Information Notice 2018-03, Operating Experience Regarding Failure to Meet Technical Specifications Requirements for Changing Plant Conditions: Difference between revisions

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| issue date = 02/26/2018
| issue date = 02/26/2018
| title = Operating Experience Regarding Failure to Meet Technical Specifications Requirements for Changing Plant Conditions
| title = Operating Experience Regarding Failure to Meet Technical Specifications Requirements for Changing Plant Conditions
| author name = McGinty T J, Miller C G
| author name = Mcginty T, Miller C
| author affiliation = NRC/NRO/DCIP, NRC/NRR/DIRS
| author affiliation = NRC/NRO/DCIP, NRC/NRR/DIRS
| addressee name =  
| addressee name =  
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| page count = 5
| page count = 5
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{{#Wiki_filter:ML17303A791 February 26, 2018 NRC INFORMATION NOTICE 2018-03: OPERATING EXPERIENCE REGARDING FAILURE TO MEET TECHNICAL SPECIFICATIONS REQUIREMENTS FOR CHANGING PLANT CONDITIONS
{{#Wiki_filter:UNITED STATES
 
NUCLEAR REGULATORY COMMISSION
 
OFFICE OF NUCLEAR REACTOR REGULATION
 
OFFICE OF NEW REACTORS
 
WASHINGTON, DC 20555-0001 February 26, 2018 NRC INFORMATION NOTICE 2018-03:               OPERATING EXPERIENCE REGARDING
 
FAILURE TO MEET TECHNICAL
 
SPECIFICATIONS REQUIREMENTS FOR
 
CHANGING PLANT CONDITIONS


==ADDRESSEES==
==ADDRESSEES==
All holders of an operating license or construction permit for a nuclear power reactor under Title 10 of the Code of Federal Regulations (10 CFR) Part 50, "Domestic Licensing of Production and Utilization Facilities," except those that have permanently ceased operations and have certified that fuel has been permanently removed from the reactor vesse All holders of an operating license for a nonpower reactor (research reactor, test reactor, or critical assembly) under 10 CFR Part 50, except those that have permanently ceased operation All holders of and applicants for a combined license under 10 CFR Part 52, "Licenses, Certifications, and Approvals for Nuclear Power Plants."
All holders of an operating license or construction permit for a nuclear power reactor under
 
Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Domestic Licensing of
 
Production and Utilization Facilities, except those that have permanently ceased operations
 
and have certified that fuel has been permanently removed from the reactor vessel.
 
All holders of an operating license for a nonpower reactor (research reactor, test reactor, or
 
critical assembly) under 10 CFR Part 50, except those that have permanently ceased
 
operations.
 
All holders of and applicants for a combined license under 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear Power Plants.


==PURPOSE==
==PURPOSE==
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice (IN) to inform addressees of several recent events in which operators failed to ensure that the requirements of the plant technical specifications (TS) were met as the plant conditions change The NRC expects recipients to review the information for applicability to their facilities and to consider actions, as appropriate, to avoid similar problem However, suggestions contained in this IN are not NRC requirements; therefore, no specific action or written response is require
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice (IN) to inform
 
addressees of several recent events in which operators failed to ensure that the requirements of
 
the plant technical specifications (TS) were met as the plant conditions changed. The NRC
 
expects recipients to review the information for applicability to their facilities and to consider
 
actions, as appropriate, to avoid similar problems. However, suggestions contained in this IN
 
are not NRC requirements; therefore, no specific action or written response is required.


==DESCRIPTION OF CIRCUMSTANCES==
==DESCRIPTION OF CIRCUMSTANCES==
Watts Bar Nuclear Plant, Unit 1 On October 22, 2015, the operating crew at the Watts Bar Nuclear Plant, Unit 1 (Watts Bar)
 
