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| issue date = 02/12/2018 | | issue date = 02/12/2018 | ||
| title = NRC Integrated Inspection Report 05000482/2017004 | | title = NRC Integrated Inspection Report 05000482/2017004 | ||
| author name = Taylor N | | author name = Taylor N | ||
| author affiliation = NRC/RGN-IV/DRP/RPB-B | | author affiliation = NRC/RGN-IV/DRP/RPB-B | ||
| addressee name = Heflin A | | addressee name = Heflin A | ||
| addressee affiliation = Wolf Creek Nuclear Operating Corp | | addressee affiliation = Wolf Creek Nuclear Operating Corp | ||
| docket = 05000482 | | docket = 05000482 | ||
| license number = NPF-042 | | license number = NPF-042 | ||
| contact person = Taylor N | | contact person = Taylor N | ||
| case reference number = EA-16-018 | | case reference number = EA-16-018 | ||
| document report number = IR 2017004 | | document report number = IR 2017004 | ||
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=Text= | =Text= | ||
{{#Wiki_filter: | {{#Wiki_filter:ruary 12, 2018 | ||
- NRC INTEGRATED INSPECTION REPORT 05000482/ | |||
==SUBJECT:== | |||
WOLF CREEK GENERATING STATION - NRC INTEGRATED INSPECTION REPORT 05000482/2017004 | |||
==Dear Mr. Heflin:== | ==Dear Mr. Heflin:== | ||
On December 31, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Wolf Creek Generating Station. | On December 31, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Wolf Creek Generating Station. On January 10, 2018, the NRC inspectors discussed the results of this inspection with Mr. C. Reasoner, Site Vice President, and other members of your staff. The results of this inspection are documented in the enclosed report. | ||
NRC inspectors documented three findings of very low safety significance (Green) in this report. | |||
All of these findings involved violations of NRC requirements. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2.a of the Enforcement Policy. | |||
Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 | If you contest the violations or significance of these NCVs, 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 Wolf Creek Generating Station. | ||
-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the Wolf Creek Generating Station | |||
Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 | If you disagree with a cross-cutting aspect assignment or a finding not associated with a regulatory requirement 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 Wolf Creek 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. | ||
-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the Wolf Creek Generating Station. | |||
-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, | |||
Sincerely, | Sincerely, | ||
/RA/ Nicholas H. Taylor, Branch Chief Project Branch B Division of Reactor Projects Docket No. 50 | /RA/ | ||
-482 License No. NPF-42 Enclosure: | Nicholas H. Taylor, Branch Chief Project Branch B Division of Reactor Projects Docket No. 50-482 License No. NPF-42 Enclosure: | ||
Inspection Report 05000482/2017004 w/ Attachments: | |||
1. Supplemental Information 2. Request for Information | |||
05000482/2017004 w/ | |||
U.S. NUCLEAR REGULATORY COMMISSION | |||
==REGION IV== | |||
Docket: 05000482 License: NPF-42 Report: 05000482/2017004 Licensee: Wolf Creek Nuclear Operating Corporation Facility: Wolf Creek Generating Station Location: 1550 Oxen Lane NE Burlington, KS 66839 Dates: October 1 through December 31, 2017 Inspectors: D. Dodson, Senior Resident Inspector F. Thomas, Resident Inspector D. Proulx, Senior Project Engineer P. Elkmann, Senior Emergency Preparedness Inspector J. Drake, Senior Reactor Inspector R. Kopriva, Senior Reactor Inspector S. Hedger, Emergency Preparedness Inspector Approved Nicholas H. Taylor By: Branch Chief, Project Branch B Division of Reactor Projects Enclosure | |||
=SUMMARY= | =SUMMARY= | ||
IR | IR 05000482/2017004; 10/01/2017 - 12/31/2017; Wolf Creek Generating Station; Operability | ||
The significance of inspection findings is indicated by their color (i.e., Green, greater than Green, White, Yellow, or Red), determined using Inspection Manual Chapter 0609, | Determinations and Functionality Assessments, Exercise Evaluation, and Problem Identification and Resolution The inspection activities described in this report were performed between October 1 and December 31, 2017, by the resident inspectors at Wolf Creek Generating Station and inspectors from the NRCs Region IV office. Three findings of very low safety significance (Green) are documented in this report. All of these findings involved violations of NRC requirements. The significance of inspection findings is indicated by their color (i.e., Green, greater than Green, | ||
White, Yellow, or Red), determined using Inspection Manual Chapter 0609, Significance Determination Process, dated April 29, 2015. Their cross-cutting aspects are determined using Inspection Manual Chapter 0310, Aspects within the Cross-Cutting Areas, dated December 4, 2014. Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement Policy. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, dated July 2016. | |||
The | |||
-1649, | |||
===Cornerstone: Initiating Events=== | ===Cornerstone: Initiating Events=== | ||
: '''Green.''' | : '''Green.''' | ||
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V | The inspectors identified a Green non-cited violation of 10 CFR Part 50, | ||
, | Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to implement the operability and functionality assessment procedure. Specifically, as of October 12, 2016, the licensee identified boric acid coating on several control rod drive mechanisms, but failed to initiate a condition report to evaluate the effect of the condition on control rod drive mechanism operability. Immediate corrective actions included initiating Condition Report 115120 and documenting a detailed operability assessment to demonstrate operability of the control rod drive mechanisms. | ||
The performance deficiency is more than minor | The performance deficiency is more than minor, and therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A, | ||
, and therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically | Significance Determination Process (SDP) for Findings At-Power, and the transient initiator screening questions of Exhibit 1, Initiating Events Screening Questions, and determined that this finding did not cause a reactor trip and loss of mitigation equipment; therefore, this finding screened to very low safety significance (Green). The inspectors determined that the finding has a safety conscious work environment cross-cutting aspect in the area of safety conscious work environement policy, in that an individual did not feel free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed. Specifically, an individual was reluctant to write a condition report to document boric acid residue on control rod drive mechanisms because the individual believed leaders were not concerned, and the individual did not want to diminish the relationship the individual had with the leaders [S.1]. (Section 4OA2) | ||
, continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A, | |||
===Cornerstone: Mitigating Systems=== | ===Cornerstone: Mitigating Systems=== | ||
: '''Green.''' | : '''Green.''' | ||
The inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a, for the | The inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to provide adequate work instructions for preventive maintenance on safety-related equipment. Specifically, preventive maintenance work instructions to inspect and clean the mechanical interlock on the D containment cooler fan motor control lacked specific guidance for adequate lubrication and did not adequately consider equipment history and operating experience. This resulted in the failure of the 42T starter relay coil in the motor control circuit for the D containment cooler fan, and subsequent unavailability on January 31, 2017. The licensees immediate actions included troubleshooting the motor control circuit, replacing the blown control power fuse for the motor control circuit, performing bench testing, installing a replacement 42T contactor to replace the damaged 42T contractor, and performing post maintenance testing of the D containment cooler fan. The licensee entered this issue into the corrective action program as Condition Reports 110725 and 111360. | ||
, installing a replacement 42T contactor to replace the damaged 42T contractor, and performing post maintenance testing of the D containment cooler fan. | |||
The licensee entered this issue into the corrective action program as Condition Reports 110725 and 111360. | |||
The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). The inspectors evaluated the finding using Exhibit 2, | The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). The inspectors evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of Inspection Manual Chapter 0609, Appendix A, | ||
Significance Determination Process (SDP) for Findings At-Power, and determined this finding is not a deficiency affecting the design or qualification of a mitigating structure, system, or component that maintained its operability or functionality; the finding does not represent a loss of system and/or function; the finding does not represent an actual loss of function of at least a single train for greater than its Technical Specification-allowed outage time; and the finding does not represent an actual loss of function of one or more non-Technical Specification trains of equipment designated as high safety-significant. Therefore, the inspectors determined the finding was of very low safety significance (Green). | |||
Inspectors did not assign a cross-cutting aspect and determined the performance deficiency is not indicative of current performance because the performance deficiency did not occur within the last three years, and the inspectors did not identify a reasonable opportunity within the last three years for the licensee to have identified the performance deficiency. | |||
(Section 1R15) | |||
===Cornerstone: Emergency Preparedness=== | ===Cornerstone: Emergency Preparedness=== | ||
: '''Green.''' | : '''Green.''' | ||
The inspectors identified that the licensee failed to correct a deficiency in emergency response organization performance identified as a result of an exercise in accordance with the requirements of 10 CFR 50.47(b)(14). The failure to identify and correct a weakness occurring during an exercise is a performance deficiency within the | The inspectors identified that the licensee failed to correct a deficiency in emergency response organization performance identified as a result of an exercise in accordance with the requirements of 10 CFR 50.47(b)(14). The failure to identify and correct a weakness occurring during an exercise is a performance deficiency within the licensees ability to foresee and correct. The licensee failed to identify that the Technical Support Center and Operations Support Center did not fully understand plant conditions and did not properly utilize in-plant mitigation and repair teams to investigate the causes of equipment failures. The issue is not an immediate safety concern because the deficient performance occurred during an exercise. This issue was documented in licensee Condition Report 117567, dated November 17, 2017. | ||
The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute and adversely affected the cornerstone objective. The | The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute and adversely affected the cornerstone objective. The licensees ability to ensure that adequate measures will be taken to protect the health and safety of the public is degraded when weak emergency response organization performance is not corrected. The finding was evaluated using Inspection Manual Chapter 0609, Appendix B, dated September 22, 2015, and was determined to be of very low safety significance because the finding was a failure to comply with NRC requirements, was not a lost or degraded risk significant planning standard, and was not a loss of planning standard function. The performance deficiency was not a loss of planning standard function because the licensee appropriately critiqued some weaknesses. The finding was determined to have a cross-cutting aspect of evaluation in the area of problem identification and resolution because the licensee did not evaluate the deficient understanding of plant conditions and failure to utilize in-plant mitigation and repair teams as a performance weakness [P.2]. (Section 1EP1) | ||
=PLANT STATUS= | =PLANT STATUS= | ||
Line 98: | Line 84: | ||
==REACTOR SAFETY== | ==REACTOR SAFETY== | ||
Cornerstones: | Cornerstones: Initiating Events, Mitigating Systems, and Barrier Integrity {{a|1R01}} | ||
==1R01 Adverse Weather Protection== | |||
{{IP sample|IP=IP 71111.01}} | |||
===.1 Readiness for Seasonal Extreme Weather Conditions=== | ===.1 Readiness for Seasonal Extreme Weather Conditions=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
On December 22, 2017, the inspectors completed an inspection of the | On December 22, 2017, the inspectors completed an inspection of the stations readiness for seasonal extreme weather conditions. The inspectors reviewed the licensees adverse weather procedures for extreme cold weather and evaluated the licensees implementation of these procedures. The inspectors verified that prior to the onset of cold weather, the licensee had corrected weather-related equipment deficiencies identified during the previous winter season. | ||
-related equipment deficiencies identified during the previous winter season. The inspectors selected three risk-significant systems that were required to be protected from extreme cold weather | |||
The inspectors selected three risk-significant systems that were required to be protected from extreme cold weather: | |||
* Essential service water system | |||
* Refueling water storage tank | |||
* Station blackout diesel generators The inspectors reviewed the licensees procedures and design information to ensure the systems or components would remain functional when challenged by extreme cold weather. The inspectors verified that operator actions described in the licensees procedures were adequate to maintain readiness of these systems. The inspectors walked down portions of these systems to verify the physical condition of insulation, heat tracing, space heaters, and other cold weather protection features. | |||
These activities constituted one sample of readiness for seasonal adverse weather, as defined in Inspection Procedure 71111.01. | These activities constituted one sample of readiness for seasonal adverse weather, as defined in Inspection Procedure 71111.01. | ||
Line 115: | Line 105: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
On November 22, 2017, the inspectors completed an inspection of the | On November 22, 2017, the inspectors completed an inspection of the stations readiness to cope with external flooding. After reviewing the licensees flooding analysis, the inspectors chose two plant areas that were susceptible to flooding: | ||
Control building 1,974 foot elevation Auxiliary building 1,974 foot elevation The inspectors reviewed plant design features and licensee procedures for coping with flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether credited operator actions could be successfully accomplished. | * Control building 1,974 foot elevation | ||
* Auxiliary building 1,974 foot elevation The inspectors reviewed plant design features and licensee procedures for coping with flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether credited operator actions could be successfully accomplished. | |||
These activities constituted one sample of readiness to cope with external flooding, as defined in Inspection Procedure 71111.01. | These activities constituted one sample of readiness to cope with external flooding, as defined in Inspection Procedure 71111.01. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R04}} | ||
==1R04 Equipment Alignment== | |||
{{IP sample|IP=IP 71111.04}} | |||
Partial Walk | Partial Walk-Down | ||
-Down | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors performed partial system | The inspectors performed partial system walk-downs of the following risk-significant systems: | ||
-significant systems: | * December 12 and 13, 2017, safety injection train A | ||
* December 18, 2017, essential service water train A The inspectors reviewed the licensees procedures and system design information to determine the correct lineup for the systems. They visually verified that critical portions of the trains were correctly aligned for the existing plant configuration. | |||
These activities constituted two partial system walk | These activities constituted two partial system walk-down samples as defined in Inspection Procedure 71111.04. | ||
-down | |||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R05}} | ||
==1R05 Fire Protection== | |||
{{IP sample|IP=IP 71111.05}} | |||
Quarterly Inspection | Quarterly Inspection | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors evaluated the | The inspectors evaluated the licensees fire protection program for operational status and material condition. The inspectors focused their inspection on four plant areas important to safety: | ||
December 14, 2017, fire area ESW | * December 14, 2017, fire area ESW-1, essential service water pump house train A, elevation 2,000 feet | ||
-1, essential service water pump house train A, elevation 2,000 feet December 14, 2017, fire area ESW | * December 14, 2017, fire area ESW-2, essential service water pump house train B, elevation 2,000 feet | ||
-2, essential service water pump house train B, elevation 2,000 feet December 19, 2017, fire area ESWC, essential service water vertical loop chase, elevations 1,974 through 2,087 feet December 22 | * December 19, 2017, fire area ESWC, essential service water vertical loop chase, elevations 1,974 through 2,087 feet | ||
, 2017, fire area C | * December 22, 2017, fire area C-1, essential service water pipe space and tank area, southeast stairway to auxiliary building and duct chase, elevation 1,974 feet For each area, the inspectors evaluated the fire plan against defined hazards and defense-in-depth features in the licensees fire protection program. The inspectors evaluated control of transient combustibles and ignition sources, fire detection and suppression systems, manual firefighting equipment and capability, passive fire protection features, and compensatory measures for degraded conditions. | ||
-1, essential service water pipe space and tank area, southeast stairway to auxiliary building and duct chase, elevation 1,974 feet For each area, the inspectors evaluated the fire plan against defined hazards and defense-in-depth features in the | |||
These activities constituted four quarterly inspection samples, as defined in Inspection Procedure 71111.05 | These activities constituted four quarterly inspection samples, as defined in Inspection Procedure 71111.05 | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R06}} | ||
==1R06 Flood Protection Measures== | |||
{{IP sample|IP=IP 71111.06}} | |||
====a. Inspection Scope==== | |||
On December 22, 2017, the inspectors completed an inspection of the stations ability to mitigate flooding due to internal causes. After reviewing the licensees flooding analysis, the inspectors chose the 2,026 foot elevation of the auxiliary building as an area containing risk-significant structures, systems, and components that were susceptible to flooding. | |||
The inspectors reviewed plant design features and licensee procedures for coping with internal flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether operator actions credited for flood mitigation could be successfully accomplished. | |||
These activities constituted completion of one flood protection measure sample as defined in Inspection Procedure 71111.06. | These activities constituted completion of one flood protection measure sample as defined in Inspection Procedure 71111.06. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R11}} | ||
==1R11 Licensed Operator Requalification Program and Licensed Operator Performance== | |||
{{IP sample|IP=IP 71111.11}} | |||
===.1 Review of Licensed Operator Requalification=== | ===.1 Review of Licensed Operator Requalification=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
On November 15, 2017, the inspectors observed an evaluated simulator scenario performed by an operating crew. The inspectors assessed the performance of the operators and the evaluators | On November 15, 2017, the inspectors observed an evaluated simulator scenario performed by an operating crew. The inspectors assessed the performance of the operators and the evaluators critique of their performance. The inspectors also assessed the modeling and performance of the simulator during the requalification activities. | ||
These activities constituted completion of one quarterly licensed operator requalification program sample, as defined in Inspection Procedure 71111.11. | These activities constituted completion of one quarterly licensed operator requalification program sample, as defined in Inspection Procedure 71111.11. | ||
Line 179: | Line 168: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
On October 26 and 27, 2017, the inspectors observed the performance of on | On October 26 and 27, 2017, the inspectors observed the performance of on-shift licensed operators in the plants main control room. At the time of the observations, the plant was in a period of heightened activity and risk due to power ascension activities following main turbine valve testing. | ||
-shift licensed operators in the | |||
In addition, the inspectors assessed the operators | In addition, the inspectors assessed the operators adherence to plant procedures, including the conduct of operations procedure and other operations department policies. | ||
These activities constituted completion of one quarterly licensed operator performance sample, as defined in Inspection Procedure 71111.11. | These activities constituted completion of one quarterly licensed operator performance sample, as defined in Inspection Procedure 71111.11. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R12}} | ||
==1R12 Maintenance Effectiveness== | |||
{{IP sample|IP=IP 71111.12}} | |||
===.1 Routine Maintenance Effectiveness=== | ===.1 Routine Maintenance Effectiveness=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed two instances of degraded performance or condition of safety | The inspectors reviewed two instances of degraded performance or condition of safety-significant structures, systems, and components (SSCs): | ||
