IR 05000443/2009007: Difference between revisions

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{{Adams|number = ML092400410}}
{{Adams
| number = ML093490999
| issue date = 12/11/2009
| title = Seabrook Station - Reply to Notice of Violation: EA-09-145 Re IR 05000443-09-007
| author name = St.Pierre G
| author affiliation = NextEra Energy Seabrook, LLC
| addressee name =
| addressee affiliation = NRC/Document Control Desk, NRC/NRR
| docket = 05000443
| license number =
| contact person =
| case reference number = EA-09-145, IR-09-007, SBK-L-09243
| document type = Licensee Response to Notice of Violation
| page count = 6
}}


{{IR-Nav| site = 05000443 | year = 2009 | report number = 007 }}
{{IR-Nav| site = 05000443 | year = 2009 | report number = 007 }}


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{{#Wiki_filter:NExTera" December 11, 2009 Docket No. 50-443 SBK-L-09243 U.S. Nuclear Regulatory Commission Attention:
[[Issue date::August 28, 2009]]
Document Control Desk Washington, DC 20555-0001 Seabrook Station Reply to a Notice of Violation, EA-09-145 References:
1. Seabrook Station, Unit No. 1 -NRC Inspection Report 05000443/2009007; Preliminary White Finding, dated August 28, 2009.2. Final Significance Determination of White Finding with Assessment Followup, and Notice of Violation (NRC Inspection Report No. 05000443/2009007, Seabrook Station, Unit No. 1), dated November 12, 2009.NextEra Energy Seabrook, LLC (NextEra Energy Seabrook), has reviewed the subject Notice of Violation and files the attached Reply to Enforcement Action 09-145 pursuant to 10 CFR 2.201.If there are any questions regarding this letter, please contact Mr. Michael D. O'Keefe, Seabrook Licensing Manager, at (603) 773-7745.


EA-09-145 Mr. Gene St. Pierre Site Vice President NextEra Energy Seabrook, LLC Seabrook Station c/o Mr. Michael O'Keefe  P.O. Box 300   Seabrook, NH 03874
Sincerely,NextEra Energy Seabrook, LLC Gene St. Pierre Vice President North cc: S. J. Collins, NRC Region I Administrator D. L. Egan, NRC Project Manager W. J. Raymond, NRC Senior Resident Inspector NextEra Energy Seabrook, LLC, P.O. Box 300, Lafayette Road, Seabrook, NH 03874 Attachment to SBK-L-09243 SBK-L-09243 Attachment Page 1 of 4 Statement of Violation:
During an NRC investigation conducted between February 25, 2009 and July 16, 2009, a violation of NRC requirements was identifie In accordance with the NRC Enforcement Policy, the violation is listed below: 10 CFR 50 Appendix B Criterion III, "Design Control," states, in part, that measures shall be established to assure that regulatory requirements and the design basis for systems and components are correctly translated into specification -and instruction Measures shall also be established for-the selection and review for suitability of application of materials and parts that are essential to the safety-related functions of the systems and components.


SUBJECT:  SEABROOK STATION, UNIT NO. 1 - NRC INSPECTION REPORT 05000443/2009007; PRELIMINARY WHITE FINDING  On July 16, 2009, the NRC completed an inspection at the Seabrook Station, Unit No.The enclosed report documents the inspection findings discussed during an exit meeting on  July 16, 2009, with Mr. Paul Freeman and other members of your stafThis inspection examined activities conducted under your license as they relate to safety and compliance with the Commission's rules and regulations and with the conditions of your licensThe inspectors reviewed selected procedures and records, observed activities, and interviewed personneThis report documents one self-revealing finding that has preliminarily been determined to be White, a finding with low to moderate increased importance to safety that may require additional NRC inspectionAs described in Section 1R18 of the attached report the finding is associated with the failure to establish adequate design control measures to modify a cooling water flange on the B emergency diesel generator (EDG), which led to the failure of the diesel during a test on February 25, 200This finding was assessed based on the best available information, using the applicable Significance Determination Process (SDP). The final resolution will be conveyed in separate correspondencFollowing the B EDG failure on February 25, 2009, NextEra investigated the event, evaluated the condition of the EDG and its support systems, and restored the EDG and its cooling system to an operable statuFollowing completion of repairs, NextEra performed extensive maintenance operability and reliability runs on the B EDG, and declared it operable on  March 2, 200This finding does not represent an immediate safety concern because of the corrective actions you have takeG. St. Pierre 2  The finding is an apparent violation of NRC requirements and is being considered for escalated enforcement action in accordance with the Enforcement Policy, which can be found on the NRC's Web site at http://www.nrc.gov/reading-rm/doc-collections/enforcement  In accordance with the NRC Inspection Manual Chapter (IMC) 0609, we intend to complete our evaluation using the best available information and issue our final determination of safety significance within 90 days of the date of this letteThe significance determination process encourages an open dialogue between the NRC staff and the licensee; however, the dialogue should not impact the timeliness of the staff's final determinatioWe understand that you continue to evaluate the results of your risk determination for the B EDG failurWe encourage you to provide the results of your evaluation to us when it is finalized using the process as described beloBefore we make a final decision on this matter, we are providing you with an opportunity  (1) to attend a Regulatory Conference where you can present to the NRC your perspective on the facts and assumptions the NRC used to arrive at the finding and assess its significance, or  (2) submit your position on the finding to the NRC in writinIf you request a Regulatory Conference, it should be held within 30 days of the date of this letter and we encourage you to submit supporting documentation at least one week prior to the conference in an effort to make the conference more efficient and effectivIf a Regulatory Conference is held, it will be open for public observatioIf you decide to submit only a written response, such submittal should be sent to the NRC within 30 days of the date of this letteIf you decline to request a Regulatory Conference or submit a written response, you relinquish your right to appeal the final SDP determination, in that by not doing either you fail to meet the appeal process outlined in the Prerequisite and Limitation Sections of Attachment 2 of IMC 060Please contact Art Burritt at 610-337-5069, and in writing, within 10 days from the issue date of this letter to notify the NRC of your intentionIf we have not heard from you within 10 days, we will continue with our significance determination and enforcement decision and you will be advised of the results of our deliberations on this matteBecause the NRC has not made a final determination in this matter, no Notice of Violation is being issued for this inspection finding at this timIn addition, please be advised that the number and characterization of the apparent violation may change as a result of further NRC revieThe final resolution of this finding will be conveyed in separate correspondencThe attached report also documents one licensee-identified finding of very low safety significance (Green) that involved a violation of NRC requirements (Section 4OA7). If you contest this violation, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission,  ATTN.: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the Seabrook StatioThe information you provide will be considered in accordance with Inspection Manual Chapter 030G. St. Pierre 3  In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure, and your response (if any), will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
The Seabrook Station Design Control Manual (DCM), developed pursuant to the above to establish design control measures for safety related components, including the emergency diesel generators (EDG), states, in Chapter 2, Section 8.0, that the Maintenance Support Evaluation (MSE) is the design control measure to be implemented in support of maintenanc When preparing the MSE, the DCM requires that the design inputs and interdisciplinary review guidelines on Figures 4-1-1 through 4-1-14 shall be used to prepare and develop the design change and understand the areas impacte DCM Figure 4-1-1, Design Inputs, and Figure 4-1-3, Independent Reviewer Guidelines, requires that the design shall consider mechanical requirements such as stresses and vibration; whether materials are suitable for the application; credible failure modes of connected equipment; and, shall account for equipment performance history.Contrary to the above, on January 31, 2009, NextEra Energy Seabrook, LLC, completed Work Order 0821400 on the B EDG without adequately establishing measures to assure that regulatory requirements and the design basis for systems and components were correctly translated into specifications and instructions.


