IR 05000331/2009007: Difference between revisions
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{{Adams|number = ML091770606}} | {{Adams | ||
| number = ML091770606 | |||
| issue date = 06/26/2009 | |||
| title = IR 05000331-09-007; (May 5, 2009 - May 22, 2009), Duane Arnold Energy Center; Biennial Baseline Inspection of the Identification and Resolution of Problems | |||
| author name = Riemer K R | |||
| author affiliation = NRC/RGN-III/DRP/B2 | |||
| addressee name = Anderson R L | |||
| addressee affiliation = FPL Energy Duane Arnold, LLC | |||
| docket = 05000331 | |||
| license number = DPR-049 | |||
| contact person = | |||
| document report number = IR-09-007 | |||
| document type = Inspection Report, Letter | |||
| page count = 30 | |||
}} | |||
{{IR-Nav| site = 05000331 | year = 2009 | report number = 007 }} | {{IR-Nav| site = 05000331 | year = 2009 | report number = 007 }} | ||
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=SUMMARY OF FINDINGS= | =SUMMARY OF FINDINGS= | ||
...................................... | IR 05000331/2009007; (May 5, 2009 - May 22, 2009), Duane Arnold Energy Center; Biennial Baseline Inspection of the Identification and Resolution of Problems. This team inspection was performed by two regional inspectors, a resident inspector and the site resident inspector. Based on the results of this inspection, one Green finding was identified by the inspectors and is considered to be a Non-Cited Violation (NCV) of NRC regulations. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process" (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The 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 2006. Identification and Resolution of Problems Overall the corrective action program (CAP) program was adequate in that issues were identified at a low threshold, evaluated and corrected. Self-assessments and audits by Nuclear Oversight (NOS) were thorough and critical of the assessed areas. Operating experience was recognized as valuable, was appropriately evaluated, and was effectively communicated in daily plant meetings and pre-job briefings. Interviews with licensee staff and a review of the employee concerns program indicated that the licensee had a positive safety culture environment that encouraged identification of issues in the CAP. However, the inspectors identified several areas of concern that prevented the CAP from being an effective tool for performance improvement. There were examples where licensee staff failed to demonstrate a challenging, questioning attitude during issue screening and evaluation, where identified program weaknesses or vulnerabilities were accepted without a strong desire for change, and where management expectations were not reinforced. For example: | ||
* Ineffective trending has been a recurring issue since 2005, based on the results of NRC, industry and station assessments. However, fixing this problem does not appear to be a station priority. Although the pieces needed to have a successful program are largely in place, there does not appear to be a drive to actually implement the process. | |||
* There were some examples of CAP issues that were inappropriately challenged either at the Initial Screening Team (IST), Management Review Committee (MRC) or both. The inspectors observed instances where IST and MRC members accepted issues without challenging the information given or considering the overall impact of the issue on the safety/risk function of the component or system. | |||
* There was a tendency to perform myopic reviews focusing on the specific issue being evaluated and not on the underlying performance concern. Standards for performing cause evaluations were not being reinforced. There were several examples where the review of extent of condition, applicability of operating experience or the basis for the conclusion were either limited or not well documented. Although some of the issues were identified during the evaluation grading, there was no priority or impetus to change the incorrect behavior. | |||
===A. NRC-Identified=== | |||
and Self-Revealed Findings | |||
===Cornerstone: Mitigating Systems=== | |||
: '''Green.''' | |||
A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," was identified by the inspectors for a failure of the licensee to promptly identify and correct a condition adverse to quality (CAQ) associated with the 'D' river water supply (RWS) pump mounting base bolted connectors. The licensee's failure to evaluate the operability of the 'D' RWS pump due to the degraded bolting was considered a performance deficiency. By not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately identify the as-left condition of the stud threads, evaluate the impact that condition had on the seismic qualification of the pump, and implement appropriate corrective actions to resolve the degraded condition. The failure to promptly identify and correct a CAQ associated with the safety-related 'D' RWS pump was a violation of NRC requirements specified in 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action." The licensee entered this issue into the Corrective Action Program (CAP Item 067412), examined the pump mounting connectors, and initiated a prompt operability determination to evaluate the seismic qualification. Based on this evaluation, the 'D' RWS pump was declared Operable but degraded. The performance deficiency was determined to be more than minor because the issue was associated with the Mitigating Systems cornerstone attribute of equipment performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated this finding using the Significance Determination Process (SDP) and determined the finding was of very low safety significance (Green) because this finding was a design or qualification deficiency that did not result in a loss of operability of the safety component. The inspectors also determined that this finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the licensee did not promptly and completely identify an adverse condition in the CAP in a timely manner commensurate with its safety significance. [P.1(a)]. (Section 4OA2.1b.(1)) | |||
===B. Licensee-Identified Violations=== | |||
No violations of significance were identified. | |||
=REPORT DETAILS= | =REPORT DETAILS= | ||
==OTHER ACTIVITIES== | ==OTHER ACTIVITIES== | ||
{{a|4OA2}} | {{a|4OA2}} | ||
==4OA2 Problem Identification and Resolution== | ==4OA2 Problem Identification and Resolution== | ||
{{IP sample|IP=IP 71152B}} | {{IP sample|IP=IP 71152B}} | ||
................................................ 3 | The activities documented in Sections | ||
===.1 through .4 constituted one biennial sample of Problem Identification and Resolution (PI&R) as defined in IP 71152.=== | |||
===.1 Assessment of the Corrective Action Program Effectiveness=== | |||
====a. Inspection Scope==== | |||
The inspectors reviewed the licensee's corrective action program (CAP) implementing procedures and attended CAP program meetings to assess the implementation of the CAP by site personnel. | |||
The inspectors reviewed risk and safety significant issues in the licensee's CAP since the last NRC PI&R inspection in April 2007. The selection of issues ensured an adequate review of issues across the NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC documented findings as sources to select issues. Additionally, the inspectors reviewed CAP items generated as a result of facility personnel's performance in daily plant activities. The inspectors also reviewed CAP items and a selection of completed investigations from the licensee's various investigation methods, including root, apparent and common cause evaluations. | |||
The inspectors performed a more extensive review of the risk significant river water supply systems and the station operational decision making (ODMI) process. The review of the river water system consisted of a five year search of related issues identified in the CAP and discussions with appropriate licensee staff to assess the licensee's efforts in addressing identified concerns. | |||
During the reviews, the inspectors evaluated whether the licensee staff's actions were in compliance with the facility's CAP and 10 CFR Part 50, Appendix B requirements. Specifically, the inspectors evaluated if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the station's CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also evaluated whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and NRC findings, including NCVs. | |||
b. Assessment (1) Effectiveness of Problem Identification Overall the CAP program was adequate in that issues were identified at a low threshold, evaluated and corrected. Workers were encouraged to identify issues and were familiar with the various avenues available (NRC, CAP, etc). This was evident by the large 4 Enclosure number of CAP items generated annually, which were reasonably distributed across the various departments. A shared computerized database was used for creating individual reports and for subsequent management of the processes of issue evaluation and response. This included determining the issue's significance, addressing such matters as regulatory compliance and reporting, and assigning any actions deemed necessary or appropriate. | |||
