IR 05000244/2014008: Difference between revisions
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{{#Wiki_filter: UNITED STATES NUCLEAR REGULATORY COMMISSION | {{#Wiki_filter: UNITED STATES NUCLEAR REGULATORY COMMISSION ril 11, 2014 | ||
==SUBJECT:== | |||
R.E. GINNA NUCLEAR POWER PLANT, LLC - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000244/2014008 | |||
05000244/2014008 | |||
==Dear Mr. Pacher:== | ==Dear Mr. Pacher:== | ||
On March 13, 2014, the U. S. Nuclear Regulatory Commission (NRC) completed an inspection at your R.E. Ginna Nuclear Power Plant, LLC (Ginna). The enclosed report documents the inspection results, which were discussed on March 13, 2014, with Mike Philippon, General Plant Manager, and other members of your staff. | On March 13, 2014, the U. S. Nuclear Regulatory Commission (NRC) completed an inspection at your R.E. Ginna Nuclear Power Plant, LLC (Ginna). The enclosed report documents the inspection results, which were discussed on March 13, 2014, with Mike Philippon, General Plant Manager, and other members of your staff. | ||
This inspection examined activities conducted under your license as they relate to identification and resolution of problems and compliance with the | This inspection examined activities conducted under your license as they relate to identification and resolution of problems and compliance with the Commissions rules and regulations and conditions of your license. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. On April 1, 2014, the operating license for Ginna held by the Constellation Energy Nuclear Group, LLC (CENG) was transferred to Exelon Generation Company, LLC. | ||
Based on the samples selected for review, the inspectors concluded that CENG was generally effective in identifying, evaluating, and resolving problems. CENG personnel identified problems and entered them into the corrective action program at a low threshold. CENG prioritized and evaluated issues commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner. | Based on the samples selected for review, the inspectors concluded that CENG was generally effective in identifying, evaluating, and resolving problems. CENG personnel identified problems and entered them into the corrective action program at a low threshold. CENG prioritized and evaluated issues commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner. | ||
This report documents one NRC-identified finding of very low safety significance (Green). | This report documents one NRC-identified finding of very low safety significance (Green). | ||
Ginna. | If you disagree with the finding or the assigned cross-cutting aspect, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region I; and the NRC resident inspector at Ginna. | ||
In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390 of the | In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390 of the NRCs Rules of Practice, a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records component of the NRCs Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRC website at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room). | ||
Sincerely, | Sincerely, | ||
/RA/ Daniel L. Schroeder, Chief Reactor Projects Branch 1 | /RA/ | ||
Daniel L. Schroeder, Chief Reactor Projects Branch 1 Division of Reactor Projects Docket No. 50-244 License No. DPR-18 | |||
Division of Reactor Projects | |||
Docket No. 50-244 License No. DPR-18 | |||
===Enclosure:=== | ===Enclosure:=== | ||
Inspection Report 05000244/2014008 w/Attachment: Supplementary Information | Inspection Report 05000244/2014008 w/Attachment: Supplementary Information | ||
REGION I== | REGION I== | ||
Docket No. 50-244 | Docket No. 50-244 License No. DPR-18 Report No. 05000244/2014008 Licensee: Constellation Energy Nuclear Group, LLC (CENG) | ||
Facility: R.E. Ginna Nuclear Power Plant, LLC Location: Ontario, NY Dates: February 24, 2014 through March 13, 2014 Team Leader: Steve Shaffer, Senior Project Engineer Inspectors: Doug Dodson, Resident Inspector, Ginna Brian Haagensen, Resident Inspector, Millstone Andrey Turilin, Project Engineer Approved by: Daniel L. Schroeder, Chief Reactor Projects Branch 1 Division of Reactor Projects Enclosure | |||
License No. DPR-18 | |||
Report No. 05000244/2014008 | |||
Licensee: Constellation Energy Nuclear Group, LLC (CENG) | |||
Facility: R.E. Ginna Nuclear Power Plant, LLC | |||
Location: Ontario, NY | |||
Dates: February 24, 2014 through March 13, 2014 | |||
Team Leader: Steve Shaffer, Senior Project Engineer | |||
Inspectors: Doug Dodson, Resident Inspector, Ginna Brian Haagensen, Resident Inspector, Millstone Andrey Turilin, Project Engineer | |||
Approved by: Daniel L. Schroeder, Chief Reactor Projects Branch 1 Division of Reactor Projects | |||
=SUMMARY= | =SUMMARY= | ||
IR 05000244/2014008; 02/24/2014 - 03/13/2014; R.E. Ginna Nuclear Power Plant, LLC (Ginna); Biennial Baseline Inspection of Problem Identification and Resolution. The inspectors identified one finding in the area of effectiveness of corrective actions. | IR 05000244/2014008; 02/24/2014 - 03/13/2014; R.E. Ginna Nuclear Power Plant, LLC (Ginna); Biennial Baseline Inspection of Problem Identification and Resolution. The inspectors identified one finding in the area of effectiveness of corrective actions. | ||
This NRC team inspection was performed by | This NRC team inspection was performed by two regional inspectors and two resident inspectors. The inspectors identified one finding of very low safety significance (Green) during this inspection. The significance of most findings is indicated by their color (i.e., greater than Green, or Green, White, Yellow, Red) and determined using Inspection Manual Chapter (IMC)0609, Significance Determination Process, dated June 2, 2011. Cross-cutting aspects are determined using IMC 0310, Aspects with Cross-Cutting Areas, dated January 1, 2014. All violations of NRC requirements are dispositioned in accordance with the NRCs Enforcement Policy, dated July 9, 2013. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4. | ||
Problem Identification and Resolution The inspectors concluded that CENG was | Problem Identification and Resolution The inspectors concluded that CENG was generally effective in identifying, evaluating, and resolving problems. CENG personnel identified problems, entered them into the corrective action program at a low threshold, and prioritized issues commensurate with their safety significance. In most cases, CENG appropriately screened issues for operability and reportability, and performed causal analyses that appropriately considered extent of condition, generic issues, and previous occurrences. The inspectors also determined that CENG typically implemented corrective actions (CAs) to address the problems identified in the corrective action program in a timely manner. | ||
The inspectors concluded that, in general, CENG adequately identified, reviewed, and applied relevant industry operating experience to Ginna operations. In addition, based on those items selected for review, the inspectors determined that | The inspectors concluded that, in general, CENG adequately identified, reviewed, and applied relevant industry operating experience to Ginna operations. In addition, based on those items selected for review, the inspectors determined that CENGs self-assessments and audits were thorough. | ||
Based on the interviews the inspectors conducted over the course of the inspection, observations of plant activities, and reviews of individual corrective action program and employee concerns program issues, the inspectors did not identify any indications that site personnel were unwilling to raise safety issues nor did they identify any conditions that could have had a negative impact on the | Based on the interviews the inspectors conducted over the course of the inspection, observations of plant activities, and reviews of individual corrective action program and employee concerns program issues, the inspectors did not identify any indications that site personnel were unwilling to raise safety issues nor did they identify any conditions that could have had a negative impact on the sites safety conscious work environment. | ||
===Cornerstone: Initiating Events=== | ===Cornerstone: Initiating Events=== | ||
: '''Green.''' | : '''Green.''' | ||
The inspectors identified a Green finding (FIN) for | The inspectors identified a Green finding (FIN) for CENGs failure to effectively implement a CA associated with an apparent cause evaluation (ACE) that addressed both heater drain tank (HDT) pumps tripping on October 21, 2012. Specifically, CENG failed to effectively implement a CA to modify all procedures in which the feedwater system would be impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power on January 14, 2014. These issues were entered into CENGs corrective action program as condition report (CR)-2014-000197 and CR-2014-001208. | ||
This finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to effectively implement | This finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to effectively implement CA-2012-003493 and modify all procedures impacted by stopping HDT or condensate booster pumps, including procedure AP-FW.1, resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. Additionally, this issue is similar to Example 4b described in IMC 0612, Appendix E, Examples of Minor Issues, issued August 11, 2009, which states that issues are not minor if procedural issues cause a reactor trip or other transient. Using Exhibit 1, Initiating Events Screening Questions, of IMC 0609, Appendix A, | ||
