| Sincerely,/RA/ - - cc w/ encl: Electronic Distribution L. Cortopassi - 3 - Electronic distribution by RIV: Regional Administrator (Marc.Dapas@nrc.gov) Deputy Regional Administrator (Steven.Reynolds@nrc.gov) DRP Director (Kriss.Kennedy@nrc.gov) DRP Deputy Director (Troy.Pruett@nrc.gov) Acting DRS Director (Jeff.Clark@nrc.gov) Senior Resident Inspector (John.Kirkland@nrc.gov) Resident Inspector (Jacob.Wingebach@nrc.gov) Branch Chief, DRP/F (Michael.Hay@nrc.gov) Senior Project Engineer, DRP/F (Nick.Taylor@nrc.gov) Project Engineer, DRP/F (Chris.Smith@nrc.gov) FCS Administrative Assistant (Janise.Schwee@nrc.gov) RIV Public Affairs Officer (Victor.Dricks@nrc.gov) RIV Public Affairs Officer (Lara.Uselding@nrc.gov) NRR Project Manager (Joseph.Sebrosky@nrc.gov) NSIR/DPR Deputy Director (Scott.Morris@nrc.gov) RIV Branch Chief, DRS/TSB (Ray.Kellar@nrc.gov) RIV RITS Coordinator (Marisa.Herrera@nrc.gov) RIV Regional Counsel (Karla.Fuller@nrc.gov) Congressional Affairs Officer (Jenny.Weil@nrc.gov) OEMail Resource OEWEB Resource (Sue.Bogle@nrc.gov) RIV/ETA: OEDO (Ernesto.Quinones@nrc.gov) RIV RSLO (Bill.Maier@nrc.gov) MC 0350 Panel Chairman (Anton.Vegel@nrc.gov) MC 0350 Panel Vice Chairman (Louise.Lund@nrc.gov) MC 0350 Panel Member (Michael.Balazik@nrc.gov) MC 0350 Panel Member (Michael.Markley@nrc.gov) ROPreports DOCUMENT NAME: [Path] ADAMS ACCESSION NUMBER: [Accession Number] SUNSI Rev Compl. Yes No ADAMS Yes No Reviewer Initials MCH Publicly Avail. Yes No Sensitive Yes No Sens. Type Initials MCH SRI:DRP/F RI:DRP/F C:DRP/F JKirkland JWingebach MHay /RA/E-Hay /RA/E-Hay /RA/ 2/10/14 2/10/14 2/10/14 OFFICIAL RECORD COPY Enclosure - C. Zoia, Operations Engineer (RIII/DRS/OB) G. Apger, Operations Engineer W. Sifre, Senior Reactor Inspector D. Kern, Senior Reactor Inspector (RI/DRS/EB2) J. Dean, Senior Reactor Engineer (NRR/DSS/SNPB) J. Drake, Branch Chief C. Norton, Project Manager (NRR/JLD/JPSB) D. Stearns, Health Physicist One finding of very low safety significance (Green) is documented in this repor This finding involved a violation of NRC requirement Additionally, NRC inspectors documented one licensee-identified violation of very low safety significanc .1 Review of Licensed Operator Performance a. Inspection Scope On December 17 through December 24, 2013, the inspectors observed the performance of on- At the time of the observations the plant was in a period of heightened activity due to the plant startu of the plant startup and power ascension up to approximately 98% powe Additionally, the inspectors observed non-licensed operator performance in the turbine and auxiliary buildings, as well as the intake structure, during component startup to support the plant startu Over 350 hours of continuous observations were conducte In additiincluding conduct of operations procedure and other operations department policie These activities constitute completion of one quarterly licensed operator performance sample(s), as defined in Inspection Procedure 71111.1 b. Observations During these observations, inspectors regularly communicated observed behaviors to management at Fort Calhoun Station and to the NR Positive behaviors observed included adequate pre-job briefings, shift turnovers, control room supervision by station management, reactivity control, surveillance testing, identification and control of new operators and conservative decision makin Several areas for improvement were identified that in some instances involved unnecessary challenge to plant operator These observations were discussed with OPPD management as they were identified and included: Inadequate vendor and station engineering support for turbine control system testin Operations staff did not receive the level of support expected when the newly installed turbine control system operated erratically during power ascensio The licensee was eventually able to make system adjustments and stabilize turbine operation, but the delay in getting adequate technical support was an unnecessary challenge to the operator The quality of the procedure used for testing of the new turbine control system was poor, which slowed down test sequenc Center and Control Room operators resulted in unnecessary delays in getting problems fixed (such as malfunctioning control room annunciators). The inspectors observed one example of a newly qualified operator misunderstanding the operation of large feedwater system valv The inspectors observed one example of maintenance personnel not using procedurally-required placekeeping tools (i.e. circle/slash), which resulted in a missed procedural step and the need to re-perform the maintenance activity on a non-safety related syste Some inconsistencies were noted in documentation of control room and fire impairment log c. Findings No findings were identifie .2 Annual Inspection The licensed operator requalification program involves two training cycles that are conducted over a 2-year perio In the first cycle, the annual cycle, the operators are administered an operating test consisting of job performance measures and simulator scenario In the second part of the training cycle, the biennial cycle, operators are administered an operating test and a comprehensive written examinatio For this annual inspection requirement, Fort Calhoun Station was in the first part of the training cycl a. Inspection Scope The inspector reviewed the results of the operating tests for the station to satisfy the annual inspection requirement On December 20, 2013, the licensee informed the lead inspector of the results, 11 of 11 crews passed the simulator portion of the operating test 46 of 49 licensed operators passed the simulator portion of the operating test 48 of 49 licensed operators passed the job performance measure portion of the examination The individuals that failed the simulator scenario portion of their operating test and the individual who failed the job performance measure portion of their operating test were successfully remediated, retested, and passed their retake operating test prior to returning to licensed operator dutie The inspector completed one inspection sample of the annual licensed operator requalification progra No findings were identifie A vehicle crash affecting vital equipment in the intake structure; A loss of offsite power to the site; Failure of a diesel generator to start with a second diesel generator unavailable due to maintenance, resulting in a station blackout condition; A large-break loss of coolant accident inside containment; Uncovering of the fuel leading to fuel damage and a zirconium-water reaction producing an explosive atmosphere inside containment; and, A hydrogen gas burn damaging the containment purge system to create a release path to the environment, - -- - - - -- - - ---Emergency Team Briefings (Action 5, closed October 19, 2012); - -Emergency Team Briefings (Action 3, closed September 6, 2012); - - - -- -Emergency Team Briefing The issue of a lack of post-job briefings was not addressed in the March 29, 2013, email; - -- - o - o - o o - - o - o o o -- - ----- -Emergency Team Briefings - - - - - .1 - .1 (Closed) Licensee Event Report 05000285/2012-017-01: Containment Valve Actuators Design Temperature Ratings Below those Required for Design Basis Accidents While performing an extent of condition review associated with the adequacy of air operated equipment inside containment to withstand containment main steam line break (MSLB) and loss of coolant accident (LOCA) temperatures, it was discovered that the Reactor Coolant System (RCS) Loop 1A Charging Line Stop Valve, the RCS Loop 2A Charging Line Stop Valve, and the Pressurizer RC-4 Auxiliary Spray Inlet Valve have nitrile based elastomers used in the air filter regulator and actuato The design temperature limit for the nitrile elastomers used in the valves is 180°F which is acceptable for the normal operating conditions inside containment of 120° However, during the main steam line break and loss of coolant accident the temperature inside containment is analyzed to reach 370° Since these valves have both open and close functions supported by an air accumulator, failure of the nitrile based elastomers could prevent the valves from fulfilling their intended safety functio The causal analysis did not determine why the nitrile elastomers were installed during original plant constructio However, it was determined that a procedural deficiency and human error resulted in the wrong type of elastomer material being used in the instrument air filter regulators when the air accumulators were added to the valves to support their safety functio .2 (Opened) Licensee Event Report 