Sincerely,/RA by James W. Clifford Acting for/        David C. Lew, Director Division of Reactor Projects  Docket Nos: 50-443 License Nos: NPF-86
Specifically, design change 08MSE2 11, implemented by Work Order, to modify and repair a two bolt flange (joint JTRO05) on the B EDG right bank turbocharger, did not adequately:
(1) control welding stresses during repair, assure post weld flange alignment was acceptable, or address the impacts of known vibrations on flange performance and gasket compression; (2) address the suitability of gasket materials relative to flange specific conditions (cupping and bowing); and, (3) consider the flange performance history and potential failures to account for equipment performance history and credible failure modes of connected equipmen As a result, the B EDG turbocharger flange JTRO05 failed during the B EDG operation on February 25, 2009, causing a rapid loss of jacket cooling water and the EDG being declared inoperable.


===Enclosure:===
This violation is associated with a White Findin SBK-L-09243 Attachment Page 2 of 4 NextEra Energy Seabrook's Reply to the Notice of Violation 1. Reason for Violation The root cause of the event was determined to be an inadequate gasket design for the turbocharger coolant outlet flange. The design change (MSE) was prepared, reviewed and approved without adequately assessing the following design inputs: 0 The joint's performance history* Evaluation of reported extrusion of the gasket 0 Possible failure modes for the new gasket design This inadequate assessment of design inputs was due to a failure to implement the Design Control programmatic requirement This resulted in the selection of a gasket design which was not appropriate for the application.
Inspection Report 05000443/2009007 


===w/Attachment:===
Contributing to the root cause were two process deficiencies:
Supplemental Information  cc w/encl:  M. Nazar, Senior Vice President and Chief Nuclear Officer  A. Khanpour, Vice President, Engineering Support M. Warner, Vice President, Nuclear Plant Support  M. Mashhadi, Senior Attorney, Florida Power & Light Company M. Ross, Managing Attorney, Florida Power & Light Company M. O'Keefe, Manager, Licensing Manager  P. Freeman, Plant General Manager  K. Wright, Manager, Nuclear Training, Seabrook Station S. Colman, FEMA, Region I Office of the Attorney General, Commonwealth of Mass K. Ayotte, Attorney General, State of NH O. Fitch, Deputy Attorney General, State of NH P. Brann, Assistant Attorney General, State of Maine R. Walker, Director, Radiation Control Program, Dept. of Public Health, Commonwealth of MA C. Pope, Director, Homeland Security & Emergency Management, State of NH R. Hughes, Director, Licensing and Performance Improvement  J. Giarrusso, MEMA, Commonwealth of Mass D. O'Dowd, Administrator, Radiological Health Section, DPHS, DHHS, State of NH J. Roy, Director of Operations, Massachusetts Municipal Wholesale Electric Company T. Crimmins, Polestar Applied Technology R. Backus, Esquire, Backus, Meyer and Solomon, NH Town of Exeter, State of New Hampshire Board of Selectmen, Town of Amesbury S. Comley, Executive Director, We the People of the United States R. Shadis, New England Coalition Staff M. Metcalf, Seacoast Anti-Pollution League G. St. Pierre 4   In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure, and your response (if any), will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
1. The Challenge Board Process for EDG maintenance did not require the basis for maintenance activities that implement design changes.2. Additional requirements were added to the work control program to ensure the EDG is treated as a system and not as a component because the EDGs are a high risk/low margin system. While these controls historically have been successful in minimizing maintenance related issues from adversely impacting the EDGs, they did not require the same level of control to be applied to engineering processes involving the EDGs:* The MSE process did not require consideration of new failure modes.* The troubleshooting process did not include additional barriers for high risk / low margin systems.II.a. Corrective Actions Taken 1. On June 4, 2009, the Seabrook Site Engineering Director issued a memo to all Engineering personnel outlining expectations to address equipment performance history, installation tolerances, and to perform failure modes analysis for design changes. In addition, the memo provided expectations for the conduct of challenge boards for any Maintenance Support Package (MSP)[succeeded the MSE process] associated with high risk/low margin systems.2. On June 11, 2009, the Systems Engineering Manager coached the EDG system engineer on expectations to initiate condition reports (CRs) any time system parameters exceed normal/nominal values. In addition to the above listed process deficiencies, the system engineer failed to initiate CRs for SBK-L-09243 Attachment Page 3 of 4 unexpected, unwanted conditions which contributed to a lack of design input to the gasket design.3. On June 12, 2009, the Systems Engineering Manager discussed the event, the design change (MSP) and the root cause results with the preparer, reviewer and approver of the MSE. This included a reiteration of points made by the Engineering Director in a memo to the department, June 4, 2009.4. On June 12, 2009, the Site Maintenance Manager reinforced with all Maintenance shops the expectation to initiate CRs for all identified unwanted conditions.