determined that both source range (SR) level trip channels (N-31 and N-32) were in the bypass position with the reactor at 27-percent rated thermal power (RTP). The SR level trip switches were left in bypass, outside of their required configuration, thereby removing a trip function required by the TS during rod withdrawa An incident prompt investigation led by Tennessee Valley Authority (the licensee) determined that the SR trip functions were inoperable from the time the reactor trip breakers (RTBs) were closed in Mode 3 on October 19, 2015, until reactor power exceeded the P-6 permissive interlock (1.66 x 10-4 percent RTP) on October 21, 201 TS 3.3.1, "Reactor Trip System Instrumentation," requires these SR trip functions to be operable with the RTBs closed in Modes 5, 4, 3, and 2 until reactor power exceeds the P-6 (the SR block permissive) interloc On October 21, 2015, at 0346 Eastern Daylight Time, the plant entered Mode 2 with both SR level trip channels inoperabl This was a mode change violation in accordance with limiting condition for operation (LCO) 3. Under these conditions, TS 3.3.1, Required Actions 4.1, 1.1 and J.1, required that the operators take immediate actions to suspend operations involving positive reactivity additions and open the RTB Two lit annunciators on the main control board indicated the bypass condition, but the operators did not take immediate action to open the RTB because they did not notice that the SR level trip channels were bypasse In addition, operators failed to note the lit annunciators during shift turnovers and board walkdowns from October 19 through October 22, 2015, and during completion of the mode change checklist board walkdown on October 20, 2015, to transition from Mode 3 to Mode By the time the operators recognized the improper configuration, reactor power was above the P-6 permissive interlock, and the SR trip functions were no longer a TS requiremen The licensee identified that the operators failed to identify a bypassed safety function during reactor testing and start-up due to inadequate tracking and validation of essential informatio Inadequate operating procedures used to control SR level trip switches prior to core reload were identified as a contributing cause that led to this even Specifically, on October 7, 2015, before core reload, the SR level trips had been placed in bypass, in accordance with the licensee's procedure for power escalation testing to avoid spurious trips and alarms during the core reload proces On October 9, 2015, core reload was completed, at which point the switches should have been returned to the normal positio However, a revision to the procedure for power escalation testing back in July 2013 had inadvertently omitted the step to return the switches to norma This issue was entered into the licensee's corrective action progra Further details appear in Watts Bar Licensee Event Report 05000390/2015-006-00, dated December 21, 2015, and in NRC Integrated Inspection Report 05000390, 05000391/2015004, dated February 12, 201 These documents are available on the NRC's public Web site under Agencywide Documents Access and Management System (ADAMS) Accession Nos. ML15355A525 and ML16043A214, respectivel Davis-Besse Nuclear Power Station, Unit 1 On May 10, 2016, at approximately 0528 hours, the Davis-Besse Nuclear Power Station (Davis-Besse) was at approximately 53 percent power and was increasing power following a refueling outag During a walkdown of control room indications, a Davis-Besse senior manager determined that all four anticipatory reactor trip system (ARTS) instrumentation channels were in bypas The ARTS initiates a reactor trip following a turbine trip or loss of both main feed pumps in order to reduce the magnitude of pressure and temperature transients on the reactor coolant system and lower the probability of a pressurizer pilot-operated relief valve actuation during these event The turbine trip function trips the reactor when the main turbine is lost at high power levels in anticipation of the associated loss of heat sin TS 3.3.16, "Anticipatory Reactor Trip System Instrumentation," requires the ARTS turbine trip function to be in normal when the plant is operating above 45 percent powe As with the Watts Bar event discussed above, the ARTS channels had been placed in bypass to support work during a refueling outage; however, the procedure did not address the need to restore the system to a normal state upon completion of the wor FirstEnergy Nuclear Operating Company (the licensee) investigated this event and determined that multiple operators were aware that the ARTS was in bypas Other operators were aware that the annunciator alarm for the ARTS in bypass was lit and that it remained lit after the main feed pump trip input for the ARTS was taken from bypass to normal during the startu All of the operators involved assumed that the startup procedure would direct the system to be placed in norma In fact, the applicable procedures required an operator to verify that the system was returned to normal before the reactor reaches 40 percent powe However, the operator on shift at that time misinterpreted the requirement as not applicable because the reactor had not yet reached 40 percent powe The licensee determined that the operators failed to work together effectively as a team to ensure that the ARTS was operable before the plant entered the mode of applicability during startu The system was placed in normal upon discovery at 53 percent power to restore operabilit This issue was entered into the licensee's corrective action progra Further details on this event appear in Davis-Besse Licensee Event Report 05000346/2016-005-00, dated July 11, 2016 (ADAMS Accession No. ML16194A343),
===Watts Bar Nuclear Plant, Unit 1===
On October 22, 2015, the operating crew at the Watts Bar Nuclear Plant, Unit 1 (Watts Bar)
determined that both source range (SR) level trip channels (N-31 and N-32) were in the bypass
 
position with the reactor at 27-percent rated thermal power (RTP). The SR level trip switches
 
were left in bypass, outside of their required configuration, thereby removing a trip function
 
required by the TS during rod withdrawal. An incident prompt investigation led by Tennessee
 
Valley Authority (the licensee) determined that the SR trip functions were inoperable from the
 
time the reactor trip breakers (RTBs) were closed in Mode 3 on October 19, 2015, until reactor
 
power exceeded the P-6 permissive interlock (1.66 x 10-4 percent RTP) on October 21, 2015.
 