The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, the inspectors determined this finding did not involve the complete or partial loss of a support system that contributes to the likelihood of, or causes, an initiating event and affects mitigation equipment and is therefore of very low safety significance (Green). This finding has a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because individuals did not follow processes, procedures, and work instructions. Specifically, CENG staff did not follow procedure CNG-CA-1.01-1005 and ensure that CAs (CA-2012-003494) were effectively implemented and addressed identified causes associated with the ACE for CR-2012-007133. | |||
[H.8] (Section 4OA2.1.c) | [H.8] (Section 4OA2.1.c) | ||
Line 102: | Line 78: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the procedures that described | The inspectors reviewed the procedures that described CENGs corrective action program at Ginna. To assess the effectiveness of the corrective action program, the inspectors reviewed performance in three primary areas: problem identification, prioritization and evaluation of issues, and corrective action implementation. The inspectors compared performance in these areas to the requirements and standards contained in Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion XVI, Corrective Action, and CENG CNG-CA-1.01-1000, Corrective Action Program, Revision 01000. For each of these areas, the inspectors considered risk insights from the stations risk analysis and reviewed CRs selected across the seven cornerstones of safety in the NRCs Reactor Oversight Process. Additionally, the inspectors attended multiple Plan-of-the-Day, Condition Report Review Committee, and Management Review Committee meetings. The inspectors selected items from the following functional areas for review: engineering, operations, maintenance, emergency preparedness, radiation protection, chemistry, physical security, and oversight programs. | ||
: (1) Effectiveness of Problem Identification In addition to the items described above, the inspectors reviewed system health reports, a sample of completed corrective and preventative maintenance work orders, completed surveillance test procedures, operator logs, and periodic trend reports. The inspectors also completed field walkdowns of various systems on site, such as the emergency diesel generators and auxiliary feedwater systems. Additionally, the inspectors reviewed a sample of CRs written to document issues identified through internal self-assessments, audits, emergency preparedness drills, and the operating experience program. The inspectors completed this review to verify that CENG entered conditions adverse to quality into their corrective action program as appropriate. | |||
: (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the evaluation and prioritization of a sample of CRs issued since the last NRC biennial Problem Identification and Resolution inspection completed in February 2012. The inspectors also reviewed CRs that were assigned lower levels of significance that did not include formal cause evaluations to ensure that they were properly classified. The inspectors review included the appropriateness of the assigned significance, the scope and depth of the causal analysis, and the timeliness of resolution. The inspectors assessed whether the evaluations identified likely causes for the issues and developed appropriate corrective actions to address the identified causes. Further, the inspectors reviewed equipment operability determinations, reportability assessments, and extent-of-condition reviews for selected problems to verify these processes adequately addressed equipment operability, reporting of issues to the NRC, and the extent of the issues. | |||
: (3) Effectiveness of Corrective Actions The inspectors reviewed CENGs completed CAs through documentation review and, in some cases, field walkdowns to determine whether the actions addressed the identified causes of the problems. The inspectors also reviewed CRs for adverse trends and repetitive problems to determine whether CAs were effective in addressing the broader issues. The inspectors reviewed CENGs timeliness in implementing CAs and effectiveness in precluding recurrence for significant conditions adverse to quality. The inspectors also reviewed a sample of CRs associated with selected non-cited violations and findings to verify that CENG personnel properly evaluated and resolved these issues. In addition, the inspectors expanded the CA review to five years to evaluate CENG actions related to the heater drain system. | |||
b. | |||
Assessment | |||
: (1) Effectiveness of Problem Identification Based on the selected samples, plant walkdowns, and interviews of site personnel in multiple functional areas, the inspectors determined that CENG identified problems and entered them into the corrective action program at a low threshold. CENG staff at Ginna initiated approximately 16,000 CRs between February 2012 and February 2014. The inspectors observed supervisors at the Plan-of-the-Day, Condition Report Review Committee, and Management Review Committee meetings appropriately questioning and challenging CRs to ensure clarification of the issues. Based on the samples reviewed, the inspectors determined that CENG trended equipment and programmatic issues, and appropriately identified problems in CRs. The inspectors verified that conditions adverse to quality identified through this review were entered into the corrective action program as appropriate. Additionally, inspectors concluded that personnel were identifying trends at low levels. In general, inspectors did not identify issues or concerns that had not been appropriately entered into the corrective action program for evaluation and resolution. In response to several questions and minor equipment observations identified by the inspectors during plant walkdowns, CENG personnel promptly initiated CRs and/or took immediate action to address the issues. | : (1) Effectiveness of Problem Identification Based on the selected samples, plant walkdowns, and interviews of site personnel in multiple functional areas, the inspectors determined that CENG identified problems and entered them into the corrective action program at a low threshold. CENG staff at Ginna initiated approximately 16,000 CRs between February 2012 and February 2014. The inspectors observed supervisors at the Plan-of-the-Day, Condition Report Review Committee, and Management Review Committee meetings appropriately questioning and challenging CRs to ensure clarification of the issues. Based on the samples reviewed, the inspectors determined that CENG trended equipment and programmatic issues, and appropriately identified problems in CRs. The inspectors verified that conditions adverse to quality identified through this review were entered into the corrective action program as appropriate. Additionally, inspectors concluded that personnel were identifying trends at low levels. In general, inspectors did not identify issues or concerns that had not been appropriately entered into the corrective action program for evaluation and resolution. In response to several questions and minor equipment observations identified by the inspectors during plant walkdowns, CENG personnel promptly initiated CRs and/or took immediate action to address the issues. | ||
: (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors determined that, in general, CENG appropriately prioritized and evaluated issues commensurate with the safety significance of the identified problem | : (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors determined that, in general, CENG appropriately prioritized and evaluated issues commensurate with the safety significance of the identified problem. | ||
CENG screened CRs for operability and reportability, categorized the CRs by significance, and assigned actions to the appropriate department for evaluation and resolution. The CR screening process considered human performance issues, radiological safety concerns, repetitiveness, adverse trends, and potential impact on the safety conscious work environment. | |||
The inspectors concluded that corrective actions for identified deficiencies were generally timely and adequately implemented. For significant conditions adverse to quality, CENG identified actions to prevent recurrence. The inspectors concluded that corrective actions to address the inspection sample of NRC non-cited violations and findings since the last problem identification and resolution inspection were timely and effective. However, the inspectors did identify some instances where | Based on the sample of CRs reviewed, the inspectors noted that the guidance provided by CENGs corrective action program implementing procedures appeared sufficient to ensure consistency in categorization of issues. Operability and reportability determinations were generally performed when conditions warranted and in most cases, the evaluations supported the conclusion. Causal analyses appropriately considered the extent of condition or problem, generic issues, and previous occurrences of the issue. | ||