-significant structures, systems, and components (SSCs): | * February 11, 2016, train B essential service water vertical loop vacuum breaker valve failed to smoothly stroke full open or closed | ||
February 11, 2016, train B essential service water vertical loop vacuum breaker valve failed to smoothly stroke full open or closed December 15, 2016, unexpected pressurizer master controller response The inspectors reviewed the extent of condition of possible common cause SSC failures and evaluated the adequacy of the | * December 15, 2016, unexpected pressurizer master controller response The inspectors reviewed the extent of condition of possible common cause SSC failures and evaluated the adequacy of the licensees corrective actions. The inspectors reviewed the licensees work practices to evaluate whether these may have played a role in the degradation of the SSCs. The inspectors assessed the licensees characterization of the degradation in accordance with 10 CFR 50.65 (the Maintenance Rule), and verified that the licensee was appropriately tracking degraded performance and conditions in accordance with the Maintenance Rule. | ||
These activities constituted completion of two maintenance effectiveness | These activities constituted completion of two maintenance effectiveness samples, as defined in Inspection Procedure 71111.12. | ||
====b. Findings==== | ====b. Findings==== | ||
Line 204: | Line 193: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
On December 21, 2017, the inspectors reviewed the | On December 21, 2017, the inspectors reviewed the licensees quality control activities through a review of parts installed in the 480 and 4160 volt safety-related NG and NB switchgears, respectively, that were purchased as commercial-grade parts but were dedicated prior to installation in a quality-grade application. | ||
-related NG and NB switchgears, respectively, that were purchased as commercial | |||
-grade parts but were dedicated prior to installation in a quality | These activities constituted completion of one quality control sample, as defined in Inspection Procedure 71111.12. | ||
-grade application | |||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R13}} | ||
==1R13 Maintenance Risk Assessments and Emergent Work Control== | |||
{{IP sample|IP=IP 71111.13}} | |||
====a. Inspection Scope==== | |||
On October 24 and 25, 2017, the inspectors reviewed one risk assessment associated with planned train A control room air conditioning unit maintenance performed by the licensee prior to changes in plant configuration and the risk management actions taken by the licensee in response to elevated risk. The inspectors also reviewed risk assessment updates related to abnormal reactor coolant system unidentified leakage results. | |||
The inspectors verified this risk assessment was performed timely and in accordance with the requirements of 10 CFR 50.65 (the Maintenance Rule) and plant procedures. | |||
The inspectors reviewed the accuracy and completeness of the licensees risk assessment and verified that the licensee implemented appropriate risk management actions based on the result of the assessment. | |||
These activities constituted completion of one maintenance risk assessment and emergent work control inspection sample, as defined in Inspection Procedure 71111.13. | These activities constituted completion of one maintenance risk assessment and emergent work control inspection sample, as defined in Inspection Procedure 71111.13. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R15}} | ||
==1R15 Operability Determinations and Functionality Assessments== | |||
{{IP sample|IP=IP 71111.15}} | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed three operability determinations that the licensee performed for degraded or nonconforming SSCs: | The inspectors reviewed three operability determinations that the licensee performed for degraded or nonconforming SSCs: | ||
October 13, 2017, operability determination of containment cooler fan A following failure to shift from slow speed to fast speed October 19 and 20, 2017, operability determination of reactor trip breaker/solid | * October 13, 2017, operability determination of containment cooler fan A following failure to shift from slow speed to fast speed | ||
-state protection system following a train A solid state protection system general warning alarm November 1, 2017, operability determination of essential service water piping with degraded wall thickness | * October 19 and 20, 2017, operability determination of reactor trip breaker/solid-state protection system following a train A solid state protection system general warning alarm | ||
* November 1, 2017, operability determination of essential service water piping with degraded wall thickness The inspectors reviewed the timeliness and technical adequacy of the licensees evaluations. Where the licensee determined the degraded SSC to be operable, the inspectors verified that the licensees compensatory measures were appropriate to provide reasonable assurance of operability. The inspectors verified that the licensee had considered the effect of other degraded conditions on the operability of the degraded SSC. | |||
These activities constituted completion of three operability and functionality review | These activities constituted completion of three operability and functionality review samples as defined in Inspection Procedure 71111.15. | ||
====b. Findings==== | ====b. Findings==== | ||
=====Introduction.===== | =====Introduction.===== | ||
The inspectors identified a Green non | The inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to provide adequate work instructions for preventive maintenance on safety-related equipment. Specifically, work instructions to inspect and clean the mechanical interlock on the D containment cooler fan motor control lacked adequate guidance to ensure appropriate lubrication. This resulted in the failure of the 42T starter relay coil in the motor control circuit for the D containment cooler fan, and subsequent unavailability on January 31, 2017. | ||
-cited violation of Technical Specification 5.4.1.a, for the | |||
-related equipment. Specifically, work instructions to inspect and clean the mechanical interlock on the D containment cooler fan motor control lacked adequate guidance to ensure appropriate lubrication. This resulted in the failure of the 42T starter relay coil in the motor control circuit for the D containment cooler fan, and subsequent unavailability on January 31, 2017. | |||
=====Description.===== | =====Description.===== | ||
On January 31, 2017, the licensee made an unplanned entry into action statements associated with Technical Specification 3.6.6, | On January 31, 2017, the licensee made an unplanned entry into action statements associated with Technical Specification 3.6.6, Containment Spray and Cooling Systems, Condition C, and Technical Requirements Manual (TRM) 3.8.11, Containment Penetration Conductor Overcurrent Protective Devices, Condition A, after the D containment cooler fan lost indication and tripped during a transfer from slow to fast speed. An acrid smell was noted in the location of the associated motor control circuit cubicle. Initial troubleshooting efforts using a thermography camera revealed a hot spot in the motor control circuitry and a blown control circuit fuse. | ||
The containment cooler fan motor starters have three contactors, one for slow speed (42S), one for fast speed (42F), and a transfer contactor (42T). The 42T contactor shorts out the slow speed windings of the motor and allows the transfer to fast speed. | |||
When personnel select the fast mode on the fans, the fans are expected to start in slow speed and shift to fast speed after approximately 60 seconds. | |||
When the failure occurred on January 31, 2017, the station was performing the pre | When the failure occurred on January 31, 2017, the station was performing the pre-test alignment steps for STS IC-616B, Slave Relay Test K616 Train B Safety Injection. | ||
-test alignment steps for STS IC | |||
-616B, | |||
While shifting the fan from slow to fast speed the unit failed to shift as expected from slow to fast speed after 60 seconds had elapsed. The red lamp for slow speed de-energized, and the red lamp for fast did not illuminate. The D containment cooler fan unit then tripped and operators took the hand-switch to pull-to-lock. Subsequent investigation revealed that the 42T starter coil, part of the transfer circuit, had overheated and deformed, causing the control power fuse to blow. | |||
Hence, lubrication was not necessarily ensured. | The inspectors reviewed the licensees basic cause evaluation for this event. The probable cause identified in the licensees basic cause evaluation (Revision 1) was, binding of the mechanical interlock, which resulted in the overheating of the coil for the 42T contactor. The inspectors noted that the applicable lubrication preventive maintenance activity instructions in Core Work Instructions ELE-0007, NG001T-NG004T Motor Control Center Inspection, Cleaning and Testing, Revision 0, were interpretive. They instructed maintenance personnel to perform the following step: | ||
IF necessary THEN lubricate the pivot points with a dry lubricant. Hence, lubrication was not necessarily ensured. | |||
Following inspector inquiry regarding inconsistencies between the causes and corrective actions identified in Revision 0 of the basic cause evaluation and the maintenance rule functional failure determination, which determined that the failure was preventable, the licensee completed revisions to the basic cause evaluation. Revision 1 of the basic cause evaluation considered additional information. Specifically, the licensee had experienced three very similar failures between 1985 and 1990, as documented in Work Orders 90034 | Following inspector inquiry regarding inconsistencies between the causes and corrective actions identified in Revision 0 of the basic cause evaluation and the maintenance rule functional failure determination, which determined that the failure was preventable, the licensee completed revisions to the basic cause evaluation. Revision 1 of the basic cause evaluation considered additional information. Specifically, the licensee had experienced three very similar failures between 1985 and 1990, as documented in Work Orders 90034-85, 91657-85, and 01314-89. Additional corrective actions were also added in Revision 1. Specifically, a new action was created to revise preventive maintenance work instructions. Core Work Instructions ELE-0007, which guide the applicable lubrication preventive maintenance activities, were revised to make lubricating in Step 8.12.5.3 mandatory and to lubricate after Step 8.12.2 in the Core Work Instructions. Areas to lubricate include the springs and the phenolic sliders at either end of the vertical moving shafts. | ||
-85, 91657-85, and 01314 | |||
-89. Additional corrective actions were also added in Revision 1. Specifically, a new action was created to revise preventive maintenance work instructions. Core Work Instructions ELE | |||
-0007, which guide the applicable lubrication preventive maintenance activities, were revised to | |||
The inspectors noted that Procedure AP 16B-003, | The inspectors noted that Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 2A, provides direction for implementing the preventive maintenance program. Section 6.2, Establishing [Preventive Maintenance] Activities, states, Develop [preventive maintenance] activities by considering the followingEquipment HistoryOperating Experience (OE) (Industry and Station). | ||
Section 6.2.2, states, [Preventive maintenance] frequencies are established and adjusted in accordance withthe following considerationsThe age of the installed equipment. | |||
The | The preventive maintenance activity instructions were originally incorporated into Revision 5 of MGE EOOP-07, Motor Control Centers, and Control Panels, Cleaning, Inspecting, and Testing, which was issued in 1990. These instructions included directions to include inspecting and lubricating the mechanical interlock during containment cooler preventive maintenance activities. The instructions in MGE EOOP-07 were later moved to Core Work Instructions ELE-007 in April 2009. This procedure did not receive any revisions prior to the failure in January 2017. | ||
The licensees immediate actions included troubleshooting the motor control circuit, replacing the blown control power fuse for motor control circuit, bench testing and installing a replacement 42T contactor to replace the damaged 42T contractor, and performing post maintenance testing of the D containment cooler fan. The D containment cooler fan was returned to service at 12:44 p.m. on February 2, 2017. The issue was entered into the licensees corrective action program as Condition Reports 110725 and 111360. | |||
=====Analysis.===== | =====Analysis.===== | ||
The inspectors determined that the | The inspectors determined that the licensees failure to meet the requirements of Technical Specification 5.4.1.a and provide adequate work instructions for preventive maintenance on safety-related equipment was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). Specifically, work instructions for preventive maintenance on the D containment cooler fan motor control center lacked adequate guidance to ensure lubrication of the mechanical interlock in the motor control circuit, which resulted in the failure of the D containment cooler fan 42T starter relay coil in the motor control circuit on January 31, 2017, and unavailability of the D containment cooler fan. | ||
-related equipment was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). Specifically, work instructions for preventive maintenance on the D containment cooler fan motor control center lacked adequate guidance to ensure lubrication | |||
The inspectors evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of Inspection Manual Chapter 0609, Appendix A, Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, and determined this finding is not a deficiency affecting the design or qualification of a mitigating SSC that maintained its operability or functionality; the finding does not represent a loss of system and/or function; the finding does not represent an actual loss of function of at least a single train for greater than its Technical Specification-allowed outage time; and the finding does not represent an actual loss of function of one or more non-Technical Specification trains of equipment designated as high safety-significant. | |||
Therefore, the inspectors determined the finding was of very low safety significance (Green). | |||
Inspectors did not assign a cross-cutting aspect and determined the performance deficiency is not indicative of current performance. The inspectors determined that the performance deficiency did not occur within the last three years, and the inspectors did not identify a reasonable opportunity within the last three years for the licensee to have identified the performance deficiency. | |||
-cutting aspect and determined the performance deficiency is not indicative of current performance. The inspectors determined that the performance deficiency did not occur within the last three years, and the inspectors | |||
=====Enforcement.===== | =====Enforcement.===== | ||
Technical Specification 5.4.1.a, requires, in part, that procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. Section 9.a of Appendix A to Regulatory Guide 1.33, Revision 2, requires, in part, that maintenance that can affect the performance of safety | Technical Specification 5.4.1.a, requires, in part, that procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. Section 9.a of Appendix A to Regulatory Guide 1.33, Revision 2, requires, in part, that maintenance that can affect the performance of safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. The licensee established Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 2A, which provides direction for implementing the preventive maintenance program to meet the Regulatory Guide 1.33 requirement. Section 6.2 of Procedure AP 16B-003 requires, in part, that preventive maintenance activities be developed by considering equipment history and operating experience. Contrary to the above, until November 7, 2017, preventive maintenance activities were not developed by adequately considering equipment history and operating experience. Specifically, the D containment cooler fan motor control preventive maintenance instructions in Core Work Instruction ELE-007 were not developed for the D containment cooler fan motor control center by adequately considering station operating experience documented in Work Orders 90034-85, 91657-85, and 01314-89. The licensee took the immediate corrective action to test and install a replacement 42T contactor in D containment cooler fan motor control circuit, and conducted post maintenance testing after replacement. | ||
-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. The licensee established Procedure AP 16B-003, | |||
Revision 2A, which provides direction for implementing the preventive maintenance program to meet the Regulatory Guide 1.33 requirement. Section 6.2 of Procedure AP 16B-003 requires, in part, that preventive maintenance activities be developed by considering equipment history and operating experience. Contrary to the above, until November 7, 2017, preventive maintenance activities were not developed by adequately considering equipment history and operating experience. Specifically, the D containment cooler fan motor control preventive maintenance instructions in Core Work Instruction ELE | |||
-007 were not developed for the D containment cooler fan motor control center by adequately considering station operating experience documented in Work Orders 90034-85, 91657-85, and 01314 | |||
-89. The licensee took the immediate corrective action to test and install a replacement 42T contactor in D containment cooler fan motor control circuit, and conducted post maintenance testing after replacement. | |||
The licensee also inspected, cleaned, and lubricated the mechanical linkage on the D containment cooler fan motor control circuit. The preventive maintenance activity instructions were also later revised. The licensee entered this issue into the corrective action program as Condition Reports 110725 and 111360. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy: | |||
NCV 05000482/2017004-01, Failure to Provide Adequate Work Instructions for Preventive Maintenance. | |||
{{a|1R18}} | |||
==1R18 Plant Modifications== | |||
{{IP sample|IP=IP 71111.18}} | |||
===.1 Temporary Modifications=== | ===.1 Temporary Modifications=== | ||
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On December 20 and 21, 2017, the inspectors reviewed a temporary modification to temporarily secure cavity cooing fans to support nuclear instrument 31 degraded cooling follow-up activities. | On December 20 and 21, 2017, the inspectors reviewed a temporary modification to temporarily secure cavity cooing fans to support nuclear instrument 31 degraded cooling follow-up activities. | ||
The inspectors verified that the licensee would implement this temporary modification in accordance with technically adequate design documents. The inspectors verified that this modification did not adversely impact the operability or availability of affected SSCs. The inspectors reviewed design documentation and plant procedures affected by the modification to verify the licensee maintained configuration control. | The inspectors verified that the licensee would implement this temporary modification in accordance with technically adequate design documents. The inspectors verified that this modification did not adversely impact the operability or availability of affected SSCs. | ||
The inspectors reviewed design documentation and plant procedures affected by the modification to verify the licensee maintained configuration control. | |||
These activities constituted completion of one sample of temporary modifications, as defined in Inspection Procedure 71111.18. | These activities constituted completion of one sample of temporary modifications, as defined in Inspection Procedure 71111.18. | ||
Line 311: | Line 289: | ||
On November 27, 2017, the inspectors reviewed a permanent plant modification to the auxiliary feedwater system to address recirculation line tornado missile vulnerabilities. | On November 27, 2017, the inspectors reviewed a permanent plant modification to the auxiliary feedwater system to address recirculation line tornado missile vulnerabilities. | ||
The inspectors reviewed the design and implementation of the | The inspectors reviewed the design and implementation of the modifications. The inspectors verified that work activities involved in implementing the modifications did not adversely impact operator actions that may be required in response to an emergency or other unplanned event. The inspectors verified that post-modification testing was adequate to establish the operability of the SSCs as modified. | ||
-modification testing was adequate to establish the operability of the | |||
These activities constituted completion of one sample of permanent modifications, as defined in Inspection Procedure 71111.18. | These activities constituted completion of one sample of permanent modifications, as defined in Inspection Procedure 71111.18. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R19}} | ||
==1R19 Post-Maintenance Testing== | |||
{{IP sample|IP=IP 71111.19}} | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed two post-maintenance testing activities that affected risk | The inspectors reviewed two post-maintenance testing activities that affected risk-significant SSCs: | ||
-significant SSCs: | * October 25, 2017, train A control room air-conditioning system | ||
October 25, 2017, train A control room air-conditioning system December | * December 19, 2017, essential service water forebay level transmitter The inspectors reviewed licensing- and design-basis documents for the SSCs and the maintenance and post-maintenance test procedures. The inspectors observed the performance of the post-maintenance tests to verify that the licensee performed the tests in accordance with approved procedures, satisfied the established acceptance criteria, and restored the operability of the affected SSCs. | ||
- and design | |||
-basis documents for the SSCs and the maintenance and post | |||
-maintenance test procedures. The inspectors observed the performance of the post | |||
-maintenance tests to verify that the licensee performed the tests in accordance with approved procedures, satisfied the established acceptance criteria, and restored the operability of the affected SSCs. | |||