ML17303A791 TS 3.3.1, Reactor Trip System Instrumentation, requires these SR trip functions to be operable
 
with the RTBs closed in Modes 5, 4, 3, and 2 until reactor power exceeds the P-6 (the SR block
 
permissive) interlock. On October 21, 2015, at 0346 Eastern Daylight Time, the plant entered
 
Mode 2 with both SR level trip channels inoperable. This was a mode change violation in
 
accordance with limiting condition for operation (LCO) 3.0.4. Under these conditions, TS 3.3.1, Required Actions 4.1, 1.1 and J.1, required that the operators take immediate actions to
 
suspend operations involving positive reactivity additions and open the RTBs. Two lit
 
annunciators on the main control board indicated the bypass condition, but the operators did not
 
take immediate action to open the RTB because they did not notice that the SR level trip
 
channels were bypassed. In addition, operators failed to note the lit annunciators during shift
 
turnovers and board walkdowns from October 19 through October 22, 2015, and during
 
completion of the mode change checklist board walkdown on October 20, 2015, to transition
 
from Mode 3 to Mode 2. By the time the operators recognized the improper configuration, reactor power was above the P-6 permissive interlock, and the SR trip functions were no longer
 
a TS requirement.
 
The licensee identified that the operators failed to identify a bypassed safety function during
 
reactor testing and start-up due to inadequate tracking and validation of essential information.
 
Inadequate operating procedures used to control SR level trip switches prior to core reload were
 
identified as a contributing cause that led to this event. Specifically, on October 7, 2015, before
 
core reload, the SR level trips had been placed in bypass, in accordance with the licensees
 
procedure for power escalation testing to avoid spurious trips and alarms during the core reload
 
process. On October 9, 2015, core reload was completed, at which point the switches should
 
have been returned to the normal position. However, a revision to the procedure for power
 
escalation testing back in July 2013 had inadvertently omitted the step to return the switches to
 
normal. This issue was entered into the licensees corrective action program.
 
Further details appear in Watts Bar Licensee Event Report 05000390/2015-006-00, dated
 
December 21, 2015, and in NRC Integrated Inspection Report 05000390, 05000391/2015004, dated February 12, 2016. These documents are available on the NRCs public Web site under
 
Agencywide Documents Access and Management System (ADAMS) Accession
 
Nos. ML15355A525 and ML16043A214, respectively.
 
Davis-Besse Nuclear Power Station, Unit 1 On May 10, 2016, at approximately 0528 hours, the Davis-Besse Nuclear Power Station
 
(Davis-Besse) was at approximately 53 percent power and was increasing power following a
 
refueling outage. During a walkdown of control room indications, a Davis-Besse senior
 
manager determined that all four anticipatory reactor trip system (ARTS) instrumentation
 
channels were in bypass. The ARTS initiates a reactor trip following a turbine trip or loss of
 
both main feed pumps in order to reduce the magnitude of pressure and temperature transients
 
on the reactor coolant system and lower the probability of a pressurizer pilot-operated relief
 
valve actuation during these events.
 
The turbine trip function trips the reactor when the main turbine is lost at high power levels in
 
anticipation of the associated loss of heat sink. TS 3.3.16, Anticipatory Reactor Trip System
 
Instrumentation, requires the ARTS turbine trip function to be in normal when the plant is
 
operating above 45 percent power. As with the Watts Bar event discussed above, the ARTS
 
channels had been placed in bypass to support work during a refueling outage; however, the
 
procedure did not address the need to restore the system to a normal state upon completion of
 
the work. FirstEnergy Nuclear Operating Company (the licensee) investigated this event and determined
 
that multiple operators were aware that the ARTS was in bypass. Other operators were aware
 
that the annunciator alarm for the ARTS in bypass was lit and that it remained lit after the main
 
feed pump trip input for the ARTS was taken from bypass to normal during the startup. All of
 
the operators involved assumed that the startup procedure would direct the system to be placed
 
in normal. In fact, the applicable procedures required an operator to verify that the system was
 
returned to normal before the reactor reaches 40 percent power. However, the operator on shift
 
at that time misinterpreted the requirement as not applicable because the reactor had not yet
 
reached 40 percent power.
 