* The extent of condition review was not adequately performed for category three | : (3) Effectiveness of Corrective Actions The inspectors concluded that corrective actions for identified deficiencies were generally timely and adequately implemented. For significant conditions adverse to quality, CENG identified actions to prevent recurrence. The inspectors concluded that corrective actions to address the inspection sample of NRC non-cited violations and findings since the last problem identification and resolution inspection were timely and effective. However, the inspectors did identify some instances where CENGs evaluation of issues was inconsistently implemented. Specifically, the inspectors identified some instances of CENG failing to meet the procedural requirements of CNG-CA-1.01-1000, Corrective Action Program, Revision 01000, and CNG-CA-1.01-1005, Apparent Cause Evaluation, Revision 00603. Specifically, the following instances were identified by inspectors as inadequate evaluation of issues: | ||
* The extent of condition review within the ACE associated with CR-2010-006323, a category two CR, was not adequately performed. The evaluation associated with CR-2010-0006323 documents that there was high resistance on the contacts of charging pump selector switch L/428A that resulted in an increase in charging pump speed and pressurizer level until operators took manual control. In April 2013, pressurizer pressure selector switch P/429A malfunctioned during reactor protection system channel 3 calibrations due to oxidation on the switch contacts. This produced an unanticipated low output to pressurizer pressure controller PC-431K when operators placed the pressure control system back to automatic control after channel 3 calibrations were complete. The low output from the selector switch resulted in a low pressure signal that caused the proportional and backup heaters to be fully energized and closure of the spray valves, and pressurizer pressure unexpectedly rose from 2228 psig to 2245 psig in one minute until the system was | * The extent of condition review was not adequately performed for category three CR-2013-001099, which documented that the as left calibration values for the reactor vessel level instrumentation system train A function generator could be left outside of the total instrument uncertainty (TIU) of 0.96 percent, because CPI-INSTR-15.1, Calibration of Reactor Vessel Level Monitoring System Train A Instrumentation, Revision 01300, had a calibration tolerance of 1 percent. Consequently, the module could meet the procedure tolerance but be left outside the TIU and be non-functional for up to 18 months. The extent of condition review failed to recognize that the B train calibration procedure CPI-INSTR-18.1, Calibration of Reactor Vessel Level Monitoring System Train B Instrumentation, Revision 01401, allowed for the same inadequate condition. CENG entered the issue into the corrective action program as CR-2014-000975. | ||
* The extent of condition review within the ACE associated with CR-2010-006323, a category two CR, was not adequately performed. The evaluation associated with CR-2010-0006323 documents that there was high resistance on the contacts of charging pump selector switch L/428A that resulted in an increase in charging pump speed and pressurizer level until operators took manual control. In April 2013, pressurizer pressure selector switch P/429A malfunctioned during reactor protection system channel 3 calibrations due to oxidation on the switch contacts. This produced an unanticipated low output to pressurizer pressure controller PC-431K when operators placed the pressure control system back to automatic control after channel 3 calibrations were complete. The low output from the selector switch resulted in a low pressure signal that caused the proportional and backup heaters to be fully energized and closure of the spray valves, and pressurizer pressure unexpectedly rose from 2228 psig to 2245 psig in one minute until the system was taken to manual control. The extent of condition review associated with CR-2010-006323 failed to recognize that L/428A and P/429A were components with similar make and model. CENG entered the issue into the corrective action program as CR-2014-001289. | |||
The inspectors independently evaluated the deficiencies noted above for significance in accordance with the guidance in IMC 0612, Appendix B, Issue Screening, and Appendix E, Examples of Minor Issues. The inspectors determined these conditions were deficiencies of minor significance, and therefore, are not subject to enforcement action in accordance with the NRCs Enforcement Policy. While the inspectors concluded that the extent of condition evaluations for the above category two and category three CRs were not adequately performed, interviews conducted by the inspectors and reviews of CRs documented as a result of inspector questions revealed sufficient information to determine the above issues were resolved adequately by CENG staff. CENG documented these issues in CR-2014-000975 and CR-2014-001289. | |||
Additionally, the inspectors identified one example of more than minor significance where CENG personnel were not effective in evaluating and implementing effective corrective actions. The finding is documented below. | |||
Additionally, the inspectors identified one example of more than minor significance | |||
where CENG personnel were not effective in evaluating and implementing effective corrective actions. The finding is documented below. | |||
====c. Findings==== | ====c. Findings==== | ||
Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues | Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues | ||
=====Introduction.===== | =====Introduction.===== | ||
The inspectors identified a Green finding (FIN) for | The inspectors identified a Green finding (FIN) for CENGs failure to effectively implement a CA associated with an ACE that addressed both HDT pumps tripping on October 21, 2012. Specifically, CENG failed to effectively implement a CA to modify all procedures in which the feedwater system would be impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power on January 14, 2014. | ||
=====Description.===== | =====Description.===== | ||
On October 21, 2012, while reducing power for the 2012 refueling outage, the | On October 21, 2012, while reducing power for the 2012 refueling outage, the A and B HDT pumps tripped off approximately one minute after the second condensate booster pump was secured. This resulted in an unplanned power reduction to approximately 48 percent in accordance with AP-FW.1, Abnormal MFW Pump Flow or NPSH, Revision 1801, using AP-TURB.5, Rapid Load Reduction, Revision 1501. | ||
The ACE for this issue determined that engineering change package (ECP)-2009-0262, | The ACE for this issue determined that engineering change package (ECP)-2009-0262, Condensate System Pressure Rerate, Revision 0000, was implemented without a complete understanding of the effect of increased main feedwater (MFW) pump suction pressure on HDT control system dynamic response. This issue was documented by CENG in CR-2012-007133. | ||
On January 13, 2014, while the plant was at 100 percent power, a low pressure condition in the condensate system tripped both running condensate booster pumps and caused air operated valve (AOV)-3959, the condensate low pressure heater bypass valve, to open. This combination caused feed pump suction pressure to increase, and HDT level went high because of the slow response of AOV-3345, the level control valve. | On January 13, 2014, while the plant was at 100 percent power, a low pressure condition in the condensate system tripped both running condensate booster pumps and caused air operated valve (AOV)-3959, the condensate low pressure heater bypass valve, to open. This combination caused feed pump suction pressure to increase, and HDT level went high because of the slow response of AOV-3345, the level control valve. | ||
Line 149: | Line 115: | ||
Using AP-FW.1 and AP-TURB.5, the plant was stabilized at approximately 79 percent power. This issue was documented by CENG as CR-2014-000196. | Using AP-FW.1 and AP-TURB.5, the plant was stabilized at approximately 79 percent power. This issue was documented by CENG as CR-2014-000196. | ||
