Information Notice 2004-01, Auxiliary Feedwater Pump Recirculation Line Orifice Fouling - Potential Common Cause Failure: Difference between revisions

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| issue date = 01/21/2004
| issue date = 01/21/2004
| title = Auxiliary Feedwater Pump Recirculation Line Orifice Fouling - Potential Common Cause Failure
| title = Auxiliary Feedwater Pump Recirculation Line Orifice Fouling - Potential Common Cause Failure
| author name = Beckner W D
| author name = Beckner W
| author affiliation = NRC/NRR/DIPM
| author affiliation = NRC/NRR/DIPM
| addressee name =  
| addressee name =  
Line 9: Line 9:
| docket = 05000266, 05000301
| docket = 05000266, 05000301
| license number = DPR-024
| license number = DPR-024
| contact person = Dozier J I, NRR/IROB 415-1014
| contact person = Dozier J, NRR/IROB 415-1014
| document report number = IN-04-001
| document report number = IN-04-001
| document type = NRC Information Notice
| document type = NRC Information Notice
| page count = 9
| page count = 9
| revision = 0
}}
}}
{{#Wiki_filter:UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR REACTOR REGULATIONWASHINGTON, January 21, 2004NRC INFORMATION NOTICE 2004-01:AUXILIARY FEEDWATER PUMPRECIRCULATION LINE ORIFICE FOULING -
{{#Wiki_filter:UNITED STATES
POTENTIAL COMMON CAUSE FAILURE
 
NUCLEAR REGULATORY COMMISSION
 
OFFICE OF NUCLEAR REACTOR REGULATION
 
WASHINGTON, D.C. 20555 January 21, 2004 NRC INFORMATION NOTICE 2004-01:                   AUXILIARY FEEDWATER PUMP
 
RECIRCULATION LINE ORIFICE FOULING -
                                                  POTENTIAL COMMON CAUSE FAILURE


==Addressees==
==Addressees==
:All holders of operating licenses or construction permits for nuclear power reactors, exceptthose that have permanently ceased operations and have certified that fuel has been permanently removed from the reactor.
:
All holders of operating licenses or construction permits for nuclear power reactors, except
 
those that have permanently ceased operations and have certified that fuel has been
 
permanently removed from the reactor.


==Purpose==
==Purpose==
:The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice to informaddressees of the potential common cause failure of auxiliary feedwater pumps because of fouling of pump recirculation line flow orifice It is expected that recipients will review the information for applicability to their facilities and consider actions, as appropriate, to avoid similar problems. However, suggestions in this information notice are not NRC requirements; therefore no specific action or written response is required.Background:Point Beach Nuclear Plant (PBNP) is a two unit sit Each unit has a turbine-driven AFW pump(pumps 1P29 and 2P29) which can supply water to both steam generator Additionally, the plant has two motor-driven AFW pumps (pumps P38A and P38B) each of which can be aligned to a steam generator in each uni Each pump has a recirculation line back to the condensate storage tanks (CSTs) to ensure minimum flow to prevent hydraulic instabilities and dissipate pump hea The recirculation line contained a pressure reducing, flow restricting orific An arrow is pointing to the recirculation flow restricting orifice (RO) in the major flow path AFW diagram provided in Figure 1 and a picture of the RO is provided in Figure The RO used a multi-stage, anti-cavitation trim package installed in the body of a globe valve tolimit flo This style of orifice or flow restrictor was installed in the AFW recirculation lines at PBNP in the past few years to eliminate cavitation caused by the old orifice This type of flow restrictor used very small channels and holes in each stage combined with a tortuous path to limit flow and prevent cavitation. Figure AFW System - Major Flow PathsFigure Recirculation Flow Restricting Orifice  
:
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice to inform
 
addressees of the potential common cause failure of auxiliary feedwater pumps because of
 
fouling of pump recirculation line flow orifices. It is expected that recipients will review the
 
information for applicability to their facilities and consider actions, as appropriate, to avoid
 
similar problems. However, suggestions in this information notice are not NRC requirements;
therefore no specific action or written response is required.
 