The licensee determined that the operators failed to work together effectively as a team to
 
ensure that the ARTS was operable before the plant entered the mode of applicability during
 
startup. The system was placed in normal upon discovery at 53 percent power to restore
 
operability. This issue was entered into the licensees corrective action program.
 
Further details on this event appear in Davis-Besse Licensee Event
 
Report 05000346/2016-005-00, dated July 11, 2016 (ADAMS Accession No. ML16194A343),
and in NRC Integrated Inspection Report 05000346/2016003, dated November 4, 2016 (ADAMS Accession No. ML16309A098).
and in NRC Integrated Inspection Report 05000346/2016003, dated November 4, 2016 (ADAMS Accession No. ML16309A098).


Grand Gulf Nuclear Station, Unit 1 On September 8, 2016, Entergy Operations, Inc. (the licensee), manually shut down the Grand Gulf Nuclear Station (Grand Gulf, Unit 1) reactor to replace pump A of the residual heat removal (RHR) system after a failed TS surveillanc Grand Gulf TS 3.4.10, "Residual Heat Removal (RHR) Shutdown Cooling System-Cold Shutdown," requires two trains of RHR to be operable when the reactor is shut dow With the A train of the RHR system inoperable for the pump replacement, the TS requires verification that an alternate method of decay heat removal is availabl This action must be completed within 1 hour of one RHR pump being taken out of service and once every 24 hours thereafter while the plant is in Mode To meet this requirement, the licensee placed the alternate decay heat removal (ADHR) system in standby after the plant reached Mode 4 on September 9, 2016, and verified its availability daily until the A train of the RHR system was restored to operability on September 23, 201 Following replacement of the A RHR system pump and while attempting to place the ADHR system in operation, licensee personnel identified that the ADHR system had not actually been available as an alternate method of decay heat remova Since August 10, 2016, the ADHR heat exchanger tube-side cooling water system had been clearance tagged as closed to support cleaning of the heat exchanger tube The licensee's daily verification of the availability of the ADHR system in accordance with the TS action statement had been administrative in natur The licensee did not require a physical walkdown of the ADHR system to verify its availabilit In addition, although the operators verified that no clearance tagouts were impacting the ADHR system, they failed to consider that a clearance tagout on the plant service water system could also affect the availability of the ADHR syste The licensee determined that when the work requiring the tagout had been completed on August 10, 2016, the "work complete" box had never been checked; therefore, the tags were left hangin The licensee's procedure for placing the ADHR system in standby did not specify that the plant service water isolation valves for the ADHR heat exchanger needed to be ope This issue was entered into the licensee's corrective action progra Additional information appears in the Grand Gulf Licensee Event Report 05000416/2016-008-01, dated August 16, 2017 (ADAMS Accession No. ML17228A233),
===Grand Gulf Nuclear Station, Unit 1===
and in NRC Special Inspection Report 05000416/2016008, dated October 27, 2017 (ADAMS Accession No. ML17303B200).
On September 8, 2016, Entergy Operations, Inc. (the licensee), manually shut down the Grand
 
Gulf Nuclear Station (Grand Gulf, Unit 1) reactor to replace pump A of the residual heat removal
 
(RHR) system after a failed TS surveillance. Grand Gulf TS 3.4.10, Residual Heat Removal
 
(RHR) Shutdown Cooling SystemCold Shutdown, requires two trains of RHR to be operable
 
when the reactor is shut down. With the A train of the RHR system inoperable for the pump
 
replacement, the TS requires verification that an alternate method of decay heat removal is
 
available. This action must be completed within 1 hour of one RHR pump being taken out of
 
service and once every 24 hours thereafter while the plant is in Mode 4. To meet this
 
requirement, the licensee placed the alternate decay heat removal (ADHR) system in standby
 
after the plant reached Mode 4 on September 9, 2016, and verified its availability daily until the
 
A train of the RHR system was restored to operability on September 23, 2016.
 
Following replacement of the A RHR system pump and while attempting to place the ADHR
 
system in operation, licensee personnel identified that the ADHR system had not actually been
 
available as an alternate method of decay heat removal. Since August 10, 2016, the ADHR
 
heat exchanger tube-side cooling water system had been clearance tagged as closed to support
 
cleaning of the heat exchanger tubes. The licensees daily verification of the availability of the
 
ADHR system in accordance with the TS action statement had been administrative in nature.
 
