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| number = ML18291A562 | | number = ML18291A562 | ||
| issue date = 10/16/2018 | | issue date = 10/16/2018 | ||
| title = | | title = NRC Biennial Problem Identification and Resolution Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 | ||
| author name = Miller G | | author name = Miller G | ||
| author affiliation = NRC/RGN-IV/DRS | | author affiliation = NRC/RGN-IV/DRS | ||
| addressee name = Bement R | | addressee name = Bement R | ||
| addressee affiliation = Arizona Public Service Co | | addressee affiliation = Arizona Public Service Co | ||
| docket = 05000528, 05000529, 05000530 | | docket = 05000528, 05000529, 05000530 | ||
| license number = NPF-041, NPF-051, NPF-074 | | license number = NPF-041, NPF-051, NPF-074 | ||
| contact person = Miller G | | contact person = Miller G | ||
| document report number = IR 2018008 | | document report number = IR 2018008 | ||
| document type = Inspection Report, Letter | | document type = Inspection Report, Letter | ||
Line 18: | Line 18: | ||
=Text= | =Text= | ||
{{#Wiki_filter: | {{#Wiki_filter:ber 16, 2018 | ||
==SUBJECT:== | |||
PALO VERDE NUCLEAR GENERATING STATION - NRC BIENNIAL PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000528/2018008, 05000529/2018008, AND 05000530/2018008 | |||
/RA-e//RA-e//RA-e//RA/ /RA/ /RA GAG for/ 9/21/ | ==Dear Mr. Bement:== | ||
On September 14, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution inspection at your Palo Verde Nuclear Generating Station, Units 1, 2, and 3. The NRC inspection team discussed the results of this inspection with Ms. M. Lacal, Senior Vice President, Regulatory and Oversight, and other members of your staff. The results of this inspection are documented in the enclosed report. | |||
The NRC inspection team reviewed the stations corrective action program and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems and to confirm that the station was complying with NRC regulations and licensee standards for corrective action programs. Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety. | |||
The team also evaluated the stations processes for use of industry and NRC operating experience information and the effectiveness of the stations audits and self-assessments. | |||
Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety. | |||
Finally the team reviewed the stations programs to establish and maintain a safety-conscious work environment and interviewed station personnel to evaluate the effectiveness of these programs. Based on the teams observations and the results of these interviews, the team found no evidence of challenges to your organizations safety-conscious work environment. | |||
Palo Verde Nuclear Generating Station employees appeared willing to raise nuclear safety concerns through at least one of the several means available. | |||
The NRC inspectors documented one finding of very low safety significance (Green) in this report, which involved a violation of NRC requirements. Additionally, the team documented two licensee-identified violations that were determined to be of very low safety significance. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy. | |||
If you contest these violations or their significance, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the Palo Verde Nuclear Generating Station. | |||
Likewise, if you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the Palo Verde Nuclear Generating Station. | |||
This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding. | |||
Sincerely, | |||
/RA Gerond George Acting for/ | |||
Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Docket Nos. 50-528, 50-529, and 50-530 License Nos. NPF-41, NPF-51, and NPF-74 Enclosure: | |||
Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 w/ attachment: Information Requests | |||
U.S. NUCLEAR REGULATORY COMMISSION | |||
==Inspection Report== | |||
Docket Number(s): 05000528, 05000529, 05000530 License Number(s): NPF-41, NPF-51, NPF-74 Report Number(s): 05000528/2018008, 05000529/2018008, and 05000530/2018008 Enterprise Identifier: I-2018-008-0001 Licensee: Arizona Public Service Company Facility: Palo Verde Nuclear Generating Station Location: Tonopah, Arizona Inspection Dates: August 27, 2018, to September 14, 2018 Inspectors: E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead) | |||
P. Jayroe, Reactor Inspector G. Kolcum, Sr. Resident Inspector D. Reinert, Resident Inspector Approved By: Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Enclosure | |||
=SUMMARY= | |||
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Palo Verde Nuclear Generating Station, Units 1, 2, and 3, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. A licensee-identified non-cited violation is discussed in report section 71152. | |||
List of Findings and Violations Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Report Section Aspect Mitigating Green H.12 71152Problem Systems NCV 05000528, 05000529, Identification and 05000530/2018008-01 Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, | |||
Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct the failures of multiple control room hand-switch operator knobs. | |||
=INSPECTION SCOPES= | |||
Inspections were conducted using the appropriate portions of the inspection procedures (IPs)in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. | |||
Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The team reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards. | |||
==OTHER ACTIVITIES - BASELINE== | |||
===71152Problem Identification and Resolution Biennial Team Inspection === | |||
{{IP sample|IP=IP 71152|count=1}} | |||
The team performed a biennial assessment of the licensees corrective action program (CAP),use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below. | |||
: (1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports and associated records, and an in-depth 5-year review of condition reports associated with the safety injection and shutdown cooling systems. | |||
: (2) Operating Experience, Self-Assessments, and Audits - The team evaluated the stations processes for use of industry and NRC operating experience. The team also evaluated the effectiveness of the stations audits and self-assessments program by reviewing a sample of nine self-assessments (benchmark, simple, formal departmental) and seven audits. | |||
: (3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, engineering, organizational effectiveness and performance improvement, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey. | |||
===71153Follow-up of Events and Notices of Enforcement Discretion Licensee Event Reports === | |||
{{IP sample|IP=IP 71153|count=1}} | |||
The team evaluated licensee event report (LER) 05000528/2018-002: Condition Prohibited by Technical Specification for Inoperable Excore Instrument Channel (ADAMS Accession Number ML18130A986). The team reviewed two licensee-identified non-cited violations associated with the LER, described in the inspection results below. | |||