05000285/2012-017-02: Containment Valve Actuators Design Temperature Ratings Below those Required for Design Basis Accidents - - .3 (Closed) Licensee Event Report 05000285/2013-001-00: Mounting of GE HFA Relays does not Meet Seismic Requirements On January 15, 2013, while reviewing a previous condition report, it was identified that a previous operability determination (OD) completed for General Electric (GE) model HFA relays was incorrect in that it did not appear to fully address the condition of the mounting screws that required torquein The seismic test results stated that the GE HFA relays passed the seismic testing, but the relays required two screws to be torqued to 5 foot-pound This condition of the additional required torqueing was initially entered into the corrective action program on December 21, 201 Currently, approximately 136 relays, that provide various indication and control functions in systems such as high pressure safety injection, charging, containment ventilation, and the emergency diesel generator, have been identified as potentially affecte Relay replacement/torqueing is in progres A cause analysis is in progress, the results of which will be published in a supplement to this LE .4 (Opened) Licensee Event Report 05000285/2013-001-01: Mounting of GE HFA Relays does not Meet Seismic Requirements - - .5 (Closed) Licensee Event Report 05000285/2013-003-00: Calculations Indicate the HPSI Pumps will Operate in Run-out During a DBA At approximately 1721 Central Standard Time, on January 30, 2013, during hydraulic evaluations for the alternate hot leg injection project, Design Engineering determined that design basis calculations indicated that the high pressure safety injection (HPSI) pumps would operate in a run-out condition under worst case design basis accident condition Previous changes to the operation of the HPSI pumps and the containment spray pumps have resulted in an increase in the injection phase time and an increase in HPSI pump flow during the acciden This could have resulted in the HPSI pumps operating in run-out for longer than the one hour manufacturer's recommended time limi A preliminary causal analysis identified that the station failed to obtain vendor technical information on HPSI pump performance in a 10 CFR 50, Appendix B, Quality Assurance validated forma An analysis of HPSI pump performance during the injection phase will be performed and design or procedural actions to prevent HPSI pump operation in the extended flow region and to ensure that sufficient net positive suction head is available will be take .6 (Opened) Licensee Event Report 05000285/2013-003-01: Calculations Indicate the HPSI Pumps will Operate in Run-out During a DBA -- - ---- .7 (Closed) Licensee Event Report 05000285/2013-008-00: Previously Installed GE IVA Relays Failed Seismic Testing On April 11, 2013, the test results of seven General Electric (GE) IAV relays indicated that three safety-related, seismically qualified, relays did not pass seismic testin The condition was entered in to the Station's corrective action progra A causal analysis determined that the failure was caused by the control spring in the relay contacting either the disk or the drag magnet during seismic testing resulting in a shor A wire used to support the spring was not installed in the relays that failed the testing, allowing the control spring to sag and make electrical contac There are a total of 45 GE IAV relays identified in the plant, of which 32 are safety-relate Twelve of these had previously been replaced and two more were verified to have the support wire installe The remaining 18 relays will be inspected, and if the support wire is missing, they will be replaced prior to plant startu .8 (Opened) Licensee Event Report 05000285/2013-008-01: Previously Installed GE IVA Relays Failed Seismic Testing - -- .9 (Opened) Licensee Event Report 05000285/2013-014-00: Unqualified Components used in Safety System Control Circuit --- - - .10 (Opened) Licensee Event Report 05000285/2013-017-00: Containment Spray Pump Design Documents do not Support Operation in Runout --- .11 (Opened) Licensee Event Report 05000285/2013-018-00: Postulated Fire Event Could Result in Shorts Impacting Safe Shutdown - - -- -- - Item 1.a is included in the restart checklist for the failure of Fort Calhoun Station to maintain procedures and equipment that protects the plant from the effects of a design basis floo These deficiencies resulted in a yellow (substantial safety significance) findin (1) Inspection Scope i. ken since NRC Inspection Report 05000285/201300 As documented in NRC Inspection Report 05000285/2013008, the inspectors reviewed this area for closure and noted discrepancies in the extent of condition area and a number of deficiencies noted in the technical bases for the flooding procedure which led to restart checklist items 1.a.1, 1.a.2, and 1.a.3 remaining ope The inspectors reviewed licensee to ensure plant safety and support closure of the restart checklist item ii. Open items (Licensee Event Reports (LER) and violations (VIO) for this portion of the restart checklist) specifically related to the Yellow finding were reviewed by the tea of condition evaluations related to the associated deficiencies that protect the plant from the effects of a design basis floo In addition, the NRC verified that adequate correextent of condition evaluations and that implementation of these corrective actions were either implemented or appropriately scheduled for implementatio Open items reviewed were: LER 2012-001, Inadequate Flooding Protection Procedure LER 2012-019, Traveling Screen Sluice Gates Found with Dual Indication LER 2011-003, Inadequate Flooding Protection Due to Ineffective Oversight VIO 2012002-01, Inadequate Procedures to Mitigate a Design Basis Flood Event VIO 2012002-02, Failure to Classify Intake Structure Sluice Gates as Safety Class III VIO 2012002-03, Failure to Meet Design Basis Requirements for Design Basis Flood Event VIO 2010007-01, Failure to Maintain External Flood Procedures (2) Observations and Findings i. Resolution of Root Cause, Corrective Action, and Extent of Condition Issues a) Flooding Finding From previous inspections, the major aspects which the licensee had not adequately addressed for the root cause analyses and associated efforts for the Yellow flooding finding were extent of condition review and addressing deficiencies in the technical n procedure The inspectors reviewed licensee actions belo Resolution of Extent of Condition Review Weaknesse In NRC Inspection Report 05000/285/2013008, the team noted several areas where the licensee had not adequately addressed the extent of condition of the inadequate flooding procedur Inspectors identified the following observations which were previously documented related to extent of conditio URI 05000285/2013008- FIN 05000285/2013008- NCV 05000285/2013008--Related Equipment For Design NCV 05000285/2013008--conservative Value for Declaring An Alert NCV 05000285/2013008-05, The inspectors observed that the licensee had entered each of these conditions into their corrective action program for resolution. tent of condition for the inadequate procedure which led to the Yellow flooding finding, the licensee performed additional reviews of their abnormal operation procedure Additionally, the licensee has post-restart actions in place to perform additional reviews associated with a procedural quality improvement effort that is part of the Performance Improvement Integrated Matrix (PIIM). Action Numbers 2013-0031 and 2013-0086 of the PIIM cover the procedural improvement program by the licensee. Ts addressing the identified deficiencies associated with the extent of condition coupled with the licensee conducting a procedure improvement initiative were adequate to address the weaknesses in the licenfinding. Resolution of Procedural Technical Bases Observation In NRC Inspection Report 05000/285/2013008, the team noted several areas where the licensee had not adequately addressed weaknesses in the technical bases of the flooding mitigation procedure The team reviewed the technical bases for procedural steps in the revised flooding procedur The technical bases prove that the procedures and the equipment they call upon would work when demanded under a design basis floo In Inspection Report 05000285/201008, the team identified the following inadequacies in the procedures to mitigate flooding: NCV 05000285/2013008-06 URI 05000285/2013008- NCV 05000285/2013008- NCV 05000285/2013008- NCV 05000285/2013008- NCV 05000285/2013008- The inspectors observed that the licensee had entered