The licensee did not require a physical walkdown of the ADHR system to verify its availability.
 
In addition, although the operators verified that no clearance tagouts were impacting the ADHR
 
system, they failed to consider that a clearance tagout on the plant service water system could
 
also affect the availability of the ADHR system. The licensee determined that when the work
 
requiring the tagout had been completed on August 10, 2016, the work complete box had
 
never been checked; therefore, the tags were left hanging. The licensees procedure for placing
 
the ADHR system in standby did not specify that the plant service water isolation valves for the
 
ADHR heat exchanger needed to be open. This issue was entered into the licensees corrective
 
action program. Additional information appears in the Grand Gulf Licensee Event Report
 
05000416/2016-008-01, dated August 16, 2017 (ADAMS Accession No. ML17228A233),
and in NRC Special Inspection Report 05000416/2016008, dated October 27, 2017 (ADAMS
 
Accession No. ML17303B200).


==DISCUSSION==
==DISCUSSION==
As specified in 10 CFR 50.36, "Technical specifications," plant TS are derived from the analysis and evaluation included in the plant safety analysis report and constitute a part of the license authorizing operation of each reactor plan Each LCO in the TS lists the mode(s) of applicability for that condition and the actions to be taken if the conditions are not me In each event summarized above, the licensees took systems out of service for activities while the plants were in a mode that did not require the system In doing so, the licensees failed to ensure that the systems were restored to operable when required by TS LCO Multiple administrative practices, including maintenance tracking systems, operating procedures, operational checklists, and operator walkdowns, aid operators in maintaining an understanding of the configuration of plant systems to ensure TS operability before entering a mode of applicability that requires a syste In each case discussed in this IN, these practices failed to accomplish their intended function when procedures were incomplete or misunderstood and when plant personnel failed to effectively and aggressively communicate concerns about unexpected tags, alarms, or indication Industry operating experience has shown that best practices, such as noting "conditional LCOs" when taking equipment out of service that is required in another mode, "caution-tagging" equipment in an abnormal alignment, and issuing
As specified in 10 CFR 50.36, Technical specifications, plant TS are derived from the analysis
 
and evaluation included in the plant safety analysis report and constitute a part of the license
 
authorizing operation of each reactor plant. Each LCO in the TS lists the mode(s) of
 
applicability for that condition and the actions to be taken if the conditions are not met. In each
 
event summarized above, the licensees took systems out of service for activities while the
 
plants were in a mode that did not require the systems. In doing so, the licensees failed to
 
ensure that the systems were restored to operable when required by TS LCOs.
 
Multiple administrative practices, including maintenance tracking systems, operating
 
procedures, operational checklists, and operator walkdowns, aid operators in maintaining an
 
understanding of the configuration of plant systems to ensure TS operability before entering a
 
mode of applicability that requires a system. In each case discussed in this IN, these practices
 
failed to accomplish their intended function when procedures were incomplete or misunderstood
 
and when plant personnel failed to effectively and aggressively communicate concerns about
 
unexpected tags, alarms, or indications. Industry operating experience has shown that best
 
practices, such as noting conditional LCOs when taking equipment out of service that is


"return-to-service" checklists to ensure that systems are returned to their expected condition when work is complete, provide additional barriers to configuration control issues and noncompliance with TS operability requirement When followed appropriately, these practices may significantly reduce the potential for TS violation
required in another mode, caution-tagging equipment in an abnormal alignment, and issuing
 
return-to-service checklists to ensure that systems are returned to their expected condition
 
when work is complete, provide additional barriers to configuration control issues and
 
noncompliance with TS operability requirements. When followed appropriately, these practices
 
may significantly reduce the potential for TS violations.


==CONTACT==
==CONTACT==
This IN requires no specific action or written respons Please direct any questions about this matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manage /RA/ (Paul G. Krohn for) /RA/ Timothy J. McGinty, Director Christopher G. Miller, Director Division of Construction Inspection Division of Inspection and Regional Support and Operational Programs Office of Nuclear Reactor Regulation Office of New Reactors
This IN requires no specific action or written response. Please direct any questions about this
 
matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor
 
Regulation (NRR) project manager.
 
/RA/ (Paul G. Krohn for)                       /RA/
Timothy J. McGinty, Director                   Christopher G. Miller, Director
 
Division of Construction Inspection           Division of Inspection and Regional Support
 
and Operational Programs                       Office of Nuclear Reactor Regulation
 
===Office of New Reactors===
Technical Contacts:      Rebecca Sigmon, NRR                          Margaret Chernoff, NRR
 
301-415-0895                                  301-415-2240
                        Rebecca.Sigmon@nrc.gov                        Margaret.Chernoff@nrc.gov
 
Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under NRC Library.
 