==INSPECTION RESULTS== | |||
- OBSERVATIONS/ASSESSMENT Corrective Action Program Assessment 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems was adequate to support nuclear safety, though some challenges were noted. In particular, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues. These are described in observations, findings, and violations below. | |||
Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues was adequate to support nuclear safety. The licensee continues to work to improve management oversight of the corrective action program, which has been consistently identified as an area for improvement by both third party and internal reviews. The team noted that the licensees actions appear to have improved management oversight, including improvements to quality and consistency of evaluation products through enhanced CARB oversight, and the addition of new tools for scoping the evaluation. However, these actions were too recently completed for the team to determine whether they have been fully successful. Additionally, the team noted that while individual problems were generally fixed, the licensee did not always expand evaluations to determine the cause or aggregate impact of multiple similar conditions. Examples are discussed below. | |||
Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of conditions adverse to quality that were classified as nonconformances, this is discussed below as a minor violation. | |||
Observations on the Corrective Action Program 71152Problem Identification and Resolution The team reviewed the engineering design change process and impact review process, and found it to be adequate and in line with industry standards. The team also screened a sample of condition reports that originated over the past 2 years and found several examples of misses tied to the design change process and impact reviews where the required updates to documentation were not completed or were incorrect. Personnel interviewed by the team indicated that these misses were sometimes identified by workers being unable to perform work activities as directed by work orders or unable to draft clearance orders due to incorrect drawings. In all examples reviewed by the team, the licensee revised or updated affected documentation after the condition report was written; however the team did not note any significant efforts to evaluate or improve the engineering design change impact review process. The team reviewed the stations use of trend codes to track these examples and identified several instances where expected trend codes were incorrectly applied or not applied at all. One particular trend code (CM 3.10) is applied to condition reports which are created in advance or just recently after a plant modification to create a tracking item for required updates to various documents; the team noted examples of documentation revisions tied to legacy modifications lumped in under this trend code. Liberal use of this particular trend code in coincidence with restricted use of more applicable trend codes may be masking potential trends in documentation revisions missed by the impact review process. The licensee documented this observation in Condition Report 18-14427. | |||
The team observed that the licensees condition report classification committees (the Screening Committee and the Condition Review Group) did not always consistently apply the corrective action program (CAP) definitions of condition adverse to quality (CAQ) and non-condition adverse to quality. In particular, a lack of guidance or familiarity in what constituted an adverse trend in a quality process CAQ versus a potential adverse trend (non-condition adverse to quality until evaluated and confirmed) led to inconsistency in classification of condition reports documenting aggregate issues. The licensee documented this observation in Condition Reports 18-13648 and 18-14334. | |||
Additionally, some identified deficiencies in quality programs were classified as non-condition adverse to quality. For example, on January 2, 2018, the licensees organizational effectiveness department issued a Corrective Action Program Elevation Letter, which identified, inconsistent identification of issues entered into the condition reporting process, CAP product quality decline, inappropriate closure of CAP actions, and rejection of CAP products including causal evaluation. The condition report associated with this letter, Condition Report 18-00055, was classified as non-condition adverse to quality. In procedure 01DP-0AP12, Condition Reporting Process the licensee defines CAQ to include, failures to comply with procedures that implement the current licensing basis (CLB), where CLB is defined to include both 10 CFR Part 50 and the licensees quality assurance program, both of which contain requirements implemented by CAP. In these examples and others reviewed by the team, the conditions adverse to quality were timely addressed, even when classified as non-condition adverse to quality. Therefore there was no violation of NRC regulations. The licensee documented this issue in Condition Report 18-13739. | |||
Assessment of Use of Operating Experience 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analysis and apparent cause evaluations. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs. | |||
Self-Assessments and Audits Assessment 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that station performance in these areas adequately supported nuclear safety. Generally, self-assessments and audits were effective at identifying deficiencies and enhancements. In all cases, deficiencies were documented in condition reports for both self-assessments and audits. Audits, in particular, were highly effective in identifying and documenting deficiencies. One self-assessment (16-10139) did not appear to have a tracking item (i.e. condition report) for an enhancement. | |||
Safety-Conscious Work Environment Assessment 71152Problem Identification and Resolution The team found no evidence of challenges to the safety-conscious work environment of station work groups. Individuals appeared willing to raise nuclear safety concerns through at least one of the several means available. | |||
==INSPECTION RESULTS== | |||
- ISSUES/FINDINGS Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to promptly identify and correct conditions adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI. | |||
The team identified a backlog of conditions adverse to quality that the licensee had failed to timely correct. The oldest of these conditions was approximately 10 years old, with several hundred having been identified at least two operating cycles prior to the inspection. The team determined that the licensee was appropriately addressing degraded components that had an impact on safety or security, but was not always tracking or timely correcting nonconformances with its design bases in cases where these nonconformances had been assessed as not impacting safety-related functions. Further, the licensee was unable to initially determine the scope of its nonconformance backlog. The licensee documented this deficiency as Condition Reports 18-13549 and 18-14426. | |||