Background:
Point Beach Nuclear Plant (PBNP) is a two unit site. Each unit has a turbine-driven AFW pump
 
(pumps 1P29 and 2P29) which can supply water to both steam generators. Additionally, the
 
plant has two motor-driven AFW pumps (pumps P38A and P38B) each of which can be aligned
 
to a steam generator in each unit. Each pump has a recirculation line back to the condensate
 
storage tanks (CSTs) to ensure minimum flow to prevent hydraulic instabilities and dissipate
 
pump heat. The recirculation line contained a pressure reducing, flow restricting orifice. An
 
arrow is pointing to the recirculation flow restricting orifice (RO) in the major flow path AFW
 
diagram provided in Figure 1 and a picture of the RO is provided in Figure 2.
 
The RO used a multi-stage, anti-cavitation trim package installed in the body of a globe valve to
 
limit flow. This style of orifice or flow restrictor was installed in the AFW recirculation lines at
 
PBNP in the past few years to eliminate cavitation caused by the old orifices. This type of flow
 
restrictor used very small channels and holes in each stage combined with a tortuous path to
 
limit flow and prevent cavitation.
 
Figure 1. AFW System - Major Flow Paths
 
Figure 2. Recirculation Flow Restricting Orifice


==Description of Circumstances==
==Description of Circumstances==
:On October 24, 2002, during post-maintenance surveillance testing of the P38A motor-drivenAFW pump at PBNP, the licensee observed AFW recirculation line flow to be 64.5 gpm, which was less than the 70 gpm acceptance criterio Normal flow through the recirculation line was 75 gp Suspecting instrument error, plant personnel vented and recalibrated the flow instrumen The P38A AFW pump was then started and tested again; however, the observed recirculation flow was essentially unchange Following that test run, the recirculation flow orifice was removed and inspecte After removal of the orifice internals, partial blockage was observed in 24 of the 54 holes in theoutermost sleev No particles were found on any of the inner sleeve Samples of the particles removed from the orifice were retained for analysi A boroscope inspection of the recirculation piping at the orifice location revealed no evidence of debri Following cleaning and reassembly, the orifice was reinstalled and the P38A AFW pump was successfully reteste Testing was successfully completed on the other three AFW pumps to verify acceptable recirculation flow by October 25, 2002.During the next several days, PBNP personnel evaluated the implications of the orifice pluggingeven An apparent cause evaluation was initiated with specific directions to assess and evaluate the potential extent of conditio An action plan was developed to identify the source of the debris found in the orifice and to determine what other testing or flushing would be required to assure that future plugging did not occur. As the investigations continued, questions developed concerning the operability of the AFWsystem while supplied by its safety-related water supply, the service water (SW) syste Although the service water supply was provided through a basket strainer, it was recognized that the strainer mesh was larger than the much finer RO channel holes and could allow debris to pass that could clog the R These concerns culminated in a meeting on October 29, 2002, at which PBNP personnel concluded that there was no longer a reasonable assurance that operation of the AFW system using its safety-related suction source of service water would not result in potential AFW recirculation line orifice clogging.In a worst case scenario, Point Beach personnel determined that it may be possible, althoughunlikely, for each of the four flow control orifices, each associated with one of the four AFW pumps, to restrict the flow through the associated recirculation lin Under such conditions, it was hypothesized that if the discharge valves for the AFW pumps were throttled, adequate flow might be unavailable through the recirculation line and pump damage could occur due to overheating.On October 29, 2002, all four AFW pumps were declared inoperabl Both units entered theirtechnical specification action statements and required actions which directs immediate action to restore an AFW system to operable statu Immediate corrective actions consisted of briefing the on-shift crew of the potential consequences of restricted recirculation flow and initiating procedure change The operators were also directed to secure a running AFW pump if the pump discharge flows should be decreased to less than 50 gpm for the motor-driven pumps or 75 gpm for the turbine-driven pump These flow rates were substantially above the point at which pump damage could occur. Information tags were placed at the AFW pump flow indicators on the main control boards to convey that informatio With these administrative controls in place, operations declared the AFW system operable, about four hours after the pumps had been declared inoperabl An incident investigation was initiated to collect andconfirm the facts of this event description beginning with the discovery of the P-38A AFW pump degraded recirculation flow during post-maintenance testing and concluding with the decision to declare the AFW system inoperable.In accordance with 10 CFR 50.72(b)(3)(v), an eight-hour ENS notification (EN #39330) wasmade on October 29, 200 The LER is available in ADAMS (Accession Number ML032890115).A PBNP multi-discipline event resolution team was formed to identify and resolve the issuesassociated with the discovery of this conditio Activities included initiation of a root cause evaluation (RCE) to determine the root and contributing causes for the postulated common-mode failure that would render all AFW pump recirculation lines with restricted flow rate The RCE concluded that this event had a direct root cause and an organizational root caus The direct root cause was the failure by design engineering to properly evaluate the potential for orifice plugging within the design proces Instead of revisiting the design for adequacy and evaluating the potential for plugging of the proposed orifices within the rigor of the design process, the 10 CFR 50.59 safety evaluation was revised to justify the proposed desig The organizational root cause was less than adequate management oversight of the design modification proces Also, in January and February 2003, a specially fabricated orifice was tested at a contractorlaboratory in an effort to determine a plugging probability with service wate Definitive testing occurred on February 21 when a debris mixture of sand, silt, and zebra mussel shells, representative of what would exist in the Point Beach SW system, was injected into a closed loop configuration of piping, an orifice, and a centrifugal pum The orifice plugged in much less than one minute after the mixture was injected into the loo These results were contrary to those of a previously performed computational particle fouling model analysis that indicated that plugging was unlikely because of the particle size distribution of debris in SW and the shear forces in the holes and channels of the orifices developed with the minimum flow required through the orifice for pump coolin Discussion:A special inspection was conducted by the NRC to evaluate the facts, circumstances, andlicensee actions, and documented in NRC Inspection Report 50-266/02-15 and 50-301/02-15 (Accession Number ML030920128). This issue was determined to be of Yellow risk significance for Unit 1, an issue with substantial importance to safety, and Red risk significance for Unit 2, an issue of high importance to safet The difference in significance between the Units was a result of the longer period of time that the AFW recirculation line pressure reduction orifices were installed in Unit (See Final Determination Letter, dated December 11, 2003,Accession Number ML033490022). This information notice requires no specific action or written respons If you have anyquestions regarding the information notice, please contact the technical contacts listed below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager./Original signed by: Terrence Reis/William D. Beckner, Chief Reactor Operations Branch Division of Inspection Program Management Office of Nuclear Reactor RegulationTechnical contacts:Jerry Dozier, NRRPaul Krohn, Region III(301) 415-1014(920) 755-2309 E-mail: jxd@nrc.govE-mail: pgk1@nrc.gov
:
On October 24, 2002, during post-maintenance surveillance testing of the P38A motor-driven
 