On January 14, 2014, at 00:17, the plant was stable at approximately 79 percent power, and operators were in AP-FW.1 to return the condensate system lineup to normal for plant recovery. Operators were directed by the procedure to close AOV-3959 and place the valve control switch in AUTO. This procedure step puts all condensate flow through the low pressure heaters, returns AOV-3959 to normal position, and causes an approximate 60 psig drop in MFW pump suction pressure. This drop causes the backpressure to decrease for the HDT pumps, which results in HDT pump discharge header flow immediately increasing even though HDT level is dropping slowly due to the slow response of AOV-3345. Input flows into the HDT did not change, because the reactor was stable, so the increase of HDT pump flow reduced the water mass in the HDT. At 00:18, HDT pressure increased above saturation pressure and swelling effects stopped. This resulted in HDT level dropping rapidly, which caused both HDT pumps to trip. Subsequently, operators used AP-TURB.5 to reduce power to approximately 48 percent in accordance with AP-FW.1. | On January 14, 2014, at 00:17, the plant was stable at approximately 79 percent power, and operators were in AP-FW.1 to return the condensate system lineup to normal for plant recovery. Operators were directed by the procedure to close AOV-3959 and place the valve control switch in AUTO. This procedure step puts all condensate flow through the low pressure heaters, returns AOV-3959 to normal position, and causes an approximate 60 psig drop in MFW pump suction pressure. This drop causes the backpressure to decrease for the HDT pumps, which results in HDT pump discharge header flow immediately increasing even though HDT level is dropping slowly due to the slow response of AOV-3345. Input flows into the HDT did not change, because the reactor was stable, so the increase of HDT pump flow reduced the water mass in the HDT. At 00:18, HDT pressure increased above saturation pressure and swelling effects stopped. This resulted in HDT level dropping rapidly, which caused both HDT pumps to trip. Subsequently, operators used AP-TURB.5 to reduce power to approximately 48 percent in accordance with AP-FW.1. CENGs ACE determined that the apparent cause of the HDT pumps tripping was Inadequate procedure direction exists for all applicable procedures to preclude low level in the HDT and minimize the sudden large reduction in MFW pump suction pressure after shutting AOV-3959. This includes optimum settings for AOV-3345 gain and trim valve settings and initial HDT level. This issue and its corresponding ACE were documented by CENG in CR-2014-000197. | ||
One of the CAs associated with the trip of the HDT pumps on October 21, 2012, CA-2012-003494, stated, | One of the CAs associated with the trip of the HDT pumps on October 21, 2012, CA-2012-003494, stated, Modify all procedures that were affected by ECP-2009-0262 and complete procedure change requests for any that are required to prevent issues when stopping HDT and condensate booster pumps. Focus on AP-TURB.5 and O-5.1. CA-2012-003494 was closed on April 23, 2013, and documented that AP-TURB.5, AP-SG.1, AP-CVCS.3, O-5.1, and O-2.1 were updated. Although CA-2012-003494 references the modification of all relevant procedures, AP-FW.1 was not revised. The ACE for CR-2014-000197 recognized that CA-2012-003494 was written to modify all applicable procedures and identified that no analysis was conducted in the CR-2012-007133 ACE about destabilizing effects on HDT level control in other abnormal procedures like AP-FW.1. However, the CR-2014-000197 ACE did not determine that CA-2012-003494 was ineffectively implemented or recognize ineffective implementation of CA-2012-003494 as an apparent or contributing cause; these facts are evidenced by the ACEs failure to identify any CAs to address the ineffectively implemented actions of CA-2012-003494. Subsequent to NRC inspector inquiries, these issues were documented by CENG in CR-2014-001208. Additionally, CA-2014-000730 and CA-2014-000731 document CENGs additional planned CAs to revise the CR-2014-000197 ACE and to evaluate whether additional CAs are necessary to adequately address the failure to effectively implement CAs. | ||
Procedure CNG-CA-1.01-1005, Apparent Cause Evaluations, Revision 00603, requires, in part, that CAs are effective and address identified causes. It also states that the CA sponsor shall review the proposed corrective, preventive, and compensatory actions to ensure the action is appropriate and will prevent recurrence. | |||
Procedure CNG-CA-1.01-1005, | |||
=====Analysis.===== | =====Analysis.===== | ||
The inspectors determined that | The inspectors determined that CENGs failure to effectively implement a CA to address all concerns related to HDT pump trips was a performance deficiency within CENGs ability to foresee and correct and should have been prevented. Specifically, CENG failed to effectively implement CA-2012-003493 to modify all procedures impacted by stopping HDT or condensate booster pumps. AP-FW.1 is such a procedure and should have been included in CA-2012-003493, but was not included. This ultimately resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. This finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to effectively implement CA-2012-003493 and modify all procedures impacted by stopping HDT or condensate booster pumps, including AP-FW.1, resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. Additionally, this issue is similar to Example 4b described in IMC 0612, Appendix E, Examples of Minor Issues, issued August 11, 2009, which states that issues are not minor if procedural issues cause a reactor trip or other transient. The inspectors evaluated the finding using IMC 0609, Attachment 0609.04, Initial Characterization of Findings, issued June 19, 2012. The attachment instructs inspectors to utilize IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012. Using Exhibit 1, Initiating Events Screening Questions, of IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, the inspectors determined this finding did not involve the complete or partial loss of a support system that contributes to the likelihood of, or cause, an initiating event and affect mitigation equipment and is therefore of very low safety significance (Green). | ||
This finding has a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because individuals did not follow processes, procedures, and work instructions. Specifically, CENG staff did not follow their Apparent Cause Evaluation procedure and ensure that CAs (CA-2012-003494) were effectively implemented and addressed identified causes associated with the ACE for CR-2012-007133. [H.8] | |||
This finding has a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because individuals did not follow processes, procedures, and work instructions. Specifically, CENG staff | |||
=====Enforcement.===== | =====Enforcement.===== | ||
CENG failed to effectively implement CA-2012-003494 and modify all procedures impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power in January 2014. These issues were entered into | CENG failed to effectively implement CA-2012-003494 and modify all procedures impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power in January 2014. These issues were entered into CENGs CAP as CR-2014-000197 and CR-2014-001208. This finding does not involve enforcement action because no violation of a regulatory requirement was identified. Because this finding does not involve a violation and is of very low safety significance, it is identified as a FIN. (FIN 05000244/2014008-01, Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues) | ||
Issues) | |||
===.2 Assessment of the Use of Operating Experience=== | ===.2 Assessment of the Use of Operating Experience=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed a sample of CRs associated with review of industry operating experience to determine whether CENG appropriately evaluated the operating | The inspectors reviewed a sample of CRs associated with review of industry operating experience to determine whether CENG appropriately evaluated the operating experience information for applicability to Ginna and had taken appropriate actions, when warranted. The inspectors also reviewed evaluations of operating experience documents associated with a sample of NRC generic communications to ensure that CENG adequately considered the underlying problems associated with the issues for resolution via their corrective action program. In addition, the inspectors observed various plant activities to determine if the station considered industry operating experience during the performance of routine and infrequently performed activities. | ||
experience information for applicability to Ginna and had taken appropriate actions, when warranted. The inspectors also reviewed evaluations of operating experience documents associated with a sample of NRC generic communications to ensure that CENG adequately considered the underlying problems associated with the issues for resolution via their corrective action program. In addition, the inspectors observed | |||
experience information for applicability, and used the information for corrective and preventive actions to identify and prevent similar issues when appropriate. The inspectors determined that operating experience was appropriately applied and lessons learned were communicated and incorporated into plant operations and procedures when applicable. The inspectors also observed that industry operating experience was routinely discussed and considered during the conduct of Plan-of-the-Day meetings and pre-job briefs. | b. Assessment The inspectors determined that CENG appropriately considered industry operating experience information for applicability, and used the information for corrective and preventive actions to identify and prevent similar issues when appropriate. The inspectors determined that operating experience was appropriately applied and lessons learned were communicated and incorporated into plant operations and procedures when applicable. The inspectors also observed that industry operating experience was routinely discussed and considered during the conduct of Plan-of-the-Day meetings and pre-job briefs. | ||
====c. Findings==== | ====c. Findings==== | ||
Line 192: | Line 148: | ||
====c. Findings==== | ====c. Findings==== | ||
No findings were identified. | No findings were identified. | ||
===.4 Assessment of Safety Conscious Work Environment=== | ===.4 Assessment of Safety Conscious Work Environment=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