These activities constituted completion of two post-maintenance testing inspection | These activities constituted completion of two post-maintenance testing inspection samples, as defined in Inspection Procedure 71111.19. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|1R22}} | ||
==1R22 Surveillance Testing== | |||
{{IP sample|IP=IP 71111.22}} | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors observed two risk-significant surveillance tests and reviewed test results to verify that these tests adequately demonstrated that the SSCs were capable of performing their safety functions: | The inspectors observed two risk-significant surveillance tests and reviewed test results to verify that these tests adequately demonstrated that the SSCs were capable of performing their safety functions: | ||
Reactor coolant system leak detection tests: | Reactor coolant system leak detection tests: | ||
October 24, 2017, STS BB | * October 24, 2017, STS BB-006, RCS [Reactor Coolant System] Water Inventory Balance Using the NPIS [Nuclear Plant Information System] Computer Other surveillance tests: | ||
-006, RCS [Reactor Coolant System] Water Inventory Balance Using the NPIS [Nuclear Plant Information System] Computer Other surveillance tests: | * November 1, 2017, STS EF-100B, ESW [Essential Service Water] System Inservice Pump B and ESW [Essential Service Water] B Check Valve Test The inspectors verified that these tests met technical specification requirements, that the licensee performed the tests in accordance with their procedures, and that the results of the test satisfied appropriate acceptance criteria. The inspectors verified that the licensee restored the operability of the affected SSCs following testing. | ||
November 1, 2017, STS EF | |||
-100B, ESW [Essential Service Water] System Inservice Pump B and ESW [Essential Service Water] | |||
B Check Valve Test The inspectors verified that these tests met technical specification requirements, that the licensee performed the tests in accordance with their procedures, and that the results of the test satisfied appropriate acceptance criteria. The inspectors verified that the licensee restored the operability of the affected SSCs following testing. | |||
These activities constituted completion of two surveillance testing inspection | These activities constituted completion of two surveillance testing inspection samples, as defined in Inspection Procedure 71111.22. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. | ||
===Cornerstone: | ===Cornerstone: Emergency Preparedness=== | ||
{{a|1EP1}} | |||
==1EP1 Exercise Evaluation== | |||
{{IP sample|IP=IP 71114.01}} | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors observed the November 14, | The inspectors observed the November 14, 2017, biennial emergency preparedness exercise to verify the exercise acceptably tested the major elements of the emergency plan and provided opportunities for the emergency response organization to demonstrate key skills and functions. The licensee demonstrated its ability to implement its emergency plan through a scenario that simulated: | ||
Loss of the condensate header leading to a red path on core cooling Fault on transformer XNB01 Failure of diesel generator NE01 Failure of the non-safety auxiliary feedwater pump Radiological release to the environment from ruptured and faulted steam generator A; the release was partially monitored and filtered The scenario rapidly escalated with a site area emergency as the initial emergency classification. During the exercise the inspectors observed activities in the control room simulator and the following dedicated emergency response facilities: | * Loss of the condensate header leading to a red path on core cooling | ||
Technical Support Center Operations Support Center Emergency Operations Facility The inspectors focused their evaluation of the | * Fault on transformer XNB01 | ||
* Failure of diesel generator NE01 | |||
* Failure of the non-safety auxiliary feedwater pump | |||
* Radiological release to the environment from ruptured and faulted steam generator A; the release was partially monitored and filtered The scenario rapidly escalated with a site area emergency as the initial emergency classification. During the exercise the inspectors observed activities in the control room simulator and the following dedicated emergency response facilities: | |||
* Technical Support Center | |||
* Operations Support Center | |||
* Emergency Operations Facility The inspectors focused their evaluation of the licensees performance on the risk-significant activities of event classification, offsite notification, recognition of offsite dose consequences, and development of protective action recommendations. | |||
The inspectors also assessed recognition of, and response to, abnormal and emergency plant conditions, the transfer of decision | The inspectors also assessed recognition of, and response to, abnormal and emergency plant conditions, the transfer of decision-making authority and emergency function responsibilities between facilities, on-site and offsite communications, protection of emergency workers, emergency repair evaluation and capability, and the overall implementation of the emergency plan to protect public health and safety and the environment. The inspectors reviewed the current revision of the facility emergency plan, emergency plan implementing procedures associated with operation of the licensees emergency response facilities, procedures for the performance of associated emergency functions, and other documents as listed in the attachment to this report. | ||
-making authority and emergency function responsibilities between facilities, on | |||
-site and offsite communications, protection of emergency workers, emergency repair evaluation and capability, and the overall implementation of the emergency plan to protect public health and safety and the environment. The inspectors reviewed the current revision of the facility emergency plan, emergency plan implementing procedures associated with operation of the | |||
The inspectors attended the post-exercise critiques in each emergency response facility to evaluate the initial licensee self | The inspectors attended the post-exercise critiques in each emergency response facility to evaluate the initial licensee self-assessment of exercise performance. The inspectors also attended a formal presentation of critique items to plant management conducted November 17, 2017. | ||
-assessment of exercise performance. The inspectors also attended a formal presentation of critique items to plant management conducted November 17, 2017. | |||
The inspectors reviewed the scenarios of previous biennial exercises and licensee drills conducted between January 2016 and October 2017 to determine whether the November 14, 2017, exercise was independent and avoided participant preconditioning, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(g). The inspectors also compared observed exercise performance with corrective action program entries and after | The inspectors reviewed the scenarios of previous biennial exercises and licensee drills conducted between January 2016 and October 2017 to determine whether the November 14, 2017, exercise was independent and avoided participant preconditioning, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(g). The inspectors also compared observed exercise performance with corrective action program entries and after-action reports for drills and exercises conducted between January 2016 and October 2017 to determine whether identified weaknesses had been corrected in accordance with the requirements of 10 CFR 50.47(b)(14), and 10 CFR Part 50, Appendix E, IV.F. | ||
-action reports for drills and exercises conducted between January 2016 and October 2017 to determine whether identified weaknesses had been corrected in accordance with the requirements of 10 CFR 50.47(b)(14), and 10 CFR Part 50, Appendix E, IV.F. | |||
The inspectors discussed the scenario with staff from Federal Emergency Management Agency Region VII to determine whether the scenario supported the Federal Emergency Management Agency evaluation objectives. | The inspectors discussed the scenario with staff from Federal Emergency Management Agency Region VII to determine whether the scenario supported the Federal Emergency Management Agency evaluation objectives. | ||
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====b. Findings==== | ====b. Findings==== | ||
Description | =====Introduction.===== | ||
The inspectors identified a Green non-cited violation of 10 CFR 50.47(b)(14) for the licensees failure to identify and correct a weakness in emergency response organization performance during a biennial emergency preparedness exercise conducted on November 14, 2017. | |||
=====Description.===== | |||
The inspectors observed an emergency preparedness exercise conducted November 14, 2017, and observed the licensees formal exercise critique conducted November 17, 2017. The inspectors determined that the licensee failed to identify emergency response organization weaknesses in Technical Support Center and Operations Support Center performance and as a result did not ensure the weaknesses would be corrected. | |||
The exercise simulated, in part, faults on an electrical transformer, electrical busses, a diesel generator failure and steam released into the turbine building. The inspectors observed that only one repair team was dispatched into the plant, while three other teams were briefed, but not dispatched. The licensee team that went into the plant was sent to evaluate equipment that was out of service at the start of the exercise, not to repair emergent equipment problems. Non-licensed operators were sent to equipment that failed during the exercise, but were not capable of diagnosing the causes of equipment problems. The inspectors observed that no diagnostic activities were performed at bus NB01 or bus PB05, the diesel generators or blackout diesel generators, or at the feed pumps. The emergency response organization also did not determine how steam was getting into the turbine building. | |||
Because they did not diagnose the fault in bus PB05, operators caused two blackout diesels to fail and would have failed the third (and last) diesel. Specifically, operators did not evaluate the cause of the first blackout diesel failure before putting the second diesel into service. When the second diesel failed, they were working toward putting the third diesel into service without understanding either failure. There was a lack of recognition that bus PB05 could have been faulted, thereby causing the blackout diesel generator failures. | |||
The inspectors | The inspectors concluded that the emergency response organization did not understand plant conditions and did not properly utilize in-plant teams to investigate and correct the causes of equipment failures. The inspectors determined that the inadequate use of in-plant repair teams and lack of understanding of plant conditions could have prevented the licensee from ensuring that adequate measures could be taken to protect the health and safety of the public because it caused the emergency response organization to degrade the plant electrical system and affected their ability to terminate the radioactive release. | ||
The inspectors observed the licensees formal critique of exercise performance conducted November 17, 2017, and noted that the licensee did not discuss the lack of understanding of plant conditions exhibited in the control room and Technical Support Center, the inadequate use of in-plant repair and mitigation teams, or the degrading of the plant electrical system by sequentially failing station blackout diesel generators. The licensee did identify a significant delay in dispatching repair team #4 into the plant as a weakness requiring correction. | |||
The inspectors evaluated the discussion between the exercise evaluators and site management and concluded that the licensee did not recognize a broader failure to effectively use repair teams to diagnose plant equipment problems. This failure was a significant contributor to the lack of understanding of plant conditions and the degrading of the plant electrical system. The inspectors concluded that the licensee failed to critique weaknesses in emergency response organization performance based on the results of the | The inspectors evaluated the discussion between the exercise evaluators and site management and concluded that the licensee did not recognize a broader failure to effectively use repair teams to diagnose plant equipment problems. This failure was a significant contributor to the lack of understanding of plant conditions and the degrading of the plant electrical system. The inspectors concluded that the licensee failed to critique weaknesses in emergency response organization performance based on the results of the licensees formal critique. | ||
=====Analysis.===== | =====Analysis.===== | ||
The | The licensees failure to correct a weakness that occurred during an exercise is a performance deficiency within the licensees ability to foresee and correct. A weakness is defined in Inspection Manual Chapter 0609, Appendix B, Emergency Preparedness Significance Determination Process, dated September 22, 2015, as emergency response organization performance that would have prevented the effective implementation of the licensees emergency plan had the circumstances occurred. The emergency response organizations lack of understanding of plant conditions and failure to utilize in-plant teams to investigate and correct the causes of equipment failures was a weakness requiring correction. The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute (training, exercises) and adversely affected the cornerstone objective. The licensees ability to ensure that adequate measures will be taken to protect the health and safety of the public is degraded when weak emergency response organization performance is not corrected. The finding was evaluated using Attachment 2, Failure to Comply Logic Flowchart, to Inspection Manual Chapter 0609, Appendix B, and was determined to be of very low safety significance (Green) because the finding was a failure to comply with NRC requirements, was not a lost or degraded risk-significant planning standard, and was not a loss of planning standard function. The finding was not a loss of planning standard function because the licensee appropriately critiqued some weaknesses associated with risk-significant activities and the 10 CFR 50.47(b) planning standards. | ||
-plant teams to investigate and correct the causes of equipment failures was a weakness requiring correction. The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute (training, exercises) and adversely affected the cornerstone objective. The | |||
-significant planning standard, and was not a loss of planning standard function. The finding was not a loss of planning standard function because the licensee appropriately critiqued some weaknesses associated with risk | The finding was determined to have a cross-cutting aspect of evaluation in the area of problem identification and resolution because the licensee did not evaluate the deficient understanding of plant conditions and failure to utilize in-plant mitigation and repair teams as a performance weakness. Licensee evaluators were focused on the established exercise objectives, which did not include understanding the causes of equipment failures or implementing an effective repair strategy [P.2]. | ||
-significant activities and the 10 CFR 50.47(b) planning standards. The finding was determined to have a cross | |||
-cutting aspect of evaluation in the area of problem identification and resolution because the licensee did not evaluate the deficient understanding of plant conditions and failure to utilize in | |||
-plant mitigation and repair teams as a performance weakness. Licensee evaluators were focused on the established exercise objectives | |||
, which did not include understanding the causes of equipment failures or implementing an effective repair strategy [P.2] | |||
. | |||
=====Enforcement.===== | =====Enforcement.===== | ||
Title 10 CFR 50.54(q)(2), requires, in part, that a power reactor licensee follow and maintain the effectiveness of an emergency plan which meets the requirements of Appendix E to 10 CFR Part 50 and the standards of 10 CFR 50.47(b). Title 10 CFR 50.47(b)(14) requires, in part, that deficiencies identified as a result of exercises or drills are (will be) corrected. Contrary to the above, on November 17, 2017, the licensee failed to correct a deficiency identified as a result of exercises or drills | Title 10 CFR 50.54(q)(2), requires, in part, that a power reactor licensee follow and maintain the effectiveness of an emergency plan which meets the requirements of Appendix E to 10 CFR Part 50 and the standards of 10 CFR 50.47(b). | ||
-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy | Title 10 CFR 50.47(b)(14) requires, in part, that deficiencies identified as a result of exercises or drills are (will be) corrected. Contrary to the above, on November 17, 2017, the licensee failed to correct a deficiency identified as a result of exercises or drills. | ||
: | |||
-02 , | Specifically, the licensee failed to identify an emergency response organization performance deficiency (weakness) occurring during the November 14, 2017, biennial exercise and did not ensure correction of the weakness. There was no actual or potential safety significance because the weak performance occurred during an exercise. This issue was documented in licensee Condition Report 117567, dated November 17, 2017. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy: NCV 05000482/2017004-02, Failure to Critique TSC and OSC Performance during a Biennial Exercise. | ||
{{a|1EP8}} | |||
- Scenario Review | ==1EP8 Exercise Evaluation - Scenario Review== | ||
{{IP sample|IP=IP 71114.08}} | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The licensee submitted the preliminary exercise scenario for the November 14, 2017, biennial exercise to the NRC on August 29, 2017, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(b). The inspectors performed an in | The licensee submitted the preliminary exercise scenario for the November 14, 2017, biennial exercise to the NRC on August 29, 2017, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(b). The inspectors performed an in-office review of the proposed scenario to determine whether it would acceptably test the major elements of the licensees emergency plan, and provide opportunities for the emergency response organization to demonstrate key skills and functions. The inspectors discussed the preliminary scenario with staff at FEMA, Region VII, to determine whether the proposed scenario supported the FEMA evaluation objectives. | ||
-office review of the proposed scenario to determine whether it would acceptably test the major elements of the | |||
====b. Findings==== | ====b. Findings==== | ||
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==OTHER ACTIVITIES== | ==OTHER ACTIVITIES== | ||
Cornerstones: | Cornerstones: Initiating Events, Mitigating Systems, Barrier Integrity, Emergency Preparedness, Public Radiation Safety, Occupational Radiation Safety, and Security | ||
{{a|4OA1}} | |||
==4OA1 Performance Indicator Verification== | |||
{{IP sample|IP=IP 71151}} | |||
===.1 Safety System Functional Failures (MS05)=== | ===.1 Safety System Functional Failures (MS05)=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
For the period of October 1, 2016 | For the period of October 1, 2016, through September 30, 2017, the inspectors reviewed licensee event reports (LERs), maintenance rule evaluations, and other records that could indicate whether safety system functional failures had occurred. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, and NUREG-1022, Event Reporting Guidelines: 10 CFR 50.72 and 50.73, Revision 3, to determine the accuracy of the data reported. | ||
, through September 30, 2017, the inspectors reviewed licensee event reports (LERs), maintenance rule evaluations, and other records that could indicate whether safety system functional failures had occurred. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99 | |||
-02, | |||
These activities constituted verification of the safety system functional failures performance indicator | These activities constituted verification of the safety system functional failures performance indicator, as defined in Inspection Procedure 71151. | ||
, as defined in Inspection Procedure 71151. | |||
====b. Findings==== | ====b. Findings==== | ||
Line 435: | Line 404: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees mitigating system performance index data for the period of October 1, 2016, through September 30, 2017, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. | ||
, through September 30, 2017 | |||
, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99 | These activities constituted verification of the mitigating system performance index for heat removal systems, as defined in Inspection Procedure 71151. | ||
-02, | |||
, as defined in Inspection Procedure 71151. | |||
====b. Findings==== | ====b. Findings==== | ||
Line 447: | Line 414: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees mitigating system performance index data for the period of October 1, 2016, through September 30, 2017, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. | ||
, through September 30, 2017 | |||
, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99 | These activities constituted verification of the mitigating system performance index for residual heat removal systems, as defined in Inspection Procedure 71151. | ||
-02, | |||
, as defined in Inspection Procedure 71151. | |||
====b. Findings==== | ====b. Findings==== | ||
Line 459: | Line 424: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees evaluated exercises and selected drill and training evolutions that occurred between July 2016 and September 2017 to verify the accuracy of the licensees data for classification, notification, and protective action recommendation opportunities. The inspectors reviewed a sample of the licensees completed classifications, notifications, and protective action recommendations to verify their timeliness and accuracy. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report. | ||
These activities constituted verification of the drill/exercise performance indicator as defined in Inspection Procedure 71151. | These activities constituted verification of the drill/exercise performance indicator as defined in Inspection Procedure 71151. | ||