However, there were some areas of concern that prevented the CAP from being an effective tool for performance improvement. There were examples where licensee staff failed to demonstrate a challenging, questioning attitude during issue screening and evaluation and where identified program weaknesses or vulnerabilities were accepted without a strong desire for change. Some specific examples were: | |||
* The inspectors observed an IST meeting reviewing CAP Issue Reports 67034 and 67028, involving foreign material found in the condensate storage tank. Both issues were screened as conditions not adverse to quality (NCAQ) on the basis that the tank was non-safety related. However, the IST failed to consider the impact the foreign material could have on the safety related high pressure core injection system, which takes suction from the CST during the initial stage of a design-basis accident. | |||
* The inspectors observed the MRC screening of CAP Issue Report 66544, regarding the potential overtorquing of the 'D' river supply pump mounting bolts. Although the report did not contain sufficient information to determine whether the pump was adequately mounted, this issue was not identified during the MRC screening. The pump is safety-related and is required to remain available during a seismic event. | |||
* Corrective Action Program Report 63741, was not considered a condition adverse to quality (CAQ) even though it identified potential degradation of cabling associated with the high pressure core injection, main steam isolation valves and reactor core isolation systems (all safety-related and/or risk significant systems). The issue had been identified during the 2009 refueling outage and was screened by the MRC. Other examples were also identified by the team and were discussed with licensee staff. The licensee initiated CAP Reports 67083 and 67412 for the above examples. Ineffective trending has been a recurring issue since 2005, based on the results of NRC, industry and station assessments. However, fixing this problem does not appear to be a station priority. Although the pieces needed to have a successful program are largely in place, there does not appear to be a drive to actually implement the process. The inspectors observed the following: | |||
* There was no stated expectation or procedural guidance regarding when to issue a trend (i.e., a minimum threshold); | |||
* From May 2008 to May 2009, over 9100 items were issued into the CAP, yet only 24 trend CAPs were initiated. Of these, 12 came from Operations and at least one from NRC; and | |||
* Some CAP evaluations (apparent cause evaluation (ACE) 1776, CAP 59216) had identified recurring events, yet there was no discussion or action to consider a common-cause evaluation. | |||
5 Enclosure This licensee initiated CAP Report 67330 for the issues with the trend program. The inspectors also noted that the licensee's procedures didn't state how risk significant, but non-safety related issues were classified. Specifically, the CAP procedures precluded these issues as being either CAQs or NCAQs, based on the specific definitions of these terms. Licensee staff was conditioned to classify only safety-significant issues as CAQs and all non-safety issues as NCAQs, regardless of risk significance. For example, CAP Report 63613, concerning degraded cabling for the main generator protection logic and turbine electro-hydraulic control systems, was screened as an NCAQ, but there was no documentation of whether the issue was risk significant or a potential plant reliability concern. The licensee initiated CAP Report 67361 to address this issue. The inspectors identified that contrary to ACP 1410.12, "Operator Burden Program," Rev. 16, (Section 3.2(4)), the Operations Manager was not presenting the status of the operator burden program to the plant health committee on a monthly basis. The licensee initiated CAP Report 67440 to address this issue. Findings Failure to promptly identify and evaluate the degraded condition associated with the 'D' RWS pump mounting base bolted connectors | |||
=====Introduction:===== | |||
A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," was identified by the inspectors for a failure of the licensee to promptly identify and correct a condition adverse to quality associated with the safety-related 'D' RWS pump. | |||
=====Description:===== | |||
On April 5, 2009, the 'D' RWS pump tripped approximately 30 seconds after being started from the control room. The pump was declared inoperable and an investigation commenced. The pump was found to be mechanically bound, with the motor supply breaker tripped on an over-current condition. A work request card (CWO A96711) was written and formal troubleshooting started. On April 7 the 'D' RWS pump was removed from the intake structure for repair. The pump was re-installed on April 13. The work was done, in accordance with the equipment-specific maintenance procedure, PUMP-J105-03, "Aurora/Johnston River Water Pumps," Revision 9. In accordance with this procedure, the pump mounting and discharge head flange bolts were torqued to 424-464 ft-lbs. | |||
During post-maintenance testing, the pump experienced high vibration readings, requiring removal and reinstallation of the pump bolts. During the reinstallation, one of the six bolts failed and the threads were stripped. The work was stopped and CAP Report No. 066544, was initiated. The CAP stated that one of the studs had stripped and that the other five studs were showing signs of thread degradation. | |||
The licensee identified that the actual, installed bolts (per the construction drawings) differed from those referenced in the maintenance procedure. This meant that the torque value stated in the procedure (424-464 ft-lbs) was incorrect. The correct value (based on the actual bolts installed) was 190-210 ft-lbs. Therefore, the pump mounting and discharge head flange bolts had been overtorqued. | |||
6 Enclosure The stripped stud was repaired and the remaining five studs were re-torqued to the correct value. However, these studs were not removed or inspected for thread degradation prior to being re-torqued. Following post-maintenance testing, the pump was declared operable on April 17 and the CWO was closed. A procedural change request was initiated to change the referenced torque value in the pump maintenance procedure. Corrective Action Program 066544 was reviewed by the MRC on April 16. The issue was properly characterized as a condition adverse to quality and the Engineering Department was tasked to perform a condition evaluation (CE 7353) addressing the extent of condition of the other RWS pumps. The completed CE was reviewed by the MRC on May 19. The MRC approved the CE, as documented, with no additional questions or changes. The inspectors noted that while the CE adequately addressed the condition of the other RWS pumps, it did not address the overtorquing of the five remaining studs on the 'D' RWS pump, specifically, whether any thread degradation had occurred which may impact the pump operability. The inspectors asked to review the documentation of the condition of the remaining five studs, specifically, whether the seismic qualification for the 'D' RWS pump was still within design bases. The licensee stated a visual examination of the studs was performed by the mechanical maintenance personnel during the final pump re-assembly and that the only documentation was the description in CAP 66544. The licensee also stated that an evaluation of the seismic qualification of the pump mounting had not been performed. The licensee initiated CAP 67412 to address the inspectors' concerns. Subsequently, the Shift Manager requested a prompt operability determination from the engineering department and the licensee initiated a work order (CWO A101663) to inspect and document the actual condition of the 'D' RWS pump mounting studs. The inspection identified no cracks, but found that all of the studs had from 3 to 5 degraded threads on each stud, amounting to anywhere from 100 percent (no thread available for engagement) to 25 percent of the thread missing. A subsequent licensee evaluation identified that the degradation significantly challenged the ability of the studs to meet the original design basis stress limits during either an operational or a design basis earthquake. Since calculations showed that the mounting stud threads would still meet the Appendix F ASME Section III code maximum allowable values, the 'D' RWS pump was declared Operable but degraded. A CAP item was initiated (OBD 000317) to ensure that the studs would be repaired no later than the next refueling outage. | |||
