems evaluate the operability of the Unit 2 component cooling significant decisions water system when unexpected, rapid heat exchanger using a systematic fouling occurred during low tide conditions (HP, IR process when faced 2008003-04, PIM# 79217) with uncertain and unexpected conditions.
H l(a)Licensee failed to follow procedures after notification Licensee did not Mitigating that Battery 2B008 terminal voltage was less than make safety- Systems required Technical Specification value, resulting in more significant decisions than a two hour delay in entering the required 2-hour using a systematic technical specification action statement (HP, IR process when faced 2008013-01, PIM# 79233) with uncertain and unexpected conditions.
H. 1 (a)Licensee did not Mitigating Licensee failed to follow procedures, resulting in make safety- Systems troubleshooting activities that were performed without a significant decisions maintenance order and control room authorization (HP, using a systematic IR 2008013-02, PIM# 79234) process when faced with uncertain and unexpected conditions.
H. 1 (a)Operations Mitigating Failure to provide adequate guidance for evaluating personnel decided to Systems momentary transients while performing emergency accept procedural diesel generator surveillance testing (HP, IR 2008006- guidance without 02, PIM# 79211) proper investigation when uncertain what guidance meant H.1(b)
"i W-- OWsývýtýf
--- 1ý o n Licensee failed to properly evaluate a degraded relay that affected the operability of Unit 3 Train A emergency diesel generator (HP, IR 2008012-02, PIM# 79249)Failure to used conservative assumptions for operability decision-making H.1(b)Resources Component Documented Cornerstone Finding Contributing Cause Failure to have adequately procedures in place to Licensee did not Mitigating ensure valve maintenance would not adversely impact have complete, Systems plant performance and reliability, resulting in a replaced accurate up-to-date saltwater cooling butterfly valve not being properly procedure H.2(c)aligned or tested post-maintenance to verify proper function of the valve prior to return to service. (HP, IR 2008003-05, PIM# 79218)Licensee failed to consider the risk associated with the Licensee did not Initiating increased likelihood of an initiating event during have complete, Events emergent work on energized safety-related 125 Vdc accurate up-to-date battery breakers (HP, IR 2008013-04, PIM# 79232) procedure H.2(c)Licensee failed to establish appropriate instructions for Licensee did not Mitigating performing maintenance activities on safety-related 125 have complete, Systems Vdc breaker, resulting in an electrical connection whose accurate up-to-date integrity was inadequate to ensure the equipment would procedure H.2(c)be able to perform its safety function (HP, IR 2008013-05, WHITE Violation, PIM# 79236)Work Control Component Documented Cornerstone Finding Contributing Cause Work was not Mitigating Licensee failed to have adequate procedures, resulting planned to address Systems in an inadvertent electrical ground on a safety-related the human-system electrical distribution bus (HP, IR 2008012-01, PIM# interface 79248) H.3(a)Licensee did not Initiating Licensee failed to have adequate procedures in place to incorporate actions Events ensure troubleshooting associated with a proportional to address operation heater bank would not adversely impact plant stability, impact of work resulting in a pressurizer pressure transient (HP, IR activities H.3(b)2008003-02, PIM# 79215)Work Practices Component
-Mqý> s " fiýIp-1_6
-~_r41o _Documented Cornerstone Finding Contributing Cause Maintenance personnel failed to adequately adjust Licensee did not use Initiating bearing oil pressure to a Unit 2 main feedwater pump, human error Events causing the main feedwater pump to trip and leading prevention to an unplanned power reduction (HP, IR 2008002-01, techniques such as PIM# 79196) proper documentation H.4(a)Licensee failed to understand, monitor and perform a Operations personnel Initiating Unit 2 reactivity manipulation in accordance with proceeded in the face Events procedural requirements, resulting in overfeeding of of uncertainty or both steam generators and an inadvertent addition of unexpected positive reactivity during a planned startup (HP, IR circumstances H.4(a)2008003-03, PIM# 79216)Licensee failed to follow procedures while performing Licensee did not use Mitigating battery performance tests, resulting in the human error Systems performance tests for one station battery being prevention terminated early instead of continuing the tests until techniques such as reaching one of the test termination criteria (HP, IR proper 2008010-05, PIM# 79243) documentation H.4(a)Licensee failed to follow procedures, resulting in Licensee did not use Mitigating commencing work to correct the identified degraded human error Systems electrical condition prior to having the appropriately prevention authorized maintenance order (HP, IR 2008013-03, techniques such as PIM# 79235) proper documentation H.4(a)Licensee failed to follow procedures for nuclear fuel Licensee did not use Initiating movement in the spent fuel pool, resulting in the human error Events placement of spent fuel assemblies into storage prevention locations different from those evaluated and approved techniques such as by the procedure (HP, IR 2008004-01, PIM# 79227) proper documentation H.4(a)Licensee failed to implement procedural guidance to Supervisory Initiating ensure a Unit 2 power reduction was properly operations personnel Events performed, resulting in the reduction of secondary did not ensure that power faster than that of primary power, leading to a the activity was steam generator low pressure pre-trip annunciator properly supervised (HP, IR 2008003-06, PIM# 79219) to ensure support of nuclear safety H.4(c)
-(9fffrU"T~ifjSlm9iI P 4 eý-ýs~fi in o i Table 1.1 -Basis for Conclusion on MC 0305 Criteria MC 0305 Guidance on Performance Observations in the Human Met Substantive Cross-Cutting Performance Area Criteria (SCC) Issues Criterion 1: Multiple Green or Sixteen findings with aspects of human Yes safety significant inspection performance.