Line 469: | Line 434: | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees records for participation in drill and training evolutions between July 2016 and September 2017 to verify the accuracy of the licensees data for drill participation opportunities. The inspectors verified that all members of the licensees emergency response organization (ERO) in the identified key positions had been counted in the reported performance indicator data. The inspectors reviewed the licensees basis for reporting the percentage of ERO members who participated in a drill. The inspectors reviewed drill attendance records and verified a sample of those reported as participating. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report. | ||
-02, | |||
These activities constituted verification of the emergency response organization drill participation performance indicator as defined in Inspection Procedure 71151. | These activities constituted verification of the emergency response organization drill participation performance indicator as defined in Inspection Procedure 71151. | ||
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====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees records of alert and notification system tests conducted between July 2016 and September 2017 to verify the accuracy of the licensees data for siren system testing opportunities. The inspectors reviewed procedural guidance on assessing alert and notification system opportunities and the results of periodic alert and notification system operability tests. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report. | ||
-02, | |||
These activities constituted verification of the alert and notification system reliability performance indicator as defined in Inspection Procedure | These activities constituted verification of the alert and notification system reliability performance indicator as defined in Inspection Procedure 71151. | ||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. {{a|4OA2}} | ||
==4OA2 Problem Identification and Resolution== | |||
{{IP sample|IP=IP 71152}} | |||
===.1 Routine Review=== | ===.1 Routine Review=== | ||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
Throughout the inspection period, the inspectors performed daily reviews of items entered into the | Throughout the inspection period, the inspectors performed daily reviews of items entered into the licensees corrective action program and periodically attended the licensees condition report screening meetings. The inspectors verified that licensee personnel were identifying problems at an appropriate threshold and entering these problems into the corrective action program for resolution. The inspectors verified that the licensee developed and implemented corrective actions commensurate with the significance of the problems identified. The inspectors also reviewed the licensees problem identification and resolution activities during the performance of the other inspection activities documented in this report. | ||
====b. Findings==== | ====b. Findings==== | ||
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====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the | The inspectors reviewed the licensees corrective action program, performance indicators, quality assessments, issues that challenge operators in performing duties, and other documentation to identify trends that might indicate the existence of a more significant safety issue. The inspectors verified that the licensee was taking corrective actions to address identified and possible adverse trends: | ||
* Licensee response to a noted increase in the number of inadequate preventive maintenance issues | |||
* Increased number of non-plant item control issues | |||
* Recent Technical Specification Bases issues and licensee use of design basis information These activities constituted completion of one semiannual trend review sample, as defined in Inspection Procedure 71152. | |||
b. Observations and Assessments The inspectors evaluated a sample of recent issues and events that occurred to determine whether issues were appropriately considered as emerging or adverse trends. | |||
The inspectors verified that these issues were addressed within the scope of the corrective action program. | |||
The inspectors review of the trends and issues identified above produced the following observations and assessments: | |||
* Inspectors reviewed the licensees response to an inspector identified possible emerging trend associated with recent preventive maintenance related issues. | |||
This possible emerging trend was discussed in Section 4OA2.2, Semiannual Trend Review, of NRC inspection report 05000482/2017002 (ML17223A285). | |||
The licensee planned to conduct training for engineers and leaders to reduce the reliance on subjective preventive maintenance acceptance criteria while considering the functional importance of the impacted equipment. | The licensee documented the inspectors concerns with the possible emerging trend in Condition Report 114437. The licensee completed a basic cause evaluation to evaluate the concerns and the possible adverse trend. The evaluation concluded that three referenced issues related to preventive maintenance program effectiveness indicate specific weaknesses in the implementation of the preventive maintenance activities. The evaluation described the probable cause of the examples of weakness in the preventive maintenance program as, a lack of a bias towards conservative decision making in the development of preventive maintenance program instructions. The licensee planned to conduct training for engineers and leaders to reduce the reliance on subjective preventive maintenance acceptance criteria while considering the functional importance of the impacted equipment. | ||
Although planned actions had not all been completed, the inspectors noted that the corrective actions to address the lack of a bias towards conservative decision making in the development of preventive maintenance program instructions were narrowly focused and did not appear to reach the entire subset of station personnel that may be involved in the development of preventive maintenance program instructions. Specifically, Section 5.0, | Although planned actions had not all been completed, the inspectors noted that the corrective actions to address the lack of a bias towards conservative decision making in the development of preventive maintenance program instructions were narrowly focused and did not appear to reach the entire subset of station personnel that may be involved in the development of preventive maintenance program instructions. Specifically, Section 5.0, Responsibilities, of Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 8A, notes that the Manager Maintenance; superintendents of mechanical, electrical, and instrumentation and control maintenance; maintenance planners; and station personnel external to the maintenance department may be involved in the documentation, oversight, or planning of preventive maintenance activities. The balance of station personnel that have responsibilities related to the development of preventive maintenance program instructions would not have been expected to receive the same level of training that was planned for engineers and leaders. | ||
, | |||
As a result, it is not clear to the inspectors that the licensees corrective actions to address the identified cause, a lack of a bias towards conservative decision making in the development of preventive maintenance program instructions, would have eliminated the vulnerability across the station. | |||
The inspectors shared these concerns with the licensee. | The inspectors shared these concerns with the licensee. | ||
* Inspectors reviewed the licensees response to a quality assurance finding identified in quality assurance assessment QA-2017-0365. The licensees basic cause evaluation noted over 30 condition reports related to control of non-plant items defined by Procedure AP 21B-003, Control of Non-Plant Items Inside or Near Plant Systems, Structures, and Components, Revisions 11A and 12, as ancillary items that are not a part of plant SSCs. Included among these condition reports were Condition Report 115174, which documented an NRC-identified concern associated with a storage cabinet that was located near safety-related essential service water piping and fire protection piping in the auxiliary building. | |||
The cabinet did not meet the definition of stable plant equipment, as defined in Procedure AP 21B-003, Revision 11A. On August 21, 2017, Condition Report 115198 documented an NRC-identified issue associated with a storage cart with unchocked wheels near auxiliary feedwater piping in the auxiliary building. The cart was not immobilized in accordance with Procedure AP 21B-003, Revision 11A. A few days later on August 25, 2017, Condition Report 115320 documented unstable items like a coat rack, platform ladder, and equipment storage cabinet that were located in the control room near plant SSCs, which was not in compliance with Procedure AP 21B-003, Revision 11A. | |||
-003, | |||
-identified | |||
The | The licensees basic cause evaluation also documented a history of challenges maintaining control of temporary equipment. Specifically, the evaluation noted a root cause evaluation in 2001 that stated that procedure clarity could be improved, but issues were resulting from, A failure to implement and enforce the process requirements. Similar issues in 2004, 2006, and 2015 were also noted. | ||
The evaluation concluded, Based on the repetitive programmatic compliance nature of the issues, there is a common weakness in the implementation enforcement of management expectations. These issues have remained of low consequence but do not meet the criteria within AP21B-003. The probable cause of non-plant items not being controlled in accordance with the requirements of AP 21B-003 was determined to be, Non-plant items requirements are not being met due to insufficient commitment with the procedure requirements. | |||
-003. | |||
-plant items not being controlled in accordance with the requirements of AP 21B | |||
-003 was determined to be, | |||
-plant items requirements are not being met due to insufficient commitment with the procedure requirements. | |||
The inspectors noted that remedial actions to address the cause included revisions to Procedure AP | The inspectors noted that remedial actions to address the cause included revisions to Procedure AP 21B-003, which removed redundancy throughout the procedure and provided clarification of criteria for stable, non-stable, and non-plant items, and communication to station personnel on the non-plant process. The inspectors reviewed the communication and revisions to Procedure AP 21B-003, and the inspectors determined that the corrective actions did not address the identified cause. Specifically, neither the communications, nor Procedure AP 21B-003 revisions, nor any other actions appeared to address insufficient commitment to procedure requirements. | ||
-stable, and non-plant items, and communication to station personnel on the non | |||
-plant process. The inspectors reviewed the communication and revisions to Procedure AP 21B-003, and the inspectors determined that the corrective actions did not address the identified cause. Specifically, neither the communications, nor Procedure AP 21B-003 revisions, nor any other actions appeared to address insufficient commitment to procedure requirements | |||
. | |||
The inspectors considered recent Technical Specification Bases issues that were associated with licensee use of design basis information. Specifically, NRC inspection report 05000482/2017003 (ML17311B223) documented an NRC-identified Green non-cited violation associated with the | The inspectors shared these concerns with the licensee. | ||
-driven auxiliary feedwater pump to be removed from service without entry into applicable Technical Specification action statements. | * The inspectors considered recent Technical Specification Bases issues that were associated with licensee use of design basis information. Specifically, NRC inspection report 05000482/2017003 (ML17311B223) documented an NRC-identified Green non-cited violation associated with the licensees failure to ensure the auxiliary feedwater system design basis was adequately represented in the Technical Specification Bases, which resulted in the Technical Specification Bases and other station procedures allowing for one train of essential service water supply to the turbine-driven auxiliary feedwater pump to be removed from service without entry into applicable Technical Specification action statements. | ||
NRC Inspection Report 05000482/2017002 (ML17223A285) documented an NRC-identified Green non-cited violation associated with the | NRC Inspection Report 05000482/2017002 (ML17223A285) documented an NRC-identified Green non-cited violation associated with the licensees failure to declare the essential service water emergency make-up to component cooing water train A valve inoperable when it was out of service, which resulted in train A component cooling water being out of service for longer than its Technical Specification allowed outage time. In both cases the Technical Specification Bases, which was inaccurate or incomplete, respectively, was referenced and utilized for work planning and implementation, while other design basis information like the Updated Safety Analysis Report was not being similarly referenced. | ||
-up to component cooing water train A valve inoperable when it was out of service, which resulted in train A component cooling water being out of service for longer than its Technical Specification allowed outage time | |||
. In both cases the Technical Specification Bases, which was inaccurate or incomplete, respectively, was referenced and utilized for work planning and implementation, while other design basis information like the Updated Safety Analysis Report was not being similarly referenced. | |||
The inspectors considered whether an adverse trend existed related to the Technical Specification Bases or how design basis information was being used and referenced. The inspectors did not determine that these two data points alone were sufficient to identify a possible emerging adverse trend. However, the inspectors shared | The inspectors considered whether an adverse trend existed related to the Technical Specification Bases or how design basis information was being used and referenced. The inspectors did not determine that these two data points alone were sufficient to identify a possible emerging adverse trend. However, the inspectors shared their observations with the licensee related to the extent of condition and current performance aspects of these issues. | ||
. | |||
====c. Findings==== | ====c. Findings==== | ||
No findings were identified. | No findings were identified. | ||
===.3 Annual Follow=== | ===.3 Annual Follow-up of Selected Issues=== | ||
====a. Inspection Scope==== | |||
The inspectors selected one issue for an in-depth follow-up. On August 17, 2017, the licensee initiated Condition Report 115120 to document that boric acid residue had remained on several control rod drive mechanisms (CRDMs) during Refueling Outage 21, but the condition had not been evaluated for operability or functionality. | |||
The inspectors assessed the licensees problem identification threshold, cause analyses, extent of condition reviews, and compensatory actions. The inspectors verified that the licensee appropriately prioritized the planned corrective actions and that these actions were adequate to correct the condition. | |||
These activities constituted completion of one annual follow-up sample as defined in Inspection Procedure 71152. | These activities constituted completion of one annual follow-up sample as defined in Inspection Procedure 71152. | ||
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=====Introduction.===== | =====Introduction.===== | ||
The inspectors identified a Green non | The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to implement the operability determination and functionality assessment procedure. | ||
-cited violation of 10 CFR Part 50, Appendix B, Criterion V | |||
, | Specifically, as of October 12, 2016, the licensee identified boric acid coating on several CRDMs, but failed to initiate a condition report to evaluate the effect of the condition on CRDM operability. | ||
=====Description.===== | =====Description.===== | ||
On September 2, 2016, reactor head penetration number 77 experienced a leak through a canopy seal weld of approximately 1.4 gpm | On September 2, 2016, reactor head penetration number 77 experienced a leak through a canopy seal weld of approximately 1.4 gpm, which led to a unit shut down. This leak resulted in spraying reactor coolant on the head, its penetrations, and other nearby equipment. Included in this equipment were several CRDMs. The licensee photographed and documented the condition in the boric acid corrosion control program in accordance with Procedure AI 16F-001, Boric Acid Leakage Evaluation, Revision 8, on October 12, 2017. In this evaluation the licensee documented, The number of CRDMs removed for cleaning was limited due to the difficulty of removal. For this reason residue was not cleaned from multiple CRDMs. The primary concern is limited cooling capability of these components with increased potential of failure; a situation that could lead to a dropped rod. Despite this statement in the boric acid leakage evaluation, no further evaluation was documented to accept the condition. | ||
, which led to a unit shut down. This leak resulted in spraying reactor coolant on the head, its penetrations | |||
, and other nearby equipment. Included in this equipment were several CRDMs. The licensee photographed and documented the condition in the boric acid corrosion control program in accordance with Procedure AI 16F | |||
-001, | |||
Licensee procedure, AP 26C-004, Operability Determination and Functionality Assessment, Revision 34B, a quality related procedure, provides instructions for initiating condition reports to enter the operability determination process. Procedure AP 26C-004, Step 5.2.1, states in part, that all personnel shall initiate a condition report for any adverse SSC condition. Because the licensee did not initiate a condition report for the boric acid residue, the licensee did not implement Procedure AP 26C-004, and no operability evaluation was performed. | |||
On August 22, 2017, following the inspectors requesting information concerning the condition of the CRDMs, the licensee initiated Condition Report 115120 to document that an evaluation for the CRDMs in which boric acid residue remained was required. | |||
The licensee produced a seven-page white paper to evaluate the heat transfer capabilities of CRDMs with 0.25 inches of dry boric acid coating on the housing, to support the operability evaluation of the CRDMs. The licensee determined that although the internal CRDM temperatures could increase up to 8 °F, this temperature increase would have a negligible effect on the CRDM service life and would not lead to a rod drop accident. | |||
-page white paper to evaluate the heat transfer capabilities of CRDMs with 0.25 inches of dry boric acid coating on the housing, to support the operability evaluation of the CRDMs. The licensee determined that although the internal CRDM temperatures could increase up to 8 °F, this temperature increase would have a negligible effect on the CRDM service life and would not lead to a rod drop accident. | |||
The | The licensees Performance Assessment Worksheet associated with Condition Report 115120, which was completed by the individuals supervisor, determined that the cognizant engineer was reluctant to write a condition report because the individual did not feel [he or she] should generate [a condition report] at the time because leaders were not concerned and [the individual] did not want to diminish the relationship [the individual] had with the leaders. In response to this performance deficiency, the licensee discussed with the individual the need to approach leaders differently, such as stating that one has a concern and that it needs to be evaluated in the corrective action program; thus, a condition report will need to be initiated. | ||
[a condition report | |||
] at the time because leaders were not concerned and [the individual | |||
] did not want to diminish the relationship | |||
[the individual | |||
] had with the leaders. | |||
Based on NRC interviews, review of previous documentation, and other inspection activities the inspectors determined that this finding was caused by the individual not feeling free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed. | |||
Based on NRC interviews, review of previous documentation, and other inspection activities the inspectors determined that this finding was caused by the individual not | |||
=====Analysis.===== | =====Analysis.===== | ||
The failure to initiate a condition report to evaluate boric acid on CRDMs is a performance deficiency. This finding is more than minor; and, therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically , continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. Additionally, the inspectors determined that the performance deficiency affected the Initiating Events cornerstone. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A, | The failure to initiate a condition report to evaluate boric acid on CRDMs is a performance deficiency. This finding is more than minor; and, therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. Additionally, the inspectors determined that the performance deficiency affected the Initiating Events cornerstone. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A, Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, and the transient initiator screening questions of Exhibit 1, Initiating Events Screening Questions, and determined that this finding did not cause a reactor trip and loss of mitigation equipment; and therefore, this finding screened to very low safety significance (Green). The inspectors determined that the finding has a SCWE cross-cutting aspect in the area of SCWE policy, in that an individual did not feel free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed. Specifically, an individual was reluctant to write a condition report to document boric acid residue on CRDMs because the individual believed leaders were not concerned, and the individual did not want to diminish the relationship the individual had with the leaders [S.1]. | ||
-Power, | |||
Specifically, | =====Enforcement.===== | ||
Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be accomplished in accordance with documented instructions, procedures, or drawings of a type appropriate to the circumstances. Licensee Procedure, AP 26C-004, Operability Determination and Functionality Assessment, Revision 34B, an Appendix B quality related procedure, provides instructions for initiating condition reports to enter the operability determination process. Procedure AP 26C-004, Step 5.2.1, states in part, that all personnel shall initiate a condition report for any adverse component condition. Contrary to the above, between October 12, 2016, and August 17, 2017, licensee personnel failed to initiate a condition report for adverse component conditions. Specifically, licensee personnel failed to initiate a condition report to document and evaluate that visible amounts of boric acid coated several CRDMs, which called into question their operability. Immediate corrective actions included initiating Condition Report 115120 and documenting a detailed operability assessment to demonstrate operability of the CRDMs. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy: NCV 050000482/2017004-03, Failure to Initiate a Condition Report for Boric Acid Evaluations. | |||
==== | {{a|4OA5}} | ||
==4OA5 Other Activities== | |||
===.1 World Association of Nuclear Operators (WANO)/Institute of Nuclear Power Operation=== | |||
(INPO) Report Review | |||
====a. Inspection Scope==== | ====a. Inspection Scope==== | ||
The inspectors reviewed the final report for the WANO assessment conducted in April and May 2017. The inspectors evaluated this report to ensure that NRC perspectives of Wolf Creek Nuclear Operating Corporation performance were consistent with any issues identified during the assessments. The inspectors also reviewed this report to determine whether any significant safety issues were identified that required further NRC follow | The inspectors reviewed the final report for the WANO assessment conducted in April and May 2017. The inspectors evaluated this report to ensure that NRC perspectives of Wolf Creek Nuclear Operating Corporation performance were consistent with any issues identified during the assessments. The inspectors also reviewed this report to determine whether any significant safety issues were identified that required further NRC follow-up. | ||
-up. | |||
====b. Findings==== | ====b. Findings==== | ||
No findings were identified. | No findings were identified. | ||
===.2 (Closed) Notice of Violation (VIO) 05000482/2015004=== | ===.2 (Closed) Notice of Violation (VIO) 05000482/2015004-01: Inadequate Measures to=== | ||
Assure SGK05A Issues Were Promptly Corrected As documented in NRC Inspection Report 05000482/2015004, the inspectors identified a Green cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees inadequate measures to assure that corrective action was taken to preclude repetition of a significant condition adverse to quality. Specifically, measures to correct train A Class 1E electrical equipment air-conditioning system (SGK05A) issues following two trips of the unit on October 18, 2013, were inadequate. | |||
This resulted in the SGK05A unit tripping twice on May 15, 2015; the train A safety-related batteries, inverters, and alternating and direct current buses being declared inoperable due to the loss of area cooling; two separate Technical Specification 3.0.3 entries; and resulting technical specification required reactor power reductions to 93 and 94.7 percent. This violation had previously been identified by the NRC as non-cited violation 05000482/2013005-04, after which the licensee failed to restore compliance. | |||
The licensee responded to the Notice of Violation in a letter dated March 10, 2016 (Agencywide Document Access and Management System (ADAMS) ML16076A358). | |||
The Inspection Report 2015004 issue was entered into the licensees corrective action program as Condition Report 102322. A root cause evaluation was subsequently completed identifying the direct cause as, Action not taken to correct contamination found within the SGK05A compressor, by replacement of the compressor, in a reasonable period of time. | |||
To address the direct cause the licensee completed installation of a replacement compressor on the SGK05A Class 1E electrical equipment air-conditioning unit prior to plant start-up following Refueling Outage 21 in November 2016. | |||
The | The inspectors walked down the physical SGK05A modification, reviewed corrective action program, work order, and modification documentation, and conducted interviews with responsible personnel. The inspectors noted that the actions to address the direct cause, which installed a new compressor design that has a new type of oil and a new diaphragm type of lube oil pressure switch (these are expected to be less susceptible to moisture intrusion and contaminant buildup), were reasonable corrective actions to address the direct cause of the violation. The inspectors also noted that extent of condition actions to issue design change packages for similar design modifications for the control room air conditioning units (SGK04A and SGK04B) were also reasonable assuming the design changes are appropriately implemented. The station completed replacement of the SGK04B unit with the new style compressor and plans to complete replacement of the SGK05B unit in the spring of 2018 and the SGK04A unit in the spring of 2019. | ||
The | The licensees root cause evaluation also determined the root cause was: | ||
Engineering leadership did not properly allocate personnel to the design change for the SGK05A compressor replacement, did not communicate the design change status effectively, and failed to realize that progress was not adequate to ensure successful completion in [Refueling Outage] 20. As a result, measures to correct SGK05A issues were inadequate and a repetitive failure occurred. | |||
To address the identified root cause, the licensees corrective actions to preclude repetition included obtaining supplemental engineering resources to assist with preparation of the design change packages for the SGK05A and SGK05B replacements. | |||
Although not classified as corrective actions to preclude repetition, the licensee also took interim actions to conduct bi-weekly maintenance readiness meetings, conducted by maintenance, to review any issues with readiness for installation of the replacement compressor. | |||
-weekly maintenance readiness meetings, conducted by maintenance, to review any issues with readiness for installation of the replacement compressor. | |||
The inspectors acknowledge that the identified root cause, if corrected, would be expected to preclude repetition of the significant condition adverse to quality related to repetitive failures of the SGK05A unit. Additional resources were applied by the station and the compressor replacement was completed in | The inspectors acknowledge that the identified root cause, if corrected, would be expected to preclude repetition of the significant condition adverse to quality related to repetitive failures of the SGK05A unit. Additional resources were applied by the station and the compressor replacement was completed in November 2016. Therefore, the inspectors determined that the licensee has restored compliance and has taken appropriate corrective actions to address the cause of this violation. | ||
With respect to extent of cause and an in | With respect to extent of cause and an in-depth analysis of the effectiveness of management control systems, the licensees root cause evaluation bound the extent of cause to the Top 10 Issues list and determined that the extent of cause included design engineering resources being challenged and impacting initiatives to complete design modifications associated with completing maintenance on the SGK05 units. An extent of cause action was created and implemented to, Establish appropriate engineering resources to support [the] ongoing SGK05 project to allow an SGK05 unit to be shut down for maintenance while the plant is on-line. Additionally, the inspectors noted actions taken in response to apparent cause evaluation 100104 were implemented to address managers not ensuring effective action plans were developed, in place, and adhered to for some important equipment issues. | ||
-depth analysis of the effectiveness | |||
-line. | |||
The inspectors reviewed Procedure AI 28A | The inspectors reviewed Procedure AI 28A-100, Condition Report Resolution, Revision 12, which describes how boundaries are established around the population of plant processes, procedures, components, or human performance jobs or tasks with the potential to exhibit the same or similar root causes. Specifically, Procedure AI 28A-100 states, The level of effort of the [extent of cause] should be commensurate with the nature and complexity of the problem. The risk significance conclusion should be utilized to determine the scope and depth of review to reasonably bound the [extent of cause] review. The procedure also describes examples of extent of cause: | ||
-100, | Environment: Determine the affect the cause has on other environments. Equipment: Determine if the cause is related to other SSCs. People: Determine if the cause affects other site personnel. Organization: Determine if the cause is related to other departments or organizations. Process: Determine if there are identical or similar processes or procedures that may be susceptible to same or similar causes. | ||
Environment: Determine the affect the cause has on other environments. Equipment: Determine if the cause is related to other SSCs. People: Determine if the cause affects other site personnel. Organization: Determine if the cause is related to other | |||
The inspectors noted that the subject cited violation involved repetitive failures to correct a significant condition adverse to quality. The inspectors also noted that Inspection Report 2012007 documented a similar failure to take corrective action to preclude repetition of essential service water leaks caused by internal corrosion and water hammer. Considering the repetitive nature of the | The inspectors noted that the subject cited violation involved repetitive failures to correct a significant condition adverse to quality. The inspectors also noted that Inspection Report 2012007 documented a similar failure to take corrective action to preclude repetition of essential service water leaks caused by internal corrosion and water hammer. Considering the repetitive nature of the problems, failure to take corrective action to preclude repetition, and considering the complexity of the SGK05A problem, which involved resource, communication, and oversight safety culture aspects, the inspectors concluded that the root cause evaluation had a weakness in the area of extent of cause level of effort as described by Procedure AI 28-100. Specifically, the extent of cause did not methodically expand its review and document other equipment, people, organizations, or processes that may be impacted by similar leadership, communication, or oversight causal aspects, which were considered by the review. | ||
-100. Specifically, the extent of cause did not methodically expand its review and document other equipment, people, organizations, or processes that may be impacted by similar leadership, communication, or oversight causal aspects, which were considered by the review. Rather, the documented extent of cause narrowly focused on SGK05 (the same equipment), design engineering (the same people and organization), and | |||
Rather, the documented extent of cause narrowly focused on SGK05 (the same equipment), design engineering (the same people and organization), and modification documentation implementation (the same process). | |||
The inspectors shared these observations with the licensee. | The inspectors shared these observations with the licensee. | ||
This review closes NOV 05000482/2015004 | This review closes NOV 05000482/2015004-01, Inadequate Measures to Assure SGK05A Issues Were Promptly Corrected, EA-16-018. | ||
-01, | |||
{{a|4OA6}} | |||
==4OA6 Meetings, Including Exit== | |||
===Exit Meeting Summary=== | ===Exit Meeting Summary=== | ||
On October 11, 2017, regional inspectors discussed the in | On October 11, 2017, regional inspectors discussed the in-office review of the preliminary scenario for the 2017 biennial exercise, submitted August 29, 2017, with Mr. T. East, Superintendent, Emergency Planning, and other members of the licensee staff. The licensee acknowledged the issues presented. | ||
-office review of the preliminary scenario for the 2017 biennial exercise, submitted August 29, 2017, with Mr. T. East, Superintendent, Emergency Planning, and other members of the licensee staff. The licensee acknowledged the issues presented. | |||
On November 17, 2017, regional inspectors presented the results of the on-site inspection of the biennial emergency preparedness exercise conducted November 14, 2017, to Mr. S. Smith, Plant Manager, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed. | On November 17, 2017, regional inspectors presented the results of the on-site inspection of the biennial emergency preparedness exercise conducted November 14, 2017, to Mr. S. Smith, Plant Manager, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed. | ||
On December 13 , 2017, regional inspectors presented the inspection results of the | On December 13, 2017, regional inspectors presented the inspection results of the annual follow up of selected issues in Section 4OA2.3.b to Mr. S. Smith, Plant Manager, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed. | ||
On January 10 , 2018, the resident inspectors presented the integrated inspection results to Mr. C. Reasoner, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed. | On January 10, 2018, the resident inspectors presented the integrated inspection results to Mr. C. Reasoner, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed. | ||
=SUPPLEMENTAL INFORMATION= | =SUPPLEMENTAL INFORMATION= | ||
Line 678: | Line 608: | ||
: [[contact::R. Adams]], Supervisor, Radiation Protection | : [[contact::R. Adams]], Supervisor, Radiation Protection | ||
: [[contact::J. Ashley]], Supervisor, System Engineering | : [[contact::J. Ashley]], Supervisor, System Engineering | ||
: [[contact::R. Audano]], Superintendent, Maintenance | : [[contact::R. Audano]], Superintendent, Maintenance | ||
: [[contact::R. Ayers]], Supervisor, Radiation Protection | : [[contact::R. Ayers]], Supervisor, Radiation Protection | ||
: [[contact::D. Bowers]], Manager, Maintenance | : [[contact::D. Bowers]], Manager, Maintenance | ||
Line 725: | Line 655: | ||
===Opened and Closed=== | ===Opened and Closed=== | ||
: 05000482/2017004 | : 05000482/2017004-01 NCV Failure to Provide Adequate Work Instructions for Preventive Maintenance (Section 1R15) | ||
-01 NCV Failure to Provide Adequate Work Instructions for Preventive Maintenance | : 05000482/2017004-02 NCV Failure to Critique TSC and OSC Performance During a Biennial Exercise (Section 1EP1) | ||
: 05000482/2017004-03 NCV Failure to Initiate a Condition Report for Boric Acid Evaluations (Section 4OA2) | |||
: 05000482/2017004 | |||
-02 NCV Failure to Critique TSC and OSC Performance During a Biennial Exercise (Section 1EP1) | |||
: 05000482/2017004 | |||
-03 NCV Failure to Initiate a Condition Report for Boric Acid Evaluations | |||
===Closed=== | ===Closed=== | ||
: 05000482/2015004-01 VIO Inadequate Measures to Assure SGK05A Issues Were Promptly Corrected (Section 4OA5) | : 05000482/2015004-01 VIO Inadequate Measures to Assure SGK05A Issues Were Promptly Corrected (Section 4OA5) | ||
==LIST OF DOCUMENTS REVIEWED== | ==LIST OF DOCUMENTS REVIEWED== | ||
}} | }} |
Latest revision as of 03:25, 19 December 2019
ML18043A114 | |
Person / Time | |
---|---|
Site: | Wolf Creek ![]() |
Issue date: | 02/12/2018 |
From: | Nick Taylor NRC/RGN-IV/DRP/RPB-B |
To: | Heflin A Wolf Creek |
Taylor N | |
References | |
EA-16-018 IR 2017004 | |
Download: ML18043A114 (56) | |
Text
ruary 12, 2018
SUBJECT:
WOLF CREEK GENERATING STATION - NRC INTEGRATED INSPECTION REPORT 05000482/2017004
Dear Mr. Heflin:
On December 31, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Wolf Creek Generating Station. On January 10, 2018, the NRC inspectors discussed the results of this inspection with Mr. C. Reasoner, Site Vice President, and other members of your staff. The results of this inspection are documented in the enclosed report.
NRC inspectors documented three findings of very low safety significance (Green) in this report.
All of these findings involved violations of NRC requirements. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2.a of the Enforcement Policy.
If you contest the violations or significance of these NCVs, 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 Wolf Creek Generating Station.
If you disagree with a cross-cutting aspect assignment or a finding not associated with a regulatory requirement 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 Wolf Creek 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/
Nicholas H. Taylor, Branch Chief Project Branch B Division of Reactor Projects Docket No. 50-482 License No. NPF-42 Enclosure:
Inspection Report 05000482/2017004 w/ Attachments:
1. Supplemental Information 2. Request for Information
U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket: 05000482 License: NPF-42 Report: 05000482/2017004 Licensee: Wolf Creek Nuclear Operating Corporation Facility: Wolf Creek Generating Station Location: 1550 Oxen Lane NE Burlington, KS 66839 Dates: October 1 through December 31, 2017 Inspectors: D. Dodson, Senior Resident Inspector F. Thomas, Resident Inspector D. Proulx, Senior Project Engineer P. Elkmann, Senior Emergency Preparedness Inspector J. Drake, Senior Reactor Inspector R. Kopriva, Senior Reactor Inspector S. Hedger, Emergency Preparedness Inspector Approved Nicholas H. Taylor By: Branch Chief, Project Branch B Division of Reactor Projects Enclosure
SUMMARY
IR 05000482/2017004; 10/01/2017 - 12/31/2017; Wolf Creek Generating Station; Operability
Determinations and Functionality Assessments, Exercise Evaluation, and Problem Identification and Resolution The inspection activities described in this report were performed between October 1 and December 31, 2017, by the resident inspectors at Wolf Creek Generating Station and inspectors from the NRCs Region IV office. Three findings of very low safety significance (Green) are documented in this report. All of these findings involved violations of NRC requirements. The significance of inspection findings is indicated by their color (i.e., Green, greater than Green,
White, Yellow, or Red), determined using Inspection Manual Chapter 0609, Significance Determination Process, dated April 29, 2015. Their cross-cutting aspects are determined using Inspection Manual Chapter 0310, Aspects within the Cross-Cutting Areas, dated December 4, 2014. Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement Policy. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, dated July 2016.
Cornerstone: Initiating Events
- Green.
The inspectors identified a Green non-cited violation of 10 CFR Part 50,
Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to implement the operability and functionality assessment procedure. Specifically, as of October 12, 2016, the licensee identified boric acid coating on several control rod drive mechanisms, but failed to initiate a condition report to evaluate the effect of the condition on control rod drive mechanism operability. Immediate corrective actions included initiating Condition Report 115120 and documenting a detailed operability assessment to demonstrate operability of the control rod drive mechanisms.
The performance deficiency is more than minor, and therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A,
Significance Determination Process (SDP) for Findings At-Power, and the transient initiator screening questions of Exhibit 1, Initiating Events Screening Questions, and determined that this finding did not cause a reactor trip and loss of mitigation equipment; therefore, this finding screened to very low safety significance (Green). The inspectors determined that the finding has a safety conscious work environment cross-cutting aspect in the area of safety conscious work environement policy, in that an individual did not feel free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed. Specifically, an individual was reluctant to write a condition report to document boric acid residue on control rod drive mechanisms because the individual believed leaders were not concerned, and the individual did not want to diminish the relationship the individual had with the leaders [S.1]. (Section 4OA2)
Cornerstone: Mitigating Systems
- Green.
The inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to provide adequate work instructions for preventive maintenance on safety-related equipment. Specifically, preventive maintenance work instructions to inspect and clean the mechanical interlock on the D containment cooler fan motor control lacked specific guidance for adequate lubrication and did not adequately consider equipment history and operating experience. This resulted in the failure of the 42T starter relay coil in the motor control circuit for the D containment cooler fan, and subsequent unavailability on January 31, 2017. The licensees immediate actions included troubleshooting the motor control circuit, replacing the blown control power fuse for the motor control circuit, performing bench testing, installing a replacement 42T contactor to replace the damaged 42T contractor, and performing post maintenance testing of the D containment cooler fan. The licensee entered this issue into the corrective action program as Condition Reports 110725 and 111360.
The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). The inspectors evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of Inspection Manual Chapter 0609, Appendix A,
Significance Determination Process (SDP) for Findings At-Power, and determined this finding is not a deficiency affecting the design or qualification of a mitigating structure, system, or component that maintained its operability or functionality; the finding does not represent a loss of system and/or function; the finding does not represent an actual loss of function of at least a single train for greater than its Technical Specification-allowed outage time; and the finding does not represent an actual loss of function of one or more non-Technical Specification trains of equipment designated as high safety-significant. Therefore, the inspectors determined the finding was of very low safety significance (Green).
Inspectors did not assign a cross-cutting aspect and determined the performance deficiency is not indicative of current performance because the performance deficiency did not occur within the last three years, and the inspectors did not identify a reasonable opportunity within the last three years for the licensee to have identified the performance deficiency.
(Section 1R15)
Cornerstone: Emergency Preparedness
- Green.