AFW pump at PBNP, the licensee observed AFW recirculation line flow to be 64.5 gpm, which
 
was less than the 70 gpm acceptance criterion. Normal flow through the recirculation line was
 
75 gpm. Suspecting instrument error, plant personnel vented and recalibrated the flow
 
instrument. The P38A AFW pump was then started and tested again; however, the observed
 
recirculation flow was essentially unchanged. Following that test run, the recirculation flow
 
orifice was removed and inspected.
 
After removal of the orifice internals, partial blockage was observed in 24 of the 54 holes in the
 
outermost sleeve. No particles were found on any of the inner sleeves. Samples of the
 
particles removed from the orifice were retained for analysis. A boroscope inspection of the
 
recirculation piping at the orifice location revealed no evidence of debris. Following cleaning
 
and reassembly, the orifice was reinstalled and the P38A AFW pump was successfully retested.
 
Testing was successfully completed on the other three AFW pumps to verify acceptable
 
recirculation flow by October 25, 2002.
 
During the next several days, PBNP personnel evaluated the implications of the orifice plugging
 
event. An apparent cause evaluation was initiated with specific directions to assess and
 
evaluate the potential extent of condition. An action plan was developed to identify the source
 
of the debris found in the orifice and to determine what other testing or flushing would be
 
required to assure that future plugging did not occur.
 
As the investigations continued, questions developed concerning the operability of the AFW
 
system while supplied by its safety-related water supply, the service water (SW) system.
 
Although the service water supply was provided through a basket strainer, it was recognized
 
that the strainer mesh was larger than the much finer RO channel holes and could allow debris
 
to pass that could clog the RO. These concerns culminated in a meeting on October 29, 2002, at which PBNP personnel concluded that there was no longer a reasonable assurance that
 
operation of the AFW system using its safety-related suction source of service water would not
 
result in potential AFW recirculation line orifice clogging.
 