Sincerely,/RA by James W. Clifford Acting for/
5. On June 30, 2009, the Site Operations Manager issued a Read and Sign memorandum to Operations personnel reinforcing expectations for initiation of CRs.6. On July 16, 2009, the Site Engineering Director issued a memorandum to convey the expectation that all unwanted conditions will be documented in a CR for trending, even if the condition is corrected as part of the maintenance activity that discovered it. In addition, the personnel involved in the subject cooling spill were individually coached regarding this expectation.
David C. Lew, Director Division of Reactor Projects Distribution w/encl: (via e-mail)  S. Collins, RA M. Dapas, DRA D. Lew, DRP J. Clifford, DRP A. Burritt, DRP L. Cline, DRP A. Turilin, DRP D. Holody, ORA W. Raymond, DRP, SRI J. Johnson, DRP, RI  E. Jacobs, DRP, OA L. Trocine, RI OEDO H. Chernoff, NRR R. Nelson, NRR D. Egan, NRR, PM R. Ennis, NRR, Backup N. Valentine, NRR ROPreportResources@nrc.gov Region I Docket Room (with concurrences)
ML092400410 SUNSI Review Complete:    LC              (Reviewer=s Initials)  DOCUMENT NAME:  G:\DRP\BRANCH3\INSPECTION\REPORTS\ISSUED\SEA0907.DOC  After declaring this document AAn Official Agency Record@ it will be released to the PubliTo receive a copy of this document, indicate in the box:  "C" = Copy without attachment/enclosure  "E" = Copy with attachment/enclosure  "N" = No copy  OFFICE RI/DRP  RI/DRP  RI/DRP  RI/DRS  RI/ORA  RI/DRP NAME WRaymond/LC for LCline/LC  ABurritt/LC for CCahill/CC    DHolody/AD for DLew/JWC for DATE 08/ 27/09 08/27/09 08/27 /09 08/27/09  08/27/09 08/27/09      OFFICIAL RECORD COPY 1 Enclosure U. S. NUCLEAR REGULATORY COMMISSION  REGION I Docket No.:  50-443  License No.:  NPF-86 Report No.:  05000443/2009007  Licensee:  NextEra Energy Seabrook, LLC Facility:  Seabrook Station, Unit NLocation:  Seabrook, New Hampshire 03874 Dates:  February 25, 2009 through July 16, 2009 Inspectors:  W. Raymond, Senior Resident Inspector    C. Cahill, Senior Reactor Analyst, DRS    K. Mangan, Senior Reactor Inspector, DRS    R. Moore, Reactor Inspector, DRP J. Heinly, Reactor Inspector, DRP J. Rady, Reactor Inspector, DRS E. Burket, Reactor Inspector, DRS  Approved by:  David C. Lew, Director Division of Reactor Projects 2 Enclosure SUMMARY OF FINDINGS IR 05000443/2009007; 02/25/2009-07/16/2009; Seabrook Station, Unit No. 1; Plant ModificationThe report covered a four-month period of inspection by resident and regional inspectorThe significance of most findings is indicated by their color (Green, White, Yellow, or Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process" (SDP) and the cross-cutting aspect of a finding is determined using IMC 0305, "Operating Reactor Assessment Program."  One apparent violation was identifieFindings for which the SDP does not apply may be Green or be assigned a severity level after NRC management revieThe NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 200Cornerstone:  Mitigating Systems  Preliminary WhitA self-revealing apparent violation of 10 CFR 50, Appendix B, Criterion III, Design Control was identified following a review of the identified causes for the failure of the B EDG jacket water cooling system on February 25, 200Specifically, NextEra's failure to adequately control design changes implemented on the B EDG jacket water cooling system in January 2009 led to the failure of the gasket on flange JTR005 in the B EDG jacket water cooling system on February 2The inspectors determined that this finding is more than minor because it is associated with the design control attribute of the Mitigating Systems Cornerstone and affects the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequenceSpecifically, design modification 08MSE11, intended to address flange JTR005 alignment and change the flange gasket design was inadequate and resulted in inoperability of the B EDIn accordance with IMC 0609, "Significance Determination Process," a Phase 3 risk analysis was performed and determined that the calculated delta CDF for the finding was 2.27E-6, which represents a low to moderate safety significance or White findinThe cause of the finding is related to the corrective action component of the cross-cutting area of problem identification and resolution because NextEra  did not thoroughly evaluate problems in a timely manner such that resolutions address causes (P.1(c)). Specifically, NextEra did not adequately evaluate deficient conditions when addressing B EDG cooling water flange leaks, failed to adequately use readily available internal operating experience, and failed to adequately evaluate and correct the impact of engine vibrations on flange JTR005 integrity, contributing to a subsequent failure of the flange. (1R18)  Other Findings  Violations of very low safety significance (Severity Level IV) that were identified by NextEra, have been reviewed by the inspectorCorrective actions taken or planned by the licensee have been entered into the licensee=s corrective action prograThese violations and the licensee=s corrective action tracking numbers are listed in Section 4OA7 of this reporEnclosure REPORT DETAILS 1. REACTOR SAFETY  Cornerstones:  Mitigating Systems 1R18 Plant Modifications (71111.18)  a. Inspection Scope  On February 25, 2009, the B EDG failed to complete a routine operability test when a leak occurred on the engine from a two bolt flange (joint JTR005) on the right bank (RB) turbocharger at the connection to the jacket water return linNRC Inspection Report 2009002 documented NextEra's immediate response and the NRC's initial review of the evenAs of the end of the inspection documented in that report, NextEra's evaluation of the causes for the failure were still ongoing and the inspectors had identified several issues of concern regarding the adequacy of the repairs and modifications completed during the January 2009 overhaul and the adequacy of corrective actions taken to assess and correct the potential effect of the RB turbo vibrations on EDG operabilitThe NRC opened URI 05000443/2009002-01 to track NextEra's completion of the root cause evaluation for the February 25 event and the NRC's subsequent review of NextEra's completed evaluatioTo close URI 05000443/2009002-01 the inspectors reviewed NextEra actions to monitor B EDG conditions and address identified deficiencies including work completed during the B EDG overhaul conducted between January 29 and February 2, 200The inspectors reviewed NextEra modifications to the B EDG jacket water cooling system piping and gaskets on flanged connections, including the design changes in 00MMOD531, 06MSE037, 08MSE211 and EC14490In particular, the inspectors reviewed the flange gasket change completed per maintenance support evaluation (MSE) 08MSE211, and the repairs conducted per work order (WO) 0821400 to address alignmenThe inspectors also reviewed NextEra actions to address vibrations in the RB turbo during engine operation and the results of the root cause investigation for the February 25, 2009 event, including the evaluations conducted for Action Request AR 19144This inspection did not represent an inspection samplb. Findings  IntroductioA self-revealing apparent violation (AV) of 10 CFR 50, Appendix B, Criterion III, Design Control was identified following a review of the identified causes for the failure of the B EDG jacket water cooling system on February 25, 200Specifically, NextEra's failure to adequately control design changes implemented on the B EDG jacket water cooling system in January 2009 led to the failure of the gasket on flange JTR005 in the B EDG jacket water cooling system on February 2DescriptioOperators shutdown the B EDG during a routine operability test on February 25, 2009, when a leak developed in the RB turbo jacket water cooling line at a 2-bolt flanged connectioThe NextEra investigation of the failure found the bolts for flange JTR005 loose and the gasket material severely damaged and blown out along a part of its circumferencPortions of the flange gasket were compressed 60% versus the 4 Enclosure vendor recommended maximum of 16%. The flange faces had irregularities (bowing and cupped surfaces) and there was a misalignment (gap) between the RB turbo outlet flange and the jacket water coolant pipe flangThe gap ranged from 0.164 to 0.245 inches, and by comparison, the installed gasket material had a nominal thickness of 0.0625 incheNextEra evaluated the apparent cause of the flange failure and repaired the flange under EC144905 and Work Order 118563The repairs included changes to address the flange misalignment, gasket material compression, and positive measures to prevent rotation of the boltThe NextEra Root Cause evaluation identified several factors that contributed to the failure of the B EDG jacket water cooling line at flange JTR00In January 2009 NextEra had implemented design change 08MSE211 to change the flange JTR005 gasket design from a 1/8-inch thick full-face gasket to a 1/16-inch annular configuratioThe design change was implemented per work order WO 0821400, which also conducted maintenance to address flange JTR005 alignmenThe root cause was that the 1/16 inch annular gasket installed under 08MSE211 was an inadequate design for the flange specific conditionThe combination of thinner gasket annular design, cupped surfaces, flexed flange, flange gap and bolt loosening from vibration resulted in gasket compression well below the minimum requireThe gasket vendor specified a bolt pre-load to achieve a 6000 psi compressive force, with a minimum of 3244 psi needed to make the flange connection leak tighNextEra found that most of the gasket surface was at 1000 psi or lesThis resulted in an essentially free floating gasket with no sealing pressure in the area where the gasket faileThus, even though flange JTR005 successfully passed a post work test as part of WO 0821400 on January 31, 2009, the as-built gasket design and flange conditions in combination with vibrations which loosened the bolts, left flange JTR005 in a condition to fail with continued B EDG operatioThe cause of the flange JTR005 leak on February 25 was the inadequate design and design control measures used to change the flange gasket from full face to annular configuratioDesign Change 08MSE211 addressed leakage considerations by stipulating attributes in the gasket design that address compressive loaMSE211 did not address the suitability of the gasket design with adequate consideration of the flange performance historThe gasket design did not adequately consider flange specific conditions (bowing under pre-load, surface irregularities), misalignment (gap) or the effects of vibratioMSE211 and WO 0821400 stipulated that the flange condition was required to be "true and flat," but provided inadequate instructions to the workers on how to achieve the required conditionThe work was assumed to be within the skill of the workeThe work order was also intended to correct flange JTR005 alignment issueNextEra concluded the excessive gap found between the flange faces was likely caused by the welding completed during WO 082140Although 08MSE211 stated, "reweld as required ensuring piping is not pulled," the design control measure was inadequate because no specific guidance was provideSimilarly, although WO 0821400 stated the repair "should eliminate any misalignment issues providing care is taken not to 'pull' the flange in final weld out," the work order provided no guidance on how to verify or measure flange JTR005 alignment after weldinDesign change 08MSE211 and WO 0821400 failed to adequately control the welding process relative to flange alignment; failed to address flange specific irregularities; and failed to address vibration that could impact bolt torque and gasket compressive loaAs a consequence, the B EDG jacket water cooling line was left in a condition to fail at flange JTR005 with continued B EDG operatioThe inspectors determined that this was a performance deficiencEnclosure  The inspectors also determined that the primary contributing cause for the performance deficiency was that NextEra did not adequately use internal operating experience or adequately evaluate deficient conditions when addressing the B EDG cooling water flange issueThe work control, corrective action and engineering records show a documented history of leakage from flange JTR00While preparing and implementing the gasket design change per 08MSE211, NextEra did not adequately research the performance history for flange JTR00Readily available plant operating experience showed that a flexible gasket material installed under 06MSE037 was a proven design providing leak free service for two yearThe flexible gasket design could better tolerate flange surface imperfections, was better for a flange experiencing vibrations, and could better accommodate gaps between flange surfaceHad the performance history been adequately considered, NextEra could have either retained the 06MSE037 proven design, or better