The inspectors identified that the licensee failed to correct a deficiency in emergency response organization performance identified as a result of an exercise in accordance with the requirements of 10 CFR 50.47(b)(14). The failure to identify and correct a weakness occurring during an exercise is a performance deficiency within the licensees ability to foresee and correct. The licensee failed to identify that the Technical Support Center and Operations Support Center did not fully understand plant conditions and did not properly utilize in-plant mitigation and repair teams to investigate the causes of equipment failures. The issue is not an immediate safety concern because the deficient performance occurred during an exercise. This issue was documented in licensee Condition Report 117567, dated November 17, 2017.
The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute and adversely affected the cornerstone objective. The licensees ability to ensure that adequate measures will be taken to protect the health and safety of the public is degraded when weak emergency response organization performance is not corrected. The finding was evaluated using Inspection Manual Chapter 0609, Appendix B, dated September 22, 2015, and was determined to be of very low safety significance because the finding was a failure to comply with NRC requirements, was not a lost or degraded risk significant planning standard, and was not a loss of planning standard function. The performance deficiency was not a loss of planning standard function because the licensee appropriately critiqued some weaknesses. The finding was determined to have a cross-cutting aspect of evaluation in the area of problem identification and resolution because the licensee did not evaluate the deficient understanding of plant conditions and failure to utilize in-plant mitigation and repair teams as a performance weakness [P.2]. (Section 1EP1)
PLANT STATUS
Wolf Creek Generating Station operated at or near full power for the entire inspection period.
REPORT DETAILS
REACTOR SAFETY
Cornerstones: Initiating Events, Mitigating Systems, and Barrier Integrity
1R01 Adverse Weather Protection
.1 Readiness for Seasonal Extreme Weather Conditions
a. Inspection Scope
On December 22, 2017, the inspectors completed an inspection of the stations readiness for seasonal extreme weather conditions. The inspectors reviewed the licensees adverse weather procedures for extreme cold weather and evaluated the licensees implementation of these procedures. The inspectors verified that prior to the onset of cold weather, the licensee had corrected weather-related equipment deficiencies identified during the previous winter season.
The inspectors selected three risk-significant systems that were required to be protected from extreme cold weather:
- Essential service water system
- Refueling water storage tank
- Station blackout diesel generators The inspectors reviewed the licensees procedures and design information to ensure the systems or components would remain functional when challenged by extreme cold weather. The inspectors verified that operator actions described in the licensees procedures were adequate to maintain readiness of these systems. The inspectors walked down portions of these systems to verify the physical condition of insulation, heat tracing, space heaters, and other cold weather protection features.
These activities constituted one sample of readiness for seasonal adverse weather, as defined in Inspection Procedure 71111.01.
b. Findings
No findings were identified.
.2 Readiness to Cope with External Flooding
a. Inspection Scope
On November 22, 2017, the inspectors completed an inspection of the stations readiness to cope with external flooding. After reviewing the licensees flooding analysis, the inspectors chose two plant areas that were susceptible to flooding:
- Control building 1,974 foot elevation
- Auxiliary building 1,974 foot elevation The inspectors reviewed plant design features and licensee procedures for coping with flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether credited operator actions could be successfully accomplished.
These activities constituted one sample of readiness to cope with external flooding, as defined in Inspection Procedure 71111.01.
b. Findings
No findings were identified.
1R04 Equipment Alignment
Partial Walk-Down
a. Inspection Scope
The inspectors performed partial system walk-downs of the following risk-significant systems:
- December 12 and 13, 2017, safety injection train A
- December 18, 2017, essential service water train A The inspectors reviewed the licensees procedures and system design information to determine the correct lineup for the systems. They visually verified that critical portions of the trains were correctly aligned for the existing plant configuration.
These activities constituted two partial system walk-down samples as defined in Inspection Procedure 71111.04.
b. Findings
No findings were identified.
1R05 Fire Protection
Quarterly Inspection
a. Inspection Scope
The inspectors evaluated the licensees fire protection program for operational status and material condition. The inspectors focused their inspection on four plant areas important to safety:
- December 14, 2017, fire area ESW-1, essential service water pump house train A, elevation 2,000 feet
- December 14, 2017, fire area ESW-2, essential service water pump house train B, elevation 2,000 feet
- December 19, 2017, fire area ESWC, essential service water vertical loop chase, elevations 1,974 through 2,087 feet
- December 22, 2017, fire area C-1, essential service water pipe space and tank area, southeast stairway to auxiliary building and duct chase, elevation 1,974 feet For each area, the inspectors evaluated the fire plan against defined hazards and defense-in-depth features in the licensees fire protection program. The inspectors evaluated control of transient combustibles and ignition sources, fire detection and suppression systems, manual firefighting equipment and capability, passive fire protection features, and compensatory measures for degraded conditions.
These activities constituted four quarterly inspection samples, as defined in Inspection Procedure 71111.05
b. Findings
No findings were identified.
1R06 Flood Protection Measures
a. Inspection Scope
On December 22, 2017, the inspectors completed an inspection of the stations ability to mitigate flooding due to internal causes. After reviewing the licensees flooding analysis, the inspectors chose the 2,026 foot elevation of the auxiliary building as an area containing risk-significant structures, systems, and components that were susceptible to flooding.
The inspectors reviewed plant design features and licensee procedures for coping with internal flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether operator actions credited for flood mitigation could be successfully accomplished.
These activities constituted completion of one flood protection measure sample as defined in Inspection Procedure 71111.06.
b. Findings
No findings were identified.
1R11 Licensed Operator Requalification Program and Licensed Operator Performance
.1 Review of Licensed Operator Requalification
a. Inspection Scope
On November 15, 2017, the inspectors observed an evaluated simulator scenario performed by an operating crew. The inspectors assessed the performance of the operators and the evaluators critique of their performance. The inspectors also assessed the modeling and performance of the simulator during the requalification activities.
These activities constituted completion of one quarterly licensed operator requalification program sample, as defined in Inspection Procedure 71111.11.
b. Findings
No findings were identified.
.2 Review of Licensed Operator Performance
a. Inspection Scope
On October 26 and 27, 2017, the inspectors observed the performance of on-shift licensed operators in the plants main control room. At the time of the observations, the plant was in a period of heightened activity and risk due to power ascension activities following main turbine valve testing.
In addition, the inspectors assessed the operators adherence to plant procedures, including the conduct of operations procedure and other operations department policies.
These activities constituted completion of one quarterly licensed operator performance sample, as defined in Inspection Procedure 71111.11.
b. Findings
No findings were identified.
1R12 Maintenance Effectiveness
.1 Routine Maintenance Effectiveness
a. Inspection Scope
The inspectors reviewed two instances of degraded performance or condition of safety-significant structures, systems, and components (SSCs):
- February 11, 2016, train B essential service water vertical loop vacuum breaker valve failed to smoothly stroke full open or closed
- December 15, 2016, unexpected pressurizer master controller response The inspectors reviewed the extent of condition of possible common cause SSC failures and evaluated the adequacy of the licensees corrective actions. The inspectors reviewed the licensees work practices to evaluate whether these may have played a role in the degradation of the SSCs. The inspectors assessed the licensees characterization of the degradation in accordance with 10 CFR 50.65 (the Maintenance Rule), and verified that the licensee was appropriately tracking degraded performance and conditions in accordance with the Maintenance Rule.
These activities constituted completion of two maintenance effectiveness samples, as defined in Inspection Procedure 71111.12.
b. Findings
No findings were identified.
.2 Quality Control
a. Inspection Scope
On December 21, 2017, the inspectors reviewed the licensees quality control activities through a review of parts installed in the 480 and 4160 volt safety-related NG and NB switchgears, respectively, that were purchased as commercial-grade parts but were dedicated prior to installation in a quality-grade application.
These activities constituted completion of one quality control sample, as defined in Inspection Procedure 71111.12.
b. Findings
No findings were identified.
1R13 Maintenance Risk Assessments and Emergent Work Control
a. Inspection Scope
On October 24 and 25, 2017, the inspectors reviewed one risk assessment associated with planned train A control room air conditioning unit maintenance performed by the licensee prior to changes in plant configuration and the risk management actions taken by the licensee in response to elevated risk. The inspectors also reviewed risk assessment updates related to abnormal reactor coolant system unidentified leakage results.
The inspectors verified this risk assessment was performed timely and in accordance with the requirements of 10 CFR 50.65 (the Maintenance Rule) and plant procedures.
The inspectors reviewed the accuracy and completeness of the licensees risk assessment and verified that the licensee implemented appropriate risk management actions based on the result of the assessment.
These activities constituted completion of one maintenance risk assessment and emergent work control inspection sample, as defined in Inspection Procedure 71111.13.
b. Findings
No findings were identified.
1R15 Operability Determinations and Functionality Assessments
a. Inspection Scope
The inspectors reviewed three operability determinations that the licensee performed for degraded or nonconforming SSCs:
- October 13, 2017, operability determination of containment cooler fan A following failure to shift from slow speed to fast speed
- October 19 and 20, 2017, operability determination of reactor trip breaker/solid-state protection system following a train A solid state protection system general warning alarm
- November 1, 2017, operability determination of essential service water piping with degraded wall thickness The inspectors reviewed the timeliness and technical adequacy of the licensees evaluations. Where the licensee determined the degraded SSC to be operable, the inspectors verified that the licensees compensatory measures were appropriate to provide reasonable assurance of operability. The inspectors verified that the licensee had considered the effect of other degraded conditions on the operability of the degraded SSC.
These activities constituted completion of three operability and functionality review samples as defined in Inspection Procedure 71111.15.
b. Findings
Introduction.
The inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to provide adequate work instructions for preventive maintenance on safety-related equipment. Specifically, work instructions to inspect and clean the mechanical interlock on the D containment cooler fan motor control lacked adequate guidance to ensure appropriate lubrication. This resulted in the failure of the 42T starter relay coil in the motor control circuit for the D containment cooler fan, and subsequent unavailability on January 31, 2017.
Description.
On January 31, 2017, the licensee made an unplanned entry into action statements associated with Technical Specification 3.6.6, Containment Spray and Cooling Systems, Condition C, and Technical Requirements Manual (TRM) 3.8.11, Containment Penetration Conductor Overcurrent Protective Devices, Condition A, after the D containment cooler fan lost indication and tripped during a transfer from slow to fast speed. An acrid smell was noted in the location of the associated motor control circuit cubicle. Initial troubleshooting efforts using a thermography camera revealed a hot spot in the motor control circuitry and a blown control circuit fuse.
The containment cooler fan motor starters have three contactors, one for slow speed (42S), one for fast speed (42F), and a transfer contactor (42T). The 42T contactor shorts out the slow speed windings of the motor and allows the transfer to fast speed.
When personnel select the fast mode on the fans, the fans are expected to start in slow speed and shift to fast speed after approximately 60 seconds.
When the failure occurred on January 31, 2017, the station was performing the pre-test alignment steps for STS IC-616B, Slave Relay Test K616 Train B Safety Injection.
While shifting the fan from slow to fast speed the unit failed to shift as expected from slow to fast speed after 60 seconds had elapsed. The red lamp for slow speed de-energized, and the red lamp for fast did not illuminate. The D containment cooler fan unit then tripped and operators took the hand-switch to pull-to-lock. Subsequent investigation revealed that the 42T starter coil, part of the transfer circuit, had overheated and deformed, causing the control power fuse to blow.
The inspectors reviewed the licensees basic cause evaluation for this event. The probable cause identified in the licensees basic cause evaluation (Revision 1) was, binding of the mechanical interlock, which resulted in the overheating of the coil for the 42T contactor. The inspectors noted that the applicable lubrication preventive maintenance activity instructions in Core Work Instructions ELE-0007, NG001T-NG004T Motor Control Center Inspection, Cleaning and Testing, Revision 0, were interpretive. They instructed maintenance personnel to perform the following step:
IF necessary THEN lubricate the pivot points with a dry lubricant. Hence, lubrication was not necessarily ensured.
Following inspector inquiry regarding inconsistencies between the causes and corrective actions identified in Revision 0 of the basic cause evaluation and the maintenance rule functional failure determination, which determined that the failure was preventable, the licensee completed revisions to the basic cause evaluation. Revision 1 of the basic cause evaluation considered additional information. Specifically, the licensee had experienced three very similar failures between 1985 and 1990, as documented in Work Orders 90034-85, 91657-85, and 01314-89. Additional corrective actions were also added in Revision 1. Specifically, a new action was created to revise preventive maintenance work instructions. Core Work Instructions ELE-0007, which guide the applicable lubrication preventive maintenance activities, were revised to make lubricating in Step 8.12.5.3 mandatory and to lubricate after Step 8.12.2 in the Core Work Instructions. Areas to lubricate include the springs and the phenolic sliders at either end of the vertical moving shafts.
The inspectors noted that Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 2A, provides direction for implementing the preventive maintenance program. Section 6.2, Establishing [Preventive Maintenance] Activities, states, Develop [preventive maintenance] activities by considering the followingEquipment HistoryOperating Experience (OE) (Industry and Station).
Section 6.2.2, states, [Preventive maintenance] frequencies are established and adjusted in accordance withthe following considerationsThe age of the installed equipment.
The preventive maintenance activity instructions were originally incorporated into Revision 5 of MGE EOOP-07, Motor Control Centers, and Control Panels, Cleaning, Inspecting, and Testing, which was issued in 1990. These instructions included directions to include inspecting and lubricating the mechanical interlock during containment cooler preventive maintenance activities. The instructions in MGE EOOP-07 were later moved to Core Work Instructions ELE-007 in April 2009. This procedure did not receive any revisions prior to the failure in January 2017.
The licensees immediate actions included troubleshooting the motor control circuit, replacing the blown control power fuse for motor control circuit, bench testing and installing a replacement 42T contactor to replace the damaged 42T contractor, and performing post maintenance testing of the D containment cooler fan. The D containment cooler fan was returned to service at 12:44 p.m. on February 2, 2017. The issue was entered into the licensees corrective action program as Condition Reports 110725 and 111360.
Analysis.
The inspectors determined that the licensees failure to meet the requirements of Technical Specification 5.4.1.a and provide adequate work instructions for preventive maintenance on safety-related equipment was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality 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 (i.e., core damage). Specifically, work instructions for preventive maintenance on the D containment cooler fan motor control center lacked adequate guidance to ensure lubrication of the mechanical interlock in the motor control circuit, which resulted in the failure of the D containment cooler fan 42T starter relay coil in the motor control circuit on January 31, 2017, and unavailability of the D containment cooler fan.
The inspectors evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of Inspection Manual Chapter 0609, Appendix A, Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, and determined this finding is not a deficiency affecting the design or qualification of a mitigating SSC that maintained its operability or functionality; the finding does not represent a loss of system and/or function; the finding does not represent an actual loss of function of at least a single train for greater than its Technical Specification-allowed outage time; and the finding does not represent an actual loss of function of one or more non-Technical Specification trains of equipment designated as high safety-significant.
Therefore, the inspectors determined the finding was of very low safety significance (Green).
Inspectors did not assign a cross-cutting aspect and determined the performance deficiency is not indicative of current performance. The inspectors determined that the performance deficiency did not occur within the last three years, and the inspectors did not identify a reasonable opportunity within the last three years for the licensee to have identified the performance deficiency.
Enforcement.
Technical Specification 5.4.1.a, requires, in part, that procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. Section 9.a of Appendix A to Regulatory Guide 1.33, Revision 2, requires, in part, that maintenance that can affect the performance of safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. The licensee established Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 2A, which provides direction for implementing the preventive maintenance program to meet the Regulatory Guide 1.33 requirement. Section 6.2 of Procedure AP 16B-003 requires, in part, that preventive maintenance activities be developed by considering equipment history and operating experience. Contrary to the above, until November 7, 2017, preventive maintenance activities were not developed by adequately considering equipment history and operating experience. Specifically, the D containment cooler fan motor control preventive maintenance instructions in Core Work Instruction ELE-007 were not developed for the D containment cooler fan motor control center by adequately considering station operating experience documented in Work Orders 90034-85, 91657-85, and 01314-89. The licensee took the immediate corrective action to test and install a replacement 42T contactor in D containment cooler fan motor control circuit, and conducted post maintenance testing after replacement.
The licensee also inspected, cleaned, and lubricated the mechanical linkage on the D containment cooler fan motor control circuit. The preventive maintenance activity instructions were also later revised. The licensee entered this issue into the corrective action program as Condition Reports 110725 and 111360. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy:
NCV 05000482/2017004-01, Failure to Provide Adequate Work Instructions for Preventive Maintenance.
1R18 Plant Modifications
.1 Temporary Modifications
a. Inspection Scope
On December 20 and 21, 2017, the inspectors reviewed a temporary modification to temporarily secure cavity cooing fans to support nuclear instrument 31 degraded cooling follow-up activities.
The inspectors verified that the licensee would implement this temporary modification in accordance with technically adequate design documents. The inspectors verified that this modification did not adversely impact the operability or availability of affected SSCs.
The inspectors reviewed design documentation and plant procedures affected by the modification to verify the licensee maintained configuration control.
These activities constituted completion of one sample of temporary modifications, as defined in Inspection Procedure 71111.18.
b. Findings
No findings were identified.
.2 Permanent Modifications
a. Inspection Scope
On November 27, 2017, the inspectors reviewed a permanent plant modification to the auxiliary feedwater system to address recirculation line tornado missile vulnerabilities.