In a worst case scenario, Point Beach personnel determined that it may be possible, although
 
unlikely, for each of the four flow control orifices, each associated with one of the four AFW
 
pumps, to restrict the flow through the associated recirculation line. Under such conditions, it
 
was hypothesized that if the discharge valves for the AFW pumps were throttled, adequate flow
 
might be unavailable through the recirculation line and pump damage could occur due to
 
overheating.
 
On October 29, 2002, all four AFW pumps were declared inoperable. Both units entered their
 
technical specification action statements and required actions which directs immediate action to
 
restore an AFW system to operable status. Immediate corrective actions consisted of briefing
 
the on-shift crew of the potential consequences of restricted recirculation flow and initiating
 
procedure changes. The operators were also directed to secure a running AFW pump if the
 
pump discharge flows should be decreased to less than 50 gpm for the motor-driven pumps or
 
75 gpm for the turbine-driven pumps. These flow rates were substantially above the point at
 
which pump damage could occur. Information tags were placed at the AFW pump flow
 
indicators on the main control boards to convey that information. With these administrative
 
controls in place, operations declared the AFW system operable, about four hours after the pumps had been declared inoperable. An incident investigation was initiated to collect and
 
confirm the facts of this event description beginning with the discovery of the P-38A AFW pump
 
degraded recirculation flow during post-maintenance testing and concluding with the decision to
 
declare the AFW system inoperable.
 
In accordance with 10 CFR 50.72(b)(3)(v), an eight-hour ENS notification (EN #39330) was
 
made on October 29, 2002. The LER is available in ADAMS (Accession Number
 
ML032890115).
 
A PBNP multi-discipline event resolution team was formed to identify and resolve the issues
 
associated with the discovery of this condition. Activities included initiation of a root cause
 
evaluation (RCE) to determine the root and contributing causes for the postulated
 
common-mode failure that would render all AFW pump recirculation lines with restricted
 
flow rates. The RCE concluded that this event had a direct root cause and an organizational
 
root cause. The direct root cause was the failure by design engineering to properly evaluate
 
the potential for orifice plugging within the design process. Instead of revisiting the design for
 
adequacy and evaluating the potential for plugging of the proposed orifices within the rigor of
 
the design process, the 10 CFR 50.59 safety evaluation was revised to justify the proposed
 
design. The organizational root cause was less than adequate management oversight of the
 
design modification process.
 
Also, in January and February 2003, a specially fabricated orifice was tested at a contractor
 
laboratory in an effort to determine a plugging probability with service water. Definitive testing
 
occurred on February 21 when a debris mixture of sand, silt, and zebra mussel shells, representative of what would exist in the Point Beach SW system, was injected into a closed
 
loop configuration of piping, an orifice, and a centrifugal pump. The orifice plugged in much
 
less than one minute after the mixture was injected into the loop. These results were contrary
 
to those of a previously performed computational particle fouling model analysis that indicated
 
that plugging was unlikely because of the particle size distribution of debris in SW and the
 
shear forces in the holes and channels of the orifices developed with the minimum flow required
 
through the orifice for pump cooling.
 
Discussion:
A special inspection was conducted by the NRC to evaluate the facts, circumstances, and
 
licensee actions, and documented in NRC Inspection Report 50-266/02-15 and 50-301/02-15 (Accession Number ML030920128). This issue was determined to be of Yellow risk
 
significance for Unit 1, an issue with substantial importance to safety, and Red risk significance
 
for Unit 2, an issue of high importance to safety. The difference in significance between the
 
Units was a result of the longer period of time that the AFW recirculation line pressure reduction
 
orifices were installed in Unit 2. (See Final Determination Letter, dated December 11, 2003, Accession Number ML033490022). This information notice requires no specific action or written response. If you have any
 
questions regarding the information notice, please contact the technical contacts listed below or
 
the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.
 
/Original signed by: Terrence Reis/
                                              William D. Beckner, Chief
 
Reactor Operations Branch
 
Division of Inspection Program Management
 
Office of Nuclear Reactor Regulation
 
Technical contacts:  Jerry Dozier, NRR              Paul Krohn, Region III
 
(301) 415-1014                  (920) 755-2309 E-mail: jxd@nrc.gov            E-mail: pgk1@nrc.gov
 
Attachment: List of Recently Issued NRC Information Notices This information notice requires no specific action or written response. If you have any
 
questions regarding the information notice, please contact the technical contacts listed below or
 
the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.
 