prepared the 08MSE211 design change to address flange JTR005 conditionFurther, NextEra did not thoroughly evaluate problems such that resolutions addressed causeSpecifically, during the repairs to flange JTR005 per WO 0821400, on January 29, workers requested the use of a locking mechanism on the flange because the fasteners were found less than the required torque (CR200901470). In an evaluation dated February 5, 2009, NextEra concluded a locking feature would be evaluated if the fasteners were loose in the futurThe flange failed during the next EDG run on February 2The failure to adequately review the request for locking devices or evaluate why they were needed was a missed opportunity to prevent vibration induced loosening of the flange boltLocking wires were added to the flange as part of the subsequent design change and repair activity under EC14490AnalysiThe performance deficiency associated with this finding was that inadequate design  control measures used to correct flange alignment and change the gasket design on the B EDG right bank turbocharger jacket water cooling line resulted in the B EDG cooling water line failure on February 25, 200The Seabrook design control manual requires that the design measures for safety related systems consider the equipment performance history and whether materials are suitable for the application and conditionSpecifically, design change 08MSE211 was inadequate because it did not adequately consider the flange performance history and the suitability of gasket materials and thickness relative to flange specific conditions (cupping and bowing); it did not adequately consider welding stresses during repair and then failed to assure flange alignment was acceptable after welding; and, it did not address the impacts of known vibrations on flange performance and gasket compressive loaThe inspectors determined that this finding is more than minor because it is associated with the design control attribute of the Mitigating Systems Cornerstone and affects the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequenceSpecifically, design modification 08MSE11, intended to address flange JTR005 alignment and change the gasket design was inadequate and resulted in inoperability of the B EDIn accordance with IMC 0609, "Significance Determination Process," Phase 1 worksheets, a Phase 2 risk analysis was required because the finding represents an actual loss of safety function of a single train for greater than the TS allowed outage time of 14 dayThe Phase 2 risk evaluation was performed in accordance with IMC 0609, Appendix A, Attachment 1, "User Guidance for Significance Determination of Reactor Inspection Findings for At-Power Situations."  The total exposure period for the degraded condition 6 Enclosure was approximately 625 hours (26 days). Using Seabrook's Phase 2 SDP notebook, pre-solved worksheets, and an initiating event likelihood of 3-30 days, the inspector identified that this finding is of potentially substantial safety significance (Yellow). The finding affected sequences in the loss of offsite power (LOOP) and LOOP and Loss of Class 1E 4.16 kV AC Bus A (E5) (LEACA) worksheetFor the LOOP condition, sequences that resulted in a station blackout (SBO) were the dominant contributor to core damage. For the LEACA condition, sequences that involved a stuck open relief valve were the dominant contributor to core damagThe sum of the sequences in the LOOP and LEACA, for the identified exposure period resulted in a YelloIn recognition that the Phase 2 notebook typically yields a conservative result, a NRC Region I Senior Reactor Analyst (SRA) performed a Phase 3 risk assessment of this findinThe SRA used the Seabrook Standardized Plant Analysis Risk (SPAR) model, Revision 3.50, dated July 2, 2009, and Graphical Evaluation Module (GEM), in conjunction with the System Analysis Programs for Hands-On Integrated Reliability Evaluations (SAPHIRE), Version 7, software to estimate the internal risk contributioIn discussions with the licensee, it was discovered that the SPAR model for Seabrook did not credit instrument air accumulatorInformation on these backup accumulators was included in the SDP notebooAdditionally, Seabrook questioned the modeling of switchgear ventilation and provided design information to support the modeling revision to reflect the design success criteriThe SRA worked with Idaho National Laboratory (INL) and modified the model to correct the instrument air dependencies and modified the ventilation success criteriSpecific changes included: 1. Basic event SWS-FAN-FC-RMCOOL (1E-3) was added to the SWS switchgear cooling fault trees (EPS-DGNA-SWS, EPS-DGNB-SWS, SWS-RMCLA, SWS-RMCLB). This event was ANDed with the existing SWS switchgear ventilation logi. Basic event IAS-TNK-FC-ADV (4.8E-8) was added to the atmospheric steam dump valve (ADV) air supply fault tree (MSS-ADVS-AIR). This event allows operation of the ADVs based on the air supply of the accumulatorThe information provided indicated that these accumulators would facilitate 10 cycles over a period of 10 hourThe following assumptions were used for this assessment:  1. To closely approximate the type of failure exhibited by the B EDG, the SRA used the B EDG failure to run basic event <EPS-EDN-FR-1B > and changed its failure probability to 1.0, representing a 100 percent failure-to-run condition. 2. The exposure time for this condition was 625 hours (546.95 hours, plus 77.75 hours of unavailability during troubleshooting and repair). 3. Based upon the nature of the failure, no additional operator recovery credit was        provide. All remaining events were left at their nominal failure probabilitie. Cutset probability calculation truncation was set at 1E-1Based upon the above assumptions, the Seabrook SPAR model internal contribution to conditional core damage probability (CCDP) was calculated at 1.8E-This low E-6 delta CCDP value represents a low to moderate safety significance (White). The dominant internal event sequences involve a loss of offsite power event with subsequent failure of the A EDG and the supplemental emergency power system (SEPS) resulting in a Station 7 Enclosure Black OuAdditionally, the site fails to recover a diesel generator within four hours and the failure to recover offsite power within four hours. These Phase 3 SPAR model results correlate well to the Phase 2 SDP Notebook dominant core damage sequenceThe Seabrook Probabilistic Safety Assessment (PSA) is a full scope model that includes events such as seismic events, internal fires and internal floodThe PSA summarizes the contribution mainly from a turbine building fire or flooding as representing approximately 31% of the total (internal and external) core damage frequency, or nearly one third of the annualized risFor the given exposure period this equates to an external events delta CCDP of 4.7E-The NRC does not have an external risk model for SeabrooConsequently, the SRA used the licensee's external risk assessment to quantify the external risk contribution for this conditioThe SRA used IMC 0609, Appendix H, "Containment Integrity Significance Determination Process," to determine if this finding was a significant contributor to a large early releasThe Seabrook containment is classified as a pressurized water reactor large-dry containment desigBased upon the dominant sequences involving loss of offsite power and station blackout (SBO) initiating events, per Appendix H, Table 5.2, "Phase 2 Assessment Factors - Type A Findings at Full Power," the failure of the B EDG does not represent a significant challenge to containment integrity early in the postulated core damage sequenceConsequently, this finding does not screen as a significant large early release contributor because the close-in populations can be effectively evacuated far in advance of any postulated release due to core damagAccordingly, the risk significance of this finding is associated with the delta CDF value, per IMC 0609, Appendix H, Figure 5.1, and not delta LERThe Seabrook model used to evaluate the condition was RISKMAN model DBGOOS which was based on SB2006NFor the given assumptions, for a failure of the B EDG to run, over the given exposure period, the licensee calculated CDF was 1.48E-The contribution from internal events was 1.01E-6, and external event contribution was 4.7E-Similar to the NRC internal risk contribution, Seabrook's model illustrates that the largest percentage of internal risk is derived from station blackout eventFor the given assumptions, the licensee and NRC results are in close agreemenAs a result, the calculated total risk significance of this finding is based upon NRC analysiThe calculated risk is the summation of internal and external risk contributions (delta CCDP internal + delta CCDP external (fires and floods) = delta CCDP total) which equates to; 1.8E-6 + 4.7E-7 = 2.27E-6 delta CCDAnnualized, this value of 2.27E-6 delta CDF represents a low to moderate safety significance or White findinThe cause of the finding is related to the corrective action component of the cross-cutting area of problem identification and resolution in that the licensee failed to thoroughly evaluate problems in a timely manner such that resolutions address causes (P.1(c)). Specifically, NextEra failed to adequately evaluate deficient conditions when addressing B EDG cooling water flange leaks, failed to adequately use readily available internal operating experience, and failed to adequately evaluate and correct the impact of engine vibrations on flange JTR005 integritEnforcemenCFR 50, Appendix B, Criterion III, "Design Control," states, in part, that measures shall be established to assure that regulatory requirements and the design basis for systems and components are correctly translated into specifications and 8 Enclosure instructionMeasures shall also be established for the selection and review for suitability of application of materials and parts that are essential to the safety-related functions of the systems and componentThe Seabrook Station Design Control Manual (DCM) was developed pursuant to the above to establish design control measures for safety related components, including the emergency diesel generatorDCM Chapter 2, Section 8.0, describes the Maintenance Support Evaluation (MSE) as the design control measure to implement in support of maintenancWhen preparing the MSE, the DCM requires that the design inputs and interdisciplinary review guidelines on Figures 4-1-1 through 4-1-14 shall be used to prepare and develop the design change and understand the areas impacteDCM Figure 4-1-1, Design Inputs, and Figure 4-1-3, Independent Reviewer Guidelines, requires that the design shall consider mechanical requirements such as stresses and vibration; whether materials are suitable for the application; credible failure modes of connected equipment; and, account for equipment performance historContrary to the above, design change 08MSE211, implemented by Work Order 0821400 on January 29 - 31, 2009, to modify and repair a two bolt flange (joint JTR005)
on the B EDG right bank turbocharger, did not adequately consider: mechanical requirements such as stresses and vibration; whether materials were suitable for the application; credible failure modes of connected equipment; and, account for equipment performance historSpecifically, design change 08MSE211 and WO 0821400 did not adequately address the suitability of materials relative to flange specific conditions (cupping and bowing); did not adequately control welding stresses during repair and did not assure post weld flange alignment was acceptable; did not adequately consider the flange performance history and potential failures; and, did not address the impacts of known vibrations on flange performance and gasket compressioAs a result, the B EDG turbocharger flange JTR005 was left in a condition to fail with continued B EDG operation, and the diesel was declared inoperable during a test on February 25, 2009, when the flange gasket blew out causing a rapid loss of jacket cooling wateThis issue was entered into Seabrook's corrective action program as CR 19144Pending final determination of significance, this finding is identified as an AV (AV 05000443/2009007-01, Inadequate B EDG Design Change). Therefore URI 05000443/2009002-01 was closeOA6 Meetings, Including Exit  Exit Meeting Summary  On July 16, 2009, the resident inspectors presented the inspection results to Mr. Paul Freeman and other members of his staff, who acknowledged the findinNextEra acknowledged that none of the material examined by the inspectors during the inspection was considered proprietary in naturEnclosure 4OA7 Licensee-Identified Violation  The following violation of very low safety significance (Severity Level IV) was identified by NextErIt was a violation of NRC requirements that met the criteria of Section VI of the NRC Enforcement Policy, NUREG-1600, for being dispositioned as a non-cited violation (NCV).