findings in the assessment period with documented aspects of human performance Criterion 2: Contributing Causes Three findings in Resources component with No have a common theme the common theme of not providing complete, corroborated by more than three accurate, and up-to-date design (3) findings and from more than documentation, procedures, and work one cornerstone (exception is packages, covering the Mitigating Systems Mitigating System) and Initiating Events cornerstones.
H.2(c)Five findings in the Work Practices Yes component with the common theme of not using human error prevention techniques and proceeding in the face of uncertainty (H.4(a))Criterion 3: The agency has a Based on the fact that the theme was seen Yes concern with the licensee's scope throughout the entire cycle with two new of efforts or progress in addressing findings in this most recent quarter we the cross-cutting area recommend keeping open the substantive performance deficiency cross-cutting issue in human performance
/resources.
Based on the fact that the theme was seen Yes throughout the entire cycle with two new findings in this most recent quarter we recommend opening a substantive cross-cutting issue in human performance
/ work practices.
C. PI&R -PIM Entries Between January 1, 2008- December 31, 2008 Conclusion
,- -o ... .it iiv_ _ :, 11iD " (b) (5)Details All of the eight findings in the cross-cutting area of Problem Identification and Resolution (PI&R) were in the corrective action program component.
Seven of the eight shared the common theme of failing to thoroughly evaluate problems such that thjeslu ons -, address causes and extent of conditions.
Lueo (b)(5))i Table 2.0 -Cross Cutting Area -Problem Identification and Resolution Corrective Action Program Component
.Documented Cornerstone Finding Contributing Cause Licensee failed to perform an adequate inspection of a Licensee did not Initiating main generator stator water pump discharge check identify a degraded Events valve, resulting in an unrecognized degraded condition condition that caused a main generator trip and subsequent completely, reactor trip (PI&R, IR 2008005-01, PIM# 79252) accurately and in a timely manner P.1(a)Licensee failed to follow procedure for saltwater cooling Licensee did not Mitigating system alignments.
An air equalizing supply valve was thoroughly evaluate Systems not secured closed contrary to procedural requirements the problem such (PI&R, IR 2008003-01, PIM# 79214) that resolutions address causes and extent of conditions P.1(c)
." 4i6 s e ý e " ýI I1ýl/ "e -sý ýLicensee took ineffective corrective actions to address Licensee did not Initiating blended flow evolutions, resulting in multiple reactivity thoroughly evaluate Events excursions occurring in the plant over the past two years the problem such (PI&R, IR 2008010-07, PIM# 79246) that resolutions address causes and extent of conditions P.1(c)Failure to meet operability determination procedural Licensee did not Mitigating requirements following unexplained load swings on thoroughly evaluate Systems emergency diesel generator (PI&R, IR 2008006-01, the problem such PIM# 79210) that resolutions address causes and extent of conditions P.1(c)Licensee failed to establish measures to assure that Licensee did not Mitigating deficient electrical connections were promptly identified thoroughly evaluate Systems and corrected (PI&R, IR 2008013-08, PIM# 79238) the problem such that resolutions address causes and extent of conditions P.1(c)Licensee failed to submit a required Licensee Event Licensee did not Mitigating Report within 60 days after discovering and event thoroughly evaluate Systems requiring a report, specifically safety-related 125 Vdc the problem such battery 2B008, which had been inoperable for greater that resolutions than the technical specification allowed outage time address causes and (PI&R, IR 2008013-06, PIM# 79237) extent of conditions P.1(c)Licensee failed to resolve degraded or nonconforming Licensee did not Mitigating conditions at the first available opportunity or thoroughly evaluate Systems appropriately justify a longer completion schedule (PI&R, the problem such IR 2008005-02, PIM# 79253) that resolutions address causes and extent of conditions P.1(c)Licensee did not properly implement procedural controls Licensee did not Barrier to adequately evaluate or repair a degraded source thoroughly evaluate Integrity handling tool used in the spent fuel, resulting in the tool the problem such being returned to service still in a degraded condition that resolutions (PI&R, IR 2008005-03, PIM# 79254) address causes and extent of conditions P.1(c)Operating Experience Comonent I Documented Cornerstone Finding Contributing Cause e a I -ec" aa, None.Table 2.1 -Basis for Conclusion on MC 0305 Criteria MC 0305 Guidance on Performance Observations in the Met Substantive Cross-Cutting Problem Identification and Resolution Criteria (SCC) Issues Area Criterion 1: Multiple Green or Eight findings in the area of Problem Yes safety significant inspection Identification and Resolution were found in findings in the assessment period this inspection cycle.with documented aspects of PI&R Criterion 2: Contributing Causes There is a common theme with seven findings Yes have a common theme sharing the same aspect of Corrective Action corroborated by more than three Program not thoroughly evaluating extent of (3) findings and from more than condition P. 1(c), in the Mitigating Systems, one cornerstone (exception is Barrier Integrity, and Initiating Events Mitigating System) cornerstones.