each of these conditions into their corrective action program for resolution. To address the overall concern with inadequacies in the technical bases of their flooding mitigation procedures, the licensee performed additional reviews of their abnormal operation procedure for acts of nature, their emergency plan implementing procedures, and their second level support procedures called on in their flooding procedure AOP-be part of the larger review performed for the procedural quality improvement effort post restart as part of the PII Action Numbers 2013-0031 and 2013-0086 of the PIIM cover the procedural improvement program by the licensee. The team concluded that had adequately resolved the identified technical issues associated with technical bases for their flooding mitigation procedures by their actions to address the identified deficiencies coupled with the effort to conduct a procedure improvement initiative as described in the their PII Conclusion The inspectors determined that the licensee had adequately addressed the extent of condition and procedural technical bases areas which had previously been of concern associated with Restart Checklist Bases Document Items Yellow Finding root and Finding extent of Yellow Finding corrective actions addressin Items 1.a.1, 1.a.2, and 1.a.3 are close ii. Resolution of Open Items Related to the Yellow Flooding Finding on the Restart Checklist Basis Document a) LER 2012- Licensee Event Report LER 2012-001 documented the deficiencies in Procedure AOP- Yellow findin The inspectors reviewed and closed the causal analyses, corrective actions, and extent of condition for this issue in Section a abov This LER is close b) LER 2012- Licensee Event Report LER 2012-019 documented a condition where intake sluice gates were found with dual indicatio With this indication, the position of the sluice gates could not be positively confirmed to be closed as required by the The licensee entered this condition into their CAP ve action The licensee took action to close the sluice gates and ensure the flooding mitigation feature was restore The inspectors began inspection of this item in NRC Inspection Report 05000285/2012012 and included its review under Finding FIN 5000285/2012012-for the position of the sluice gates, the licensee revised their maintenance procedure to provide an affirmative method of ensuring the sluice gates were close The inspectors reviewed this method and considered the method adequat This LER is close c) LER 2011- Licensee Event Report LER 2011-003 documented that the predominant cause of the Yellow flooding finding for an inadequate flooding mitigation procedure was historical ineffective oversight by station managemen The licensee came to this conclusion as a result of their root cause analyse The inspectors noted that station management had been changed and new managers in the principal positions were supplied in an operating agreement with Exelon Nuclea The remaining aspects for the inadequate flooding protection were addressed under CR 2010-the review of the causal analyses, corrective actions, and extent of condition for this issue in Section a abov This LER is closed. d) VIO 2012002- Violation VIO 2012004-01 documented multiple examples of a violation of Technical Specification procedures to mitigate an external flooding even The procedural guidance for flooding was inadequate to mitigate the consequences of external floodin The inadequacies were a failure to provide operators with sufficient information to ensure a transfer of power from offsite to an onsite emergency diesel generator prior to a loss of offsite power; a failure to identify that the class-1E powered motor operators of the six intake structure sluice gates were located at an elevation of 1,010 feet mean sea level (below the design basis flood level); a failure to identify that three of the six sluice gate motor operators would be de-energized when offsite power was transferred from offsite to one onsite emergency diesel generator; and a failure to adequately ensure the fuel transfer hose to emergency diesel generator day tanks was staged prior to river level exceeding 1,004 feet mean sea leve The licensee entered these conditions into their CAP as Condition Report CR 2010-238 The inspectors reviewed the e action The failures were adequately corrected by the licensee with procedure revision The inspectors conducted walkthroughs with licensee operators and maintenance personnel in the simulator to ensure the revisions adequately addressed the issue This violation is close e) VIO 2012002- Violation VIO 2011002-02 documented a violation of 10 CFR Part 50, Appendix ensee to classify the six intake structure exterior sluice gates and their motor operators as Safety Class and lower the intake cell sluice gates as a method to control level in those cells would require the sluice gates to be classified as safety class equipmen The re-affirmed the validity of the original violatio The licensee entered this condition into their CAP as Condition Report CR 2010-238 The inspectors that is currently under revie The new method uses four new lines which tap off of the circulating water system trash rack blowdown pipin This method requires all sluice gates to be fully closed and not used for controlling cell leve Four new valves in the blowdown piping would be used to control the intake cell level during a floo Inspectors reviewed the modification and mination to use this new method while the licensing amendment is under review and found them adequate to support plant safet This violation is close f) VIO 2012002- Violation VIO 2012002-03 documented a violation of 10 CFR 50, Appendix B, to meet design basis requirements for protection of the safety related raw water system during a design basis flood for flood levels between 1,010-1,014 feet mean sea level (msl) as identified in Updated Safety Analysis Report, Section Specifically, the design basis states, in part, that water level inside the intake cells can be controlled during a design basis flood by positioning the exterior sluice gates to restrict the inflow into the cell Inspectors identified that the sluice gate motor operators would be submerged below 1,014 feet msl adversely affecting the abilty to position the sluice gate The licensee entered this condition into their CAP as Condition Report CR 2010-2387corrective action These actions, as previously discussed, included a ling intake cell level during flooding conditions up to the design basis floo This violation is close g) VIO 2010007- Violation VIO 2010007-01 documented the original concern the NRC identified ign basis floo The NRC conducted numerous follow-readiness for a design basis flood even The root cause analyses for the condition were reviewed during the inspections of Sections 1.a.1, 1.a.2, and 1.a.3 of the Restart Checklist Basis Documen Inspection Report 05000285/2013008 identified areas of concern which were re-inspected and deemed to be satisfactorily addressed by the licensee as previously documented in this repor This violation is close (3) Assessment Results i. Flooding Finding the inspectors in the extent of condition area and the in the technical bases for the flooding procedure, restart checklist items 1.a.1, 1.a.2, and 1.a.3 were close ii. Resolution of open Items associated with the Yellow Flooding Finding Based on the reviews the team conducted, the following items were closed: a) LER 2012-001Inadequate Flooding Protection Procedure b) LER 2012-019Traveling Screen Sluice Gates Found with Dual Indication c) LER 2011-003Inadequate Flooding Protection Due to Ineffective Oversight d) VIO 2012002-01Inadequate Procedures to Mitigate a Design Basis Flood Event e) VIO 2012002-02Failure to Classify Intake Structure Sluice Gates as Safety Class III f) VIO 2012002-03Failure to Meet Design Basis Requirements for Design Basis Flood Event g) VIO 2010007-01Failure to Maintain External Flood Procedures iii. Overall Assessment of Item 1.a: Flooding Issue Yellow Finding (CLOSED) of the Restart Checklist are close (1) Inspection Scope The team reviewed the assessment of the failure of the M-2 contactor in the reactor protection system that occurred June 14, 201 The team verified that the licensee adequately identified the root and contributing causes of the risk significant issue; verified that the extent of condition and extent of causes of the risk significant issue were identified, and verified that the corrective actions adequately addressed the causes to preclude repetition. (Restart Checklist Basis Document Items 1.b.1; 1.b.2; 1.b.3) An open item specifically related to the White finding