=====Analysis:===== | |||
The licensee's failure to evaluate the operability of the 'D' RWS pump due to the degraded bolting was considered a performance deficiency. By not performing this evaluation, the licensee failed to recognize that the affected studs had significant thread wear, and required replacement in order to restore the pump to full operability. | |||
Traditional enforcement did not apply since there were no actual safety consequences or potential for impacting the NRC's regulatory function, and the finding was not the result of any willful violation. The performance deficiency was more than minor because the issue was associated with the Mitigating Systems cornerstone attribute of equipment performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. | |||
Specifically, by not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately 7 Enclosure evaluate the impact the condition had on the seismic qualification of this safety-related component. The inspectors evaluated this finding using the SDP in accordance with IMC 0609, "Significance Determination Process," Attachment 0609.04, "Phase 1 - Initial Screening and Characterization of findings," Table 4a for the Mitigating Systems cornerstone. Since this finding is a design or qualification deficiency that did not result in a loss of operability of the safety component, the finding was determined to be of very low safety significance (Green). The failure to accurately and completely characterize the actual as-left condition of the studs precluded the ability to evaluate the potential impact the condition had on the seismic qualification of the safety-related component. The inspectors determined that this finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the licensee did not promptly and completely identify an adverse condition in the CAP in a timely manner commensurate with its safety significance. [P.1(a)] | |||
=====Enforcement:===== | |||
The 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, between April 14, 2009, and May 19, 2009, the licensee's initial identification, screening, evaluation, and implemented corrective actions associated with the over-torquing of the 'D' RWS pump mounting base bolted connectors, failed to promptly identify and correct a condition adverse to quality regarding the seismic qualification of safety related components. Specifically, by not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately identify the as-left condition of the stud threads, evaluate the impact that condition had on the seismic qualification of the pump, and implement appropriate corrective actions to resolve the degraded condition. Once this issue was identified by the inspectors, the licensee entered this issue into the CAP, examined the pump mounting connectors, and initiated a prompt operability determination to evaluate the seismic qualification. The 'D' RWS pump was subsequently declared Operable but degraded and a CAP tracking item was initiated to return the pump to the fully operable condition. Because this violation was of very low safety significance and issue was entered into the licensee's CAP, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000331/2009007-01). (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors observed that the majority of issues were of low level and were either closed to trend or at a level appropriate for a condition evaluation. Some of these issues were closed to a work request or to another CAP report, but the inspectors noted that both the parent and daughter documents had the necessary verbiage to document the interrelationship. Although fewer in number, the inspectors did not have any concerns with those issues assigned an ACE or root cause evaluation. There were no items in the operations, engineering, or maintenance backlogs that were risk significant, individually or collectively. The inspectors also identified no issues during the review of the ODMI process. | |||
8 Enclosure The inspectors observed that standards for performing cause evaluations were not being reinforced. There were several examples where the review of the extent of condition, applicability of operating experience, or the basis for the conclusion were either limited or not well documented. There was a tendency to perform myopic reviews focusing on the specific issue being evaluated rather than the underlying performance concern. | |||
* Apparent Cause Evaluation 1922 was written to investigate higher than expected dose rates in the radwaste surge tank following a water transfer. Although the ACE identified some issues with how water transfers were conducted in general, it only focused on the specific circumstances. Additionally, the ACE failed to consider whether previously identified operating experience could have prevented this event. | |||
* Apparent Cause Evaluation 1833 was written to investigate why one security crew did not have the necessary fire brigade trained personnel. Although the ACE identified a similar, prior event, there was no discussion of why the corrective actions from that event failed to prevent recurrence. | |||
* Apparent Cause Evaluation 1776 was written to investigate why a degraded cable issue had not been captured in the CAP. However, the ACE did not evaluate this issue, but only addressed the operability impact of the degraded cable. Additionally, the ACE identified several, similar prior events, but did not evaluate whether a common-cause evaluation was warranted. | |||
* Apparent Cause Evaluation 1780 was written to investigate an unposted high radiation area identified on the torus catwalk. The ACE had a very limited extent-of-condition evaluation and failed to consider whether previously identified operating experience could have prevented this event. | |||
* Apparent Cause Evaluation 1802 was written to investigate events where operating crews failed to maintain critical parameters within prescribed limits. The extent of condition was limited to a listing of internal operating experience and did not address other areas of plant operations where a similar condition could exist. Each of the above ACEs had been graded by the respective, initiating departments prior to issuance. | |||
In some cases, these issues were identified during the grading, but there was no expectation or impetus to change the "incorrect" behavior, as the ACEs received passing scores. The licensee initiated CAP Reports 67100, 67307, and 67331 to address the issues identified by the inspectors. Corrective Action Program Report 58355 was initiated after the licensee identified that the 'B' standby diesel generator lube oil temperature was high due to a failed switch. | |||
The MRC concluded that an ACE was not required as the cause of the issue was simple and known and that the extent of condition was understood. However, the inspectors noted that there was no causal analysis regarding why the switch failed. The licensee initiated CAP Report 58355 to evaluate why the cause of the switch failure was not evaluated. Findings No findings of significance were identified. | |||
9 Enclosure (3) Effectiveness of Corrective Actions The inspectors concluded that over the 2 year period encompassed by the inspection, the licensee implemented effective corrective actions. The inspectors identified no significant examples where problems recurred. However, the inspectors identified some examples where issues identified in CAP evaluations were not fully addressed by corrective actions. For example: | |||
* Root cause evaluations 1074 and 1075 addressed weaknesses in the CAP program identified by an industry audit. The evaluations identified several items of concern, yet there were no clearly identified corrective actions associated with each of these items. | |||
* Corrective Action Program Report 62896 was written to address an unexpected alarm on an average power range monitor (APRM) due to age related degradation of a relay. Although the CAP evaluation identified other, similar relays susceptible to similar failure in the APRM system (which was safety-related), there were no corrective actions to evaluate the plant risk in order to prioritize repairs. The above examples were due, in part, to the issues with the quality of the cause evaluations discussed above, and will be addressed in the associated CAP report items. However, the licensee did initiate CAP Report 67237 to evaluate the issues with root cause evaluations 1074 and 1075. The inspectors also identified numerous examples where extensions for corrective actions were granted without having an adequate basis or documenting the justification. | |||
The licensee issued CAP Report 65894 to address this issue. Findings No findings of significance were identified. | |||
===.2 Assessment of the Use of Operating Experience=== | |||
====a. Inspection Scope==== | |||