Screening: The performance deficiency was minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives. | |||
=====Enforcement:===== | |||
This failure to comply with 10 CFR 50, Appendix B, Criterion XVI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy. | |||
Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR 50, Appendix B, Criterion VI. | |||
The team identified that the CAP procedure directed the use of the Cause Analysis Manual in performing some cause evaluations. This cause evaluation process is an activity affecting quality required by 10 CFR 50, Appendix B and the licensees Quality Assurance Program. | |||
The licensee failed to control the Cause Analysis Manual in accordance with the Palo Verde Nuclear Generating Station Operations Quality Assurance Program Description, Revision 0, Section 2.6, Document Control. The licensee documented this violation in Condition Report 18-13996. | |||
Screening: The performance deficiency is minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives. | |||
=====Enforcement:===== | |||
This failure to comply with 10 CFR 50, Appendix B, Criterion VI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy. | |||
Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy. | |||
Violation: 10 CFR Part 50, Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. | |||
Contrary to the above, on May 24, 2007, the licensee failed to perform the installation of the Unit 1, channel C excore nuclear instrument preamplifier connection, an activity affecting quality, in accordance with these instructions, procedures, or drawings. The licensee determined that a human performance error occurred during the performance of the 2007 work order which explicitly stated that the o-rings were required for environmental qualification. As a result, the excore detector would not have performed its safety function during a design basis main steam line break. | |||
Significance/Severity Level: The team determined this finding was of very low safety significance (Green) because a minimum of two excore detector channels always remained available to trip the reactor during a main steam line break. Redundant channels were not affected and were available to perform the required safety function to trip the reactor. | |||
Corrective Action Reference(s): Condition Report 18-12217 Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy. | |||
Violation: 10 CFR 50.73(a)(2)(i)(B) requires, in part, that the holder of an operating license shall submit an licensee event report within 60 days of discovery of the event, which includes any operation or condition which was prohibited by technical specifications. | |||
Contrary to the above, the licensee failed to submit a licensee event report within 60 days of April 23, 2016, after discovering that the Unit 1 channel C excore was in a condition which was prohibited by technical specifications. The detector was found in a configuration without o-rings at two electrical connection interfaces. Condition Report 16-06735 documented the non-conforming condition, but was closed without performing a reportability review. | |||
Significance/Severity Level: This violation was considered as traditional enforcement because the failure to notify the NRC had the potential for impacting the NRCs ability to perform its regulatory function. Consistent with the guidance in Section 6.9, Paragraph d.9, of the NRC Enforcement Policy, the failure to report the condition prohibited by technical specifications was determined to be a Severity Level IV violation. | |||
Corrective Action Reference(s): Condition Report 18-02569 Non-Cited Violation (NCV): Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Report Section Aspect Mitigating Green None 71152Problem Systems NCV 05000528; 05000529; Identification and 05000530/2018008-01 Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action for failure to promptly correct a condition adverse to quality. Specifically, since October 30, 2014, the licensee failed to implement prompt corrective actions to correct an adverse condition related to the failure of control room hand-switch operator knobs. | |||
=====Description:===== | |||
While performing control room observations on August 28, 2018, the team identified that various control room hand-switches were missing operator knobs. The control room switches are Coordinated Manual Controls 910 series currently manufactured and supported by Senasys. The switches are operated by turning the selector knob, which rotates a cam at the end of the knob shaft, pushing a set of plungers which will make or break electrical contact continuity within the contact block. The primary purpose of the knob is to allow operators to change the status of equipment in the plant. | |||
The team identified a total of eighteen missing operator knobs among the three unit control rooms. Fourteen of these controlled safety-related, technical specification (TS)-related, or emergency operating procedure (EOP)-related components:1 Broken Number Number Number Oldest switches safety-related TS-related EOP-related Unit 1 5 4 2 2 October 30, 2014 Unit 2 7 6 3 2 October 18, 2015 Unit 3 6 1 0 2 April 27, 2018 Total 18 11 5 6 The licensee had provided one or two spare operator knobs in each control room that could be used to operate a hand-switch when necessary during routine, alarm, abnormal, or emergency events. However, the licensee had performed no formal evaluation of the use of these spare knobs as a compensatory action or of the aggregate impact to each control room during off-normal or emergency scenarios. The licensee did not control the spare knobs despite having dedicated them as basic components for use in safety-related applications. All equivalent knobs in the plant reference simulators were intact. The licensee did not model or brief this discrepancy between the simulator and the plant during training scenarios. Neither did the licensee list the missing knobs on the simulator differences list or evaluate the missing knobs in the overall simulator program of maintenance, testing, and correction of discrepancies with the actual plant. | |||
Corrective Action(s): As an immediate corrective action, the licensee provided five additional knobs for each control room and provided a formal communication to control room staff regarding their use. | |||
Corrective Action Reference(s): Condition Reports 18-13575 and 18-14201. | |||
=====Performance Assessment:===== | |||
Performance Deficiency: The failure to promptly identify and correct a condition adverse to quality related to the failure of control room hand-switch operator knobs as required by 10 CFR 50, Appendix B, Criterion XVI was a performance deficiency. | |||