was reviewed by the tea The team verified that the licensee had performed adequate root cause and extent of condition evaluations related to the associated deficiencie In addition, the NRC verified that adequate corrective actions were identified associated with the root and contributing causes and extent of condition evaluations and that implementation of these corrective actions are either implemented or appropriately scheduled for implementation. (VIO 2011007-01) Specifically, the team assessed Revision 4 of the Root Cause Analysis (RCA) for CR 2011-00451, for which the problem statement was: Protection System M-2 contractor was identified as on November 3, 2008 and non-conforming maintenance was performed. The M-2 contractor remained in a degraded and non-conforming condition without an appropriate analysis to evaluate until it failed surveillance testing on June 14, This revision to the root cause changed the wording significantl The assessment was based on the evaluation criteria from Section 02.02 of NRC Inspection Procedure 95001, which aligned with this ite The inspection objectives were to: Provide assurance that the root and contributing causes of risk-significant issues were understood; Provide assurance that the extent-of-condition and extent-of-cause of risk- significant issues were identified; Provide assurance that the licensee's corrective actions for risk-significant performance issues were, or will be, sufficient to address the root and contributing causes and to preclude repetitio (2) Observations and Findings Determine that the problem was evaluated using a systematic methodology to identify the root and contributing cause The team determined that the licensee evaluated this problem using a systematic methodology to identify the root and contributing cause Specifically, RCA 2011-00451 employed the use of event and causal factor charting, barrier analysis, comparative analysis, and causal factor test, root and contributing cause statements, and the root and contributing cause testin The barrier analysis and event and causal factor chart associated with RCA 2011-00451 identified a number of failed barriers that appeared to play a significant role in the events leading to the failure of the reactor protection system M-2 contacto Included in the analysis were failures of the Preventive maintenance program, operations procedures, system engineering, degraded non-conforming process, work control process, and the Plant Review Committee Proces Based on the analysis, the licensee concluded the following were the root and contributing causes of the failure to address the degraded M-2 contactor in the reactor protection system: RC-1: Electrical Maintenance workers did not follow the procedure / work order instructions for the M-2 contactor issu When presented with conditions outside of the expected, they did not use the Human Performance Tool DUCS (Distracted, Uncertain, Confused, Stop) to obtain the necessary guidance to correct the issu RC-2: The Operations Department did not have an effective nuclear safety culture and ownership of plant equipment necessary to challenge unexpected events and take prompt action to drive the action to restore degraded equipment to reliable operatio CC-1: System Engineering did not recognize and implement their responsibility to perform appropriate evaluations to address plant technical issues and act as the site technical conscienc CC-2: Preventive Maintenance strategies were not implemented to replace the M-contactors before they exhibited degradation and did not consider the increased failure rate associated with their reaching end of service lif CC-3: Engineering judgment used to support Operability Evaluations was not rigorous or formally documente CC-4: The Plant Review Committee Degraded / Nonconforming condition subcommittee process was allowed to change operations department decisions on whether equipment was degraded without operations concurrence or formal documentation of the basi CC-5: Operations surveillance test guidance allowed pausing surveillance tests to perform repairs, which is a practice that is contrary to industry practices and regulatory guidanc CC-6: Operations knowledge of Technical Specification requirements related to the M-contactors was inadequate resulting in entry into TS 2.15(1) instead of TS 2. Determine that the root cause evaluation was conducted to a level of detail commensurate with the significance of the proble The team determined that the RCA was conducted to a level of detail commensurate with the significance of the proble Specifically, the licensee performed a significant revision to the RCA based on the inspection concerns documented in IR 2013-00 The licensee systematically used Methods 1 and 2 for cause testing as defined by FCSG 24 5, Report and Cause The eight causal statements, developed from merged causal factors, were evaluated using the flow char Two causal statements were identified as Root Causes and the other six were determined to be Contributing Cause Determine that the root cause evaluation included a consideration of prior occurrences of the problem and knowledge of prior operating experienc The team determined that the RCA included evaluation of both internal and industry operating experience as documented in Attachment 4 to RCA 2011-0045 Determine that the root cause evaluation addressed the extent of condition and the extent of cause of the proble The team reviewed the RCA as it relates to extent of condition and extent of caus For extent of condition, the licensee used same-same, same-similar, similar-same, and similar-similar evaluation method which is documented as Attachment 3 to RCA 2011-0045 Based on this analysis, the licensee determined that an extent of condition does exis The licensee based this conclusion, in part, on the findings of Condition Report CR 2012-09494, related to deficiencies in identifying degraded/nonconforming conditions and in the performance of operability determination For extent of cause, the licensee determined an extent of cause does exist for the root causes identified in this analysi They believe the extent of causes have been addressed by the collective sum of all corrective actions from the following RCAs: 2011-01719, Incorrect Technical Specification Entered when AI-3-M2 Contactor failed 2011-03025, Area for Improvement (EN 1-1) 2012-03986, Organizational Ineffectiveness 2012-08125, Engineering Design / Configuration Control 2012-08132, Site Operational Focus and Conservative Decision Making 2012-08135, Human Performance 2012-08134, Equipment Reliability / Work Mangement 2012-08137, Regulatory Process and Infrastructure 2012-09491, End of Service Life 2012-09494, Deficiencies in Identifying Degraded and Non-Conforming Condition and Performing Operability Determinations 2013-05570, Design and Licensing Bases Configuration Control The team concluded that RCA 2011-00451 determined an appropriate extent of condition and appropriate extent of cause for the root cause related to the reactor protection system M-2 contactor issu Determine that the root cause, extent of condition, and extent of cause evaluations appropriately considered the safety culture components as described in IMC 031 The root cause, extent of condition, and extent of cause evaluations appropriately considered the safety culture components as described in IMC 031 Specifically, the licensee documented their consideration of the IMC 0310 cross-cutting aspects in Attachment 9 of RCA 2011-0045 The licensee identified several cross-cutting aspects in the area of human performance, problem identification and resolution (PI&R), and other components that were applicable to issues related to deficiencies in degraded/nonconforming condition review and operability evaluation The final evaluation concluded that only a small number of the safety culture attributes were not to be applicable to RCA 2011-0045 Determine that appropriate corrective actions are specified for each root and contributing caus The team reviewed Attachment K to 2011-00451 and determined that generally the proposed corrective actions were appropriate to address the root and contributing causes identifie Determine that a schedule has been established for implementing and completing the corrective action The team determined that due dates have been established for implementation and completion of corrective action Determine that quantitative or qualitative measures of success have been developed for determining the effectiveness of the corrective actions to prevent recurrenc The team determined that quantitative or qualitative measures of