10 CFR 50, Appendix B, Criterion XVI, Corrective Action, requires that measures be established to assure that conditions adverse to quality are promptly identified and correcteIn the case of significant conditions adverse to quality, the measure shall assure that the cause of the condition is determined and corrective action is taken to preclude repetitioThe Florida Power and Light (FPL) Energy Quality Assurance Topical Report (QATR) was written pursuant to the above and states in Section A-6 that FPL implements a corrective action program to promptly identify and correct conditions adverse to qualitProcedure PI-AA-205 requires that significant conditions adverse to quality be resolved through corrective actions to prevent recurrencContrary to the above, NextEra Nuclear Oversight issued a finding on April 9, 2009, (QR 090-017) after determining that past corrective actions for B EDG turbocharger vibration issues were inadequate and have not been effective based on a past and recent history of increased vibration, bolt failures, bolt loosening, turbocharger related coolant piping weld failures, coolant system leaks and a failure in some instances to document these conditions in the condition reporting systeThe failure to resolve long standing and increasing vibration and related issues for the B EDG constituted ineffective corrective actioThe finding was more than minor because the ineffective action to resolve turbocharger vibrations impacted the availability and reliability of a mitigating systeFurther, turbocharger vibration was causal to the B EDG failure on February 25, 2009 (reference Section 1R18 above). The finding had very low safety significance because it did not involve a loss of safety function or impact the safety function for a time greater than the allowed outage time in the technical specificationWhile increased vibrations were causal to the February 25th B EDG failure, they were not the root cause since the cooling water system would have failed due the inadequate gasket design and irregular flange conditionFurther, the finding identified in QR 09-017 is separate from NRC Violation 20090701 since the inadequate design change resulting in the February 25 B EDG failure occurred during the discrete time period of January 29-31, 2009, whereas the corrective actions for the B EDG turbocharger vibrations have been ongoing for a longer period of time (reference 2001 CR 200107312). The inspectors determined that the Criterion XVI violation was licensee-identifieNextEra entered the issue into the corrective action program as CR 0019437A-1 Attachment SUPPLIMENTAL INFORMATION  KEY POINTS OF CONTACT Licensee personnel R. Arn, Engineering K. Browne, Assistant Operations Manager R. Campo, Plant Engineer P. Freeman, Plant General Manager G. Kim, Risk Analyst K. Kiper, Risk Analyst N. Levesque, Engineering Supervisor E. Metcalf, Operations Manager M. Ossing, Engineering Support Manager M. Palumbo, Plant Engineer R. Plante, Maintenance Supervisor R. Samson, Maintenance Supervisor G. St. Pierre, Site Vice President  LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED  Opened 05000443/2009007-01 AV Inadequate B EDG Design Change  Closed  05000443/2009002-01 URI B EDG Emergency Shutdown During Testing on 2/25/09  LIST OF DOCUMENTS REVIEWED  Miscellaneous Operations Logs - Various MRC Associates Report, Modal Analysis of the Turbocharger on the B EDG, June 1992 Fairbank Morse Engineering Report, Turbocharger Vibration, September 27, 1991 Risk Significance of DG-B Failure February 25, 2009, 5/7/09 and 5/27/2009 Engineering Evaluations EE-09-002, Revision 0, 6/24/09; Revision 1, 7/29/09 B EDG Vibration Monitoring Data System Engineering Notes on B EDG turbocharger vibrations, July 1999 Fairbank Morse/Coltec Industries Engineering Report, Turbocharger Vibration, 9/27/91 ARC Associates Report, Modal Analysis of the Turbocharger Section of the B Diesel Generator, 6/9/92
7. On August 7, and August 24, 2009, work management guidance documents were revised to provide meeting structure, bases, and expectations for the diesel pre-maintenance and pre-start challenge meetings.8. On August 27, 2009, the Design Change Manual was changed to require challenge boards for all MSPs for high risk/low margin systems.IJ.b. Results Achieved There have been no failures of the emergency diesel generators since the corrective actions have been implemented.