Screening: The performance deficiency was more than minor, and therefore a finding, because it affected the configuration control attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Since October 30, 2014, the licensee had failed to implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control rooms of all three units. | |||
Significance: The team performed the initial significance determination using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train. | |||
Four of the eighteen switches met none of these criteria, though one of those four controlled a breaker that was included in the probabilistic risk model. The other fourteen switches variously met one or more of the criteria. Because of this overlap, the numbers in the table to not sum horizontally. | |||
Cross Cutting Aspect: This finding had a cross-cutting aspect in the area of human performance, avoid complacency, in that the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee did not implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control room (H.12). | |||
=====Enforcement:===== | |||
Violation: Title 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. | |||
Contrary to this requirement, the licensee failed to assure that conditions adverse to quality were promptly corrected. Specifically, since October 30, 2014, the licensee failed to correct a condition adverse to quality related to broken operator knobs in the control room, to which 10 CFR Part 50, Appendix B, applies. Consequently, the licensees failure to implement prompt corrective actions to correct an adverse condition related to the broken operator knobs in the control room resulted in not returning the switch to the vendor drawing configuration and specifications. | |||
Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy. | |||
Licensee Event Condition Prohibited by Technical 71153 Follow-up of Events Report Specifications for an Inoperable and Notices of Enforcement (Closed) Excore Instrument Channel Discretion (LER 05000528/2018-002) | |||
==EXIT MEETINGS AND DEBRIEFS== | |||
On September 14, 2018, the team presented the inspection results to Ms. M. Lacal, Senior Vice President, Regulatory & Oversight, and other members of the licensee staff. The team confirmed that any proprietary or sensitive information reviewed was controlled to protect from public disclosure. | |||
=DOCUMENTS REVIEWED= | |||
Condition Reports | |||
10-00424 16-04624 17-12748 18-00837 18-06960 16-19560 | |||
2-00391 16-04625 17-13751 18-00869 18-07751 16-19864 | |||
13-00349 16-04628 17-13780 18-01277 16-13267 16-20048 | |||
13-00736 16-04646 17-14018 18-01512 16-13529 16-20333 | |||
14-01375 17-08432 17-14219 18-01657 16-13896 16-20383 | |||
14-01904 17-08633 17-14504 18-01685 16-14370 16-20395 | |||
14-02854 17-08634 17-15012 18-01702 16-14791 18-12743 | |||
15-02470 17-08636 17-15793 18-01737 16-14896 18-13345 | |||
15-02897 17-08672 17-16181 16-10666 16-15709 18-13446 | |||
15-06128 17-08818 17-16495 16-10742 16-16024 18-13575 | |||
15-07118 17-09022 17-16497 16-11578 16-16585 18-13996 | |||
16-03489 17-09222 17-16552 16-11605 16-16995 18-14126 | |||
16-03566 17-09257 17-16563 16-12160 18-07903 18-14201 | |||
16-03843 17-09326 17-17371 16-12430 18-07964 18-14212 | |||
16-03914 17-09336 16-07329 16-12465 18-08156 18-14215 | |||
16-04598 17-09524 16-07589 16-12783 18-08409 18-14218 | |||
17-16181 17-09656 16-07632 16-12797 18-08466 18-14222 | |||
17-16495 17-10518 16-08413 16-13128 18-08815 18-14223 | |||
17-16497 17-11997 16-09123 18-02462 18-09130 18-14224 | |||
17-16552 17-12205 16-09548 18-02960 18-09679 18-14226 | |||
17-16563 16-04677 16-09997 18-03038 18-10024 18-14372 | |||
17-17371 16-04977 16-10139 18-03154 18-10995 | |||
17-17791 16-04980 16-10173 18-03173 18-11453 | |||
17-17965 16-04982 16-10185 18-03177 18-12086 | |||
17-18155 16-04984 17-17791 18-03346 18-12157 | |||
18-00055 16-05436 17-17965 18-04528 18-12174 | |||
15-07118 16-05926 17-18155 18-04994 18-12217 | |||
16-03489 16-05966 18-00055 18-05015 18-12423 | |||
16-03566 16-06026 18-00055 18-05879 16-18951 | |||
16-03843 16-06578 18-00086 18-06317 16-19295 | |||
16-03914 17-12265 18-00194 18-06774 16-19296 | |||
16-04598 17-12466 18-00202 18-06912 16-19554 | |||
Plus approximately 100 anonymous condition reports initiated between January 1, 2018, and | |||
August 7, 2018, and the text of most of the several hundred condition reports issued while the | |||
team was on site. | |||
Work Orders | |||
24481 4340548 4616104 4699032 4842349 | |||
4316976 4412917 4699031 4699034 4857178 | |||
Audit Reports | |||
2016-007 2016-010 2017-009 2018-003 | |||
2016-009 2017-003 2018-002 | |||
Procedures | |||
Number Title Revision | |||
01DP-0AP01 Procedure Process 59 | |||
01DP-0AP12 Condition Reporting Process 23, 24, 29, 30 | |||
01DP-0AP22 Procedure Writers Guide 10 | |||
01DP-0AP58-01 Trend Analysis and Coding Administrative Guideline 1 | |||
2DP-0AP01 Plant Review Board 22 | |||
2DP-0MC08, Control of Purchasing Material and Equipment | |||
5DP-0CC05 Simulator Instructors Guide and Reporting 0 | |||
15DP-0TR08 Systematic Approach to Training 14 | |||
30DP-0AC02 Station Rework Reduction 5 | |||
30DP-0WM15 Fix-It-Now Multi-Discipline Team 13 | |||
31MT-9SI02 High Pressure Safety Injection Pump Disassembly, 32 | |||
Examination, and Assembly | |||
40AL-9RK6A Panel B06A Alarm Responses 19 | |||
40AO-9ZZ21 Acts of Nature 38 | |||
40DP-9OP15 Operator Challenges and Discrepancy Tracking 29 | |||
40DP-9OP20 Watch Standing Practices 48 | |||
40DP-9OP26 Operations Condition Reporting Process and Operability 45 | |||
Determination / Functional Assessment | |||
40DP-9OP33 Shift Turnover 35 | |||
40DP-9WP01 Operations Processing of Work Orders 34 | |||
40DP-9ZZ04 Time Critical Action (TCA) Program 13 | |||
40OP-9AF02 Non-Essential Auxiliary Feedwater Pump Operation 20 | |||
40OP-9CH03 RCP Seal Injection System 30 | |||
60DP-0QQ02 Trend Analysis and Coding 27 | |||
65DP-0QQ01 Industry Operating Experience Review 41 | |||
73TD-0ZZ03 System Engineering Handbook 25 | |||
75RP-9RP20 Use and Control of HEPA Filtration and Vacuum 5 | |||
Equipment | |||
81DP-0EE10 Design Change Process 45 | |||
Procedures | |||
Number Title Revision | |||
93DP-0LC18 Part 21 Reporting Process 2 | |||
Miscellaneous | |||
Documents Revision | |||
Number Title or Date | |||
2018 PVNGS Condition Reports CRG Refuse Back to August 27, 2018 | |||
SC Rate / Through Rate Performance | |||
Active Night Orders August 10, 2017 | |||
Active Standing Orders August 10, 2017 | |||
Control Room Discrepancies August 10, 2017 | |||
Open Operator Burdens August 10, 2017 | |||
Operations Challenges List August 10, 2017 | |||
Operator Work Arounds August 10, 2017 | |||
Organizational Effectiveness Monthly Performance March 2018 | |||
Summary: 2018 1st Quarter | |||
Organizational Effectiveness Quarterly Performance 2nd Quarter | |||
Summary 2018 | |||