During interviews with station personnel, the inspectors assessed the safety conscious work environment at Ginna. Specifically, the inspectors interviewed personnel to determine whether they were hesitant to raise safety concerns to their management | During interviews with station personnel, the inspectors assessed the safety conscious work environment at Ginna. Specifically, the inspectors interviewed personnel to determine whether they were hesitant to raise safety concerns to their management and/or the NRC. The inspectors also interviewed the station Employee Concerns Program coordinator to determine what actions are implemented to ensure employees were aware of the program and its availability with regards to raising safety concerns. | ||
The inspectors reviewed the Employee Concerns Program files to ensure that CENG entered issues into the corrective action program when appropriate. | |||
b. Assessment | b. Assessment During interviews, Ginna staff expressed a willingness to use the corrective action program to identify plant issues and deficiencies and stated that they were willing to raise safety issues. The inspectors noted that no one interviewed stated that they personally experienced or were aware of a situation in which an individual had been retaliated against for raising a safety issue. All persons interviewed demonstrated an adequate knowledge of the corrective action program and the Employee Concerns Program. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable safety conscious work environment and no significant challenges to the free flow of information. | ||
During interviews, Ginna staff expressed a willingness to use the corrective action program to identify plant issues and deficiencies and stated that they were willing to raise safety issues. The inspectors noted that no one interviewed stated that they personally experienced or were aware of a situation in which an individual had been retaliated against for raising a safety issue. All persons interviewed demonstrated an adequate knowledge of the corrective action program and the Employee Concerns Program. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable safety conscious work environment and no significant challenges to the free flow of information. | |||
====c. Findings==== | ====c. Findings==== | ||
Line 212: | Line 164: | ||
==4OA6 Meetings, Including Exit== | ==4OA6 Meetings, Including Exit== | ||
On March 13, 2014, the inspectors presented the inspection results to Mr. Michael | On March 13, 2014, the inspectors presented the inspection results to Mr. Michael Philippon, Plant General Manager, and other members of the Ginna staff. The inspectors verified that no proprietary information was retained by the inspectors or documented in this report. | ||
Philippon, Plant General Manager, and other members of the Ginna staff. The inspectors verified that no proprietary information was retained by the inspectors or documented in this report. | |||
ATTACHMENT: | ATTACHMENT: | ||
Line 223: | Line 173: | ||
===Licensee Personnel=== | ===Licensee Personnel=== | ||
: [[contact::J. Pacher]], Site Vice President | : [[contact::J. Pacher]], Site Vice President | ||
: [[contact::M. Philippon]], Plant General Manager | : [[contact::M. Philippon]], Plant General Manager | ||
: [[contact::C. Barrett]], Associate Engineer | : [[contact::C. Barrett]], Associate Engineer | ||
: [[contact::J. Brzezniak]], Software Engineer | : [[contact::J. Brzezniak]], Software Engineer | ||
: [[contact::D. Crowley]], Principal Engineer | : [[contact::D. Crowley]], Principal Engineer | ||
: [[contact::R. Fellows]], Control Room Supervisor | : [[contact::R. Fellows]], Control Room Supervisor | ||
: [[contact::D. Garofoli]], Principal Engineering Analyst | : [[contact::D. Garofoli]], Principal Engineering Analyst | ||
: [[contact::C. Hook]], Employee Concerns Program Coordinator | : [[contact::C. Hook]], Employee Concerns Program Coordinator | ||
: [[contact::D. Hudnut]], Simulator Testing Engineer | : [[contact::D. Hudnut]], Simulator Testing Engineer | ||
: [[contact::M. Ives]], General Supervisor, Security Operations | : [[contact::M. Ives]], General Supervisor, Security Operations | ||
: [[contact::J. Jackson]], Supervisor, Engineering | : [[contact::J. Jackson]], Supervisor, Engineering | ||
: [[contact::J. Jackson]], Manager of Licensing | : [[contact::J. Jackson]], Manager of Licensing | ||
: [[contact::T. Joachimczyk]], Shift Manager | : [[contact::T. Joachimczyk]], Shift Manager | ||
: [[contact::J. Jones]], Supervisor, Engineering | : [[contact::J. Jones]], Supervisor, Engineering | ||
: [[contact::D. Kenneston]], Supervisor, Security Programs | : [[contact::D. Kenneston]], Supervisor, Security Programs | ||
: [[contact::S. Kimbrough]], Principal Engineer | : [[contact::S. Kimbrough]], Principal Engineer | ||
: [[contact::H. Klingenberger]], Senior Engineering Analyst | : [[contact::H. Klingenberger]], Senior Engineering Analyst | ||
: [[contact::P. Ledain]], Senior Analyst, Performance Improvement | : [[contact::P. Ledain]], Senior Analyst, Performance Improvement | ||
: [[contact::T. Mogren]], Engineering Manager | : [[contact::T. Mogren]], Engineering Manager | ||
: [[contact::T. Paglia]], Operations Manager | : [[contact::T. Paglia]], Operations Manager | ||
: [[contact::E. Palmer]], Director, Security | : [[contact::E. Palmer]], Director, Security | ||
: [[contact::D. Pascuzzi]], Supervisor, Engineering | : [[contact::D. Pascuzzi]], Supervisor, Engineering | ||
: [[contact::W. Rapin]], Principle Engineer | : [[contact::W. Rapin]], Principle Engineer | ||
: [[contact::J. Sperr]], Supervisor, Engineering | : [[contact::J. Sperr]], Supervisor, Engineering | ||
: [[contact::B. Weaver]], Supervisor, Engineering | : [[contact::B. Weaver]], Supervisor, Engineering | ||
: [[contact::J. Zapetis]], Senior Engineering Analyst | : [[contact::J. Zapetis]], Senior Engineering Analyst | ||
==LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED== | ==LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED== | ||
===Opened and Closed=== | ===Opened and Closed=== | ||
: 05000244/2014008-01 | : 05000244/2014008-01 FIN Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues | ||
Issues | |||
==LIST OF DOCUMENTS REVIEWED== | ==LIST OF DOCUMENTS REVIEWED== | ||
}} | }} |
Revision as of 06:50, 4 November 2019
ML14101A325 | |
Person / Time | |
---|---|
Site: | Ginna ![]() |
Issue date: | 04/11/2014 |
From: | Daniel Schroeder Reactor Projects Branch 1 |
To: | Joseph Pacher Exelon Generation Co |
Schroeder D | |
References | |
IR-14-008 | |
Download: ML14101A325 (21) | |
Text
UNITED STATES NUCLEAR REGULATORY COMMISSION ril 11, 2014
SUBJECT:
R.E. GINNA NUCLEAR POWER PLANT, LLC - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000244/2014008
Dear Mr. Pacher:
On March 13, 2014, the U. S. Nuclear Regulatory Commission (NRC) completed an inspection at your R.E. Ginna Nuclear Power Plant, LLC (Ginna). The enclosed report documents the inspection results, which were discussed on March 13, 2014, with Mike Philippon, General Plant Manager, and other members of your staff.
This inspection examined activities conducted under your license as they relate to identification and resolution of problems and compliance with the Commissions rules and regulations and conditions of your license. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. On April 1, 2014, the operating license for Ginna held by the Constellation Energy Nuclear Group, LLC (CENG) was transferred to Exelon Generation Company, LLC.
Based on the samples selected for review, the inspectors concluded that CENG was generally effective in identifying, evaluating, and resolving problems. CENG personnel identified problems and entered them into the corrective action program at a low threshold. CENG prioritized and evaluated issues commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner.
This report documents one NRC-identified finding of very low safety significance (Green).
If you disagree with the finding or the assigned cross-cutting aspect, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region I; and the NRC resident inspector at Ginna.
In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390 of the NRCs Rules of Practice, a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records component of the NRCs Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRC website at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Daniel L. Schroeder, Chief Reactor Projects Branch 1 Division of Reactor Projects Docket No. 50-244 License No. DPR-18
Enclosure:
Inspection Report 05000244/2014008 w/Attachment: Supplementary Information
REGION I==
Docket No. 50-244 License No. DPR-18 Report No. 05000244/2014008 Licensee: Constellation Energy Nuclear Group, LLC (CENG)
Facility: R.E. Ginna Nuclear Power Plant, LLC Location: Ontario, NY Dates: February 24, 2014 through March 13, 2014 Team Leader: Steve Shaffer, Senior Project Engineer Inspectors: Doug Dodson, Resident Inspector, Ginna Brian Haagensen, Resident Inspector, Millstone Andrey Turilin, Project Engineer Approved by: Daniel L. Schroeder, Chief Reactor Projects Branch 1 Division of Reactor Projects Enclosure
SUMMARY
IR 05000244/2014008; 02/24/2014 - 03/13/2014; R.E. Ginna Nuclear Power Plant, LLC (Ginna); Biennial Baseline Inspection of Problem Identification and Resolution. The inspectors identified one finding in the area of effectiveness of corrective actions.