The inspectors reviewed the licensee's implementation of the facility's Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, observed daily station and pre-job briefings to observe the use of OE information, and reviewed completed evaluations of OE issues and events. The inspectors' review was to determine whether the licensee was effectively integrating OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensee's program was sufficient to prevent future occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and effectively and timely implemented. | |||
10 Enclosure b. Assessment In general, OE was effectively used at the station. The inspectors observed that OE was discussed as part of the daily station and pre-job briefings. Industry OE was effectively disseminated across the various plant departments and no issues were identified during the inspectors' review of licensee OE evaluations. During interviews, several licensee personnel commented favorably on the use of OE in their daily activities. | |||
Findings No findings of significance were identified. | |||
===.3 Assessment of Self-Assessments and Audits=== | |||
====a. Inspection Scope==== | |||
The inspectors assessed the licensee staff's ability to identify and enter issues into the CAP program, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits. | |||
b. Assessment The inspectors considered the quality of the NOS audits to be thorough and critical. The self-assessments were acceptable but, as expected, they were not at the same level of quality as the audits. The inspectors observed that CAP items had been initiated for issues identified through the NOS audits and self-assessments. The inspectors identified that the maintenance department, contrary to the other plant departments, had not performed a "quick-hit" self-assessment in the past 2 years. The licensee initiated CAP Report 67376 to address this issue. Findings No findings of significance were identified. | |||
===.4 Assessment of Safety-Conscious Work Environment=== | |||
====a. Inspection Scope==== | |||
The inspectors assessed the licensee's safety-conscious work environment through the reviews of the facility's ECP implementing procedures, discussions with ECP coordinators, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results of licensee safety culture surveys. The inspectors reviewed the following ECP case files (titles redacted): 09-06R, 06-03, 07-06, 07-03R, 08-05, 08-08, and 08-02. These files involved potential cases of harassment and intimidation for raising safety issues. b. Assessment The inspectors determined that the plant staff were aware of the importance of having a strong SCWE and expressed a willingness to raise safety issues. No one interviewed 11 Enclosure had experienced retaliation for safety issues raised, or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP process. | |||
These results were similar with the findings of the licensee's safety culture surveys. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable SCWE. | |||
The inspectors determined that the ECP process was being effectively implemented. The inspectors review of several, selected case files (generated from 2006-2009) concerning apparent cases of harassment and intimidation for raising safety concerns determined that the licensee had appropriately investigated and taken effective action to address the individual issues and promote a strong SCWE. However, during the interviews, several individuals did not know who the site ECP coordinator was nor were familiar with the site Differing Professional Opinion process (which was another forum, similar to the ECP, for raising safety issues). The inspectors also identified a potential vulnerability in the ECP process based on how issues were classified. Specifically, the inspectors noted that based on the classification, some issues had more relaxed requirements regarding documentation and feedback to the originator which may lead individuals to believe that the ECP was not effectively addressing issues. The licensee initiated CAP Report 67378 to address this concern. Findings No findings of significance were identified. | |||
{{a|4OA6}} | |||
==4OA6 Management Meetings== | |||
===.1 Exit Meeting Summary=== | |||
* On May 22, 2009, the inspectors presented the inspection results to Mr. Anderson and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary. | |||
* On June 16, 2009, the inspectors held a teleconference with Mr. Anderson and other members of his staff, to discuss the finding and NCV for the failure to identify and correct a CAQ associated with the 'D' RWS pump. ATTACHMENT: | |||
=SUPPLEMENTAL INFORMATION= | =SUPPLEMENTAL INFORMATION= | ||
==KEY POINTS OF CONTACT== | ==KEY POINTS OF CONTACT== | ||
Licensee * | |||
: [[contact::R. Anderson]], Site Vice President * | |||
: [[contact::R. Murrell]], Licensing Engineer | |||
: [[contact::D. Brigl]], Employee Concerns Investigator | |||
: [[contact::S. Catron]], Licensing Manager | |||
: [[contact::D. Curtland]], General Plant Manager | |||
: [[contact::M. Davis]], Emergency Preparedness Manager | |||
: [[contact::P. Dutcher]], Maintenance Support General Supervisor | |||
: [[contact::P. Giroir]], Operations Support Manager | |||
: [[contact::B. Porter]], Radiation Protection/Chemistry Manager | |||
: [[contact::G. Rushworth]], Assistant Operations Manager | |||
: [[contact::J. Schwertfeger]], Security Operations Supervisor | |||
: [[contact::J. Swales]], Mechanical Design Supervisor | |||
*Present during the June 16, 2009, teleconference | |||
Nuclear Regulatory Commission | |||
: [[contact::K. Riemer]], Chief, Branch 2, Division of Reactor Projects | |||
==LIST OF ITEMS== | ==LIST OF ITEMS== | ||
OPENED, CLOSED AND DISCUSSED .. | OPENED, CLOSED AND DISCUSSED | ||
===Opened and Closed=== | |||
: 05000331/2009007-01 NCV Failure to promptly identify and evaluate the degraded condition associated with the 'D' RWS pump mounting | |||
base bolted connectors (Section 4OA2.1b.(1)) | |||
Attachment | |||
==LIST OF DOCUMENTS REVIEWED== | ==LIST OF DOCUMENTS REVIEWED== | ||
............................................ | The following is a list of documents reviewed during the inspection. | ||
: Inclusion on this list does not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that selected sections of portions of the documents were evaluated as part of the overall inspection effort. | |||
: Inclusion of a document on this list does not imply NRC acceptance of the document or any part of it, unless this is stated in the body of the inspection report. | |||
: PLANT PROCEDURES Number Description or Title Date or Revision | |||
: NA-AA-200 Employee Concerns Program Process Description Revision 0 | |||
: PA-AA-102 Operating Experience Program Revision 0 | |||
: PI-AA-204 Condition Identification and Screening Process Revision 2 | |||
: PI-AA-205 Condition Evaluation and Corrective Action Revision 1 | |||
: NP-809 Nuclear Policy: | |||
: Safety Conscious Work Environment Revision 0 | |||
: NAP-412 Operational Decision-Making Revision 6 | |||
: NAP-424 Employee Concerns Program Revision 2 | |||
: CP 0060 Differing Professional Opinions Revision 0 | |||
: OP-001 Operator burden and clearance audit Revision 43 | |||
: ACP 101.01 Procedure use and adherence Revision 45 | |||
: ACP 102.35 Performance Monitoring and Improvement Revision 11 | |||
: ACP 114.8 Action Request Trending Revision 6 | |||
: ACP 1208.6 Equipment Reliability Process Description Revision 7 | |||
: ACP 1410.12 Operator burden program Revision 16 | |||
: MD-042 Bolting Practices Revision 9 | |||
: PUMP-J105-03 Equipment-Specific Maintenance Procedure AURORA/JOHNSTON River Water Pumps Revision 9 & 10 & 11 | |||
: Root Cause Evaluation Manual Revision 17 | |||
: Apparent Cause Evaluation Manual Revision 10 | |||
: CAP Trend Code Manual Revision 5 | |||
: Common Cause Effectiveness Manual Revision 3 | |||
: Corrective Action Effectiveness Manual Revision 3 | |||
: CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 035236 CAQ - A SBDG As-Found Frequency OOS During STP 3.8.1-06 3/11/2005 | |||
: CAP 036841 'A' River Water Supply Pump dp Not Within ASME Limits 6/20/2005 | |||
: CAP 037283 NCAQ - PCIS Maint. Rule Yellow Associated with PASS Decommissioning 7/29/2005 | |||
: CAP 042761 High RHRSW Strainer dp Alarm 6/16/2006 | |||
: CAP 042926 | |||
: CAQ-Upward Step Change in 'B' Recirc MG on 6/25/2006 6/16/2006 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 047115 | |||
: CAQ-Worker on Wrong RWP Has Dose Rate Alarm, HP Dispatched Finds High Rad Area 2/7/2007 | |||
: CAP 048889 Turbine Vibrations Not Returning to Expected Values 4/6/2007 | |||
: CAP 049550 RCIC LCO not entered for planned work as scheduled due to emergent work 5/7/2007 | |||
: CAP 049684 NCAQ Inaccuracies in the 2006 Annual Radiological Environmental Operating Report 5/10/2007 | |||
: CAP 049711 NRC DEP PI opportunities 5/11/2007 | |||
: CAP 049725 NRC weekly debrief 5/11/2007 | |||