/Original signed by: Terrence Reis/
                                              William D. Beckner, Chief
 
Reactor Operations Branch
 
Division of Inspection Program Management
 
Office of Nuclear Reactor Regulation
 
Technical contacts:   Jerry Dozier, NRR              Paul Krohn, Region III
 
(301) 415-1014                 (920) 755-2309 E-mail: jxd@nrc.gov            E-mail: pgk1@nrc.gov
 
Attachment: List of Recently Issued NRC Information Notices
 
DISTRIBUTION:
ADAMS
 
IN File
 
DOCUMENT NAME: G:\RORP\OES\Staff Folders\Dozier\InformationNoticeonPointBeachOrifice.wpd
 
Adams Accession No.:ML040140460
OFFICE    OES:IROB:DIPM Tech Editor                  DLPM                SRI:RIII
 
NAME      IJDozier            PKleene                DWSpaulding        PKrohn
 
DATE      12/03/2003          12/09/2003              01/14/2004          01/13/2004 OFFICE    BC:RIII            SC:OES:IROB:DIPM C:IROB:DIPM
 
NAME      AVegel              TReis                  WDBeckner
 
DATE      01/13 /2004        01/14/2004              01/21/2004 OFFICIAL RECORD COPY
 
Attachment LIST OF RECENTLY ISSUED
 
NRC INFORMATION NOTICES
 
_____________________________________________________________________________________
Information                                              Date of
 
Notice No.              Subject                          Issuance        Issued to
 
_____________________________________________________________________________________
2002-26, Sup 2    Additional Failure of Steam          01/09/2004      All holders of an operating license
 
Dryer After A Recent Power                            or a construction permit for
 
Uprate                                                nuclear power reactors, except
 
those that have permanently
 
ceased operations and have
 
certified that fuel has been
 
permanently removed from the
 
reactor.
 
2003-11, Sup 1    Leakage Found on Bottom-              01/08/2004      All holders of operating licenses
 
Mounted Instrumentation                                or construction permits for
 
Nozzles                                                nuclear power reactors, except
 
those that have permanently
 
ceased operations and have
 
certified that fuel has been
 
permanently removed from the
 
reactor.
 
2003-22          Heightened Awareness for              12/09/2003      All medical licensees and NRC
 
Patients Containing Detectable                        Master Materials License medical
 
Amounts of Radiation from                              use permittees.
 
Medical Administrations
 
2003-21          High-Dose-Rate-Remote-                11/24/2003      All medical licensees.
 
Afterloader Equipment Failure
 
2003-20          Derating Whiting Cranes              10/22/2003      All holders of operating licenses
 
Purchased Before 1980                                  for nuclear power reactors, except those who have
 
permanently ceased operations
 
and have certified that fuel has
 
been permanently removed from
 
the reactor vessel; applicable
 
decommissioning reactors, fuel
 
facilities, and independent spent
 
fuel storage installations.
 
Note:            NRC generic communications may be received in electronic format shortly after they are
 
issued by subscribing to the NRC listserver as follows:
                To subscribe send an e-mail to <listproc@nrc.gov >, no subject, and the following
 
command in the message portion:
                                    subscribe gc-nrr firstname lastname


===Attachment:===
______________________________________________________________________________________
List of Recently Issued NRC Information Notices This information notice requires no specific action or written respons If you have anyquestions regarding the information notice, please contact the technical contacts listed below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager./Original signed by: Terrence Reis/William D. Beckner, Chief Reactor Operations Branch Division of Inspection Program Management Office of Nuclear Reactor RegulationTechnical contacts:Jerry Dozier, NRRPaul Krohn, Region III(301) 415-1014(920) 755-2309 E-mail: jxd@nrc.govE-mail: pgk1@nrc.gov
OL = Operating License