success have been developed for determining the effectiveness of the corrective actions to prevent recurrenc (3) Assessment Results The team concluded that for Item 1.b: Reactor Protection System Contact Failure - White Finding, the root and contributing causes of risk-significant issues were understood; the extent-of-condition and extent-of-cause of risk-significant issues were -significant performance issues were, or will be, sufficient to address the root and contributing causes and to preclude repetitio All items in Section tactor Failure - are close System Readiness for Restart Following Extended Plant Shutdown Systems that have been shut down for prolonged periods may be subject to different environments than those experienced during power operation The NRC verified that the licensee adequately evaluated the effects of the extended shutdown to ensure that the structures, systems, and components are ready for plant restart and they conform to the appropriate licensing and design bases requirement (1) - (2) Observations and Findings No findings or observations. (3) Assessment Results Inspectors concluded that based on their reviews of the cause evaluations, and the extent of cause/extent of condition reviews, that this area has been reviewed by the licensee to a sufficient level of detai Items 2.b.2.1, 2.b.2.2, 2.b.2.3, and 2.b.2.4 are close Section 3 of the Restart Checklist addresses major programs and processes in place at FC Section 3 reviews will also include an assessment of how the licensee appropriately addressed the NRC Inspection Procedure 95003 key attributes as described in Section Corrective Action Program (1) Inspection Scope i. ken since NRC Inspection Report 05000285/201300 In Inspection Report 05000285/2013008, the inspectors reviewed this area for closure and observed that because the licensee was continuing implementation of corrective actions to improve the effectiveness of the CAP, the licensee had unsatisfactory results on effectiveness reviews, and because the licensee was still generating additional corrective actions to address CAP effectiveness, items 3.a.1, 3.a.2, 3.a.3, and 3.a.4 remained ope ascertain whether they were sufficient to ensure the CAP was adequate to support plant restar Performance Deficiency associated with the CA inadequate operating experience reviews identified in NRC Inspection Report 05000285/201300 In that report, the team determined that the effort by the licensee to lump operating experience weaknesses in the RCA did not provide for the proper analysis needed to address this deficiency which was prevalent in nearly all of the Fundamental Performance Deficiency RCA Therefore, restart checklist items 3.a.8, 3.a.9, 3.a.10, and 3.a.11 remained open pending the verification of the effective resolutio The inspectors reviewed licensee actions to ascertain whether they were sufficient to ensure that operating experience reviews by the licensee were adequat Finally, in NRC Inspection Report 05000285/2013008, the team performed a problem identification and resolution team inspectio That team concluded that overall, the CAP at FCS was functional in identifying, evaluating, and correcting issues with various degrees of effectivenes The team had a large number of observations provided in each of the areas of CAP, and observed that there was significant room for improvemen Based on all the observations identified by the team, in all 3 areas of CAP, restart checklist item 3.a.12 remained open for additional inspections to ensure an improved implementation of the CAP was in plac The ascertain whether they were sufficient to ensure the CAP was being adequately implemente ii. Open items (Licensee Event Reports (LER), noncited violations (NCV), and violations (VIO) specifically related to the corrective action program were reviewed by the tea The team extent of condition evaluations related to the associated deficiencies noted in the corrective actions were identextent of condition evaluations and that implementation of these corrective actions were either implemented or appropriately scheduled for implementatio Open items reviewed were: VIO 2011006- NCV 2011006- NCV 2010003- LER 2012- LER 2012- LER 2012- (2) Observations and Findings i. Corrective Action and Operational Experience Programs Assessment a) Resolution of Corrective Action Program Deficiencies NRC Inspection Report 05000/285/2013008 documented that based on the results on effectiveness reviews, and because the licensee was still generating additional corrective actions to address CAP effectiveness, restart checklist items 3.a.1, 3.a.2, 3.a.3, and 3.a.4 would remain ope The inspectors assessed licensee actions addressing the noted deficiencie The inspectors reviewed CR 2013-08675 which was initiated after the inspection documented in Inspection Report 05000285/201300 The licensee performed a root cause analysis to evaluate the quality and timeliness of CAP actions and the fact that prior actions taken to prevent recurrence of problems had not been fully effectiv The root cause was determined by the licensee to be: Station personnel have not consistently followed CAP procedures and station leadership has not reinforced CAP procedure compliance, as a result improvements in CAP performance have been limite Corrective actions taken to address this were the establishment of a CAP oversight function and to develop and implement CAP Fundamentals reinforced through an accountability model for specific CAP behavior Each of these actions were put in place with periodic effectiveness measures being used to monitor progres The inspectors reviewed the first effectiveness measurement results and noted continued improvement in the functioning of the CA The final effectiveness measures and continued actions for improvement of the CAP are contained in the PIIM in Action Plan Numbers 2013-Plan - -n - Root Cause a 2013-- Corrective The licensee also identified six contributing causes that included: CAP volume has significantly increased without significant process or prioritization changes to ensure quality and timeliness requirements can be maintaine The CAP strategy for improving performance was not well implemented and understood at all levels in the organizatio The ActionWay software is not being used as an effective barrier to ensure that certain required actions within the CAP process are performed and that certain prohibited actions are prevente Inadequate procedure guidance for action types in ActionWay has led to inappropriate use and untimely resolution of conditions adverse to qualit Station personnel have not received the requisite training to assure that station leadership and staff have the knowledge and skills to effectively and efficiently implement the CAP progra Station trending has been time consuming and ineffective due a large number of flat level codes, the inability to trend on common subjects, and the lack of connectivity between event and cause code cause The inspectors determined that the corrective actions to address the contributing causes appeared to adequately address the deficiencie Based on ectiveness measurement to monitor sustained improvement and make corrections when needed, and the continued station focus on CAP improvements contained in the PIIM, the inspectors considered that the CAP was adequately healthy and should continue to improv Based on this assessment Restart Checklist Basis Document Items 3.a.1, Extent of C acy of Corrective to Monitor Program Improvements, are close b) Resolution of the Functional Performance Deficiency Associated with the CAP In NRC Inspection Report 05000/285/2013008, the team noted that the licensee had chartered a team to perform another root cause analysis in this area and therefore assessing closure of this area would not be appropriate until that effort was completed and inspected by the NR The licensee completed the root cause analysis as part of CR 2013-0867 This root cause addressed both the CAP deficiencies and the functional performance deficiency associated with the CAP since both were closely relate Actions to correct the fundamental performance deficiency were reviewed and found to be adequat The inspectors noted the actions were bounded by the actions to improve the effectiveness of the CAP, including the emphasis of the continued CAP improvements contained in the PII Based on this assessment Restart Checklist Basis Document Items 3.a.5, Performance Deficiency Associated , are close c) Resolution of Operational Experience Program Deficiencies In NRC Inspection Report 05000/285/2013008, the team concluded that the operating experience, was too