ML21244A499

Enclosure 2 - James A. FitzPatrick Nuclear Power Plant-Response to Contested Violation and Final White Finding and Revised Notice of Violation-Inspection Report 0500333/2021090

ML21244A499
Person / Time
Site:	FitzPatrick
Issue date:	09/03/2021
From:	David Lew NRC Region 1
To:
References
EA-20-138 IR 2021090
Download: ML21244A499 (4)

See also: IR 05000333/2021090

Text

ENCLOSURE 2

REVISED FINDING IN RESPONSE TO CONTESTED VIOLATION

Defective Part Results in High Pressure Coolant Injection System Pressure Control Valve

Failure

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating White NOV [H.1] - 71153

Systems05000333/2020012-01 Resources

Open

EA-20-138

The inspectors documented a self-revealed White finding and related violation of FitzPatrick

Technical Specifications (TS 3.5.1). The finding included failures to comply with Title 10 of

the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion V, Instructions,

Procedures and Drawings and Criterion XV, Nonconforming Materials, Parts, or

Components. Exelon Generation, LLC (ExGen) did not adequately implement quality-related

procedures which contributed to FitzPatricks failure to identify a nonconforming component,

which was verified as acceptable for use. Subsequently, FitzPatricks maintenance staff

installed the nonconforming component which caused the inoperability of the HPCI system on

April 10, 2020.

Description:

The HPCI system at FitzPatrick provides an emergency source of water following a transient

or accident. This high pressure source of coolant is delivered from two water sources using

steam generated from the reactor to drive the associated turbine and pump. The HPCI

system pump can deliver up to 4,250 gallons per minute and may be operated across a wide

range of reactor pressures. The HPCI system pump and turbine are supported by an oil

system designed to lubricate bearings and provide adequate pressure to control the steam

turbine stop and control valves.

During a HPCI maintenance window in December 2017, an emergent need arose for a

replacement pressure control valve (PCV). ExGen did not have a replacement PCV on site at

the time, and subsequently located a replacement PCV at Limerick. On December 16, 2017,

ExGen issued purchase order (P.O.) 637326 to move the HPCI system PCV from the

Limerick warehouse to FitzPatrick during a planned HPCI system maintenance window. Due

to the emergent demand, the purchase order was issued in parallel with a document review

by FitzPatrick. Per issue report (IR) 04348906, originated on June 6, 2020, the PCV was put

on user hold at Limerick on October 20, 2017, due to the shelf-life expiring within 5 days.

This IR states the valve was transferred to FitzPatrick on December 15, 2017, with an expired

shelf-life annotated in Passport (the licensees component tracking database). Additionally,

the IR states that prior to releasing the PCV for installation, Fitzpatricks quality receipt

inspection identified, reviewed, and dispositioned the shelf-life issue with FitzPatrick

Procurement Engineering.

Procedure SM-AA-300-1001, Section 4.10.2, specified that when the requesting facility

(FitzPatrick) is not a specific user of the procured component that the existing Catalogue

Identification (CID) at the target site (Limerick) shall be reviewed by the requesting site. The

purpose of this review is to ensure that quality and technical requirements of the component

are adequate for the requesting facilitys need; and, that the review shall be performed by a

procurement engineer (PE) for a safety-related component. The CID was not in a ready state

Notice of Violation 2

at the time of request, as a user hold existed in Passport for a shelf-life concern. The

document package associated with P.O. No. 011466532 included electronic correspondence

documenting that appropriate Fitzpatrick staff reviewed the document package for P.O. No.

0011466532 and found it to be acceptable. FitzPatricks review did not identify discrepant

information located within Exelons equipment database (e.g., the CID facility-specific section

in Passport panel D202).

The FitzPatrick procurement staff authorized Limerick to transfer a component in hold status

in the Passport system without initiating a new hold upon receipt of the component at the

destination site (FitzPatrick). These actions were not in accordance with the requirements of

procedure SM-AA-102, Warehouse Operations, Rev. 23. Procedure SM-AA-102, specified

that items released on hold shall be tracked by a respective Action Request (AR) assignment,

Work Order task or Issue report with respective assignments to track the released material.

Specifically, the licensee failed to ensure that a component released on hold was adequately

tracked by a respective AR assignment, work order task or issue report with respective

assignments to ensure requisite component quality, and the Catalogue ID (CID) for this

component was set to READY. Additionally, a hold tag was required to be attached to the

component upon receipt of the transfer at the receiving site and entered into the sites hold

tag log. These actions were not performed. The failure to initiate a hold upon receipt of the

PCV or initiate tracking documents resulted in opportunities for FitzPatrick to identify the

discrepant information located within the equipment database. The formal actions to

disposition the hold, as required per SM-AA-102, provided a reasonable opportunity, under

these specific circumstances, for FitzPatrick to identify that the PCV was nonconforming.

Descriptive information relating to the nonconforming condition was readily available in

several panels in the licensees component tracking data base. For example, panel D202

included a readily available note which stated need to replace diaphragm 116-00134 prior to

use in plant.

The review of P.O. No. 011466532 did not identify the discrepant information located within

the CID facility specific section in Passport panel D202. The document package associated

with the P.O. included electronic correspondence (i.e., a one-line email) documenting that a

senior procurement engineer reviewed the document package for the P.O. and found it to be

acceptable. The use of panel D202 is described in Section 4.29 of SM-AA-300-1001,

Procurement Engineering Process and Responsibility, Rev 24. Specifically, the procedure

states Additional comments and the basis for site applicability may be added under the CID

facility specific section in Passport panel D202, AAA route list, D201 panel OLE field, or BOM

NOTES, as appropriate. The guidance in Procedure SM-AA-300-1001, combined with the

failures to follow procedural requirements for applying hold tags and initiating tracking

documentation further inform the agencys conclusion that reasonable opportunities existed to

foresee and prevent the installation of the nonconforming PCV.