This NRC team inspection was performed by two regional inspectors and two resident inspectors. The inspectors identified one finding of very low safety significance (Green) during this inspection. The significance of most findings is indicated by their color (i.e., greater than Green, or Green, White, Yellow, Red) and determined using Inspection Manual Chapter (IMC)0609, Significance Determination Process, dated June 2, 2011. Cross-cutting aspects are determined using IMC 0310, Aspects with Cross-Cutting Areas, dated January 1, 2014. All violations of NRC requirements are dispositioned in accordance with the NRCs Enforcement Policy, dated July 9, 2013. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4.
Problem Identification and Resolution The inspectors concluded that CENG was generally effective in identifying, evaluating, and resolving problems. CENG personnel identified problems, entered them into the corrective action program at a low threshold, and prioritized issues commensurate with their safety significance. In most cases, CENG appropriately screened issues for operability and reportability, and performed causal analyses that appropriately considered extent of condition, generic issues, and previous occurrences. The inspectors also determined that CENG typically implemented corrective actions (CAs) to address the problems identified in the corrective action program in a timely manner.
The inspectors concluded that, in general, CENG adequately identified, reviewed, and applied relevant industry operating experience to Ginna operations. In addition, based on those items selected for review, the inspectors determined that CENGs self-assessments and audits were thorough.
Based on the interviews the inspectors conducted over the course of the inspection, observations of plant activities, and reviews of individual corrective action program and employee concerns program issues, the inspectors did not identify any indications that site personnel were unwilling to raise safety issues nor did they identify any conditions that could have had a negative impact on the sites safety conscious work environment.
Cornerstone: Initiating Events
- Green.
The inspectors identified a Green finding (FIN) for CENGs failure to effectively implement a CA associated with an apparent cause evaluation (ACE) that addressed both heater drain tank (HDT) pumps tripping on October 21, 2012. Specifically, CENG failed to effectively implement a CA to modify all procedures in which the feedwater system would be impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power on January 14, 2014. These issues were entered into CENGs corrective action program as condition report (CR)-2014-000197 and CR-2014-001208.
This finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to effectively implement CA-2012-003493 and modify all procedures impacted by stopping HDT or condensate booster pumps, including procedure AP-FW.1, resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. Additionally, this issue is similar to Example 4b described in IMC 0612, Appendix E, Examples of Minor Issues, issued August 11, 2009, which states that issues are not minor if procedural issues cause a reactor trip or other transient. Using Exhibit 1, Initiating Events Screening Questions, of IMC 0609, Appendix A,
The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, the inspectors determined this finding did not involve the complete or partial loss of a support system that contributes to the likelihood of, or causes, an initiating event and affects mitigation equipment and is therefore of very low safety significance (Green). This finding has a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because individuals did not follow processes, procedures, and work instructions. Specifically, CENG staff did not follow procedure CNG-CA-1.01-1005 and ensure that CAs (CA-2012-003494) were effectively implemented and addressed identified causes associated with the ACE for CR-2012-007133.
[H.8] (Section 4OA2.1.c)
REPORT DETAILS
OTHER ACTIVITIES (OA)
4OA2 Problem Identification and Resolution
This inspection constitutes one biennial sample of problem identification and resolution as defined by Inspection Procedure 71152. All documents reviewed during this inspection are listed in the Attachment to this report.
.1 Assessment of Corrective Action Program Effectiveness
a. Inspection Scope
The inspectors reviewed the procedures that described CENGs corrective action program at Ginna. To assess the effectiveness of the corrective action program, the inspectors reviewed performance in three primary areas: problem identification, prioritization and evaluation of issues, and corrective action implementation. The inspectors compared performance in these areas to the requirements and standards contained in Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion XVI, Corrective Action, and CENG CNG-CA-1.01-1000, Corrective Action Program, Revision 01000. For each of these areas, the inspectors considered risk insights from the stations risk analysis and reviewed CRs selected across the seven cornerstones of safety in the NRCs Reactor Oversight Process. Additionally, the inspectors attended multiple Plan-of-the-Day, Condition Report Review Committee, and Management Review Committee meetings. The inspectors selected items from the following functional areas for review: engineering, operations, maintenance, emergency preparedness, radiation protection, chemistry, physical security, and oversight programs.
- (1) Effectiveness of Problem Identification In addition to the items described above, the inspectors reviewed system health reports, a sample of completed corrective and preventative maintenance work orders, completed surveillance test procedures, operator logs, and periodic trend reports. The inspectors also completed field walkdowns of various systems on site, such as the emergency diesel generators and auxiliary feedwater systems. Additionally, the inspectors reviewed a sample of CRs written to document issues identified through internal self-assessments, audits, emergency preparedness drills, and the operating experience program. The inspectors completed this review to verify that CENG entered conditions adverse to quality into their corrective action program as appropriate.
- (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the evaluation and prioritization of a sample of CRs issued since the last NRC biennial Problem Identification and Resolution inspection completed in February 2012. The inspectors also reviewed CRs that were assigned lower levels of significance that did not include formal cause evaluations to ensure that they were properly classified. The inspectors review included the appropriateness of the assigned significance, the scope and depth of the causal analysis, and the timeliness of resolution. The inspectors assessed whether the evaluations identified likely causes for the issues and developed appropriate corrective actions to address the identified causes. Further, the inspectors reviewed equipment operability determinations, reportability assessments, and extent-of-condition reviews for selected problems to verify these processes adequately addressed equipment operability, reporting of issues to the NRC, and the extent of the issues.
- (3) Effectiveness of Corrective Actions The inspectors reviewed CENGs completed CAs through documentation review and, in some cases, field walkdowns to determine whether the actions addressed the identified causes of the problems. The inspectors also reviewed CRs for adverse trends and repetitive problems to determine whether CAs were effective in addressing the broader issues. The inspectors reviewed CENGs timeliness in implementing CAs and effectiveness in precluding recurrence for significant conditions adverse to quality. The inspectors also reviewed a sample of CRs associated with selected non-cited violations and findings to verify that CENG personnel properly evaluated and resolved these issues. In addition, the inspectors expanded the CA review to five years to evaluate CENG actions related to the heater drain system.
b.
Assessment
- (1) Effectiveness of Problem Identification Based on the selected samples, plant walkdowns, and interviews of site personnel in multiple functional areas, the inspectors determined that CENG identified problems and entered them into the corrective action program at a low threshold. CENG staff at Ginna initiated approximately 16,000 CRs between February 2012 and February 2014. The inspectors observed supervisors at the Plan-of-the-Day, Condition Report Review Committee, and Management Review Committee meetings appropriately questioning and challenging CRs to ensure clarification of the issues. Based on the samples reviewed, the inspectors determined that CENG trended equipment and programmatic issues, and appropriately identified problems in CRs. The inspectors verified that conditions adverse to quality identified through this review were entered into the corrective action program as appropriate. Additionally, inspectors concluded that personnel were identifying trends at low levels. In general, inspectors did not identify issues or concerns that had not been appropriately entered into the corrective action program for evaluation and resolution. In response to several questions and minor equipment observations identified by the inspectors during plant walkdowns, CENG personnel promptly initiated CRs and/or took immediate action to address the issues.