===Attachment:===
CP = Construction Permit}}
List of Recently Issued NRC Information NoticesDISTRIBUTION:ADAMS IN FileDOCUMENT NAME: G:\RORP\OES\Staff Folders\Dozier\InformationNoticeonPointBeachOrifice.wpdAdams Accession No.:ML040140460OFFICEOES:IROB:DIPMTech EditorDLPMSRI:RIIINAMEIJDozierPKleeneDWSpauldingPKrohnDATE12/03/200312/09/200301/14/200401/13/2004OFFICEBC:RIIISC:OES:IROB:DIPMC:IROB:DIPMNAMEAVegelTReisWDBecknerDATE01/13 /200401/14/200401/21/2004OFFICIAL RECORD COPY
______________________________________________________________________________________OL = Operating License CP = Construction PermitAttachment LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICES_____________________________________________________________________________________InformationDate of Notice N SubjectIssuanceIssued to_____________________________________________________________________________________2002-26, Sup 2Additional Failure of SteamDryer After A Recent Power Uprate01/09/2004All holders of an operating licenseor a construction permit for nuclear power reactors, except those that have permanently ceased operations and have certified that fuel has been permanently removed from the reactor.2003-11, Sup 1Leakage Found on Bottom-Mounted Instrumentation Nozzles01/08/2004All holders of operating licensesor construction permits for nuclear power reactors, except those that have permanently ceased operations and have certified that fuel has been permanently removed from the reactor.2003-22Heightened Awareness forPatients Containing Detectable Amounts of Radiation from Medical Administrations12/09/2003All medical licensees and NRCMaster Materials License medical use permittees.2003-21High-Dose-Rate-Remote-Afterloader Equipment Failure11/24/2003All medical licensees.2003-20Derating Whiting CranesPurchased Before 198010/22/2003All holders of operating licensesfor nuclear power reactors, except those who have permanently ceased operations and have certified that fuel has been permanently removed from the reactor vessel; applicable decommissioning reactors, fuel facilities, and independent spent fuel storage installations.Note:NRC generic communications may be received in electronic format shortly after they areissued by subscribing to the NRC listserver as follows:To subscribe send an e-mail to <listproc@nrc.gov >, no subject, and the followingcommand in the message portion:subscribe gc-nrr firstname lastname}}


{{Information notice-Nav}}
{{Information notice-Nav}}

Latest revision as of 02:22, 24 November 2019

Auxiliary Feedwater Pump Recirculation Line Orifice Fouling - Potential Common Cause Failure
ML040140460
Person / Time
Site: Point Beach  NextEra Energy icon.png
Issue date: 01/21/2004
From: Beckner W
NRC/NRR/DIPM
To:
Dozier J, NRR/IROB 415-1014
References
IN-04-001
Download: ML040140460 (9)


UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR REACTOR REGULATION

WASHINGTON, D.C. 20555 January 21, 2004 NRC INFORMATION NOTICE 2004-01: AUXILIARY FEEDWATER PUMP

RECIRCULATION LINE ORIFICE FOULING -

POTENTIAL COMMON CAUSE FAILURE

Addressees

All holders of operating licenses or construction permits for nuclear power reactors, except

those that have permanently ceased operations and have certified that fuel has been

permanently removed from the reactor.

Purpose

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

addressees of the potential common cause failure of auxiliary feedwater pumps because of

fouling of pump recirculation line flow orifices. It is expected that recipients will review the

information for applicability to their facilities and consider actions, as appropriate, to avoid

similar problems. However, suggestions in this information notice are not NRC requirements;

therefore no specific action or written response is required.

Background:

Point Beach Nuclear Plant (PBNP) is a two unit site. Each unit has a turbine-driven AFW pump

(pumps 1P29 and 2P29) which can supply water to both steam generators. Additionally, the

plant has two motor-driven AFW pumps (pumps P38A and P38B) each of which can be aligned

to a steam generator in each unit. Each pump has a recirculation line back to the condensate

storage tanks (CSTs) to ensure minimum flow to prevent hydraulic instabilities and dissipate

pump heat. The recirculation line contained a pressure reducing, flow restricting orifice. An

arrow is pointing to the recirculation flow restricting orifice (RO) in the major flow path AFW

diagram provided in Figure 1 and a picture of the RO is provided in Figure 2.

The RO used a multi-stage, anti-cavitation trim package installed in the body of a globe valve to

limit flow. This style of orifice or flow restrictor was installed in the AFW recirculation lines at

PBNP in the past few years to eliminate cavitation caused by the old orifices. This type of flow

restrictor used very small channels and holes in each stage combined with a tortuous path to

limit flow and prevent cavitation.