PRB Meeting Minutes: Monthly PRB (October 2017) Oct 31, 2017 | |||
and U1R20 Refueling Outage Restart | |||
PRB Monthly and U2R20 Startup Meeting Minutes April 28, 2017 | |||
PVNGS Operations Quality Assurance Program 0, 0a | |||
Description (QAPD) | |||
Simulator to Unit Differences August 22, 2018 | |||
Training Slides: Introduction to Cause Analysis November 16, | |||
2016 | |||
13-NS-C088 Mission Time Study 1 | |||
Design Equivalent Containment Construction Vent Concrete Cover Rework 0 | |||
Change 00462 and Design Drawing Detail Revision | |||
Drawing 12-E- Diesel Storage Tank Conduit Plan & Section 12 | |||
2YU-009 | |||
NLR17C030201 Licensed Operator Continuing Training April 5, 2017 | |||
INFORMATION REQUESTS | |||
ML18291A562 | |||
SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002 | |||
By: EAR Yes No Publicly Available Sensitive | |||
OFFICE RI/IPAT SRI/PBA RI/PBD C/PBD SRI/IPAT TL/IPAT | |||
NAME PJayroe GKolcum DReinert NOKeefe ERuesch GMiller | |||
SIGNATURE /RA-e/ /RA-e/ /RA-e/ /RA/ /RA/ /RA GAG for/ | |||
DATE 9/21/2018 9/21/2018 9/21/2018 10/16/2018 10/16/2018 10/16/2018 | |||
}} | }} |
Latest revision as of 16:35, 18 December 2019
ML18291A562 | |
Person / Time | |
---|---|
Site: | Palo Verde |
Issue date: | 10/16/2018 |
From: | Geoffrey Miller Division of Reactor Safety IV |
To: | Bement R Arizona Public Service Co |
Miller G | |
References | |
IR 2018008 | |
Download: ML18291A562 (22) | |
Text
ber 16, 2018
SUBJECT:
PALO VERDE NUCLEAR GENERATING STATION - NRC BIENNIAL PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000528/2018008, 05000529/2018008, AND 05000530/2018008
Dear Mr. Bement:
On September 14, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution inspection at your Palo Verde Nuclear Generating Station, Units 1, 2, and 3. The NRC inspection team discussed the results of this inspection with Ms. M. Lacal, Senior Vice President, Regulatory and Oversight, and other members of your staff. The results of this inspection are documented in the enclosed report.
The NRC inspection team reviewed the stations corrective action program and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems and to confirm that the station was complying with NRC regulations and licensee standards for corrective action programs. Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.
The team also evaluated the stations processes for use of industry and NRC operating experience information and the effectiveness of the stations audits and self-assessments.
Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.
Finally the team reviewed the stations programs to establish and maintain a safety-conscious work environment and interviewed station personnel to evaluate the effectiveness of these programs. Based on the teams observations and the results of these interviews, the team found no evidence of challenges to your organizations safety-conscious work environment.
Palo Verde Nuclear Generating Station employees appeared willing to raise nuclear safety concerns through at least one of the several means available.
The NRC inspectors documented one finding of very low safety significance (Green) in this report, which involved a violation of NRC requirements. Additionally, the team documented two licensee-identified violations that were determined to be of very low safety significance. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.
If you contest these violations or their significance, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the Palo Verde Nuclear Generating Station.
Likewise, if you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the Palo Verde Nuclear Generating Station.
This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA Gerond George Acting for/
Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Docket Nos. 50-528, 50-529, and 50-530 License Nos. NPF-41, NPF-51, and NPF-74 Enclosure:
Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 w/ attachment: Information Requests
U.S. NUCLEAR REGULATORY COMMISSION
Inspection Report
Docket Number(s): 05000528, 05000529, 05000530 License Number(s): NPF-41, NPF-51, NPF-74 Report Number(s): 05000528/2018008, 05000529/2018008, and 05000530/2018008 Enterprise Identifier: I-2018-008-0001 Licensee: Arizona Public Service Company Facility: Palo Verde Nuclear Generating Station Location: Tonopah, Arizona Inspection Dates: August 27, 2018, to September 14, 2018 Inspectors: E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead)
P. Jayroe, Reactor Inspector G. Kolcum, Sr. Resident Inspector D. Reinert, Resident Inspector Approved By: Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Enclosure
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Palo Verde Nuclear Generating Station, Units 1, 2, and 3, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. A licensee-identified non-cited violation is discussed in report section 71152.
List of Findings and Violations Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Report Section Aspect Mitigating Green H.12 71152Problem Systems NCV 05000528, 05000529, Identification and 05000530/2018008-01 Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50,
Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct the failures of multiple control room hand-switch operator knobs.
INSPECTION SCOPES
Inspections were conducted using the appropriate portions of the inspection procedures (IPs)in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html.
Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The team reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
OTHER ACTIVITIES - BASELINE
71152Problem Identification and Resolution Biennial Team Inspection
The team performed a biennial assessment of the licensees corrective action program (CAP),use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below.
- (1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports and associated records, and an in-depth 5-year review of condition reports associated with the safety injection and shutdown cooling systems.
- (2) Operating Experience, Self-Assessments, and Audits - The team evaluated the stations processes for use of industry and NRC operating experience. The team also evaluated the effectiveness of the stations audits and self-assessments program by reviewing a sample of nine self-assessments (benchmark, simple, formal departmental) and seven audits.
- (3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, engineering, organizational effectiveness and performance improvement, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey.
71153Follow-up of Events and Notices of Enforcement Discretion Licensee Event Reports
The team evaluated licensee event report (LER) 05000528/2018-002: Condition Prohibited by Technical Specification for Inoperable Excore Instrument Channel (ADAMS Accession Number ML18130A986). The team reviewed two licensee-identified non-cited violations associated with the LER, described in the inspection results below.