: CAP 049726 NRC weekly debrief EP drill critique process 5/11/2007 | |||
: CAP 050247 Corrective Action Inventory at DAEC Continues to Increase on a Long Term Trend 6/7/2007 | |||
: CAP 050437 EP snapshot self-assessment on RCE corrective actions 6/15/2007 | |||
: CAP 050438 EP Snapshot self-assessment on RCE corrective actions 6/15/2007 | |||
: CAP 050594 Unplanned risk level of yellow due to severe thunderstorm watch 6/22/2007 | |||
: CAP 050635 Conduct operator training on transition for ED with ATWS 5/11/2007 | |||
: CAP 050636 LOR EOP training activities 6/25/2007 | |||
: CAP 051042 DAEC emergency plan table B-1 7/12/2007 | |||
: CAP 051129 | |||
: CAQ-CAs of | |||
: RCE 1029 Were Not Effective in Preventing Copper Coil Leak 7/17/2007 | |||
: CAP 051288 | |||
: CAQ-DAEC Year-to-Date Dose Increased Over 3000 millirem on Daily Exposure Rep. 7/24/2007 | |||
: CAP 051343 Focused Self Assessment of Design and Reliability of Intake Structures and Equipment 7/26/2007 | |||
: CAP 052666 CAQ - 50.72 notifications during EP drills 9/21/2007 | |||
: CAP 052776 | |||
: CAQ-Potential MOV Stroke Delay Times are Not Accounted For 9/26/2007 | |||
: CAP 052797 CAQ - Loss of Trending Data 9/27/2007 | |||
: CAP 052960 CAQ - Damage to 1B42 Bus Bars When Tagging Out 1B4234A 10/5/2007 | |||
: CAP 053115 | |||
: CAQ-Degraded Condition Not Documented in | |||
: CAP 10/12/2007 | |||
: CAP 053208 CAQ - CAP052817 did not consider past operability 10/16/2007 | |||
: CAP 053487 | |||
: NCAQ-Decrease in Indicated Core Flow 10/28/2007 | |||
: CAP 053759 NCAQ - Declining Trend in Training for CA Extension 11/9/2007 | |||
: CAP 053880 CAQ - 3Q07 Maintenance | |||
: DRUM-Increase in Clock Resets for the Quarter 11/16/2007 | |||
: CAP 054037 CAQ - Standby Transformer Voltage Concerns 12/10/2007 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 054053 CAQ - 'A' and 'B' SBDG Auto Start Due to 161KV Breaker Cycling (DAEC to Fairfax) 12/1/2007 | |||
: CAP 054293 | |||
: CAQ-Reactor Level Lowered 2 Inches Without Operator Action 12/14/2007 | |||
: CAP 055211 | |||
: CAQ-B Recirc Pump Seal Pressure Increase 2/1/2008 | |||
: CAP 055300 NCAQ - NOS Identified Negative Trend in Blocked Access to Fire Protection Equipment 2/5/2008 | |||
: CAP 055365 CAQ - PSV1800B Failed As-Found Seat Leakage Testing 2/7/2008 | |||
: CAP 055441 | |||
: CAQ-STREAM Analysis Driver-Management Tolerance of Performance 2/11/2008 | |||
: CAP 055559 | |||
: CAQ-NRC Identified Concern During CDBI 2/14/2008 | |||
: CAP 055801 | |||
: CAQ-Security Department Without Fire Brigade Personnel for 2 hours 2/25/2008 | |||
: CAP 056556 CAQ - Inconsistent, Non-standardized CAP Trending 3/25/2008 | |||
: CAP 057138 CAQ - Potential license operator restriction 4/22/2008 | |||
: CAP 057465 1E053B3 Expansion Bellows Leaking 5/7/2008 | |||
: CAP 057570 Trend - HCU Alarm 5/13/2008 | |||
: CAP 057678 | |||
: NCAQ-CV1569 Appears to Have Partially Cycled Based on Downstream Temperatures 5/18/2008 | |||
: CAP 057717 Confusion on Concurrent and Independent Verification 5/20/2008 | |||
: CAP 057980 CAQ - NRC commitment not met in past operability calculation 5/28/2008 | |||
: CAP 058085 1P205A and B Decreasing Vane Pass Trends 7/25/2008 | |||
: CAP 058097 | |||
: CAQ-1X001 Main Transformer Hot Connection 6/3/2008 | |||
: CAP 058142 'A' SBLC Pump Momentary Pressure Drop 6/4/2008 | |||
: CAP 058928 Fermanite Valve V07-0247 Repair 8/26/2008 | |||
: CAP 058978 'A' RHRSW Strainer dp Pegged Low 7/18/2008 | |||
: CAP 059090 NCAQ - Ops burdens review meetings 7/24/2008 | |||
: CAP 059294 'A' SFU Unit Required 1 Bolt & Nut to be Replaced 8/4/2008 | |||
: CAP 059308 Main Steam Line Temperatures Approaching Upper Limit 8/5/2008 | |||
: CAP 059348 Discrepancy Between Pipe Support Drawing Load and Calculation Loads 8/6/2008 | |||
: CAP 059388 | |||
: CAQ-SECR Pipe Supports Appear to Have Missing Bolts 8/7/2008 | |||
: CAP 059395 | |||
: CAQ-Undersized Bolt on A SFU Housing Flange 8/7/2008 | |||
: CAP 059432 Undesired Recirc Flow Changes 8/8/2008 | |||
: CAP 059444 RWS | |||
: STP-NS | |||
: 100102 Indicates 1P117D Degrading 8/10/2008 | |||
: CAP 059468 Pipe Support Discrepancies 8/11/2008 | |||
: CAP 059495 NCAQ - High risk activities not on the risk report or discussed at production meet 8/12/2008 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 059731 | |||
: CAQ-RCE 1076 CATPR 2.1 Corrective Actions May Not Have Been Effectively Implemented 8/22/2008 | |||
: CAP 059783 | |||
: CAQ-Both MSR Second Stage Drain Tanks (1T092A and 1T092B) Have One Controller 8/25/2008 | |||
: CAP 059861 | |||
: CAQ-HPCI Steam Exhaust Breaker Drawing Discrepancy 8/27/2008 | |||
: CAP 059892 | |||
: CAQ-HPCI Steam Exhaust Vacuum Breaker Piping Configuration Does Not Match Design Calc 8/28/2008 | |||
: CAP 060140 Error in HPCI Steam Exhaust Vacuum Breaker Piping Design Calc 9/10/2008 | |||
: CAP 060140 | |||
: CAQ-Mistake Discovered In the HPCI Steam Exhaust Vacuum Breaker Piping Design Calc. 9/10/2008 | |||
: CAP 060168 CAQ - NRC inspector question regarding HPCI SR 3.5.1.1 9/11/2008 | |||
: CAP 060168 | |||
: CAQ-NRC Inspector Question Regarding HPCI SR 3.5.1.1 9/11/2008 | |||
: CAP 060283 | |||
: NCAQ-HPCI Operability Questioned During Performance of A77986 9/16/2008 | |||
: CAP 060388 | |||
: NCAQ-Missing Fasteners in MG SET Room 9/18/2008 | |||
: CAP 060543 CAQ - Functionality assessment not performed 9/24/2008 | |||
: CAP 060616 Corrosion Noted on West Shell Flange on 1E053A Heat Exchanger 9/29/2008 | |||
: CAP 060874 Valve Installed in the Plant Not per the Design Documents 10/9/2008 | |||
: CAP 060968 CAQ - Potential Negative Trend Identified with Recent Scaffold Installations 10/14/2008 | |||
: CAP 061237 'B' Chiller Oil Pressure Continues to Degrade 10/23/2008 | |||
: CAP 061328 | |||
: NCAQ-Initiating an ODM Issue for Main Generator Low Frequency Alarms 10/27/2008 | |||
: CAP 061511 Anomalies Noted with 'B' SBDG Engine Overspeed Switch 11/4/2008 | |||
: CAP 061513 NCAQ - Question on LCO 3.8.1 Condition B required action B.3 11/4/2008 | |||
: CAP 061709 NCAQ - Work Request Card Voided to CAP That Was Closed to Trend 11/13/2008 | |||
: CAP 061725 | |||
: CAQ-Bolt Missing From Hanger (next to MO2202) 11/13/2008 | |||
: CAP 062741 CAQ - Failure to Address Trend in NRC Identified Issues 11/14/2008 | |||
: CAP 062046 | |||
: CAQ-NRC Cross-Cutting Findings 12/2/2008 | |||
: CAP 062175 | |||
: CAQ-Main Turbine Bypass Valve BV1 Position Feedback Signal is Intermittent 12/7/2008 | |||
: CAP 062246 NCAQ - | |||
: BV-1 False Open Signal-Need to Restore Reliability & Implement Bridge Strategy 12/10/2008 | |||
: CAP 062255 CAQ - Trend in low level HU errors in operations since 11/26/08 12/10/2008 | |||
: CAP 062569 Unplanned Reactor SCRAM due to Loss of Circ Pit Level 2/1/2009 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 062569 'C' RWS Pump dp Not Within ASME Limits 12/29/2008 | |||
: CAP 062602 'A' RWS Subsystem Inoperable Due to | |||
: HSS-2911A Out of Position 12/31/2008 | |||
: CAP 062760 | |||
: NCAQ-Missing Fasteners-Drywell EQ Boxes 1/9/2009 | |||
: CAP 062896 | |||
: CAQ-APRM Inop Trip with No Back Panel Indications 1/15/2009 | |||
: CAP 062919 CAQ - TS LCO 3.8.1b required action B.3 exited prematurely 1/15/2009 | |||
: CAP 062989 NCAQ - 4 | |||
th Quarter 2008 DAEC DRUMs to be Postponed 1/19/2009 | |||
: CAP 063486 | |||
: CAQ-Increased Dose Rates in Radwaste Surge Tank 2/3/2009 | |||
: CAP 063758 NCAQ - Potential trend in procedural use and compliance 2/7/2009 | |||
: CAP 063828 During the IVVI, FME Was Found in RPV 2/8/2009 | |||
: CAP 063867 | |||
: CAQ-Perform Aggregate Review of | |||
: ECP 1871 Related CAPs 2/9/2009 | |||
: CAP 063912 INR | |||
: IVVI-09-04 & -05 Steam Dryer Indications 2/10/2009 | |||
: CAP 064512 | |||
: CAQ-Diver in Torus Received Accum. Dose and Dose Rate Alarms on Electronic Dosimeter 2/20/2009 | |||
: CAP 064644 CAQ - Rack Dwg M155-012<7> 1C08 Depicts Freq Meter & Volt Meter Term. Incorrectly 2/19/2009 | |||
: CAP 064746 | |||
: CAQ-LLRT Spill Causes Concern in Clean Area: | |||
: RB 786' by Reactor Water Sample Valves 2/20/2009 | |||
: CAP 064786 | |||
: CAQ-Three Personnel Contaminations in the Hotwell 2/21/2009 | |||
: CAP 065300 NCAQ - Two risk reviews for the same evolution evaluated differently 2/27/2009 | |||
: CAP 065311 RFP Discharge Piping DBD003 Spring Can is Unable to be Set Properly 2/27/2009 | |||
: CAP 065874 | |||
: NCAQ-FO Boxes Missing Cover Screws 3/17/2009 | |||
: CAP 065970 NCAQ - MRC Identified Trend of CAP for Plugged Drains 3/20/2009 | |||
: CAP 066009 NCAQ - Initiating an ODMI for HP Turbine Steam Leak to Track Completion of Repair 3/23/2009 | |||
: CAP 066066 NCAQ - 1T93B Leak and CV1077B Observed cycling Full Open to Full Closed 3/25/2009 | |||
: CAP 066341 CAQ - 1P117D Trip 4/5/2009 | |||
: CAP 066485 CAQ - River Water Supply Pump D Failure 4/12/2009 | |||
: CAP 066528 NCAQ - Several Significance Level B CAPs Inappropriately Closed to a S/L C CAP 4/14/2009 | |||