ML17303A791                          *via email
 
OFFICE TECH EDITOR*    NRR/DIRS/IOEB*    NRR/DSS/SSTB*    NRR/DSS/SSTB/BC*      NRR/IOEB/DIRS/BC*
NAME  JDougherty      RSigmon            MChernoff        VCusumano            RElliott
 
DATE  11/22/17        12/21/17          12/22/17          1/12/18              12/22/17 OFFICE NRR/DIRS/IRGB/PM NRR/DIRS/IRGB/LA  NRR/DIRS/IRGB/BC  NRO/DCIP/D            NRR/DIRS/D
 
NAME  TMensah*        ELee              HChernoff        TMcGinty (PKroh for)  CMiller


Technical Contacts: Rebecca Sigmon, NRR Margaret Chernoff, NRR 301-415-0895 301-415-2240 Rebecca.Sigmon@nrc.gov Margaret.Chernoff@nrc.gov Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under NRC Librar IN 2018-03  }}
DATE  1/12/18          1/29/18            2/6/18            2/20/18              2/26/18}}


{{Information notice-Nav}}
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Latest revision as of 11:02, 29 October 2019

Operating Experience Regarding Failure to Meet Technical Specifications Requirements for Changing Plant Conditions
ML17303A791
Person / Time
Issue date: 02/26/2018
From: Mcginty T, Chris Miller
Division of Construction Inspection and Operational Programs, Division of Inspection and Regional Support
To:
Tanya Mensah
References
IN-18-003
Download: ML17303A791 (5)
v • d • e


UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR REACTOR REGULATION

OFFICE OF NEW REACTORS

WASHINGTON, DC 20555-0001 February 26, 2018 NRC INFORMATION NOTICE 2018-03: OPERATING EXPERIENCE REGARDING

FAILURE TO MEET TECHNICAL

SPECIFICATIONS REQUIREMENTS FOR

CHANGING PLANT CONDITIONS

ADDRESSEES

All holders of an operating license or construction permit for a nuclear power reactor under

Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Domestic Licensing of

Production and Utilization Facilities, except those that have permanently ceased operations

and have certified that fuel has been permanently removed from the reactor vessel.

All holders of an operating license for a nonpower reactor (research reactor, test reactor, or

critical assembly) under 10 CFR Part 50, except those that have permanently ceased

operations.

All holders of and applicants for a combined license under 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear Power Plants.

PURPOSE

The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice (IN) to inform

addressees of several recent events in which operators failed to ensure that the requirements of

the plant technical specifications (TS) were met as the plant conditions changed. The NRC

expects recipients to review the information for applicability to their facilities and to consider

actions, as appropriate, to avoid similar problems. However, suggestions contained in this IN

are not NRC requirements; therefore, no specific action or written response is required.

DESCRIPTION OF CIRCUMSTANCES

Watts Bar Nuclear Plant, Unit 1

On October 22, 2015, the operating crew at the Watts Bar Nuclear Plant, Unit 1 (Watts Bar)

determined that both source range (SR) level trip channels (N-31 and N-32) were in the bypass

position with the reactor at 27-percent rated thermal power (RTP). The SR level trip switches

were left in bypass, outside of their required configuration, thereby removing a trip function

required by the TS during rod withdrawal. An incident prompt investigation led by Tennessee

Valley Authority (the licensee) determined that the SR trip functions were inoperable from the

time the reactor trip breakers (RTBs) were closed in Mode 3 on October 19, 2015, until reactor

power exceeded the P-6 permissive interlock (1.66 x 10-4 percent RTP) on October 21, 2015.

ML17303A791 TS 3.3.1, Reactor Trip System Instrumentation, requires these SR trip functions to be operable

with the RTBs closed in Modes 5, 4, 3, and 2 until reactor power exceeds the P-6 (the SR block

permissive) interlock. On October 21, 2015, at 0346 Eastern Daylight Time, the plant entered

Mode 2 with both SR level trip channels inoperable. This was a mode change violation in

accordance with limiting condition for operation (LCO) 3.0.4. Under these conditions, TS 3.3.1, Required Actions 4.1, 1.1 and J.1, required that the operators take immediate actions to

suspend operations involving positive reactivity additions and open the RTBs. Two lit

annunciators on the main control board indicated the bypass condition, but the operators did not

take immediate action to open the RTB because they did not notice that the SR level trip

channels were bypassed. In addition, operators failed to note the lit annunciators during shift

turnovers and board walkdowns from October 19 through October 22, 2015, and during

completion of the mode change checklist board walkdown on October 20, 2015, to transition

from Mode 3 to Mode 2. By the time the operators recognized the improper configuration, reactor power was above the P-6 permissive interlock, and the SR trip functions were no longer

a TS requirement.