INSPECTION RESULTS
- OBSERVATIONS/ASSESSMENT Corrective Action Program Assessment 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems was adequate to support nuclear safety, though some challenges were noted. In particular, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues. These are described in observations, findings, and violations below.
Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues was adequate to support nuclear safety. The licensee continues to work to improve management oversight of the corrective action program, which has been consistently identified as an area for improvement by both third party and internal reviews. The team noted that the licensees actions appear to have improved management oversight, including improvements to quality and consistency of evaluation products through enhanced CARB oversight, and the addition of new tools for scoping the evaluation. However, these actions were too recently completed for the team to determine whether they have been fully successful. Additionally, the team noted that while individual problems were generally fixed, the licensee did not always expand evaluations to determine the cause or aggregate impact of multiple similar conditions. Examples are discussed below.
Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of conditions adverse to quality that were classified as nonconformances, this is discussed below as a minor violation.
Observations on the Corrective Action Program 71152Problem Identification and Resolution The team reviewed the engineering design change process and impact review process, and found it to be adequate and in line with industry standards. The team also screened a sample of condition reports that originated over the past 2 years and found several examples of misses tied to the design change process and impact reviews where the required updates to documentation were not completed or were incorrect. Personnel interviewed by the team indicated that these misses were sometimes identified by workers being unable to perform work activities as directed by work orders or unable to draft clearance orders due to incorrect drawings. In all examples reviewed by the team, the licensee revised or updated affected documentation after the condition report was written; however the team did not note any significant efforts to evaluate or improve the engineering design change impact review process. The team reviewed the stations use of trend codes to track these examples and identified several instances where expected trend codes were incorrectly applied or not applied at all. One particular trend code (CM 3.10) is applied to condition reports which are created in advance or just recently after a plant modification to create a tracking item for required updates to various documents; the team noted examples of documentation revisions tied to legacy modifications lumped in under this trend code. Liberal use of this particular trend code in coincidence with restricted use of more applicable trend codes may be masking potential trends in documentation revisions missed by the impact review process. The licensee documented this observation in Condition Report 18-14427.
The team observed that the licensees condition report classification committees (the Screening Committee and the Condition Review Group) did not always consistently apply the corrective action program (CAP) definitions of condition adverse to quality (CAQ) and non-condition adverse to quality. In particular, a lack of guidance or familiarity in what constituted an adverse trend in a quality process CAQ versus a potential adverse trend (non-condition adverse to quality until evaluated and confirmed) led to inconsistency in classification of condition reports documenting aggregate issues. The licensee documented this observation in Condition Reports 18-13648 and 18-14334.
Additionally, some identified deficiencies in quality programs were classified as non-condition adverse to quality. For example, on January 2, 2018, the licensees organizational effectiveness department issued a Corrective Action Program Elevation Letter, which identified, inconsistent identification of issues entered into the condition reporting process, CAP product quality decline, inappropriate closure of CAP actions, and rejection of CAP products including causal evaluation. The condition report associated with this letter, Condition Report 18-00055, was classified as non-condition adverse to quality. In procedure 01DP-0AP12, Condition Reporting Process the licensee defines CAQ to include, failures to comply with procedures that implement the current licensing basis (CLB), where CLB is defined to include both 10 CFR Part 50 and the licensees quality assurance program, both of which contain requirements implemented by CAP. In these examples and others reviewed by the team, the conditions adverse to quality were timely addressed, even when classified as non-condition adverse to quality. Therefore there was no violation of NRC regulations. The licensee documented this issue in Condition Report 18-13739.
Assessment of Use of Operating Experience 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analysis and apparent cause evaluations. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs.
Self-Assessments and Audits Assessment 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that station performance in these areas adequately supported nuclear safety. Generally, self-assessments and audits were effective at identifying deficiencies and enhancements. In all cases, deficiencies were documented in condition reports for both self-assessments and audits. Audits, in particular, were highly effective in identifying and documenting deficiencies. One self-assessment (16-10139) did not appear to have a tracking item (i.e. condition report) for an enhancement.
Safety-Conscious Work Environment Assessment 71152Problem Identification and Resolution The team found no evidence of challenges to the safety-conscious work environment of station work groups. Individuals appeared willing to raise nuclear safety concerns through at least one of the several means available.
INSPECTION RESULTS
- ISSUES/FINDINGS Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to promptly identify and correct conditions adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI.
The team identified a backlog of conditions adverse to quality that the licensee had failed to timely correct. The oldest of these conditions was approximately 10 years old, with several hundred having been identified at least two operating cycles prior to the inspection. The team determined that the licensee was appropriately addressing degraded components that had an impact on safety or security, but was not always tracking or timely correcting nonconformances with its design bases in cases where these nonconformances had been assessed as not impacting safety-related functions. Further, the licensee was unable to initially determine the scope of its nonconformance backlog. The licensee documented this deficiency as Condition Reports 18-13549 and 18-14426.
Screening: The performance deficiency was minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.
Enforcement:
This failure to comply with 10 CFR 50, Appendix B, Criterion XVI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.
Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR 50, Appendix B, Criterion VI.
The team identified that the CAP procedure directed the use of the Cause Analysis Manual in performing some cause evaluations. This cause evaluation process is an activity affecting quality required by 10 CFR 50, Appendix B and the licensees Quality Assurance Program.
The licensee failed to control the Cause Analysis Manual in accordance with the Palo Verde Nuclear Generating Station Operations Quality Assurance Program Description, Revision 0, Section 2.6, Document Control. The licensee documented this violation in Condition Report 18-13996.
Screening: The performance deficiency is minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.
Enforcement:
This failure to comply with 10 CFR 50, Appendix B, Criterion VI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.
Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Violation: 10 CFR Part 50, Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Contrary to the above, on May 24, 2007, the licensee failed to perform the installation of the Unit 1, channel C excore nuclear instrument preamplifier connection, an activity affecting quality, in accordance with these instructions, procedures, or drawings. The licensee determined that a human performance error occurred during the performance of the 2007 work order which explicitly stated that the o-rings were required for environmental qualification. As a result, the excore detector would not have performed its safety function during a design basis main steam line break.