general to effectively address the operating experience portion of the CAP. The NRCwith operating experience was that the site Operating Experience Program was not effectively being implemented to enhance the performance of FC During this inspection the inspectors noted actions by the licensee to enhance the use of operating experienc An example of this was in CR 2013-02062 where the licensee noted the operating experience program should be reviewed to determine if any changes can be made to enhance the security organization use of operating experienc The inspectors noted similar instances in other areas, including improved use of operating experience in root cause analyse The inspectors noted that improvement in the use of operating experience was incoroporated into the PIIM in Action Plan Number 2013-Experience was also included in the PIIM as part of the Performance Improvement Program ensuring the CAP Coordinators for each department drive the use of operating experienc Based on these observations, the inspectors concluded that the licensee had taken adequate actions to increase the use of operating experience in various station work processes and had inititiatives in their PIIM to continue improvements in this are Based on this assessment Restart Checklist Basis Document Items 3.a.8, 3.a.9, acy of Corrective Actions to Monitor Program Improvements, are close d) NRC Problem Identification and Resolution Team Inspection In NRC Inspection Report 05000/285/2013008, it was documented that the NRC performed a problem identification and resolution team inspection but did not close Item 3.a.12, noting the need for additional inspections to ensure an improved implementation of the CAP was in plac Since that inspection, the licensee performed the additional root cause in CR 2013-08675 and implemented corrective action These corrective actions were reviewed by the NRC and it was determined that they adequately addressed the main deficiencies noted during the previous inspectio Based on the extaddressing improvements to the CAP that determined adequate actions have been taken by the licensee and future actions will continue to be implemented and effectiveness monitored, Restart Checklist basis Document Item 3.a.12, s complet e) Overall Assessment The inspectors determined that the corrective actions to address the root and contributing causes addressing the CAP deficiencies appeared comprehensive and were resulting in performance improvement Additionally, the licensee has implemented measurement processes to monitor the effectiveness of improvements so that corrections can be implemented when neede The station has in place CAP improvements initiatives contained in the PIIM that will drive continued improvements to the progra ii. Resolution of Open Items Related to the Correction Action Program Area in the Restart Checklist Basis Document a) (Discussed) VIO 05000285/2011006- This violation inovled the failure to take effective corrective action following the initial discovery of water intrusion in cable vault manholes MH-5 and MH-31 in 1998, 2005, 2009, and 201 Specifically, the licensee failed to take effective corrective action to establish an appropriate monitoring frequency which took into account variable environmental conditions to mitigate potential common mode failure of raw water 4160 V motor cables in underground ducts and manholes identified during the Component Design Basis Inspection performed in 200 This item was inspected as part of the 2013 License Renewal inspection and was documented in Inspection Report 05000285/201300 That team determined that the licensee initiated Condition Report 2013-11857 for the conditio The team concluded that, although the licensee had installed an alarm system to identify a high water level, the licensee had insufficient time to demonstrate reliability and effectiveness of the syste This violation remains open pending future inspection of completed corrective action The inspectors determined the corrective actions appeared adequate and closed this item on the Restart Checklist Basis Documen b) NCV 05000285/2011006- - team identified a deficiency regarding the equate procedures for gathering, analyzing, and communicating information related to low-level performance vulnerabilities and repeat occurrences prior to the emergence of more significant event Inspectors originally reviewed licensee actions as part of the team inspection documented in Inspection Report 05000285/2013008 from which they concluded the licensee still had performance gaps in effective trending to resolve issues at lower levels, especially equipment trendin The inspectors noted that the licensee took action to address this condition as part of Condition Report CR 2013-08675 in April 201 The root cause found that trending was not effective due to the lack of configuration of the CAP software to provide the functionality to efficiently and accurately code and included software changes to the CAP software to establish a tiered coding structure and utilize the existing Exelon fleet model for trending code The inspectors reviewed recent examples of trends and noted improvement in trending within the CA From this, the inspectors considered that the licensee had adequately addressed this noncited violation and this Restart Checklist Basis Document item is close c) NCV 05000285/2010003-Operation for High River Level This NCV documented a failure to include an adequate limiting condition for operation in the technical specificatio Specifically, the reactor could not be placed in a cold shutdown condition using normal operating procedures when the river level exceeded 1009 feet mean sea level, as required by Technical Specification 2.1 The inspectors confirmed that licensee entered this condition into their corrective action progra The inspectors noted that the licensee had changed procedure AOP-cold shutdown at a time where plant and flood conditions permitte The inspectors also confirmed that the licensee submitted a license amendment request to change Technical Specification 2.16 to require plant shutdown at 1004 feet mean sea leve The inspectors reviewed this level relative to the actions and time needed to place the plant in cold shutdown and considered them adequat On January 28, 2014, the NRC issued Amendment No. 274 to OPPD approving the River Level, (ADAMS ML 14003A003). This NCV is closed on the Restart Checklist Basis Documen d) Licensee Event Report 05000285/2012- This LER documented a condition where a pressurizer heater sheath (Number 26 heater) was found cracked after it had faile This condition was considered a degradation of the reactor coolant system boundar The licensee conducted a root cause for the condition and concluded that fabrication of the heater sheath during the manufacturing process induced high tensile residual stresses on the outer surface of the sheaths which led to the failur The inspectors reviewed this causal analysis and the corrective actions associated with i The inspectors observed that the heater sheath has been removed and replaced, and that other heater sheaths have been inspected and none of them had indications of crackin The inspectors also concluded that the heater design, which included a secondary seal (not the RCS pressure boundary) prevented any leakage from the reactor coolant system, and functioned as anticipated for such a conditio The inspectors also confirmed that future inspections of heaters were included as corrective actions for this conditio This LER and Restart Checklist Basis Document item is close e) Licensee Event Report 05000285/2012- This LER documented a condition where Static "0" Ring pressure switches with certain housing styles exhibit a setpoint shift when exposed to a change in temperature if the switch body is not vente These pressure switches that provide signals for high containment pressure to the reactor protection system and engineered safeguards actuation circuitry had this configuratio The inspectors determined that from a review of an evaluation of actual data that safety analysis limits were not exceede The inspectors also examined the instruments and confirmed that as corrective action the licensee had removed the vent plug Also, the inspectors confirmed that the causal factor of inadequate vendor documentation was addressed by the licensee. This LER and Restart Checklist Basis Document item is close f) - -- Section 5 of the Restart Checklist is provided to assess the key attributes of NRC Inspection Procedure 95003. Performing Inspection Procedure 95003 will provide the NRC with supplemental information regarding licensee