: CAP 066544 CAQ - 1P117D-(1) Discharge Base Mounting Stud Threads Are Stripped 4/14/2009 | |||
: CAP 066724 CAQ - Overdue Focused Self Assessment 4/22/2009 | |||
: CAP 066855 NCAQ - Untimely Review of PI&R Inspection Self Assessment Report by MRC 4/27/2009 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: CAP 067412 CAQ - NRC PI&R Concerns With D River Water Pump Mounting 5/20/2009 | |||
: CAP 067433 Corrective Action Not Performed per | |||
: CA 50628 5/21/2009 | |||
: CE 5829 CAQ - Large Number of CAPs Initiated During 50.59/Mod Inspection 10/23/2007 | |||
: CE 6419 Trend in General Maintenance Misposition Events 5/14/2008 | |||
: CE 6616 CAQ - Recent Trend in Bolting Issues 8/13/2008 | |||
: CE 7149 NCAQ - Refuel Bridge Outage Performance Improvement 2/21/2009 | |||
: ACE 1488 High 'B' RHRSW Strainer dp 9/8/2005 | |||
: ACE 1727 STP Alarm Not Received As Expected 5/9/2007 | |||
: ACE 1736 Required Simulator Testing Not Finished on Time Revision 0 | |||
: ACE 1737 Plant Modifications Installed Without Adequate Training 5/24/2007 | |||
: ACE 1740 Repetitive Failure to Provide Satisfactory Corrective Action 6/1/2007 | |||
: ACE 1741 Trend in Configuration Control Loss During Fabrication & Welding 6/4/2007 | |||
: ACE 1767 Newly Installed RWS Check Valve Weight is Greater than Analyzed 9/18/2007 | |||
: ACE 1768 CAQ - Unplanned tech spec LCO for PAM Instrumentation Revision 0 | |||
: ACE 1773 CAQ - Unexpected APRM A, C & E upscale and 1/2 scram during STP 3.3.1.1-34 Revision 0 | |||
: ACE 1774 STP would render 'B' SBDG unavailable Revision 0 | |||
: ACE 1776 | |||
: CAQ-Degraded Condition Not Documented in | |||
: CAP 11/26/2007 | |||
: ACE 1780 | |||
: CAQ-Worker on Wrong RWP Has Dose Rate Alarm, HP Dispatched Finds High Rad Area 2/15/2008 | |||
: ACE 1788 NCAQ - Perform Common Cause Evaluation as Noted in Activity Description 8/31/2007 | |||
: ACE 1801 Evaluation of | |||
: OP.1-1 AFI from 2007 INPO plant evaluation Revision 1 | |||
: ACE 1802 2007 INPO AFI | |||
: OP.1-2 - Critical parameter monitoring Revision 0 | |||
: ACE 1807 INPO AFI | |||
: EN.1-1 1/15/2008 | |||
: ACE 1814 INPO AFI | |||
: OR.2-2 Revision 0 | |||
: ACE 1824 | |||
: CV-4914 Failed to Open Within ASME Acceptance Criteria 2/12/2008 | |||
: ACE 1833 | |||
: CAQ-Security Department Without Fire Brigade Personnel for 2 hours 3/24/2008 | |||
: ACE 1849 Apparent Cause Eval for Expansion Bellows Leakage 5/31/2008 | |||
: ACE 1860 Unusual event declared based on loss of communications capability Revision 0 | |||
: ACE 1872 Unplanned technical specification LCO due to failure of FY2747 Revision 0 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: ACE 1878 | |||
: CAQ-RCE 1076 CATPR 2.1 Corrective Actions May Not Have Been Effectively Implemented 10/10/2008 | |||
: ACE 1882 | |||
: CAQ-NRC Inspector Question Regarding HPCI SR 3.5.1.1 9/11/2008 | |||
: ACE 1883 Isophase Bus Duct Project Scope Change 9/17/2008 | |||
: ACE 1891 CCE - Five clearance preparation issues were identified between 9/24/08-9/29/08 Revision 0 | |||
: ACE 1901 Common Cause Evaluation | |||
: CAQ-NRC Cross-Cutting Findings 1/5/2009 | |||
: ACE 1904 | |||
: CAQ-Main Turbine Bypass Valve BV1 Position Feedback Signal is Intermittent 1/15/2009 | |||
: ACE 1908 'C' RWS Pump dp not within ASME Limits 1/5/2009 | |||
: ACE 1909 'A' RWS Subsystem Inoperable Due to | |||
: HSS-2911A Out of Position 12/31/2008 | |||
: ACE 1910 NCAQ - Adverse Trend in Missed Surveillances 1/16/2009 | |||
: ACE 1913 | |||
: CAQ-APRM Inop Trip with No Back Panel Indications 3/22/2009 | |||
: ACE 1917 Failed IST Closure Test - V23-0049 2/8/2009 | |||
: ACE 1918 | |||
: CAQ-Perform Aggregate Review of | |||
: ECP 1871 Related CAPs 3/2/2009 | |||
: ACE 1919 | |||
: CAQ-Perform Aggregate Review-ECP 1748-SBDG Governor Modification Activity Issues Common Cause Evaluation Due After the RFO | |||
(3/31/2009) 2/12/2009 | |||
: ACE 1922 | |||
: CAQ-Increased Dose Rates In Radwaste Surge Tank 2/24/2009 | |||
: ACE 1924 CAQ - CV4413, 'A' Outboard MSIV High Leakage 2/7/2009 | |||
: ACE 1926 Three Personnel Contaminations in the Hotwell 2/21/2009 | |||
: ACE 1927 Common Cause Evaluation | |||
: CAQ-LLRT Spill Causes Concern in Clean Area: | |||
: RB 786' by Reactor Water Sample Valves 3/30/2009 | |||
: ACE 1928 | |||
: CAQ-Diver in Torus Received Accum. Dose and Dose Rate Alarms on Electronic Dosimeter 4/29/2009 | |||
: ACE 1934 CAQ - Safety-Equipment Placed Into Operation Before Work Complete 3/9/2009 | |||
: RCE 1050 1K004 Compressor Overheats-Unplanned LCO 3/13/2006 | |||
: RCE 1053 RHRSW Pump Motor Cooler Inoperabilities Revision 3 | |||
: EFR 044304 Effectiveness Review for | |||
: RCE 1053 7/16/2008 | |||
: RCE 1067 Root cause analysis of 2006 LOR examination failures 6/26/2007 | |||
: RCE 1068 Ops training SA - teamwork between ops dept and ops training 5/2/2007 | |||
: RCE 1069 Organizational Responses Not Meeting Expectations 5/2/2007 | |||
: RCE 1070 Root cause analysis of control room simulator fidelity issues 6/27/2007 | |||
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision | |||
: RCE 1072 Damage to 1B42 Bus Bars When Tagging Out | |||
: 1B4234A 10/9/2007 | |||
: RCE 1072 A Loss of Vital Bus 1B42 (480 VAC) Revision 1 | |||
: RCE 1073 Steam Leak on 'B' RFP Min Flow Line Vent Revision 2 | |||
: RCE 1074 STREAM Analysis Driver-Ineffective Corrective Actions 4/24/2008 | |||
: EFR 049673 | |||
: CAQ-EFR for RC1 CATPR1 Ineffective Corrective Actions | |||
: RCE 1074 4/24/2008 | |||
: RCE 1075 Organization Tolerance of Performance 2/25/2008 | |||
: RCE 1076 CAQ - Danger Tag Hung and Verified on the Wrong Breaker 2/22/2008 | |||
: RCE 1077 SCAQ - Safety - DZNPS Electrician Receives Shock 10/14/2008 | |||
: RCE 1078 'B' EDG Output Breaker Trip 11/2/2008 | |||
: RCE 1079 'B' Cooling Tower West Riser Failure Revision 0 | |||
: RCE 1080 RFO21 Electrical Configuration Errors Revision 1 | |||
: OPERATING EXPERIENCE Number Description or TitleDate or Revision | |||
: CAP 018948 Deficiencies Identified Pertaining to Source Control 10/6/1997 | |||
: CAP 055830 | |||
: NCAQ-Rapid FPL Internal | |||
: OE-Turkey Point Clock Reset 2/26/2008 | |||
: CAP 057420 | |||
: NCAQ-Rapid OE PTN Valve Out-of-position 5/6/2008 | |||
: CE 6224 Rapid | |||
: OE-Turkey Point Site Clock Reset: | |||
: Wrong RWP Resulted In ED Alarm 2/28/2008 | |||
: CE 6293 | |||
: NCAQ-Rapid | |||
: OE-Turkey Point Configuration Control Issue and Potential HU Event 3/21/2008 | |||
: OE 21336 External Operating Experience 8/13/2007 | |||
: OE 23312 Perform OE Evaluation-GE | |||
: TIL 1588 Explosive Gas Mixture in Stator Water Tanks 10/31/2007 | |||
: OE 27315 Perform OE Evaluation-A 10CFR Part 21 Replacement Relief Valve Spring 3/21/2008 | |||
: OE 27347 Perform OE Evaluation-Part 21 GE CR120 Relay Coils 3/22/2008 | |||
: OE 29924 Perform OE Evaluation-NRC Information Notice | |||
: IN 2008-11, Service Water Degradations at Brunswick 6/23/2008 | |||
: OTH 20109 Source Control-I&C Use of Calibration 10/14/1997 | |||
: Attachment AUDITS, ASSESSMENTS AND | |||
: SELF-ASSESSMENTS Number Description or TitleDate or Revision | |||
: SA 20302 SnapShot Evaluation of the DAEC Probabilistic Risk Assessment (PRA) Program 6/22/2007 | |||
: SA 24116 Mechanical Maintenance Benchmarking Trip for Relief Valve Test Bench 11/29/2007 | |||
: SA 25100 Self Assessment of Systems Engineering Trending 1/8/2008 | |||
: SA 25844 Quick Hit Self-Assessment on Transformer, Switchyard, and Grid Reliability 2/4/2008 | |||
: SA 26184 NCAQ - Conduct a Fleet Self-Assessment of the Corrective Action Program 2/14/2008 | |||
: SA 28416 Perform Quick Hit Assessment on Snubber Program 5/1/2008 | |||
: SA 28418 ASME Repair / Replacement Program Self Assessment 5/1/2008 | |||
: SA 29096 FSA Conduct a Focused Self-Assessment of the Performance Improvement Programs 5/16/2008 | |||
: SA 29192 This Action Supersedes/Replaces | |||
: OTH 29156 and | |||
: SA 48465 5/20/2008 | |||
: SA 30765 NCAQ - Conduct a Quick Hit Self-Assessment on RCA Postings 7/31/2008 | |||
: SA 32236 Concept of Department Fundamentals is Not Understood in All Areas 9/29/2008 | |||
: SA 33284 Industry Focused Self-Assessment of | |||
: EPA 10/30/2008 | |||
: SA 34254 Evaluate station summer readiness Revision 1 | |||
: SA 35513 Perform a Quick-Hit Assessment of ODMIs 1/22/2009 | |||
: SA 36477 2009 DAEC Pre-PI&R CAP Self Assessment 4/29/2009 | |||
: SA 36716 Perform Quick Hit SA on DAEC Commitment Tracking Program 3/16/2009 | |||
: SA 37311 Post Outage Validation of PADS/Security Computer Active Personnel 3/31/2009 | |||
: SA 43996 Operating Experience Program 6/28/2007 | |||
: SA 44138 Conduct a Self-Assessment of the Conduct of Maintenance 10/3/2006 | |||
: SA 44139 Perform a Focused Self-Assessment for | |||
: FME 10/3/2006 | |||
: SA 44237 Mod / 50.59 Self Assessment 10/23/2006 | |||
: SA 45808 | |||
: ACP 1408.1 and Work Order Screening Improvements 4/25/2007 | |||
: SA 46247 SOER 02-04 Self Assessment 5/29/2007 | |||