The licensee identified that the operators failed to identify a bypassed safety function during

reactor testing and start-up due to inadequate tracking and validation of essential information.

Inadequate operating procedures used to control SR level trip switches prior to core reload were

identified as a contributing cause that led to this event. Specifically, on October 7, 2015, before

core reload, the SR level trips had been placed in bypass, in accordance with the licensees

procedure for power escalation testing to avoid spurious trips and alarms during the core reload

process. On October 9, 2015, core reload was completed, at which point the switches should

have been returned to the normal position. However, a revision to the procedure for power

escalation testing back in July 2013 had inadvertently omitted the step to return the switches to

normal. This issue was entered into the licensees corrective action program.

Further details appear in Watts Bar Licensee Event Report 05000390/2015-006-00, dated

December 21, 2015, and in NRC Integrated Inspection Report 05000390, 05000391/2015004, dated February 12, 2016. These documents are available on the NRCs public Web site under

Agencywide Documents Access and Management System (ADAMS) Accession

Nos. ML15355A525 and ML16043A214, respectively.

Davis-Besse Nuclear Power Station, Unit 1 On May 10, 2016, at approximately 0528 hours0.00611 days <br />0.147 hours <br />8.730159e-4 weeks <br />2.00904e-4 months <br />, the Davis-Besse Nuclear Power Station

(Davis-Besse) was at approximately 53 percent power and was increasing power following a

refueling outage. During a walkdown of control room indications, a Davis-Besse senior

manager determined that all four anticipatory reactor trip system (ARTS) instrumentation

channels were in bypass. The ARTS initiates a reactor trip following a turbine trip or loss of

both main feed pumps in order to reduce the magnitude of pressure and temperature transients

on the reactor coolant system and lower the probability of a pressurizer pilot-operated relief

valve actuation during these events.

The turbine trip function trips the reactor when the main turbine is lost at high power levels in

anticipation of the associated loss of heat sink. TS 3.3.16, Anticipatory Reactor Trip System

Instrumentation, requires the ARTS turbine trip function to be in normal when the plant is

operating above 45 percent power. As with the Watts Bar event discussed above, the ARTS

channels had been placed in bypass to support work during a refueling outage; however, the

procedure did not address the need to restore the system to a normal state upon completion of

the work. FirstEnergy Nuclear Operating Company (the licensee) investigated this event and determined

that multiple operators were aware that the ARTS was in bypass. Other operators were aware

that the annunciator alarm for the ARTS in bypass was lit and that it remained lit after the main

feed pump trip input for the ARTS was taken from bypass to normal during the startup. All of

the operators involved assumed that the startup procedure would direct the system to be placed

in normal. In fact, the applicable procedures required an operator to verify that the system was

returned to normal before the reactor reaches 40 percent power. However, the operator on shift

at that time misinterpreted the requirement as not applicable because the reactor had not yet

reached 40 percent power.

The licensee determined that the operators failed to work together effectively as a team to

ensure that the ARTS was operable before the plant entered the mode of applicability during

startup. The system was placed in normal upon discovery at 53 percent power to restore

operability. This issue was entered into the licensees corrective action program.

Further details on this event appear in Davis-Besse Licensee Event

Report 05000346/2016-005-00, dated July 11, 2016 (ADAMS Accession No. ML16194A343),

and in NRC Integrated Inspection Report 05000346/2016003, dated November 4, 2016 (ADAMS Accession No. ML16309A098).

Grand Gulf Nuclear Station, Unit 1

On September 8, 2016, Entergy Operations, Inc. (the licensee), manually shut down the Grand

Gulf Nuclear Station (Grand Gulf, Unit 1) reactor to replace pump A of the residual heat removal

(RHR) system after a failed TS surveillance. Grand Gulf TS 3.4.10, Residual Heat Removal

(RHR) Shutdown Cooling SystemCold Shutdown, requires two trains of RHR to be operable

when the reactor is shut down. With the A train of the RHR system inoperable for the pump

replacement, the TS requires verification that an alternate method of decay heat removal is

available. This action must be completed within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> of one RHR pump being taken out of

service and once every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> thereafter while the plant is in Mode 4. To meet this

requirement, the licensee placed the alternate decay heat removal (ADHR) system in standby

after the plant reached Mode 4 on September 9, 2016, and verified its availability daily until the

A train of the RHR system was restored to operability on September 23, 2016.