- (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors determined that, in general, CENG appropriately prioritized and evaluated issues commensurate with the safety significance of the identified problem.
CENG screened CRs for operability and reportability, categorized the CRs by significance, and assigned actions to the appropriate department for evaluation and resolution. The CR screening process considered human performance issues, radiological safety concerns, repetitiveness, adverse trends, and potential impact on the safety conscious work environment.
Based on the sample of CRs reviewed, the inspectors noted that the guidance provided by CENGs corrective action program implementing procedures appeared sufficient to ensure consistency in categorization of issues. Operability and reportability determinations were generally performed when conditions warranted and in most cases, the evaluations supported the conclusion. Causal analyses appropriately considered the extent of condition or problem, generic issues, and previous occurrences of the issue.
- (3) Effectiveness of Corrective Actions The inspectors concluded that corrective actions for identified deficiencies were generally timely and adequately implemented. For significant conditions adverse to quality, CENG identified actions to prevent recurrence. The inspectors concluded that corrective actions to address the inspection sample of NRC non-cited violations and findings since the last problem identification and resolution inspection were timely and effective. However, the inspectors did identify some instances where CENGs evaluation of issues was inconsistently implemented. Specifically, the inspectors identified some instances of CENG failing to meet the procedural requirements of CNG-CA-1.01-1000, Corrective Action Program, Revision 01000, and CNG-CA-1.01-1005, Apparent Cause Evaluation, Revision 00603. Specifically, the following instances were identified by inspectors as inadequate evaluation of issues:
- The extent of condition review was not adequately performed for category three CR-2013-001099, which documented that the as left calibration values for the reactor vessel level instrumentation system train A function generator could be left outside of the total instrument uncertainty (TIU) of 0.96 percent, because CPI-INSTR-15.1, Calibration of Reactor Vessel Level Monitoring System Train A Instrumentation, Revision 01300, had a calibration tolerance of 1 percent. Consequently, the module could meet the procedure tolerance but be left outside the TIU and be non-functional for up to 18 months. The extent of condition review failed to recognize that the B train calibration procedure CPI-INSTR-18.1, Calibration of Reactor Vessel Level Monitoring System Train B Instrumentation, Revision 01401, allowed for the same inadequate condition. CENG entered the issue into the corrective action program as CR-2014-000975.
- The extent of condition review within the ACE associated with CR-2010-006323, a category two CR, was not adequately performed. The evaluation associated with CR-2010-0006323 documents that there was high resistance on the contacts of charging pump selector switch L/428A that resulted in an increase in charging pump speed and pressurizer level until operators took manual control. In April 2013, pressurizer pressure selector switch P/429A malfunctioned during reactor protection system channel 3 calibrations due to oxidation on the switch contacts. This produced an unanticipated low output to pressurizer pressure controller PC-431K when operators placed the pressure control system back to automatic control after channel 3 calibrations were complete. The low output from the selector switch resulted in a low pressure signal that caused the proportional and backup heaters to be fully energized and closure of the spray valves, and pressurizer pressure unexpectedly rose from 2228 psig to 2245 psig in one minute until the system was taken to manual control. The extent of condition review associated with CR-2010-006323 failed to recognize that L/428A and P/429A were components with similar make and model. CENG entered the issue into the corrective action program as CR-2014-001289.
The inspectors independently evaluated the deficiencies noted above for significance in accordance with the guidance in IMC 0612, Appendix B, Issue Screening, and Appendix E, Examples of Minor Issues. The inspectors determined these conditions were deficiencies of minor significance, and therefore, are not subject to enforcement action in accordance with the NRCs Enforcement Policy. While the inspectors concluded that the extent of condition evaluations for the above category two and category three CRs were not adequately performed, interviews conducted by the inspectors and reviews of CRs documented as a result of inspector questions revealed sufficient information to determine the above issues were resolved adequately by CENG staff. CENG documented these issues in CR-2014-000975 and CR-2014-001289.
Additionally, the inspectors identified one example of more than minor significance where CENG personnel were not effective in evaluating and implementing effective corrective actions. The finding is documented below.
c. Findings
Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues
Introduction.
The inspectors identified a Green finding (FIN) for CENGs failure to effectively implement a CA associated with an ACE that addressed both HDT pumps tripping on October 21, 2012. Specifically, CENG failed to effectively implement a CA to modify all procedures in which the feedwater system would be impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power on January 14, 2014.
Description.
On October 21, 2012, while reducing power for the 2012 refueling outage, the A and B HDT pumps tripped off approximately one minute after the second condensate booster pump was secured. This resulted in an unplanned power reduction to approximately 48 percent in accordance with AP-FW.1, Abnormal MFW Pump Flow or NPSH, Revision 1801, using AP-TURB.5, Rapid Load Reduction, Revision 1501.
The ACE for this issue determined that engineering change package (ECP)-2009-0262, Condensate System Pressure Rerate, Revision 0000, was implemented without a complete understanding of the effect of increased main feedwater (MFW) pump suction pressure on HDT control system dynamic response. This issue was documented by CENG in CR-2012-007133.
On January 13, 2014, while the plant was at 100 percent power, a low pressure condition in the condensate system tripped both running condensate booster pumps and caused air operated valve (AOV)-3959, the condensate low pressure heater bypass valve, to open. This combination caused feed pump suction pressure to increase, and HDT level went high because of the slow response of AOV-3345, the level control valve.
Using AP-FW.1 and AP-TURB.5, the plant was stabilized at approximately 79 percent power. This issue was documented by CENG as CR-2014-000196.
On January 14, 2014, at 00:17, the plant was stable at approximately 79 percent power, and operators were in AP-FW.1 to return the condensate system lineup to normal for plant recovery. Operators were directed by the procedure to close AOV-3959 and place the valve control switch in AUTO. This procedure step puts all condensate flow through the low pressure heaters, returns AOV-3959 to normal position, and causes an approximate 60 psig drop in MFW pump suction pressure. This drop causes the backpressure to decrease for the HDT pumps, which results in HDT pump discharge header flow immediately increasing even though HDT level is dropping slowly due to the slow response of AOV-3345. Input flows into the HDT did not change, because the reactor was stable, so the increase of HDT pump flow reduced the water mass in the HDT. At 00:18, HDT pressure increased above saturation pressure and swelling effects stopped. This resulted in HDT level dropping rapidly, which caused both HDT pumps to trip. Subsequently, operators used AP-TURB.5 to reduce power to approximately 48 percent in accordance with AP-FW.1. CENGs ACE determined that the apparent cause of the HDT pumps tripping was Inadequate procedure direction exists for all applicable procedures to preclude low level in the HDT and minimize the sudden large reduction in MFW pump suction pressure after shutting AOV-3959. This includes optimum settings for AOV-3345 gain and trim valve settings and initial HDT level. This issue and its corresponding ACE were documented by CENG in CR-2014-000197.
One of the CAs associated with the trip of the HDT pumps on October 21, 2012, CA-2012-003494, stated, Modify all procedures that were affected by ECP-2009-0262 and complete procedure change requests for any that are required to prevent issues when stopping HDT and condensate booster pumps. Focus on AP-TURB.5 and O-5.1. CA-2012-003494 was closed on April 23, 2013, and documented that AP-TURB.5, AP-SG.1, AP-CVCS.3, O-5.1, and O-2.1 were updated. Although CA-2012-003494 references the modification of all relevant procedures, AP-FW.1 was not revised. The ACE for CR-2014-000197 recognized that CA-2012-003494 was written to modify all applicable procedures and identified that no analysis was conducted in the CR-2012-007133 ACE about destabilizing effects on HDT level control in other abnormal procedures like AP-FW.1. However, the CR-2014-000197 ACE did not determine that CA-2012-003494 was ineffectively implemented or recognize ineffective implementation of CA-2012-003494 as an apparent or contributing cause; these facts are evidenced by the ACEs failure to identify any CAs to address the ineffectively implemented actions of CA-2012-003494. Subsequent to NRC inspector inquiries, these issues were documented by CENG in CR-2014-001208. Additionally, CA-2014-000730 and CA-2014-000731 document CENGs additional planned CAs to revise the CR-2014-000197 ACE and to evaluate whether additional CAs are necessary to adequately address the failure to effectively implement CAs.