The inspectors reviewed the design and implementation of the modifications. The inspectors verified that work activities involved in implementing the modifications did not adversely impact operator actions that may be required in response to an emergency or other unplanned event. The inspectors verified that post-modification testing was adequate to establish the operability of the SSCs as modified.
These activities constituted completion of one sample of permanent modifications, as defined in Inspection Procedure 71111.18.
b. Findings
No findings were identified.
1R19 Post-Maintenance Testing
a. Inspection Scope
The inspectors reviewed two post-maintenance testing activities that affected risk-significant SSCs:
- October 25, 2017, train A control room air-conditioning system
- December 19, 2017, essential service water forebay level transmitter The inspectors reviewed licensing- and design-basis documents for the SSCs and the maintenance and post-maintenance test procedures. The inspectors observed the performance of the post-maintenance tests to verify that the licensee performed the tests in accordance with approved procedures, satisfied the established acceptance criteria, and restored the operability of the affected SSCs.
These activities constituted completion of two post-maintenance testing inspection samples, as defined in Inspection Procedure 71111.19.
b. Findings
No findings were identified.
1R22 Surveillance Testing
a. Inspection Scope
The inspectors observed two risk-significant surveillance tests and reviewed test results to verify that these tests adequately demonstrated that the SSCs were capable of performing their safety functions:
Reactor coolant system leak detection tests:
- October 24, 2017, STS BB-006, RCS [Reactor Coolant System] Water Inventory Balance Using the NPIS [Nuclear Plant Information System] Computer Other surveillance tests:
- November 1, 2017, STS EF-100B, ESW [Essential Service Water] System Inservice Pump B and ESW [Essential Service Water] B Check Valve Test The inspectors verified that these tests met technical specification requirements, that the licensee performed the tests in accordance with their procedures, and that the results of the test satisfied appropriate acceptance criteria. The inspectors verified that the licensee restored the operability of the affected SSCs following testing.
These activities constituted completion of two surveillance testing inspection samples, as defined in Inspection Procedure 71111.22.
b. Findings
No findings were identified.
Cornerstone: Emergency Preparedness
1EP1 Exercise Evaluation
a. Inspection Scope
The inspectors observed the November 14, 2017, biennial emergency preparedness exercise to verify the exercise acceptably tested the major elements of the emergency plan and provided opportunities for the emergency response organization to demonstrate key skills and functions. The licensee demonstrated its ability to implement its emergency plan through a scenario that simulated:
- Loss of the condensate header leading to a red path on core cooling
- Fault on transformer XNB01
- Failure of diesel generator NE01
- Failure of the non-safety auxiliary feedwater pump
- Radiological release to the environment from ruptured and faulted steam generator A; the release was partially monitored and filtered The scenario rapidly escalated with a site area emergency as the initial emergency classification. During the exercise the inspectors observed activities in the control room simulator and the following dedicated emergency response facilities:
- Operations Support Center
- Emergency Operations Facility The inspectors focused their evaluation of the licensees performance on the risk-significant activities of event classification, offsite notification, recognition of offsite dose consequences, and development of protective action recommendations.
The inspectors also assessed recognition of, and response to, abnormal and emergency plant conditions, the transfer of decision-making authority and emergency function responsibilities between facilities, on-site and offsite communications, protection of emergency workers, emergency repair evaluation and capability, and the overall implementation of the emergency plan to protect public health and safety and the environment. The inspectors reviewed the current revision of the facility emergency plan, emergency plan implementing procedures associated with operation of the licensees emergency response facilities, procedures for the performance of associated emergency functions, and other documents as listed in the attachment to this report.
The inspectors attended the post-exercise critiques in each emergency response facility to evaluate the initial licensee self-assessment of exercise performance. The inspectors also attended a formal presentation of critique items to plant management conducted November 17, 2017.
The inspectors reviewed the scenarios of previous biennial exercises and licensee drills conducted between January 2016 and October 2017 to determine whether the November 14, 2017, exercise was independent and avoided participant preconditioning, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(g). The inspectors also compared observed exercise performance with corrective action program entries and after-action reports for drills and exercises conducted between January 2016 and October 2017 to determine whether identified weaknesses had been corrected in accordance with the requirements of 10 CFR 50.47(b)(14), and 10 CFR Part 50, Appendix E, IV.F.
The inspectors discussed the scenario with staff from Federal Emergency Management Agency Region VII to determine whether the scenario supported the Federal Emergency Management Agency evaluation objectives.
These activities constituted one exercise evaluation sample as defined in Inspection Procedure 71114.01.
b. Findings
Introduction.
The inspectors identified a Green non-cited violation of 10 CFR 50.47(b)(14) for the licensees failure to identify and correct a weakness in emergency response organization performance during a biennial emergency preparedness exercise conducted on November 14, 2017.
Description.
The inspectors observed an emergency preparedness exercise conducted November 14, 2017, and observed the licensees formal exercise critique conducted November 17, 2017. The inspectors determined that the licensee failed to identify emergency response organization weaknesses in Technical Support Center and Operations Support Center performance and as a result did not ensure the weaknesses would be corrected.
The exercise simulated, in part, faults on an electrical transformer, electrical busses, a diesel generator failure and steam released into the turbine building. The inspectors observed that only one repair team was dispatched into the plant, while three other teams were briefed, but not dispatched. The licensee team that went into the plant was sent to evaluate equipment that was out of service at the start of the exercise, not to repair emergent equipment problems. Non-licensed operators were sent to equipment that failed during the exercise, but were not capable of diagnosing the causes of equipment problems. The inspectors observed that no diagnostic activities were performed at bus NB01 or bus PB05, the diesel generators or blackout diesel generators, or at the feed pumps. The emergency response organization also did not determine how steam was getting into the turbine building.
Because they did not diagnose the fault in bus PB05, operators caused two blackout diesels to fail and would have failed the third (and last) diesel. Specifically, operators did not evaluate the cause of the first blackout diesel failure before putting the second diesel into service. When the second diesel failed, they were working toward putting the third diesel into service without understanding either failure. There was a lack of recognition that bus PB05 could have been faulted, thereby causing the blackout diesel generator failures.
The inspectors concluded that the emergency response organization did not understand plant conditions and did not properly utilize in-plant teams to investigate and correct the causes of equipment failures. The inspectors determined that the inadequate use of in-plant repair teams and lack of understanding of plant conditions could have prevented the licensee from ensuring that adequate measures could be taken to protect the health and safety of the public because it caused the emergency response organization to degrade the plant electrical system and affected their ability to terminate the radioactive release.
The inspectors observed the licensees formal critique of exercise performance conducted November 17, 2017, and noted that the licensee did not discuss the lack of understanding of plant conditions exhibited in the control room and Technical Support Center, the inadequate use of in-plant repair and mitigation teams, or the degrading of the plant electrical system by sequentially failing station blackout diesel generators. The licensee did identify a significant delay in dispatching repair team #4 into the plant as a weakness requiring correction.
The inspectors evaluated the discussion between the exercise evaluators and site management and concluded that the licensee did not recognize a broader failure to effectively use repair teams to diagnose plant equipment problems. This failure was a significant contributor to the lack of understanding of plant conditions and the degrading of the plant electrical system. The inspectors concluded that the licensee failed to critique weaknesses in emergency response organization performance based on the results of the licensees formal critique.
Analysis.
The licensees failure to correct a weakness that occurred during an exercise is a performance deficiency within the licensees ability to foresee and correct. A weakness is defined in Inspection Manual Chapter 0609, Appendix B, Emergency Preparedness Significance Determination Process, dated September 22, 2015, as emergency response organization performance that would have prevented the effective implementation of the licensees emergency plan had the circumstances occurred. The emergency response organizations lack of understanding of plant conditions and failure to utilize in-plant teams to investigate and correct the causes of equipment failures was a weakness requiring correction. The finding is more than minor because it was associated with the emergency response organization performance cornerstone attribute (training, exercises) and adversely affected the cornerstone objective. The licensees ability to ensure that adequate measures will be taken to protect the health and safety of the public is degraded when weak emergency response organization performance is not corrected. The finding was evaluated using Attachment 2, Failure to Comply Logic Flowchart, to Inspection Manual Chapter 0609, Appendix B, and was determined to be of very low safety significance (Green) because the finding was a failure to comply with NRC requirements, was not a lost or degraded risk-significant planning standard, and was not a loss of planning standard function. The finding was not a loss of planning standard function because the licensee appropriately critiqued some weaknesses associated with risk-significant activities and the 10 CFR 50.47(b) planning standards.
The finding was determined to have a cross-cutting aspect of evaluation in the area of problem identification and resolution because the licensee did not evaluate the deficient understanding of plant conditions and failure to utilize in-plant mitigation and repair teams as a performance weakness. Licensee evaluators were focused on the established exercise objectives, which did not include understanding the causes of equipment failures or implementing an effective repair strategy [P.2].
Enforcement.
Title 10 CFR 50.54(q)(2), requires, in part, that a power reactor licensee follow and maintain the effectiveness of an emergency plan which meets the requirements of Appendix E to 10 CFR Part 50 and the standards of 10 CFR 50.47(b).
Title 10 CFR 50.47(b)(14) requires, in part, that deficiencies identified as a result of exercises or drills are (will be) corrected. Contrary to the above, on November 17, 2017, the licensee failed to correct a deficiency identified as a result of exercises or drills.
Specifically, the licensee failed to identify an emergency response organization performance deficiency (weakness) occurring during the November 14, 2017, biennial exercise and did not ensure correction of the weakness. There was no actual or potential safety significance because the weak performance occurred during an exercise. This issue was documented in licensee Condition Report 117567, dated November 17, 2017. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy: NCV 05000482/2017004-02, Failure to Critique TSC and OSC Performance during a Biennial Exercise.
1EP8 Exercise Evaluation - Scenario Review
a. Inspection Scope
The licensee submitted the preliminary exercise scenario for the November 14, 2017, biennial exercise to the NRC on August 29, 2017, in accordance with the requirements of 10 CFR Part 50, Appendix E, IV.F(2)(b). The inspectors performed an in-office review of the proposed scenario to determine whether it would acceptably test the major elements of the licensees emergency plan, and provide opportunities for the emergency response organization to demonstrate key skills and functions. The inspectors discussed the preliminary scenario with staff at FEMA, Region VII, to determine whether the proposed scenario supported the FEMA evaluation objectives.
b. Findings
No findings were identified.
OTHER ACTIVITIES
Cornerstones: Initiating Events, Mitigating Systems, Barrier Integrity, Emergency Preparedness, Public Radiation Safety, Occupational Radiation Safety, and Security
4OA1 Performance Indicator Verification
.1 Safety System Functional Failures (MS05)
a. Inspection Scope
For the period of October 1, 2016, through September 30, 2017, the inspectors reviewed licensee event reports (LERs), maintenance rule evaluations, and other records that could indicate whether safety system functional failures had occurred. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, and NUREG-1022, Event Reporting Guidelines: 10 CFR 50.72 and 50.73, Revision 3, to determine the accuracy of the data reported.
These activities constituted verification of the safety system functional failures performance indicator, as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
.2 Mitigating Systems Performance Index: Heat Removal Systems (MS08)
a. Inspection Scope
The inspectors reviewed the licensees mitigating system performance index data for the period of October 1, 2016, through September 30, 2017, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.
These activities constituted verification of the mitigating system performance index for heat removal systems, as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
.3 Mitigating Systems Performance Index: Residual Heat Removal Systems (MS09)
a. Inspection Scope
The inspectors reviewed the licensees mitigating system performance index data for the period of October 1, 2016, through September 30, 2017, to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.
These activities constituted verification of the mitigating system performance index for residual heat removal systems, as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
.4 Drill/Exercise Performance (EP01)
a. Inspection Scope
The inspectors reviewed the licensees evaluated exercises and selected drill and training evolutions that occurred between July 2016 and September 2017 to verify the accuracy of the licensees data for classification, notification, and protective action recommendation opportunities. The inspectors reviewed a sample of the licensees completed classifications, notifications, and protective action recommendations to verify their timeliness and accuracy. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report.
These activities constituted verification of the drill/exercise performance indicator as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
.5 Emergency Response Organization Drill Participation (EP02)
a. Inspection Scope
The inspectors reviewed the licensees records for participation in drill and training evolutions between July 2016 and September 2017 to verify the accuracy of the licensees data for drill participation opportunities. The inspectors verified that all members of the licensees emergency response organization (ERO) in the identified key positions had been counted in the reported performance indicator data. The inspectors reviewed the licensees basis for reporting the percentage of ERO members who participated in a drill. The inspectors reviewed drill attendance records and verified a sample of those reported as participating. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report.
These activities constituted verification of the emergency response organization drill participation performance indicator as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
.6 Alert and Notification System Reliability (EP03)
a. Inspection Scope
The inspectors reviewed the licensees records of alert and notification system tests conducted between July 2016 and September 2017 to verify the accuracy of the licensees data for siren system testing opportunities. The inspectors reviewed procedural guidance on assessing alert and notification system opportunities and the results of periodic alert and notification system operability tests. The inspectors used Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data. The specific documents reviewed are described in the attachment to this report.
These activities constituted verification of the alert and notification system reliability performance indicator as defined in Inspection Procedure 71151.
b. Findings
No findings were identified.
4OA2 Problem Identification and Resolution
.1 Routine Review
a. Inspection Scope
Throughout the inspection period, the inspectors performed daily reviews of items entered into the licensees corrective action program and periodically attended the licensees condition report screening meetings. The inspectors verified that licensee personnel were identifying problems at an appropriate threshold and entering these problems into the corrective action program for resolution. The inspectors verified that the licensee developed and implemented corrective actions commensurate with the significance of the problems identified. The inspectors also reviewed the licensees problem identification and resolution activities during the performance of the other inspection activities documented in this report.
b. Findings
No findings were identified.
.2 Semiannual Trend Review
a. Inspection Scope
The inspectors reviewed the licensees corrective action program, performance indicators, quality assessments, issues that challenge operators in performing duties, and other documentation to identify trends that might indicate the existence of a more significant safety issue. The inspectors verified that the licensee was taking corrective actions to address identified and possible adverse trends:
- Licensee response to a noted increase in the number of inadequate preventive maintenance issues
- Increased number of non-plant item control issues
- Recent Technical Specification Bases issues and licensee use of design basis information These activities constituted completion of one semiannual trend review sample, as defined in Inspection Procedure 71152.
b. Observations and Assessments The inspectors evaluated a sample of recent issues and events that occurred to determine whether issues were appropriately considered as emerging or adverse trends.
The inspectors verified that these issues were addressed within the scope of the corrective action program.
The inspectors review of the trends and issues identified above produced the following observations and assessments:
- Inspectors reviewed the licensees response to an inspector identified possible emerging trend associated with recent preventive maintenance related issues.
This possible emerging trend was discussed in Section 4OA2.2, Semiannual Trend Review, of NRC inspection report 05000482/2017002 (ML17223A285).
The licensee documented the inspectors concerns with the possible emerging trend in Condition Report 114437. The licensee completed a basic cause evaluation to evaluate the concerns and the possible adverse trend. The evaluation concluded that three referenced issues related to preventive maintenance program effectiveness indicate specific weaknesses in the implementation of the preventive maintenance activities. The evaluation described the probable cause of the examples of weakness in the preventive maintenance program as, a lack of a bias towards conservative decision making in the development of preventive maintenance program instructions. The licensee planned to conduct training for engineers and leaders to reduce the reliance on subjective preventive maintenance acceptance criteria while considering the functional importance of the impacted equipment.
Although planned actions had not all been completed, the inspectors noted that the corrective actions to address the lack of a bias towards conservative decision making in the development of preventive maintenance program instructions were narrowly focused and did not appear to reach the entire subset of station personnel that may be involved in the development of preventive maintenance program instructions. Specifically, Section 5.0, Responsibilities, of Procedure AP 16B-003, Planning and Scheduling Preventive Maintenance, Revision 8A, notes that the Manager Maintenance; superintendents of mechanical, electrical, and instrumentation and control maintenance; maintenance planners; and station personnel external to the maintenance department may be involved in the documentation, oversight, or planning of preventive maintenance activities. The balance of station personnel that have responsibilities related to the development of preventive maintenance program instructions would not have been expected to receive the same level of training that was planned for engineers and leaders.
As a result, it is not clear to the inspectors that the licensees corrective actions to address the identified cause, a lack of a bias towards conservative decision making in the development of preventive maintenance program instructions, would have eliminated the vulnerability across the station.
The inspectors shared these concerns with the licensee.
- Inspectors reviewed the licensees response to a quality assurance finding identified in quality assurance assessment QA-2017-0365. The licensees basic cause evaluation noted over 30 condition reports related to control of non-plant items defined by Procedure AP 21B-003, Control of Non-Plant Items Inside or Near Plant Systems, Structures, and Components, Revisions 11A and 12, as ancillary items that are not a part of plant SSCs. Included among these condition reports were Condition Report 115174, which documented an NRC-identified concern associated with a storage cabinet that was located near safety-related essential service water piping and fire protection piping in the auxiliary building.
The cabinet did not meet the definition of stable plant equipment, as defined in Procedure AP 21B-003, Revision 11A. On August 21, 2017, Condition Report 115198 documented an NRC-identified issue associated with a storage cart with unchocked wheels near auxiliary feedwater piping in the auxiliary building. The cart was not immobilized in accordance with Procedure AP 21B-003, Revision 11A. A few days later on August 25, 2017, Condition Report 115320 documented unstable items like a coat rack, platform ladder, and equipment storage cabinet that were located in the control room near plant SSCs, which was not in compliance with Procedure AP 21B-003, Revision 11A.