Figure 1. AFW System - Major Flow Paths

Figure 2. Recirculation Flow Restricting Orifice

Description of Circumstances

On October 24, 2002, during post-maintenance surveillance testing of the P38A motor-driven

AFW pump at PBNP, the licensee observed AFW recirculation line flow to be 64.5 gpm, which

was less than the 70 gpm acceptance criterion. Normal flow through the recirculation line was

75 gpm. Suspecting instrument error, plant personnel vented and recalibrated the flow

instrument. The P38A AFW pump was then started and tested again; however, the observed

recirculation flow was essentially unchanged. Following that test run, the recirculation flow

orifice was removed and inspected.

After removal of the orifice internals, partial blockage was observed in 24 of the 54 holes in the

outermost sleeve. No particles were found on any of the inner sleeves. Samples of the

particles removed from the orifice were retained for analysis. A boroscope inspection of the

recirculation piping at the orifice location revealed no evidence of debris. Following cleaning

and reassembly, the orifice was reinstalled and the P38A AFW pump was successfully retested.

Testing was successfully completed on the other three AFW pumps to verify acceptable

recirculation flow by October 25, 2002.

During the next several days, PBNP personnel evaluated the implications of the orifice plugging

event. An apparent cause evaluation was initiated with specific directions to assess and

evaluate the potential extent of condition. An action plan was developed to identify the source

of the debris found in the orifice and to determine what other testing or flushing would be

required to assure that future plugging did not occur.

As the investigations continued, questions developed concerning the operability of the AFW

system while supplied by its safety-related water supply, the service water (SW) system.

Although the service water supply was provided through a basket strainer, it was recognized

that the strainer mesh was larger than the much finer RO channel holes and could allow debris

to pass that could clog the RO. These concerns culminated in a meeting on October 29, 2002, at which PBNP personnel concluded that there was no longer a reasonable assurance that

operation of the AFW system using its safety-related suction source of service water would not

result in potential AFW recirculation line orifice clogging.

In a worst case scenario, Point Beach personnel determined that it may be possible, although

unlikely, for each of the four flow control orifices, each associated with one of the four AFW

pumps, to restrict the flow through the associated recirculation line. Under such conditions, it

was hypothesized that if the discharge valves for the AFW pumps were throttled, adequate flow

might be unavailable through the recirculation line and pump damage could occur due to

overheating.

On October 29, 2002, all four AFW pumps were declared inoperable. Both units entered their

technical specification action statements and required actions which directs immediate action to

restore an AFW system to operable status. Immediate corrective actions consisted of briefing

the on-shift crew of the potential consequences of restricted recirculation flow and initiating

procedure changes. The operators were also directed to secure a running AFW pump if the

pump discharge flows should be decreased to less than 50 gpm for the motor-driven pumps or

75 gpm for the turbine-driven pumps. These flow rates were substantially above the point at

which pump damage could occur. Information tags were placed at the AFW pump flow

indicators on the main control boards to convey that information. With these administrative

controls in place, operations declared the AFW system operable, about four hours after the pumps had been declared inoperable. An incident investigation was initiated to collect and

confirm the facts of this event description beginning with the discovery of the P-38A AFW pump

degraded recirculation flow during post-maintenance testing and concluding with the decision to

declare the AFW system inoperable.

In accordance with 10 CFR 50.72(b)(3)(v), an eight-hour ENS notification (EN #39330) was

made on October 29, 2002. The LER is available in ADAMS (Accession Number

ML032890115).

A PBNP multi-discipline event resolution team was formed to identify and resolve the issues

associated with the discovery of this condition. Activities included initiation of a root cause

evaluation (RCE) to determine the root and contributing causes for the postulated

common-mode failure that would render all AFW pump recirculation lines with restricted

flow rates. The RCE concluded that this event had a direct root cause and an organizational

root cause. The direct root cause was the failure by design engineering to properly evaluate

the potential for orifice plugging within the design process. Instead of revisiting the design for

adequacy and evaluating the potential for plugging of the proposed orifices within the rigor of

the design process, the 10 CFR 50.59 safety evaluation was revised to justify the proposed

design. The organizational root cause was less than adequate management oversight of the

design modification process.

Also, in January and February 2003, a specially fabricated orifice was tested at a contractor

laboratory in an effort to determine a plugging probability with service water. Definitive testing

occurred on February 21 when a debris mixture of sand, silt, and zebra mussel shells, representative of what would exist in the Point Beach SW system, was injected into a closed

loop configuration of piping, an orifice, and a centrifugal pump. The orifice plugged in much

less than one minute after the mixture was injected into the loop. These results were contrary

to those of a previously performed computational particle fouling model analysis that indicated

that plugging was unlikely because of the particle size distribution of debris in SW and the

shear forces in the holes and channels of the orifices developed with the minimum flow required

through the orifice for pump cooling.