Condition Reports Root Cause Analysis for CR 191440, 194370 Action Requests 00191440, 00191586, 00191608 CR200901470, CR199917417, CR200901470, CR200107312, CR200304671, CR200509803, CR200210604, CR200412056, CR200505245, CR200509803, CR200800136, CR200801690, CR200809251, CR200809307, CR200901505 A-2 Attachment Design Changes DCR 94-00012, EDG Safety Classification Review, DCN 01 06MSE037, EDG Cooling Water System Gasket Replacement (AFLAS) 00MMOD531, EDG Turbocharger Cooling Water Piping Upgrade, DCN 12 94-064, D.G. Cooling Water System Gasket Replacement, Rev 01 08MSE211, EDG Turbocharger CC Water Piping Optional Gasket Configuration and Bolting Type EC144905, EDG Turbocharger CC Piping Outlet Cover Modification/Gasket Replacement
III. Corrective Steps to Avoid Further Violations 1. The Engineering Director performed an in-field case study with the Engineering Fix It Now (EFIN) group and each Design Engineering group using the root cause evaluation document to discuss the timeline, event and lessons learned, as well as the memo issued from the Engineering Director to the entire Engineering Department dated 6/4/09 discussing lessons learned and key takeaways, and highlighting actual versus expected performance.


Drawings Drawing B20466, DG Cooling Water System Detail Drawing 1-NHY-310882, CWD for Pressurizer Pressure Control Valve PCV-456B P&ID 1-NHY-506402, DB - DG B Lube Oil System Control Loop Diagram P&ID 1-NHY-504120, DG - DG Temperature Scanner Logic Diagram P&ID 1-NHY-310008, 4160 Bus E6 One Line Diagram P&ID 1-DG-B20463, Diesel Generator Lube Oil System Train B Detail 1-NHY-310002, Unit Electrical Distribution One Line Diagram, Rev. 40 1-NHY-310010, D1A and DG-1B One Line Diagram Sh.1, Rev. 14 1-NHY-310010, DG-1A and DG-1B One Line Diagram Sh.2, Rev. 4  Work Orders Work Orders (WO) 0821400, 0812472, 0442764, 05131067, 072419, 0805715, 01185637  Procedures PI-AA-205, Condition Identification and Corrective Action PI-AA-01, Corrective Action and Condition Reporting ES0815.002, General Welding Procedure, Rev 00, Chg 21 ES0815.004, Welding of Carbon Steel Materials, Rev 00, Chg 08 ES1807.001, Visual Examination Procedure for Welding, Rev 07, Chg 02 MA-AA-203, Work Order Planning Process, Rev 5 MA-AA-202, Work Order Execution Process, Rev 2 MS0517.03, Flange Maintenance, Rev 9
This action was completed on October 31, 2009.2. The NextEra Energy Design Control Manual (NADC) has been revised to: 1) address Failure Modes and Effects Analysis (FMEA) of new designs, and, 2) add instructions to address equipment/material/installation tolerances.