performance, as necessary to determine the breadth and depth of safety, organizational, and programmatic issue While the procedure does allow for focus to be applied to areas where performance issues have been previously identified, the procedure does require that some sample reviews be performed for all key attributes of the affected strategic performance area The key attributes are listed as separate subsections belo It is intended that the activities in these subsections be conducted in conjunction with reviews and inspections for Sections 1 - 4, rather than a stand-alone revie Procedure Quality Item 5.c is included in the restart checklist because the licensee performed an integrated assessment and identified 15 Fundamental Performance Deficiencies (FPD) that resulted in the overall performance decline at the statio One of the deficiencies This FPD was entered into corrective action program as CR 2012-0813 The NRC assessed Management evaluation, adequacy of extent of condition and extent of causal analysis, and adequacy of associated corrective action a. Inspection Scope During April 2013, a two-week NRC onsite inspection was conducted to review the The inspectors conducted a review of the status of operations department procedures, including Emergency Operating Procedures (EOPs), Abnormal Operating Procedures (AOPs), Operating Procedures (OPs), Alarm Response Procedures (ARPs) and Operating Instructions (OIs). In addition, the inspectors also reviewed several internal and external assessments conducted for Operations Department procedures, condition reports, root cause analyses and apparent cause analyse These reviews were conducted to provide the inspection team an insight into the current quality of operations procedures as well as the anticipated quality of procedures required to support restart of the uni The observations and findings of this inspection were documented in NRC IMC 0350 Inspection Report 05000285/2013010, dated July 11, 201 Overall, the inspection team concluded that the status of procedures used by Operations was not of sufficient quality to support closure of this are The scope of this inspection was to 1) evaluate known deficiencies in Operations procedures and verify the licensee implemented adequate corrective actions commensurate with their importance to safety, and 2) assess the adequacy of licensee actions to be taken prior to restart to gain assurance that Operations procedures are adequat This inspection reviewed the following Restart Checklist Basis Document items: 5. Licensee Assessment of the Fundamental Performance Defiency of Procedure Quality/Procedure Management, 5. Adequacy of extent-of-condition and extent of cause, and 5. Adequacy of corrective action Observations and Findings Following the inspection in April 2013, the licensee initiated and completed a Procedure Recovery project (CR 2013-08856) to address procedure quality concern This project included almost 300 procedures, identified by six Priority definitions: Priority 1: procedures included all safety related ARPs, EOPs and AOPs that branch to OIs, OIs associated with the EOP/AOP set, and procedures with prior NRC concern Priority 2: procedures included EOPs and AOPs without present OI branching, and AOPs associated with safety system Priority 3: procedures included OIs associated with safety related systems Priority 4: procedures included AOPs and OIs associated with only non-safety related system Priority 5: procedures included OIs associated with systems that will neither be used nor conditions encountered before completion of the review proces Priority 6: procedures included OIs designated as non-safety relate The process used to conduct the recovery project included the following elements: Verification process of ensuring procedures are technically correct, operational correctness, and procedures accurately adhere to guidance in the tor Validation process of confirming procedures are compatible with expected operator responses and plant equipment. Validation methods included walk-through, table-top, simulator, and referenc To assess the adequacy of the Procedure Recovery project in meeting the inspection requirements, a sample of each procedure type was selected and reviewe The review consisted of the procedure revision in use prior to the upgrade project, the electronic change package (including requisite forms, markups, reviews, comments, etc.) and the new procedure revision issue In addition, condition reports, root and apparent cause analyses, external and internal procedure assessments, and procedure related training documentation were reviewe c. Assessment Results The inspector concluded that the licensee adequately scoped the set of Operations procedures to be reviewed and upgraded prior to plant restar The licensee adequately evaluated and corrected known procedure deficiencies as well as identified and corrected a substantial number of deficiencies identified during implementation of the Procedure Recovery projec Based on the results Project effectively improved Operations procedures to support a safe plant restar Restart Checklist Basis Document items 5.c.1, 5.c.2 and 5.c.3 are close (1) Restart Checklist Basis Document Items NCV 2012301-01, 04 and 06 a. Inspection Scope The inspectors reviewed the adequacy of following non-cited violations that were specific items in the Restart Checklist Basis Document: NCV 2012301-01Seven Examples of Inadequate Procedures for the Mitigating Systems Cornerstone NCV 2012301-04Five Examples of Inadequate Procedures for the Initiating Events Cornerstone NCV 2012301-06Inadequate Procedures with Four Examples for the Barrier Integrity Cornerstone During April 2013, a two-week onsite inspection was conducted to review the The inspectors reviewed condition reports associated with these violations and procedural changes incorporated as a result of these violation The assessment documented that Condition Report 2012-03140 was written to encompass all of the examples of procedural deficiencies in the alarm response procedures that were identified in non-cited violations NCV 2012301-01, NCV 012301-04, and NCV 2012301-0 However, a revised apparent cause analysis was in progress and therefore could not be inspecte Although the specific procedural deficiencies documented in the three non-cited violations had been corrected, it was decided these checklist items would remain open pending a future inspection of the revised apparent cause analysis and any associated corrective action Inspection results were documented in NRC IMC 0350 Inspection Report 05000285/2013010, dated July 11, 201 The scope of this follow-up inspection is a review of the revised apparent cause analysis for CR 2012-03140 and associated corrective action Observations and Findings Apparent Cause Analysis Report, Annunciator Response Procedure (ARP) Quality Issues, Revision 1, was approved May 1, 201 The revised Apparent Cause Analyis concluded that there was a flaw in the original analysi As a result, the Apparent Cause Analysis identified apparent cause was changed; the Extent of Condition was revised to bring this section into compliance with FCSG 24-4, Condition Report and Cause Analysis, and FCSG-24-5, Cause Evaluation Manual; and corrective actions were updated and revised based on the completed actions and revised analysi Extent of Cause analysis and corrective actions resulted in improved verification and validation processes through changes to procedures SO-G-30, Procedure Change and Generation, and SO-G-74, EOP/AOP Procedure Generation Progra Extent of Condition analysis identified some operating procedures (EOPs, AOPs, Operating Instructions, Operating Procedures and Annunciaor Response Procedure) were technically inaccurate, lacked clarity, and deviated from the owner's group guideline Corrective actions included a Procedure Recovery Project that included a review and validation of procedure technical accuracy and clarity for all operating document c. Assessment Results The inspector concluded that the licensee adequately addressed the Apparent Cause and Contributing Causes, Extent of Condition and Extent of Cause through the revision of the Apparent Cause Analysis for CR 2012-0314 Therefore, Restart Checklist Items NCV 2012301-01, 04, and 06 are close (2) Restart Checklist Basis Document Item 5.c - NCV 2011002-01, Inadequate Operating Instruction Results in a Loss of Auxiliary Feedwater a. Inspection Scope During April 2013, a two-week onsite inspection was conducted to review this NCV as part of the overall assessment of the procedural quality attribut The inspectors reviewed Condition