Discussion:

A special inspection was conducted by the NRC to evaluate the facts, circumstances, and

licensee actions, and documented in NRC Inspection Report 50-266/02-15 and 50-301/02-15 (Accession Number ML030920128). This issue was determined to be of Yellow risk

significance for Unit 1, an issue with substantial importance to safety, and Red risk significance

for Unit 2, an issue of high importance to safety. The difference in significance between the

Units was a result of the longer period of time that the AFW recirculation line pressure reduction

orifices were installed in Unit 2. (See Final Determination Letter, dated December 11, 2003, Accession Number ML033490022). This information notice requires no specific action or written response. If you have any

questions regarding the information notice, please contact the technical contacts listed below or

the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

/Original signed by: Terrence Reis/

William D. Beckner, Chief

Reactor Operations Branch

Division of Inspection Program Management

Office of Nuclear Reactor Regulation

Technical contacts: Jerry Dozier, NRR Paul Krohn, Region III

(301) 415-1014 (920) 755-2309 E-mail: jxd@nrc.gov E-mail: pgk1@nrc.gov

Attachment: List of Recently Issued NRC Information Notices This information notice requires no specific action or written response. If you have any

questions regarding the information notice, please contact the technical contacts listed below or

the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

/Original signed by: Terrence Reis/

William D. Beckner, Chief

Reactor Operations Branch

Division of Inspection Program Management

Office of Nuclear Reactor Regulation

Technical contacts: Jerry Dozier, NRR Paul Krohn, Region III

(301) 415-1014 (920) 755-2309 E-mail: jxd@nrc.gov E-mail: pgk1@nrc.gov

Attachment: List of Recently Issued NRC Information Notices

DISTRIBUTION:

ADAMS

IN File

DOCUMENT NAME: G:\RORP\OES\Staff Folders\Dozier\InformationNoticeonPointBeachOrifice.wpd

Adams Accession No.:ML040140460

OFFICE OES:IROB:DIPM Tech Editor DLPM SRI:RIII

NAME IJDozier PKleene DWSpaulding PKrohn

DATE 12/03/2003 12/09/2003 01/14/2004 01/13/2004 OFFICE BC:RIII SC:OES:IROB:DIPM C:IROB:DIPM

NAME AVegel TReis WDBeckner

DATE 01/13 /2004 01/14/2004 01/21/2004 OFFICIAL RECORD COPY

Attachment LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

_____________________________________________________________________________________

Information Date of

Notice No. Subject Issuance Issued to

_____________________________________________________________________________________

2002-26, Sup 2 Additional Failure of Steam 01/09/2004 All holders of an operating license

Dryer After A Recent Power or a construction permit for

Uprate nuclear power reactors, except

those that have permanently

ceased operations and have

certified that fuel has been

permanently removed from the

reactor.

2003-11, Sup 1 Leakage Found on Bottom- 01/08/2004 All holders of operating licenses

Mounted Instrumentation or construction permits for

Nozzles nuclear power reactors, except

those that have permanently

ceased operations and have

certified that fuel has been

permanently removed from the

reactor.

2003-22 Heightened Awareness for 12/09/2003 All medical licensees and NRC

Patients Containing Detectable Master Materials License medical

Amounts of Radiation from use permittees.

Medical Administrations

2003-21 High-Dose-Rate-Remote- 11/24/2003 All medical licensees.

Afterloader Equipment Failure

2003-20 Derating Whiting Cranes 10/22/2003 All holders of operating licenses

Purchased Before 1980 for nuclear power reactors, except those who have

permanently ceased operations

and have certified that fuel has

been permanently removed from

the reactor vessel; applicable

decommissioning reactors, fuel

facilities, and independent spent

fuel storage installations.

Note: NRC generic communications may be received in electronic format shortly after they are

issued by subscribing to the NRC listserver as follows:

To subscribe send an e-mail to <listproc@nrc.gov >, no subject, and the following

command in the message portion:

subscribe gc-nrr firstname lastname

______________________________________________________________________________________

OL = Operating License

CP = Construction Permit