Manuals FPLE Quality Assurance Topical Report (QATR), Section A-6, "Corrective Action" Design Change Manual (DCM), Revisions 37- 45 DCM Sections 1.0, 2.0 andDCM Figures 4-1-1 through 4-1-14  DCM Figure 4-1-1, Design Inputs DCM Figure 4-1-3, Independent Reviewer Guidelines A-3 Attachment LIST OF ACRONYMS  AR  Action Request CR  Condition Report DCM  Design Control Manual EDG Emergency Diesel Generator LERs  Licensee Event Reports MSE  Maintenance Support Evaluation NCV                Non-Cited Violation NRC  U.S. Nuclear Regulatory Commission NRR  Nuclear Reactor Regulation PARS  Publicly Available Records RB  Right Bank RV                  Reactor Vessel SDP Significance Determination Process TS Technical Specifications UFSAR Updated Final Safety Analysis Report WO                  Work Order
This action was completed on August 27, 200 SBK-L-09243 Attachment Page 4 of 4 IV. Date When Full Compliance Was Achieved A new flange design, which included a gasket with a more robust design, was developed and installed in the B EDG cooling system, the diesel surveillance was completed and the B EDG was declared operable on March 2, 2009. Full compliance was achieved when the diesel was declared operable.
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Revision as of 15:10, 24 August 2018

Seabrook Station - Reply to Notice of Violation: EA-09-145 Re IR 05000443-09-007
ML093490999
Person / Time
Site: Seabrook NextEra Energy icon.png
Issue date: 12/11/2009
From: St.Pierre G
NextEra Energy Seabrook
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
EA-09-145, IR-09-007, SBK-L-09243
Download: ML093490999 (6)
v • d • e


Text

NExTera" December 11, 2009 Docket No. 50-443 SBK-L-09243 U.S. Nuclear Regulatory Commission Attention:

Document Control Desk Washington, DC 20555-0001 Seabrook Station Reply to a Notice of Violation, EA-09-145 References:

1. Seabrook Station, Unit No. 1 -NRC Inspection Report 05000443/2009007; Preliminary White Finding, dated August 28, 2009.2. Final Significance Determination of White Finding with Assessment Followup, and Notice of Violation (NRC Inspection Report No. 05000443/2009007, Seabrook Station, Unit No. 1), dated November 12, 2009.NextEra Energy Seabrook, LLC (NextEra Energy Seabrook), has reviewed the subject Notice of Violation and files the attached Reply to Enforcement Action 09-145 pursuant to 10 CFR 2.201.If there are any questions regarding this letter, please contact Mr. Michael D. O'Keefe, Seabrook Licensing Manager, at (603) 773-7745.