: SA 46257 Mechanical Maintenance Benchmarking for Relief Valve Test Bench 11/29/2007 | |||
: SA 48037 Conduct of operations/operations fundamentals Revision 0 | |||
: SA 48470 NCAQ - Perform Benchmarking on I&C Human Performance Fundamentals 12/18/2007 | |||
: SA 48471 NCAQ - Perform Benchmarking of I&C Work Management, Scheduling, and Implementation 12/18/2007 | |||
: Attachment AUDITS, ASSESSMENTS AND | |||
: SELF-ASSESSMENTS Number Description or TitleDate or Revision | |||
: SA 48472 NCAQ - Perform Benchmarking of Electrical Safety and Flash Protection 12/18/2007 | |||
: SA 48474 NCAQ - Perform Benchmarking of Scaffold Control 12/18/2007 | |||
: PDA-08-011 2008 Radiation Protection Assessment 4/4/2008 | |||
: PDA-08-012 Systems Engineering 4/30/2008 | |||
: PDA-08-022 Corrective Actions 7/2/2008 | |||
: PDA-08-025 Corrective and Preventive Maintenance 8/14/2008 | |||
: PDA-08-040 Corrective Action Program 12/29/2008 | |||
: PDA-09-001 Security 1/27/2009 | |||
: PDA-09-005 Radiation Protection 4/20/2009 | |||
: PDA-09-013 Maintenance Planning and Scheduling 5/14/2009 | |||
: NG-07-0467 Quality Assurance Finding-"Corrective Program Deficiency Repetitive Failure to Provide Satisfactory Corrective Action" 5/29/2007 | |||
: CAP Problem Area Assessment August 2007 | |||
: CONDITION REPORTS GENERATED DURING INSPECTION Number Description or TitleDate or Revision | |||
: CAP 067083 NCAQ--2 CAPs Incorrectly Pre-Screened for IST 5/7/2009 | |||
: CAP 067100 | |||
: NCAQ-ACE OE Review Quality 5/7/2009 | |||
: CAP 067237 Inconsistent use of Root Cause Evaluation Process 5/14/2009 | |||
: CAP 067330 NRC PI&R Inspection-Trending Issues 5/19/2009 | |||
: CAP 067331 NRC PI&R Inspection ACE Quality Issues 5/19/2009 | |||
: CAP 067361 PI&R Identified Issue-CAP 63613 Classification as NCAQ Questioned 5/20/2009 | |||
: CAP 067376 PI&R Inspection Observation-Maintenance Self-Assessments 5/20/2009 | |||
: CAP 067378 NRC PI&R Inspection Observations-DPO Process 5/202009 | |||
: CAP 067398 PI&R Issue, | |||
: CAP 58355 | |||
: Did not have Causal Analysis of Switch Failure 5/20/2009 | |||
: CAP 067412 NRC P&IR Concerns with D River Water Pump Mounting 5/20/2009 | |||
: CAP 067433 NRC PI&R Inspection-Corrective Action Not Performed per CA50628 5/21/2009 | |||
: CAP 067440 NRC PI&R Inspection Operator Burden 5/21/2009 | |||
: CAP 067441 NRC PI&R Inspection-ECP "Out of Scope" Investigations 5/21/2009 | |||
: Attachment MISCELLANEOUS | |||
: Number Description or TitleDate or Revision | |||
: EMA A96711 1P117D 'D' RWS Pump Mounting Base Anchor Bolts Revision 0 CAL-IELP-M92- | |||
: 106 Seismic-Stress Analysis of Johnston Vertical Pump (25 | |||
: NLC-1 Stage Revision 0 | |||
: BECH-C016 Drawing-Standard Details Equipment Foundation Schedule Revision 21 | |||
===Work Orders=== | |||
: Number Description or TitleDate or Revision | |||
: CWO A80062 Replace 1P117D Pump-Indicated Degraded Condition 9/22/2008 CWO A96711 1P117D-Pull Pump-Repair Pump-Return Pump to Original Location 4/7/2009 | |||
: Department Roll-Up Meeting Reports Number Description or TitleDate or Revision | |||
: 3Q2008 DAEC Station DRUM Report 12/18/2008 3Q2008 DAEC Chemistry/Environmental DRUM Report 11/20/2008 3Q2008 DAEC Radiation Protection DRUM Report 11/18/2008 3Q2008 DAEC Operations DRUM Report 11/12/2008 3Q2008 DAEC Training DRUM Report 11/3/2008 3Q2008 DAEC Maintenance DRUM Report 11/21/2008 3Q2008 DAEC Engineering DRUM Report 11/19/2008 4Q2008&1Q2009 DAEC Radiation Protection DRUM Report 4/28/2009 4Q2008&1Q2009 DAEC Training DRUM Report 4/29/2009 4Q2008&1Q2009 DAEC Maintenance DRUM Report 4/30/2009 1Q2009 DAEC Engineering DRUM Report 5/10/2009 | |||
: Attachment | |||
==LIST OF ACRONYMS== | ==LIST OF ACRONYMS== | ||
: [[USED]] [[]] | : [[USED]] [[]] | ||
: [[ACE]] [[Apparent Cause Evaluation]] | : [[ACE]] [[Apparent Cause Evaluation]] | ||
Line 1,039: | Line 583: | ||
: [[DPO]] [[Differing Professional Opinion]] | : [[DPO]] [[Differing Professional Opinion]] | ||
: [[DRP]] [[Division of Reactor Projects]] | : [[DRP]] [[Division of Reactor Projects]] | ||
: [[DRUM]] [[Department Roll-up Meeting ECP Employee Concerns Program]] | : [[DRUM]] [[Department Roll-up Meeting]] | ||
: [[ECP]] [[Employee Concerns Program]] | |||
: [[EDG]] [[Emergency Diesel Generator]] | : [[EDG]] [[Emergency Diesel Generator]] | ||
: [[ESW]] [[Emergency Service Water]] | : [[ESW]] [[Emergency Service Water]] | ||
Line 1,045: | Line 590: | ||
: [[HELB]] [[High Energy Line Break]] | : [[HELB]] [[High Energy Line Break]] | ||
: [[HPCI]] [[High Pressure Coolant Injection]] | : [[HPCI]] [[High Pressure Coolant Injection]] | ||
: [[IMC]] [[Inspection Manual Chapter IN Information Notices]] | : [[IMC]] [[Inspection Manual Chapter]] | ||
: [[IN]] [[Information Notices]] | |||
: [[IP]] [[Inspection Procedure]] | : [[IP]] [[Inspection Procedure]] | ||
: [[IST]] [[Issue Screening Team]] | : [[IST]] [[Issue Screening Team]] | ||
: [[LER]] [[Licensee Event Report]] | : [[LER]] [[Licensee Event Report]] | ||
: [[LPCI]] [[Low Pressure Coolant Injection MG Motor-Generator]] | : [[LPCI]] [[Low Pressure Coolant Injection]] | ||
: [[MG]] [[Motor-Generator]] | |||
: [[MOV]] [[Motor Operated Valves]] | : [[MOV]] [[Motor Operated Valves]] | ||
: [[MPFF]] [[Maintenance Preventable Functional Failure]] | : [[MPFF]] [[Maintenance Preventable Functional Failure]] | ||
: [[MRC]] [[Management Review Committee]] | : [[MRC]] [[Management Review Committee]] | ||
: [[NCV]] [[Non-Cited Violation NOS Nuclear oversight]] | : [[NCV]] [[Non-Cited Violation]] | ||
: [[NOS]] [[Nuclear oversight]] | |||
: [[NRC]] [[U.S. Nuclear Regulatory Commission]] | : [[NRC]] [[U.S. Nuclear Regulatory Commission]] | ||
: [[OE]] [[Operating Experience]] | : [[OE]] [[Operating Experience]] | ||
: [[PARS]] [[Publicly Available Records]] | : [[PARS]] [[Publicly Available Records]] | ||
: [[PM]] [[Preventive Maintenance RCE Root Cause Evaluation]] | : [[PM]] [[Preventive Maintenance]] | ||
: [[RCE]] [[Root Cause Evaluation]] | |||
: [[RCIC]] [[Reactor Core Isolation Cooling]] | : [[RCIC]] [[Reactor Core Isolation Cooling]] | ||
: [[RHR]] [[Residual Heat Removal]] | : [[RHR]] [[Residual Heat Removal]] | ||
: [[RHRSW]] [[Residual Heat Removal Service Water]] | : [[RHRSW]] [[Residual Heat Removal Service Water]] | ||
: [[RPS]] [[Radiation Protection Specialist RPS Reactor Protection System]] | : [[RPS]] [[Radiation Protection Specialist]] | ||
: [[RPS]] [[Reactor Protection System]] | |||
: [[RWS]] [[River Water Supply]] | : [[RWS]] [[River Water Supply]] | ||
: [[SCAQ]] [[Significant Condition Adverse to Quality]] | : [[SCAQ]] [[Significant Condition Adverse to Quality]] |
Revision as of 02:11, 26 August 2018
ML091770606 | |
Person / Time | |
---|---|
Site: | Duane Arnold |
Issue date: | 06/26/2009 |
From: | Riemer K R NRC/RGN-III/DRP/B2 |
To: | Anderson R L Duane Arnold |
References | |
IR-09-007 | |
Download: ML091770606 (30) | |
Text
June 26, 2009
Mr. Richard Vice President Duane Arnold Energy Center 3277 DAEC Road Palo, IA 52324-9785
SUBJECT: DUANE ARNOLD ENERGY CENTER PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000331/2009007
Dear Mr. Anderson:
On May 22, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution (PI&R) inspection at the Duane Arnold Energy Center. The enclosed report documents the inspection results, which were discussed on June 16, 2009, with you and other members of your staff. The 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 license. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. The inspection concluded that your staff was effective at identifying problems and incorporating them into the corrective action program. In general, issues were appropriately prioritized, evaluated, and corrected, audits and self-assessments were thorough and probing, and operating experience was appropriately screened and disseminated. Your staff was aware of the importance of having a strong safety-conscious work environment and expressed a willingness to raise safety issues. Based on the results of this inspection, one NRC-identified finding of very low safety significance was identified which involved a violation of NRC requirements. However, because of the very low safety significance, and because the issue was entered into the corrective action program, the NRC is treating this issue as a non-cited violation (NCV) in accordance with Section VI.A.1 of the NRC Enforcement Policy. If you contest the subject or severity of this NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission - Region III, 2443 Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector Office at the Duane Arnold Energy Center. In addition, if you disagree with the characterization of the finding in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region III, and the NRC Resident Inspector at Duane Arnold Energy Center. The information you provide will be considered in accordance with Inspection Manual Chapter 0305.