Following replacement of the A RHR system pump and while attempting to place the ADHR

system in operation, licensee personnel identified that the ADHR system had not actually been

available as an alternate method of decay heat removal. Since August 10, 2016, the ADHR

heat exchanger tube-side cooling water system had been clearance tagged as closed to support

cleaning of the heat exchanger tubes. The licensees daily verification of the availability of the

ADHR system in accordance with the TS action statement had been administrative in nature.

The licensee did not require a physical walkdown of the ADHR system to verify its availability.

In addition, although the operators verified that no clearance tagouts were impacting the ADHR

system, they failed to consider that a clearance tagout on the plant service water system could

also affect the availability of the ADHR system. The licensee determined that when the work

requiring the tagout had been completed on August 10, 2016, the work complete box had

never been checked; therefore, the tags were left hanging. The licensees procedure for placing

the ADHR system in standby did not specify that the plant service water isolation valves for the

ADHR heat exchanger needed to be open. This issue was entered into the licensees corrective

action program. Additional information appears in the Grand Gulf Licensee Event Report

05000416/2016-008-01, dated August 16, 2017 (ADAMS Accession No. ML17228A233),

and in NRC Special Inspection Report 05000416/2016008, dated October 27, 2017 (ADAMS

Accession No. ML17303B200).

DISCUSSION

As specified in 10 CFR 50.36, Technical specifications, plant TS are derived from the analysis

and evaluation included in the plant safety analysis report and constitute a part of the license

authorizing operation of each reactor plant. Each LCO in the TS lists the mode(s) of

applicability for that condition and the actions to be taken if the conditions are not met. In each

event summarized above, the licensees took systems out of service for activities while the

plants were in a mode that did not require the systems. In doing so, the licensees failed to

ensure that the systems were restored to operable when required by TS LCOs.

Multiple administrative practices, including maintenance tracking systems, operating

procedures, operational checklists, and operator walkdowns, aid operators in maintaining an

understanding of the configuration of plant systems to ensure TS operability before entering a

mode of applicability that requires a system. In each case discussed in this IN, these practices

failed to accomplish their intended function when procedures were incomplete or misunderstood

and when plant personnel failed to effectively and aggressively communicate concerns about

unexpected tags, alarms, or indications. Industry operating experience has shown that best

practices, such as noting conditional LCOs when taking equipment out of service that is

required in another mode, caution-tagging equipment in an abnormal alignment, and issuing

return-to-service checklists to ensure that systems are returned to their expected condition

when work is complete, provide additional barriers to configuration control issues and

noncompliance with TS operability requirements. When followed appropriately, these practices

may significantly reduce the potential for TS violations.

CONTACT

This IN requires no specific action or written response. Please direct any questions about this

matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor

Regulation (NRR) project manager.

/RA/ (Paul G. Krohn for) /RA/

Timothy J. McGinty, Director Christopher G. Miller, Director

Division of Construction Inspection Division of Inspection and Regional Support

and Operational Programs Office of Nuclear Reactor Regulation

Office of New Reactors

Technical Contacts: Rebecca Sigmon, NRR Margaret Chernoff, NRR

301-415-0895 301-415-2240

Rebecca.Sigmon@nrc.gov Margaret.Chernoff@nrc.gov

Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under NRC Library.

ML17303A791 *via email

OFFICE TECH EDITOR* NRR/DIRS/IOEB* NRR/DSS/SSTB* NRR/DSS/SSTB/BC* NRR/IOEB/DIRS/BC*

NAME JDougherty RSigmon MChernoff VCusumano RElliott

DATE 11/22/17 12/21/17 12/22/17 1/12/18 12/22/17 OFFICE NRR/DIRS/IRGB/PM NRR/DIRS/IRGB/LA NRR/DIRS/IRGB/BC NRO/DCIP/D NRR/DIRS/D

NAME TMensah* ELee HChernoff TMcGinty (PKroh for) CMiller

DATE 1/12/18 1/29/18 2/6/18 2/20/18 2/26/18


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