Significance/Severity Level: The team determined this finding was of very low safety significance (Green) because a minimum of two excore detector channels always remained available to trip the reactor during a main steam line break. Redundant channels were not affected and were available to perform the required safety function to trip the reactor.
Corrective Action Reference(s): Condition Report 18-12217 Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Violation: 10 CFR 50.73(a)(2)(i)(B) requires, in part, that the holder of an operating license shall submit an licensee event report within 60 days of discovery of the event, which includes any operation or condition which was prohibited by technical specifications.
Contrary to the above, the licensee failed to submit a licensee event report within 60 days of April 23, 2016, after discovering that the Unit 1 channel C excore was in a condition which was prohibited by technical specifications. The detector was found in a configuration without o-rings at two electrical connection interfaces. Condition Report 16-06735 documented the non-conforming condition, but was closed without performing a reportability review.
Significance/Severity Level: This violation was considered as traditional enforcement because the failure to notify the NRC had the potential for impacting the NRCs ability to perform its regulatory function. Consistent with the guidance in Section 6.9, Paragraph d.9, of the NRC Enforcement Policy, the failure to report the condition prohibited by technical specifications was determined to be a Severity Level IV violation.
Corrective Action Reference(s): Condition Report 18-02569 Non-Cited Violation (NCV): Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Report Section Aspect Mitigating Green None 71152Problem Systems NCV 05000528; 05000529; Identification and 05000530/2018008-01 Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action for failure to promptly correct a condition adverse to quality. Specifically, since October 30, 2014, the licensee failed to implement prompt corrective actions to correct an adverse condition related to the failure of control room hand-switch operator knobs.
Description:
While performing control room observations on August 28, 2018, the team identified that various control room hand-switches were missing operator knobs. The control room switches are Coordinated Manual Controls 910 series currently manufactured and supported by Senasys. The switches are operated by turning the selector knob, which rotates a cam at the end of the knob shaft, pushing a set of plungers which will make or break electrical contact continuity within the contact block. The primary purpose of the knob is to allow operators to change the status of equipment in the plant.
The team identified a total of eighteen missing operator knobs among the three unit control rooms. Fourteen of these controlled safety-related, technical specification (TS)-related, or emergency operating procedure (EOP)-related components:1 Broken Number Number Number Oldest switches safety-related TS-related EOP-related Unit 1 5 4 2 2 October 30, 2014 Unit 2 7 6 3 2 October 18, 2015 Unit 3 6 1 0 2 April 27, 2018 Total 18 11 5 6 The licensee had provided one or two spare operator knobs in each control room that could be used to operate a hand-switch when necessary during routine, alarm, abnormal, or emergency events. However, the licensee had performed no formal evaluation of the use of these spare knobs as a compensatory action or of the aggregate impact to each control room during off-normal or emergency scenarios. The licensee did not control the spare knobs despite having dedicated them as basic components for use in safety-related applications. All equivalent knobs in the plant reference simulators were intact. The licensee did not model or brief this discrepancy between the simulator and the plant during training scenarios. Neither did the licensee list the missing knobs on the simulator differences list or evaluate the missing knobs in the overall simulator program of maintenance, testing, and correction of discrepancies with the actual plant.
Corrective Action(s): As an immediate corrective action, the licensee provided five additional knobs for each control room and provided a formal communication to control room staff regarding their use.
Corrective Action Reference(s): Condition Reports 18-13575 and 18-14201.
Performance Assessment:
Performance Deficiency: The failure to promptly identify and correct a condition adverse to quality related to the failure of control room hand-switch operator knobs as required by 10 CFR 50, Appendix B, Criterion XVI was a performance deficiency.
Screening: The performance deficiency was more than minor, and therefore a finding, because it affected the configuration control attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Since October 30, 2014, the licensee had failed to implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control rooms of all three units.
Significance: The team performed the initial significance determination using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.
Four of the eighteen switches met none of these criteria, though one of those four controlled a breaker that was included in the probabilistic risk model. The other fourteen switches variously met one or more of the criteria. Because of this overlap, the numbers in the table to not sum horizontally.
Cross Cutting Aspect: This finding had a cross-cutting aspect in the area of human performance, avoid complacency, in that the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee did not implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control room (H.12).
Enforcement:
Violation: Title 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.
Contrary to this requirement, the licensee failed to assure that conditions adverse to quality were promptly corrected. Specifically, since October 30, 2014, the licensee failed to correct a condition adverse to quality related to broken operator knobs in the control room, to which 10 CFR Part 50, Appendix B, applies. Consequently, the licensees failure to implement prompt corrective actions to correct an adverse condition related to the broken operator knobs in the control room resulted in not returning the switch to the vendor drawing configuration and specifications.
Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.
Licensee Event Condition Prohibited by Technical 71153 Follow-up of Events Report Specifications for an Inoperable and Notices of Enforcement (Closed) Excore Instrument Channel Discretion (LER 05000528/2018-002)
EXIT MEETINGS AND DEBRIEFS
On September 14, 2018, the team presented the inspection results to Ms. M. Lacal, Senior Vice President, Regulatory & Oversight, and other members of the licensee staff. The team confirmed that any proprietary or sensitive information reviewed was controlled to protect from public disclosure.