Consequently, without identifying adverse information concerning the PCV, procurement staff

verified a nonconforming component as acceptable for use. As a result of the nonconforming

part installation, on April 10, 2020, at 1:15 AM, while conducting monthly technical

specification surveillance testing of the HPCI auxiliary oil system, operators identified an oil

leak on 23PCV-12 as a result of a tear in the subject diaphragm. Ultimately, the HPCI system

was declared inoperable and placed the station into a higher licensee-established risk

category (Yellow). ExGen notified the NRC of the inoperability per 10 CFR Part

50.72(b)(3)(v)(D) via Event Notification 54647. The 23PCV-12 valve was replaced and the

HPCI system restored to operable status on April 10, 2020, at 8:02 PM.

Notice of Violation 3

Corrective Actions: ExGen performed immediate corrective actions to replace the

nonconforming HPCI system PCV. ExGen also performed a fleet-wide stand down for

procurement staff to conduct additional training. Additionally, ExGen created a separate

action for each ExGen site to validate that a similar condition does not exist regarding other of

nonconforming materials, parts, or components within their inventory tracking database.

Furthermore, ExGen revised its warehouse and procurement procedures, adding steps

pertaining to items subject to 10 CFR Part 21 notifications and items with holds.

Corrective Action References: IR 4334315, IR 4348906

Performance Assessment:

Performance Deficiency: The inspectors determined that FitzPatricks did not comply with the

requirements and guidance of quality-related procurement procedures, which contributed to

ExGens failure to adequately identify and control a nonconforming item.

Procedure SM-AA-102, Warehouse Operations, Rev 23, states items that are on hold at one

site can be released to another site while on hold only if an action item is created at the

receiving site to track resolution of the item before the transfer occurs, and the item is added

to the receiving sites hold tag log. Additionally, a hold tag shall be attached to the item upon

receipt of the transfer at the receiving site.

On December 16, 2017, FitzPatrick failed to follow SM-AA-102. Adherence to the

requirements of this procedure, as well as using guidance provided in SM-AA-300-1001,

would have presented a reasonable opportunity for FitzPatrick to identify and assess readily

available information that was within the licensees Catalogue ID database and also linked to

the ExGen corrective action program. Consequently, without reviewing readily available

adverse information concerning the PCV, procurement staff verified a nonconforming

component as acceptable for use. Subsequently, FitzPatricks maintenance staff installed the

nonconforming component which caused the inoperability of the HPCI system.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the Equipment Performance 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. Specifically, the HPCI system was unavailable to perform its

safety function as a result of the failed PCV.

Significance: The performance deficiency was assessed by a Region I Senior Reactor

Analyst (SRA) and NRR Senior Risk Analysis and determined that prior risk assessment was

still valid for the failed HPCI system. The finding was determined to be of low to moderate

safety significance (White). The risk important core damage sequences were dominated by

internal events, primarily loss of condenser heat sink and loss of main feedwater. The

dominant core damage sequence is loss of condenser heat sink, failure of high-pressure

injection (HPI), and failure to manually depressurize the reactor. See Enclosure 1 to this final

determination report and the Attachment, HPCI Oil PCV Failure Detailed Risk Evaluation, to

the preliminary determination report (ADAMS Accession Number: ML21020A108) for a

detailed review of the quantitative and qualitative criteria considered in the final risk

determination.

Notice of Violation 4

The inspectors assessed the significance of the finding using Appendix A, The Significance

Determination Process (SDP) for Findings At-Power. The inspectors reviewed Inspection

Manual Chapter (IMC) 0609, Attachment 4, Initial Characterization of Findings, and

determined the finding affects the mitigating system cornerstone. The inspectors evaluated

the significance of this finding using Inspection Manual Chapter (IMC) 0609, Appendix A, The

Significance Determination Process (SDP) for Findings at Power, Exhibit 2 - Mitigating

Systems Screening Questions. The inspectors determined that the finding represented a loss

of the PRA function of a single train, the HPCI system, for greater than its technical

specification (TS) allowed outage time and required a detailed risk evaluation (DRE).

A Region I Senior Reactor Analyst (SRA) performed a detailed risk evaluation. The finding

was determined to be of low to moderate safety significance (White). The risk important core

damage sequences were dominated by internal events, primarily loss of condenser heat sink

and loss of main feedwater. The dominant core damage sequence is loss of condenser heat

sink, failure of high-pressure injection (HPI), and failure to manually depressurize the reactor.

This final determination report and the Attachment, HPCI Oil PCV Failure Detailed Risk

Evaluation, to the preliminary determination report provide a detailed review of the

quantitative and qualitative criteria considered in the final risk determination (ADAMS

Accession Number: ML21020A108).

Cross-Cutting Aspect: H.1 - Resources: Leaders ensure that personnel, equipment,

procedures, and other resources are available and adequate to support nuclear safety. The

cause of the finding was determined to be associated with a cross-cutting aspect of

Resources in the Human Performance area because ExGen staff failed to identify and

address a nonconformance during verification of the quality of the HPCI system PCV.

Specifically, the inspectors determined there were multiple ways for ExGen to reasonably

identify a nonconformance associated with the PCV diaphragm which had not been

addressed. Furthermore, procurement implementing procedures did not provide adequate

guidance to ensure that procedure users would identify and resolve this issue. Having

comprehensive steps within the relevant procedure would likely have prevented installation of

the defective part at FitzPatrick.