Criterion 3: The agency has a Due to the fact that this theme is apparent Yes concern with the licensee's scope throughout the inspection cycle with four of efforts or progress in addressing findings in the most recent quarter we the cross-cutting area recommend keeping open a substantive performance deficiency cross-cutting issue in the problem identification and resolution area.D. Summary/Conclusions of PI&R inspections The PI&R inspection was completed on October 3, 2008. The inspection team determined that once problems were identified, the licensee usually entered the issues into the corrective action program but was inconsistent in ensuring that identified problems were thoroughly evaluated in a timely manner and identified several issues with the quality of cause evaluations and the completeness of corrective action documents.
They also identified that operability assessments and reportability reviews were not being implemented consistent with procedural guidance and many of these assessments did not demonstrate the appropriate level of technical rigor to support conclusions made for operability or reportability.
The team determined that the licensee was adequately evaluating industry operating experience for relevance to the facility, and had entered applicable items in the corrective action program in accordance with stations procedures.
All of the individuals interviewed expressed a willingness to raise safety concerns and were able to provide multiple examples of avenues available.
Overall, the interviewees expressed positive experiences in raising concerns to their supervisors and through their chain of management.
During this inspection, the team reviewed the licensee's evaluations, actions, and plans to assess the progress in addressing the open substantive cross-cutting issues in human performance and problem identification and resolution.
After evaluating the licensee's root cause evaluations for these substantive cross-cutting issues, the team determined that the root cause evaluations did not include appropriate information and detail to identify the reasons for the insufficient progress in addressing the substantive cross-cutting issues. Also, the team could not assess and evaluate the effectiveness of the corrective actions because the licensee was in the early stages of implementation of their improvement plans.Part of the PI&R inspection was to follow-up on the Confirmatory Order items. During this inspection, the PI&R inspection team felt that sufficient progress had been made to close items 1, 2.d, 2.e, 2.f, 2.i, 2.j, 2.k, and 3. The inspectors did not feel that sufficient progress had been made on the other remaining Confirmatory Order items and so recommended keeping those items open. Southern California Edison submitted a letter updating the status of these open items in January 2009. NRC plans to perform a PI&R/Confirmatory Order inspection in June 2009 to followup on the Order actions and licensee efforts to address the open Substantive Cross-Cutting issues.5. Performance Indicator Verification All performance indicators are Green. No significant issues were identified during the ireview of licensee performance-indicators.
- 6. Licensee and NRC action on safety significant PIs and inspection findings A. Results of any follow-up actions taken by the licensee and the NRC to current safety significant Pis and Inspection findings.A Special Inspection was performed as a result of loose electrical connection issues. The Special Inspection performed on-site inspection from August 4-8, 2008 with in-office review continuing through December 11, 2008. As a result of this special inspection, the NRC issued Southern California Edison a finding of low-to-moderate safety significance (White) for the failure to establish appropriate instructions to perform maintenance activities on safety-related 125 Vdc station batter breaker. This violation was issued as part of the special inspection report, IR 2008013.B. Planned NRC follow-up actions due to safety significant PIs and inspection findings.NRC will be performing a Supplemental Inspection Procedure 95001,"Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area" for the White violation that was issued as a result of the Special Inspection performed on the loose electrical connections.
- 7. Non-SDP Severity Level III or greater violations currently proposed or issued January 1 -December 31, 2008.None.8. Longstanding or emergent safety issues for possible trend problems.None.9. Potential Greater-than-Green PIs or inspection findings I Open Unresolved Items Potential Greater-than-Green PI/Inspection Finding None.Open Unresolved Item 1)05000361/05000362/2008012-04
-Open Confirmatory Order items.2)05000361/05000362/2008010-03
-Omission of Station Black-Out Profile During Battery Service Tests 3)05000361/05000362/2008013-07
-Degraded Electrical Connections
- 10. Inspections planned through June 30. 2010.All required baseline inspections were completed in CY 2008. See Proposed Inspection Plan for future inspections.
NRC will be performing a Supplemental Inspection IP 95001 to address White battery breaker issue. Additionally, we plan to perform a PI&R/Confirmatory Order inspection in June 2009 as previously discussed.
NRC will be performing Steam Generator replacement inspections commencing in 2009 and continuing through 2010. The NRC will be performing its triennial heat sink inspection and an EP exercise inspection in August 2009. The NRC will perform its triennial fire protection inspection starting in May 2010.11. Conclusions from any independent assessment (i.e. INPO, IAEA, OSART. etc)(b)(4)12. Miscellaneous Topics 13. Attachments Plant Issues Matrix Performance Indicator Summary Proposed Inspection Plan