The licensees basic cause evaluation also documented a history of challenges maintaining control of temporary equipment. Specifically, the evaluation noted a root cause evaluation in 2001 that stated that procedure clarity could be improved, but issues were resulting from, A failure to implement and enforce the process requirements. Similar issues in 2004, 2006, and 2015 were also noted.
The evaluation concluded, Based on the repetitive programmatic compliance nature of the issues, there is a common weakness in the implementation enforcement of management expectations. These issues have remained of low consequence but do not meet the criteria within AP21B-003. The probable cause of non-plant items not being controlled in accordance with the requirements of AP 21B-003 was determined to be, Non-plant items requirements are not being met due to insufficient commitment with the procedure requirements.
The inspectors noted that remedial actions to address the cause included revisions to Procedure AP 21B-003, which removed redundancy throughout the procedure and provided clarification of criteria for stable, non-stable, and non-plant items, and communication to station personnel on the non-plant process. The inspectors reviewed the communication and revisions to Procedure AP 21B-003, and the inspectors determined that the corrective actions did not address the identified cause. Specifically, neither the communications, nor Procedure AP 21B-003 revisions, nor any other actions appeared to address insufficient commitment to procedure requirements.
The inspectors shared these concerns with the licensee.
- The inspectors considered recent Technical Specification Bases issues that were associated with licensee use of design basis information. Specifically, NRC inspection report 05000482/2017003 (ML17311B223) documented an NRC-identified Green non-cited violation associated with the licensees failure to ensure the auxiliary feedwater system design basis was adequately represented in the Technical Specification Bases, which resulted in the Technical Specification Bases and other station procedures allowing for one train of essential service water supply to the turbine-driven auxiliary feedwater pump to be removed from service without entry into applicable Technical Specification action statements.
NRC Inspection Report 05000482/2017002 (ML17223A285) documented an NRC-identified Green non-cited violation associated with the licensees failure to declare the essential service water emergency make-up to component cooing water train A valve inoperable when it was out of service, which resulted in train A component cooling water being out of service for longer than its Technical Specification allowed outage time. In both cases the Technical Specification Bases, which was inaccurate or incomplete, respectively, was referenced and utilized for work planning and implementation, while other design basis information like the Updated Safety Analysis Report was not being similarly referenced.
The inspectors considered whether an adverse trend existed related to the Technical Specification Bases or how design basis information was being used and referenced. The inspectors did not determine that these two data points alone were sufficient to identify a possible emerging adverse trend. However, the inspectors shared their observations with the licensee related to the extent of condition and current performance aspects of these issues.
c. Findings
No findings were identified.
.3 Annual Follow-up of Selected Issues
a. Inspection Scope
The inspectors selected one issue for an in-depth follow-up. On August 17, 2017, the licensee initiated Condition Report 115120 to document that boric acid residue had remained on several control rod drive mechanisms (CRDMs) during Refueling Outage 21, but the condition had not been evaluated for operability or functionality.
The inspectors assessed the licensees problem identification threshold, cause analyses, extent of condition reviews, and compensatory actions. The inspectors verified that the licensee appropriately prioritized the planned corrective actions and that these actions were adequate to correct the condition.
These activities constituted completion of one annual follow-up sample as defined in Inspection Procedure 71152.
b. Findings
Introduction.
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to implement the operability determination and functionality assessment procedure.
Specifically, as of October 12, 2016, the licensee identified boric acid coating on several CRDMs, but failed to initiate a condition report to evaluate the effect of the condition on CRDM operability.
Description.
On September 2, 2016, reactor head penetration number 77 experienced a leak through a canopy seal weld of approximately 1.4 gpm, which led to a unit shut down. This leak resulted in spraying reactor coolant on the head, its penetrations, and other nearby equipment. Included in this equipment were several CRDMs. The licensee photographed and documented the condition in the boric acid corrosion control program in accordance with Procedure AI 16F-001, Boric Acid Leakage Evaluation, Revision 8, on October 12, 2017. In this evaluation the licensee documented, The number of CRDMs removed for cleaning was limited due to the difficulty of removal. For this reason residue was not cleaned from multiple CRDMs. The primary concern is limited cooling capability of these components with increased potential of failure; a situation that could lead to a dropped rod. Despite this statement in the boric acid leakage evaluation, no further evaluation was documented to accept the condition.
Licensee procedure, AP 26C-004, Operability Determination and Functionality Assessment, Revision 34B, a quality related procedure, provides instructions for initiating condition reports to enter the operability determination process. Procedure AP 26C-004, Step 5.2.1, states in part, that all personnel shall initiate a condition report for any adverse SSC condition. Because the licensee did not initiate a condition report for the boric acid residue, the licensee did not implement Procedure AP 26C-004, and no operability evaluation was performed.
On August 22, 2017, following the inspectors requesting information concerning the condition of the CRDMs, the licensee initiated Condition Report 115120 to document that an evaluation for the CRDMs in which boric acid residue remained was required.
The licensee produced a seven-page white paper to evaluate the heat transfer capabilities of CRDMs with 0.25 inches of dry boric acid coating on the housing, to support the operability evaluation of the CRDMs. The licensee determined that although the internal CRDM temperatures could increase up to 8 °F, this temperature increase would have a negligible effect on the CRDM service life and would not lead to a rod drop accident.
The licensees Performance Assessment Worksheet associated with Condition Report 115120, which was completed by the individuals supervisor, determined that the cognizant engineer was reluctant to write a condition report because the individual did not feel [he or she] should generate [a condition report] at the time because leaders were not concerned and [the individual] did not want to diminish the relationship [the individual] had with the leaders. In response to this performance deficiency, the licensee discussed with the individual the need to approach leaders differently, such as stating that one has a concern and that it needs to be evaluated in the corrective action program; thus, a condition report will need to be initiated.
Based on NRC interviews, review of previous documentation, and other inspection activities the inspectors determined that this finding was caused by the individual not feeling free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed.
Analysis.
The failure to initiate a condition report to evaluate boric acid on CRDMs is a performance deficiency. This finding is more than minor; and, therefore a finding, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, continued failure to write condition reports and evaluate boric acid contamination could have a worse outcome under different circumstances. Additionally, the inspectors determined that the performance deficiency affected the Initiating Events cornerstone. The inspectors evaluated the finding using Inspection Manual Chapter 0609, Appendix A, Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012, and the transient initiator screening questions of Exhibit 1, Initiating Events Screening Questions, and determined that this finding did not cause a reactor trip and loss of mitigation equipment; and therefore, this finding screened to very low safety significance (Green). The inspectors determined that the finding has a SCWE cross-cutting aspect in the area of SCWE policy, in that an individual did not feel free to raise nuclear safety concerns without fear of retribution, with confidence that his/her concerns will be addressed. Specifically, an individual was reluctant to write a condition report to document boric acid residue on CRDMs because the individual believed leaders were not concerned, and the individual did not want to diminish the relationship the individual had with the leaders [S.1].
Enforcement.
Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be accomplished in accordance with documented instructions, procedures, or drawings of a type appropriate to the circumstances. Licensee Procedure, AP 26C-004, Operability Determination and Functionality Assessment, Revision 34B, an Appendix B quality related procedure, provides instructions for initiating condition reports to enter the operability determination process. Procedure AP 26C-004, Step 5.2.1, states in part, that all personnel shall initiate a condition report for any adverse component condition. Contrary to the above, between October 12, 2016, and August 17, 2017, licensee personnel failed to initiate a condition report for adverse component conditions. Specifically, licensee personnel failed to initiate a condition report to document and evaluate that visible amounts of boric acid coated several CRDMs, which called into question their operability. Immediate corrective actions included initiating Condition Report 115120 and documenting a detailed operability assessment to demonstrate operability of the CRDMs. This violation is being treated as a non-cited violation, consistent with Section 2.3.2.a of the NRC Enforcement Policy: NCV 050000482/2017004-03, Failure to Initiate a Condition Report for Boric Acid Evaluations.
4OA5 Other Activities
.1 World Association of Nuclear Operators (WANO)/Institute of Nuclear Power Operation
(INPO) Report Review
a. Inspection Scope
The inspectors reviewed the final report for the WANO assessment conducted in April and May 2017. The inspectors evaluated this report to ensure that NRC perspectives of Wolf Creek Nuclear Operating Corporation performance were consistent with any issues identified during the assessments. The inspectors also reviewed this report to determine whether any significant safety issues were identified that required further NRC follow-up.
b. Findings
No findings were identified.
.2 (Closed) Notice of Violation (VIO) 05000482/2015004-01: Inadequate Measures to
Assure SGK05A Issues Were Promptly Corrected As documented in NRC Inspection Report 05000482/2015004, the inspectors identified a Green cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees inadequate measures to assure that corrective action was taken to preclude repetition of a significant condition adverse to quality. Specifically, measures to correct train A Class 1E electrical equipment air-conditioning system (SGK05A) issues following two trips of the unit on October 18, 2013, were inadequate.
This resulted in the SGK05A unit tripping twice on May 15, 2015; the train A safety-related batteries, inverters, and alternating and direct current buses being declared inoperable due to the loss of area cooling; two separate Technical Specification 3.0.3 entries; and resulting technical specification required reactor power reductions to 93 and 94.7 percent. This violation had previously been identified by the NRC as non-cited violation 05000482/2013005-04, after which the licensee failed to restore compliance.
The licensee responded to the Notice of Violation in a letter dated March 10, 2016 (Agencywide Document Access and Management System (ADAMS) ML16076A358).
The Inspection Report 2015004 issue was entered into the licensees corrective action program as Condition Report 102322. A root cause evaluation was subsequently completed identifying the direct cause as, Action not taken to correct contamination found within the SGK05A compressor, by replacement of the compressor, in a reasonable period of time.
To address the direct cause the licensee completed installation of a replacement compressor on the SGK05A Class 1E electrical equipment air-conditioning unit prior to plant start-up following Refueling Outage 21 in November 2016.
The inspectors walked down the physical SGK05A modification, reviewed corrective action program, work order, and modification documentation, and conducted interviews with responsible personnel. The inspectors noted that the actions to address the direct cause, which installed a new compressor design that has a new type of oil and a new diaphragm type of lube oil pressure switch (these are expected to be less susceptible to moisture intrusion and contaminant buildup), were reasonable corrective actions to address the direct cause of the violation. The inspectors also noted that extent of condition actions to issue design change packages for similar design modifications for the control room air conditioning units (SGK04A and SGK04B) were also reasonable assuming the design changes are appropriately implemented. The station completed replacement of the SGK04B unit with the new style compressor and plans to complete replacement of the SGK05B unit in the spring of 2018 and the SGK04A unit in the spring of 2019.
The licensees root cause evaluation also determined the root cause was:
Engineering leadership did not properly allocate personnel to the design change for the SGK05A compressor replacement, did not communicate the design change status effectively, and failed to realize that progress was not adequate to ensure successful completion in [Refueling Outage] 20. As a result, measures to correct SGK05A issues were inadequate and a repetitive failure occurred.
To address the identified root cause, the licensees corrective actions to preclude repetition included obtaining supplemental engineering resources to assist with preparation of the design change packages for the SGK05A and SGK05B replacements.
Although not classified as corrective actions to preclude repetition, the licensee also took interim actions to conduct bi-weekly maintenance readiness meetings, conducted by maintenance, to review any issues with readiness for installation of the replacement compressor.
The inspectors acknowledge that the identified root cause, if corrected, would be expected to preclude repetition of the significant condition adverse to quality related to repetitive failures of the SGK05A unit. Additional resources were applied by the station and the compressor replacement was completed in November 2016. Therefore, the inspectors determined that the licensee has restored compliance and has taken appropriate corrective actions to address the cause of this violation.
With respect to extent of cause and an in-depth analysis of the effectiveness of management control systems, the licensees root cause evaluation bound the extent of cause to the Top 10 Issues list and determined that the extent of cause included design engineering resources being challenged and impacting initiatives to complete design modifications associated with completing maintenance on the SGK05 units. An extent of cause action was created and implemented to, Establish appropriate engineering resources to support [the] ongoing SGK05 project to allow an SGK05 unit to be shut down for maintenance while the plant is on-line. Additionally, the inspectors noted actions taken in response to apparent cause evaluation 100104 were implemented to address managers not ensuring effective action plans were developed, in place, and adhered to for some important equipment issues.
The inspectors reviewed Procedure AI 28A-100, Condition Report Resolution, Revision 12, which describes how boundaries are established around the population of plant processes, procedures, components, or human performance jobs or tasks with the potential to exhibit the same or similar root causes. Specifically, Procedure AI 28A-100 states, The level of effort of the [extent of cause] should be commensurate with the nature and complexity of the problem. The risk significance conclusion should be utilized to determine the scope and depth of review to reasonably bound the [extent of cause] review. The procedure also describes examples of extent of cause:
Environment: Determine the affect the cause has on other environments. Equipment: Determine if the cause is related to other SSCs. People: Determine if the cause affects other site personnel. Organization: Determine if the cause is related to other departments or organizations. Process: Determine if there are identical or similar processes or procedures that may be susceptible to same or similar causes.
The inspectors noted that the subject cited violation involved repetitive failures to correct a significant condition adverse to quality. The inspectors also noted that Inspection Report 2012007 documented a similar failure to take corrective action to preclude repetition of essential service water leaks caused by internal corrosion and water hammer. Considering the repetitive nature of the problems, failure to take corrective action to preclude repetition, and considering the complexity of the SGK05A problem, which involved resource, communication, and oversight safety culture aspects, the inspectors concluded that the root cause evaluation had a weakness in the area of extent of cause level of effort as described by Procedure AI 28-100. Specifically, the extent of cause did not methodically expand its review and document other equipment, people, organizations, or processes that may be impacted by similar leadership, communication, or oversight causal aspects, which were considered by the review.
Rather, the documented extent of cause narrowly focused on SGK05 (the same equipment), design engineering (the same people and organization), and modification documentation implementation (the same process).
The inspectors shared these observations with the licensee.
This review closes NOV 05000482/2015004-01, Inadequate Measures to Assure SGK05A Issues Were Promptly Corrected, EA-16-018.
4OA6 Meetings, Including Exit
Exit Meeting Summary
On October 11, 2017, regional inspectors discussed the in-office review of the preliminary scenario for the 2017 biennial exercise, submitted August 29, 2017, with Mr. T. East, Superintendent, Emergency Planning, and other members of the licensee staff. The licensee acknowledged the issues presented.
On November 17, 2017, regional inspectors presented the results of the on-site inspection of the biennial emergency preparedness exercise conducted November 14, 2017, to Mr. S. Smith, Plant Manager, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.
On December 13, 2017, regional inspectors presented the inspection results of the annual follow up of selected issues in Section 4OA2.3.b to Mr. S. Smith, Plant Manager, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.
On January 10, 2018, the resident inspectors presented the integrated inspection results to Mr. C. Reasoner, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
- R. Adams, Supervisor, Radiation Protection
- J. Ashley, Supervisor, System Engineering
- R. Audano, Superintendent, Maintenance
- R. Ayers, Supervisor, Radiation Protection
- D. Bowers, Manager, Maintenance
- W. Brandt, Shift Manager
- K. Clark, Technician, Fire Protection
- M. Corbin, Superintendent, Security Operations
- J. Cuffe, Supervisor, Radiation Protection
- D. Dees, Superintendent, Operations Support
- T. East, Superintendent, Emergency Planning
- J. Edwards, Manager, Operations
- R. Fincher, Manager, Quality
- R. French, Supervisor, Radiation Protection
- J. Fritton, Oversight
- G. Fugate, Director, Plant Support
- L. Fure, Master Technician, Radiation Protection
- A. Gilliam, Technician, Radiation Protection
- C. Gross, Manager, Chemistry
- C. Hafenstine, Manager, Regulatory Affairs
- D. Hall, Manager, Strategic Projects
- A. Heflin, President and Chief Executive Officer
- P. Herrman, Manager, Design Engineering
- R. Hobby, Licensing Engineer
- J. Isch, Superintendent, Operations Work Controls
- R. Jung, Instructor, Fire Protection
- J. Knust, Licensing Engineer
- R. Lane, Manager, Integrated Plant Scheduling
- B. Lee, Superintendent, Technical Training
- D. Mand, Director, Engineering
- J. McCoy, Vice President, Engineering
- W. Muilenburg, Supervisor, Licensing
- A. Patrzalek, Supervisor, Chemistry
- G. Pendergrass, Manager, Performance Improvement
- E. Peterson, Employee Concerns Program Coordinator
- C. Reasoner, Site Vice President
- J. Schepers, Supervisor, Radiation Protection
- M. Skiles, Manager, Security
- T. Slenker, Supervisor, Operations Support
- S. Smith, Plant Manager
- L. Stone, Licensing Engineer
- A. Stull, Vice President and Chief Administrative Officer
- J. Suter, Supervisor, Fire Protection
- M. Tate, Superintendent, Security Operations
- J. Yunk, Manager, Training
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened and Closed
- 05000482/2017004-01 NCV Failure to Provide Adequate Work Instructions for Preventive Maintenance (Section 1R15)
- 05000482/2017004-02 NCV Failure to Critique TSC and OSC Performance During a Biennial Exercise (Section 1EP1)
- 05000482/2017004-03 NCV Failure to Initiate a Condition Report for Boric Acid Evaluations (Section 4OA2)
Closed
- 05000482/2015004-01 VIO Inadequate Measures to Assure SGK05A Issues Were Promptly Corrected (Section 4OA5)