DOCUMENTS REVIEWED
Condition Reports
10-00424 16-04624 17-12748 18-00837 18-06960 16-19560
2-00391 16-04625 17-13751 18-00869 18-07751 16-19864
13-00349 16-04628 17-13780 18-01277 16-13267 16-20048
13-00736 16-04646 17-14018 18-01512 16-13529 16-20333
14-01375 17-08432 17-14219 18-01657 16-13896 16-20383
14-01904 17-08633 17-14504 18-01685 16-14370 16-20395
14-02854 17-08634 17-15012 18-01702 16-14791 18-12743
15-02470 17-08636 17-15793 18-01737 16-14896 18-13345
15-02897 17-08672 17-16181 16-10666 16-15709 18-13446
15-06128 17-08818 17-16495 16-10742 16-16024 18-13575
15-07118 17-09022 17-16497 16-11578 16-16585 18-13996
16-03489 17-09222 17-16552 16-11605 16-16995 18-14126
16-03566 17-09257 17-16563 16-12160 18-07903 18-14201
16-03843 17-09326 17-17371 16-12430 18-07964 18-14212
16-03914 17-09336 16-07329 16-12465 18-08156 18-14215
16-04598 17-09524 16-07589 16-12783 18-08409 18-14218
17-16181 17-09656 16-07632 16-12797 18-08466 18-14222
17-16495 17-10518 16-08413 16-13128 18-08815 18-14223
17-16497 17-11997 16-09123 18-02462 18-09130 18-14224
17-16552 17-12205 16-09548 18-02960 18-09679 18-14226
17-16563 16-04677 16-09997 18-03038 18-10024 18-14372
17-17371 16-04977 16-10139 18-03154 18-10995
17-17791 16-04980 16-10173 18-03173 18-11453
17-17965 16-04982 16-10185 18-03177 18-12086
17-18155 16-04984 17-17791 18-03346 18-12157
18-00055 16-05436 17-17965 18-04528 18-12174
15-07118 16-05926 17-18155 18-04994 18-12217
16-03489 16-05966 18-00055 18-05015 18-12423
16-03566 16-06026 18-00055 18-05879 16-18951
16-03843 16-06578 18-00086 18-06317 16-19295
16-03914 17-12265 18-00194 18-06774 16-19296
16-04598 17-12466 18-00202 18-06912 16-19554
Plus approximately 100 anonymous condition reports initiated between January 1, 2018, and
August 7, 2018, and the text of most of the several hundred condition reports issued while the
team was on site.
Work Orders
24481 4340548 4616104 4699032 4842349
4316976 4412917 4699031 4699034 4857178
Audit Reports
2016-007 2016-010 2017-009 2018-003
2016-009 2017-003 2018-002
Procedures
Number Title Revision
01DP-0AP01 Procedure Process 59
01DP-0AP12 Condition Reporting Process 23, 24, 29, 30
01DP-0AP22 Procedure Writers Guide 10
01DP-0AP58-01 Trend Analysis and Coding Administrative Guideline 1
2DP-0AP01 Plant Review Board 22
2DP-0MC08, Control of Purchasing Material and Equipment
5DP-0CC05 Simulator Instructors Guide and Reporting 0
15DP-0TR08 Systematic Approach to Training 14
30DP-0AC02 Station Rework Reduction 5
30DP-0WM15 Fix-It-Now Multi-Discipline Team 13
31MT-9SI02 High Pressure Safety Injection Pump Disassembly, 32
Examination, and Assembly
40AL-9RK6A Panel B06A Alarm Responses 19
40AO-9ZZ21 Acts of Nature 38
40DP-9OP15 Operator Challenges and Discrepancy Tracking 29
40DP-9OP20 Watch Standing Practices 48
40DP-9OP26 Operations Condition Reporting Process and Operability 45
Determination / Functional Assessment
40DP-9OP33 Shift Turnover 35
40DP-9WP01 Operations Processing of Work Orders 34
40DP-9ZZ04 Time Critical Action (TCA) Program 13
40OP-9AF02 Non-Essential Auxiliary Feedwater Pump Operation 20
40OP-9CH03 RCP Seal Injection System 30
60DP-0QQ02 Trend Analysis and Coding 27
65DP-0QQ01 Industry Operating Experience Review 41
73TD-0ZZ03 System Engineering Handbook 25
75RP-9RP20 Use and Control of HEPA Filtration and Vacuum 5
Equipment
81DP-0EE10 Design Change Process 45
Procedures
Number Title Revision
93DP-0LC18 Part 21 Reporting Process 2
Miscellaneous
Documents Revision
Number Title or Date
2018 PVNGS Condition Reports CRG Refuse Back to August 27, 2018
SC Rate / Through Rate Performance
Active Night Orders August 10, 2017
Active Standing Orders August 10, 2017
Control Room Discrepancies August 10, 2017
Open Operator Burdens August 10, 2017
Operations Challenges List August 10, 2017
Operator Work Arounds August 10, 2017
Organizational Effectiveness Monthly Performance March 2018
Summary: 2018 1st Quarter
Organizational Effectiveness Quarterly Performance 2nd Quarter
Summary 2018
PRB Meeting Minutes: Monthly PRB (October 2017) Oct 31, 2017
and U1R20 Refueling Outage Restart
PRB Monthly and U2R20 Startup Meeting Minutes April 28, 2017
PVNGS Operations Quality Assurance Program 0, 0a
Description (QAPD)
Simulator to Unit Differences August 22, 2018
Training Slides: Introduction to Cause Analysis November 16,
2016
13-NS-C088 Mission Time Study 1
Design Equivalent Containment Construction Vent Concrete Cover Rework 0
Change 00462 and Design Drawing Detail Revision
Drawing 12-E- Diesel Storage Tank Conduit Plan & Section 12
NLR17C030201 Licensed Operator Continuing Training April 5, 2017
INFORMATION REQUESTS
SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002
By: EAR Yes No Publicly Available Sensitive
OFFICE RI/IPAT SRI/PBA RI/PBD C/PBD SRI/IPAT TL/IPAT
NAME PJayroe GKolcum DReinert NOKeefe ERuesch GMiller
SIGNATURE /RA-e/ /RA-e/ /RA-e/ /RA/ /RA/ /RA GAG for/
DATE 9/21/2018 9/21/2018 9/21/2018 10/16/2018 10/16/2018 10/16/2018