Sincerely,NextEra Energy Seabrook, LLC Gene St. Pierre Vice President North cc: S. J. Collins, NRC Region I Administrator D. L. Egan, NRC Project Manager W. J. Raymond, NRC Senior Resident Inspector NextEra Energy Seabrook, LLC, P.O. Box 300, Lafayette Road, Seabrook, NH 03874 Attachment to SBK-L-09243 SBK-L-09243 Attachment Page 1 of 4 Statement of Violation:

During an NRC investigation conducted between February 25, 2009 and July 16, 2009, a violation of NRC requirements was identifie In accordance with the NRC Enforcement Policy, the violation is listed below: 10 CFR 50 Appendix B Criterion III, "Design Control," states, in part, that measures shall be established to assure that regulatory requirements and the design basis for systems and components are correctly translated into specification -and instruction Measures shall also be established for-the selection and review for suitability of application of materials and parts that are essential to the safety-related functions of the systems and components.

The Seabrook Station Design Control Manual (DCM), developed pursuant to the above to establish design control measures for safety related components, including the emergency diesel generators (EDG), states, in Chapter 2, Section 8.0, that the Maintenance Support Evaluation (MSE) is the design control measure to be implemented in support of maintenanc When preparing the MSE, the DCM requires that the design inputs and interdisciplinary review guidelines on Figures 4-1-1 through 4-1-14 shall be used to prepare and develop the design change and understand the areas impacte DCM Figure 4-1-1, Design Inputs, and Figure 4-1-3, Independent Reviewer Guidelines, requires that the design shall consider mechanical requirements such as stresses and vibration; whether materials are suitable for the application; credible failure modes of connected equipment; and, shall account for equipment performance history.Contrary to the above, on January 31, 2009, NextEra Energy Seabrook, LLC, completed Work Order 0821400 on the B EDG without adequately establishing measures to assure that regulatory requirements and the design basis for systems and components were correctly translated into specifications and instructions.

Specifically, design change 08MSE2 11, implemented by Work Order, to modify and repair a two bolt flange (joint JTRO05) on the B EDG right bank turbocharger, did not adequately:

(1) control welding stresses during repair, assure post weld flange alignment was acceptable, or address the impacts of known vibrations on flange performance and gasket compression; (2) address the suitability of gasket materials relative to flange specific conditions (cupping and bowing); and, (3) consider the flange performance history and potential failures to account for equipment performance history and credible failure modes of connected equipmen As a result, the B EDG turbocharger flange JTRO05 failed during the B EDG operation on February 25, 2009, causing a rapid loss of jacket cooling water and the EDG being declared inoperable.

This violation is associated with a White Findin SBK-L-09243 Attachment Page 2 of 4 NextEra Energy Seabrook's Reply to the Notice of Violation 1. Reason for Violation The root cause of the event was determined to be an inadequate gasket design for the turbocharger coolant outlet flange. The design change (MSE) was prepared, reviewed and approved without adequately assessing the following design inputs: 0 The joint's performance history* Evaluation of reported extrusion of the gasket 0 Possible failure modes for the new gasket design This inadequate assessment of design inputs was due to a failure to implement the Design Control programmatic requirement This resulted in the selection of a gasket design which was not appropriate for the application.

Contributing to the root cause were two process deficiencies:

1. The Challenge Board Process for EDG maintenance did not require the basis for maintenance activities that implement design changes.2. Additional requirements were added to the work control program to ensure the EDG is treated as a system and not as a component because the EDGs are a high risk/low margin system. While these controls historically have been successful in minimizing maintenance related issues from adversely impacting the EDGs, they did not require the same level of control to be applied to engineering processes involving the EDGs:* The MSE process did not require consideration of new failure modes.* The troubleshooting process did not include additional barriers for high risk / low margin systems.II.a. Corrective Actions Taken 1. On June 4, 2009, the Seabrook Site Engineering Director issued a memo to all Engineering personnel outlining expectations to address equipment performance history, installation tolerances, and to perform failure modes analysis for design changes. In addition, the memo provided expectations for the conduct of challenge boards for any Maintenance Support Package (MSP)[succeeded the MSE process] associated with high risk/low margin systems.2. On June 11, 2009, the Systems Engineering Manager coached the EDG system engineer on expectations to initiate condition reports (CRs) any time system parameters exceed normal/nominal values. In addition to the above listed process deficiencies, the system engineer failed to initiate CRs for SBK-L-09243 Attachment Page 3 of 4 unexpected, unwanted conditions which contributed to a lack of design input to the gasket design.3. On June 12, 2009, the Systems Engineering Manager discussed the event, the design change (MSP) and the root cause results with the preparer, reviewer and approver of the MSE. This included a reiteration of points made by the Engineering Director in a memo to the department, June 4, 2009.4. On June 12, 2009, the Site Maintenance Manager reinforced with all Maintenance shops the expectation to initiate CRs for all identified unwanted conditions.

5. On June 30, 2009, the Site Operations Manager issued a Read and Sign memorandum to Operations personnel reinforcing expectations for initiation of CRs.6. On July 16, 2009, the Site Engineering Director issued a memorandum to convey the expectation that all unwanted conditions will be documented in a CR for trending, even if the condition is corrected as part of the maintenance activity that discovered it. In addition, the personnel involved in the subject cooling spill were individually coached regarding this expectation.

7. On August 7, and August 24, 2009, work management guidance documents were revised to provide meeting structure, bases, and expectations for the diesel pre-maintenance and pre-start challenge meetings.8. On August 27, 2009, the Design Change Manual was changed to require challenge boards for all MSPs for high risk/low margin systems.IJ.b. Results Achieved There have been no failures of the emergency diesel generators since the corrective actions have been implemented.

III. Corrective Steps to Avoid Further Violations 1. The Engineering Director performed an in-field case study with the Engineering Fix It Now (EFIN) group and each Design Engineering group using the root cause evaluation document to discuss the timeline, event and lessons learned, as well as the memo issued from the Engineering Director to the entire Engineering Department dated 6/4/09 discussing lessons learned and key takeaways, and highlighting actual versus expected performance.

This action was completed on October 31, 2009.2. The NextEra Energy Design Control Manual (NADC) has been revised to: 1) address Failure Modes and Effects Analysis (FMEA) of new designs, and, 2) add instructions to address equipment/material/installation tolerances.

This action was completed on August 27, 200 SBK-L-09243 Attachment Page 4 of 4 IV. Date When Full Compliance Was Achieved A new flange design, which included a gasket with a more robust design, was developed and installed in the B EDG cooling system, the diesel surveillance was completed and the B EDG was declared operable on March 2, 2009. Full compliance was achieved when the diesel was declared operable.

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