Report 2011-0839 and the associated Root Cause Analysi The inspectors documented one concern from this review associated with Contributing Cause (verification and validation) of infrequently used procedures or procedure sectithat did not have an associated corrective actio The licensee documented this issue in Condition Report 2013-0867 It was decided this checklist item would remain open until a corrective action for Contributing Cause 8.2 was developed and implemente The scope of this follow-up inspection is a review of the corrective action for Contributing Cause Observations and Findings CR 2013-08677 was reviewe Action Item 3, "Establish and implement criteria to ensure periodic V&V of infrequently used procedures and procedure sections is performed" was completed and approved by the station on July 18, 201 c. Assessment Results The inspector reviewed the criteria and its implementation and concluded that the licensee adequately addressed the corrective action for Contributing Cause 8.2 of CR 2011-083 Therefore, Restart Checklist Item NCV 2011002-01 is close (3) Restart Checklist Basis Document items 5.c - NCV 2010004-10, Inadequate Maintenance Procedure Results in a Plant Shutdown a. Inspection Scope During April 2013, a two-week onsite inspection was conducted to review this NCV as part of the overall assessment of the procedural quality attribut The inspectors reviewed LER 2010-Procedure Causes Station Shutdoondition reports, causal analyses, procedures) to verify the licensee had performed adequate casual analyses and extent of condition/extent of cause evaluations related to this issu In addition, the inspectors verified adequate corrective actions were identified for the associated causes and extent of condition/extent of cause evaluations and that implementation of these corrective actions were either implemented or appropriately scheduled for implementatio Observations and Findings LER 2010-002 and CR 2010-1704 (including causal analysis and extent of condition/extent of cause) were reviewe Changes to procedure EM-PM-EX-1100, and found to adequately address the deficiencie c. Assessment Results The inspector concluded that the licensee adequately identified Root and Contributing Causes, and adequately addressed corrective actions to preclude recurrenc Therefore, Restart Checklist Item 5.c - NCV 2010004-10 will be close Equipment Performance -- b. Observations and findings cause analysis determined the causes of the issue were the lack of detail in the Reliability Centered Maintenance (RCM) basis documentation for prescribing adequate circuit breaker maintenance, failure to incorporate all sources of maintenance recommendations, and insufficient coordination and ownership by separate engineering groups to adequately trend breaker performance and identify all required maintenance activitie The licensee corrective actions included completion of a gap analysis to identify vendor and industry recommended breaker maintenance and deficiencies in the FCS progra The licensee developed a detailed preventive maintenance basis document for switchgear and breaker maintenance based on the results of the gap analysi The licensee revised applicable maintenance procedures to capture the new maintenance requirements and also revised procedures for trending and monitoring breaker performance, to include a system engineer revie The inspectors concluded the cause analysis and corrective actions appear adequate to minimize recurrence of the issu c. Assessment Results This activity constitutes closure of NCV 2010004-09 as listed in the Restart Checklist Basis Documen Configuration Control Review of LER 2012-- Inspection Scope The inspectors reviewed the licensee actions associated with LER 2012-008Technical Specification Violation for Fuel Movement (VA-66) that included associated documents (condition reports, causal analyses, procedures) to verify the licensee had performed adequate casual analyses and extent of condition/extent of cause evaluations related to this issu In addition, to verify adequate corrective actions were identified associated with the causes and extent of condition/extent of cause evaluations and that implementation of these corrective actions were either implemented or appropriately scheduled for implementatio b. Observations and Findings A review of LER 2012-008, Condition Report 2011-07800 and Apparent Cause Analysis Summary Report, -66 Elemental Iodine Removal Efficiency Test Failure, Revision The Apparent Cause identified was lack of Management Oversight and failure of Engineering to take a pro-active approach in the prevention of future test failures. Action Items (AI) included: 1. Revision of procedure SE-ST-VA-Charcoal Filter VA-charcoal sample results and predict replacement, 2. Replacement of the depleted charcoal currently installed, and 3. Change the frequency of the charcoal testing from eighteen months to 1 yea Action Items 1 and 2 have been complete Action Item 3 is scheduled to be completed under EC 5785 The Apparent Cause Analysis Summary Report documented that the Extent of Condition will be addressed under Condition Report 2011-779 c. Assessment Results The inspector concluded that the licensee adequately assessed and developed corrective actions to address the apparent cause of the performance deficiency associated with this Licensee Event Repor Therefore, Restart Checklist Basis Document Item 5.e (LER 2012-008) will be close However, LER 2012-008 will remain OPEN until Action Item 3 is verified complete by inspectio Review of LER 2012- a. Inspection Scope LER 2012-012 that included documents (condition reports, causal analyses, procedures) to verify the licensee had performed adequate casual analyses and extent of condition/extent of cause evaluations related to this issu In addition, the inspectors verified that adequate corrective actions were identified associated with the causes and extent of condition/extent of cause evaluations and that implementation of these corrective actions were either implemented or appropriately scheduled for implementatio b. Observations and Findings A review of LER 2012-012, Condition Reports 2012-01956, 2012-03140, 2012-04815 and 2013-Extent of Cause Action for NRC Non-cited Violation, Revision The Apparent Cause Analysis (ACA) from CR 2013-09711 identified the original Apparent Cause Analysis for CR 2012-03140 (deficiencies in several ARPs found during NRC Initial Licensed Operator exam conducted in August 2012) was inaccurate in that s guide rather than an incorrect ARP validation proces The ACA from CR 2013-09711 also documented the following causes and extent of conditions: Apparent Cause #1 (AC-1) Operations Department corrective action program prioritization valued correcting the specified condition to a much greater degree than investigating the extent of condition and ensuring corrective action in a timeframe commensurate with the risk of the problem recurring or extending to other procedure Contributing Cause #1 (CC-1) The original Apparent Cause Analysis for CR 2012-03140 was inaccurate in that the Apparent Cause Analysis faulted the An Extent of Condition exists with all ARP An Extent of Cause exists with most EOPs, AOPs, and Operating Instruction The findings in the Apparent Cause Analysis contributed to the decision to conduct a procedure upgrade project that included the Alarm Response Procedures identified affected by LER 2012-01 The Alarm Response Procedure (ARP-CB--SI- associated with sluicing of Safety Injection Tanks were reviewed and compared with the revision prior to the changes identified by the upgrade projec Assessment Results The inspector concluded that the licensee adequately assessed and developed corrective actions to address the apparent cause of the performance deficiency associated with this Licensee Event Repor Therefore, Restart Checklist Basis Document Item 5.e (LER 2012-012) is close L. Cortopassi, Site Vice President The lead inspector obtained the final annual examination results and telephonically exited with Mr. R. Cade, Manager, Operations Training, on December 30, 201 The inspector did not review any proprietary information during this inspectio violation of NRC requirements which meets the criteria of the NRC Enforcement Policy for being dispositioned as a non-cited violation requires that measures shall be established to assure thatthe design basis for those structures, systems, and components to which this appendix applies are correctly translated into specifications, drawings, procedures, and instructions.specifications, drawings, procedures, and instructions - -
| | ==Dear Mr. Cortopassi:== |