Procedure CNG-CA-1.01-1005, Apparent Cause Evaluations, Revision 00603, requires, in part, that CAs are effective and address identified causes. It also states that the CA sponsor shall review the proposed corrective, preventive, and compensatory actions to ensure the action is appropriate and will prevent recurrence.
Analysis.
The inspectors determined that CENGs failure to effectively implement a CA to address all concerns related to HDT pump trips was a performance deficiency within CENGs ability to foresee and correct and should have been prevented. Specifically, CENG failed to effectively implement CA-2012-003493 to modify all procedures impacted by stopping HDT or condensate booster pumps. AP-FW.1 is such a procedure and should have been included in CA-2012-003493, but was not included. This ultimately resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. This finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to effectively implement CA-2012-003493 and modify all procedures impacted by stopping HDT or condensate booster pumps, including AP-FW.1, resulted in both HDT pumps tripping and an unplanned power reduction of approximately 31 percent power. Additionally, this issue is similar to Example 4b described in IMC 0612, Appendix E, Examples of Minor Issues, issued August 11, 2009, which states that issues are not minor if procedural issues cause a reactor trip or other transient. The inspectors evaluated the finding using IMC 0609, Attachment 0609.04, Initial Characterization of Findings, issued June 19, 2012. The attachment instructs inspectors to utilize IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012. Using Exhibit 1, Initiating Events Screening Questions, of IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, the inspectors determined this finding did not involve the complete or partial loss of a support system that contributes to the likelihood of, or cause, an initiating event and affect mitigation equipment and is therefore of very low safety significance (Green).
This finding has a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because individuals did not follow processes, procedures, and work instructions. Specifically, CENG staff did not follow their Apparent Cause Evaluation procedure and ensure that CAs (CA-2012-003494) were effectively implemented and addressed identified causes associated with the ACE for CR-2012-007133. [H.8]
Enforcement.
CENG failed to effectively implement CA-2012-003494 and modify all procedures impacted by stopping HDT or condensate booster pumps, which resulted in both HDT pumps tripping and an unplanned power reduction from approximately 79 percent power to approximately 48 percent power in January 2014. These issues were entered into CENGs CAP as CR-2014-000197 and CR-2014-001208. This finding does not involve enforcement action because no violation of a regulatory requirement was identified. Because this finding does not involve a violation and is of very low safety significance, it is identified as a FIN. (FIN 05000244/2014008-01, Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues)
.2 Assessment of the Use of Operating Experience
a. Inspection Scope
The inspectors reviewed a sample of CRs associated with review of industry operating experience to determine whether CENG appropriately evaluated the operating experience information for applicability to Ginna and had taken appropriate actions, when warranted. The inspectors also reviewed evaluations of operating experience documents associated with a sample of NRC generic communications to ensure that CENG adequately considered the underlying problems associated with the issues for resolution via their corrective action program. In addition, the inspectors observed various plant activities to determine if the station considered industry operating experience during the performance of routine and infrequently performed activities.
b. Assessment The inspectors determined that CENG appropriately considered industry operating experience information for applicability, and used the information for corrective and preventive actions to identify and prevent similar issues when appropriate. The inspectors determined that operating experience was appropriately applied and lessons learned were communicated and incorporated into plant operations and procedures when applicable. The inspectors also observed that industry operating experience was routinely discussed and considered during the conduct of Plan-of-the-Day meetings and pre-job briefs.
c. Findings
No findings were identified.
.3 Assessment of Self-Assessments and Audits
a. Inspection Scope
The inspectors reviewed a sample of audits, including the most recent audit of the corrective action program, departmental self-assessments, and assessments performed by independent organizations. Inspectors performed these reviews to determine if CENG entered problems identified through these assessments into the corrective action program, when appropriate, and whether CENG initiated corrective actions to address identified deficiencies. The inspectors evaluated the effectiveness of the audits and assessments by comparing audit and assessment results against self-revealing and NRC-identified observations made during the inspection.
b. Assessment The inspectors concluded that self-assessments, audits, and other internal CENG assessments were generally critical, thorough, and effective in identifying issues. The inspectors observed that CENG personnel knowledgeable in the subject completed these audits and self-assessments in a methodical manner. CENG completed these audits and self-assessments to a sufficient depth to identify issues which were then entered into the corrective action program for evaluation. In general, the station implemented corrective actions associated with the identified issues commensurate with their safety significance.
c. Findings
No findings were identified.
.4 Assessment of Safety Conscious Work Environment
a. Inspection Scope
During interviews with station personnel, the inspectors assessed the safety conscious work environment at Ginna. Specifically, the inspectors interviewed personnel to determine whether they were hesitant to raise safety concerns to their management and/or the NRC. The inspectors also interviewed the station Employee Concerns Program coordinator to determine what actions are implemented to ensure employees were aware of the program and its availability with regards to raising safety concerns.
The inspectors reviewed the Employee Concerns Program files to ensure that CENG entered issues into the corrective action program when appropriate.
b. Assessment During interviews, Ginna staff expressed a willingness to use the corrective action program to identify plant issues and deficiencies and stated that they were willing to raise safety issues. The inspectors noted that no one interviewed stated that they personally experienced or were aware of a situation in which an individual had been retaliated against for raising a safety issue. All persons interviewed demonstrated an adequate knowledge of the corrective action program and the Employee Concerns Program. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable safety conscious work environment and no significant challenges to the free flow of information.
c. Findings
No findings were identified.
4OA6 Meetings, Including Exit
On March 13, 2014, the inspectors presented the inspection results to Mr. Michael Philippon, Plant General Manager, and other members of the Ginna staff. The inspectors verified that no proprietary information was retained by the inspectors or documented in this report.
ATTACHMENT:
SUPPLEMENTARY INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
- J. Pacher, Site Vice President
- M. Philippon, Plant General Manager
- C. Barrett, Associate Engineer
- J. Brzezniak, Software Engineer
- D. Crowley, Principal Engineer
- R. Fellows, Control Room Supervisor
- D. Garofoli, Principal Engineering Analyst
- C. Hook, Employee Concerns Program Coordinator
- D. Hudnut, Simulator Testing Engineer
- M. Ives, General Supervisor, Security Operations
- J. Jackson, Supervisor, Engineering
- J. Jackson, Manager of Licensing
- T. Joachimczyk, Shift Manager
- J. Jones, Supervisor, Engineering
- D. Kenneston, Supervisor, Security Programs
- S. Kimbrough, Principal Engineer
- H. Klingenberger, Senior Engineering Analyst
- P. Ledain, Senior Analyst, Performance Improvement
- T. Mogren, Engineering Manager
- T. Paglia, Operations Manager
- E. Palmer, Director, Security
- D. Pascuzzi, Supervisor, Engineering
- W. Rapin, Principle Engineer
- J. Sperr, Supervisor, Engineering
- B. Weaver, Supervisor, Engineering
- J. Zapetis, Senior Engineering Analyst
LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED
Opened and Closed
- 05000244/2014008-01 FIN Failure to Effectively Implement Corrective Actions Associated with Heater Drain Tank Pump Tripping Issues