Sincerely,/RA/ Kenneth Riemer, Chief Branch 2 Division of Reactor Projects Docket No. 50-331 License No. DPR-49
Enclosure:
Inspection Report 05000331/2009007
w/Attachment:
Supplemental Information cc w/encl: M. Nazar, Senior Vice President and Chief Nuclear Officer M. Ross, Vice President and Associate General Counsel A. Khanpour, Vice President, Nuclear Engineering D. Curtland, Plant Manager S. Catron, Manager, Regulatory Affairs M. Mashhadi, Senior Attorney T. Jones, Vice President, Nuclear Operations, Midwest Region P. Wells, Vice President, Safety Assurance R. Hughes, Director, Licensing and Performance Improvement D. McGhee, Iowa Dept. of Public Health Chairman, Linn County, Board of Supervisors R. McCabe, Chairman, Regional Assistance Committee, DHS/FEMA Region VII M. Rasmusson, State Liaison Officer
SUMMARY OF FINDINGS
IR 05000331/2009007; (May 5, 2009 - May 22, 2009), Duane Arnold Energy Center; Biennial Baseline Inspection of the Identification and Resolution of Problems. This team inspection was performed by two regional inspectors, a resident inspector and the site resident inspector. Based on the results of this inspection, one Green finding was identified by the inspectors and is considered to be a Non-Cited Violation (NCV) of NRC regulations. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process" (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The 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 2006. Identification and Resolution of Problems Overall the corrective action program (CAP) program was adequate in that issues were identified at a low threshold, evaluated and corrected. Self-assessments and audits by Nuclear Oversight (NOS) were thorough and critical of the assessed areas. Operating experience was recognized as valuable, was appropriately evaluated, and was effectively communicated in daily plant meetings and pre-job briefings. Interviews with licensee staff and a review of the employee concerns program indicated that the licensee had a positive safety culture environment that encouraged identification of issues in the CAP. However, the inspectors identified several areas of concern that prevented the CAP from being an effective tool for performance improvement. There were examples where licensee staff failed to demonstrate a challenging, questioning attitude during issue screening and evaluation, where identified program weaknesses or vulnerabilities were accepted without a strong desire for change, and where management expectations were not reinforced. For example:
- Ineffective trending has been a recurring issue since 2005, based on the results of NRC, industry and station assessments. However, fixing this problem does not appear to be a station priority. Although the pieces needed to have a successful program are largely in place, there does not appear to be a drive to actually implement the process.
- There were some examples of CAP issues that were inappropriately challenged either at the Initial Screening Team (IST), Management Review Committee (MRC) or both. The inspectors observed instances where IST and MRC members accepted issues without challenging the information given or considering the overall impact of the issue on the safety/risk function of the component or system.
- There was a tendency to perform myopic reviews focusing on the specific issue being evaluated and not on the underlying performance concern. Standards for performing cause evaluations were not being reinforced. There were several examples where the review of extent of condition, applicability of operating experience or the basis for the conclusion were either limited or not well documented. Although some of the issues were identified during the evaluation grading, there was no priority or impetus to change the incorrect behavior.
A. NRC-Identified
and Self-Revealed Findings
Cornerstone: Mitigating Systems
- Green.
A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," was identified by the inspectors for a failure of the licensee to promptly identify and correct a condition adverse to quality (CAQ) associated with the 'D' river water supply (RWS) pump mounting base bolted connectors. The licensee's failure to evaluate the operability of the 'D' RWS pump due to the degraded bolting was considered a performance deficiency. By not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately identify the as-left condition of the stud threads, evaluate the impact that condition had on the seismic qualification of the pump, and implement appropriate corrective actions to resolve the degraded condition. The failure to promptly identify and correct a CAQ associated with the safety-related 'D' RWS pump was a violation of NRC requirements specified in 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action." The licensee entered this issue into the Corrective Action Program (CAP Item 067412), examined the pump mounting connectors, and initiated a prompt operability determination to evaluate the seismic qualification. Based on this evaluation, the 'D' RWS pump was declared Operable but degraded. The performance deficiency was determined to be more than minor because the issue was associated with the Mitigating Systems cornerstone attribute of equipment performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated this finding using the Significance Determination Process (SDP) and determined the finding was of very low safety significance (Green) because this finding was a design or qualification deficiency that did not result in a loss of operability of the safety component. The inspectors also determined that this finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the licensee did not promptly and completely identify an adverse condition in the CAP in a timely manner commensurate with its safety significance. P.1(a). (Section 4OA2.1b.(1))
B. Licensee-Identified Violations
No violations of significance were identified.
REPORT DETAILS
OTHER ACTIVITIES
4OA2 Problem Identification and Resolution
The activities documented in Sections
.1 through .4 constituted one biennial sample of Problem Identification and Resolution (PI&R) as defined in IP 71152.
.1 Assessment of the Corrective Action Program Effectiveness
a. Inspection Scope
The inspectors reviewed the licensee's corrective action program (CAP) implementing procedures and attended CAP program meetings to assess the implementation of the CAP by site personnel.
The inspectors reviewed risk and safety significant issues in the licensee's CAP since the last NRC PI&R inspection in April 2007. The selection of issues ensured an adequate review of issues across the NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC documented findings as sources to select issues. Additionally, the inspectors reviewed CAP items generated as a result of facility personnel's performance in daily plant activities. The inspectors also reviewed CAP items and a selection of completed investigations from the licensee's various investigation methods, including root, apparent and common cause evaluations.
The inspectors performed a more extensive review of the risk significant river water supply systems and the station operational decision making (ODMI) process. The review of the river water system consisted of a five year search of related issues identified in the CAP and discussions with appropriate licensee staff to assess the licensee's efforts in addressing identified concerns.
During the reviews, the inspectors evaluated whether the licensee staff's actions were in compliance with the facility's CAP and 10 CFR Part 50, Appendix B requirements. Specifically, the inspectors evaluated if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the station's CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also evaluated whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and NRC findings, including NCVs.
b. Assessment (1) Effectiveness of Problem Identification Overall the CAP program was adequate in that issues were identified at a low threshold, evaluated and corrected. Workers were encouraged to identify issues and were familiar with the various avenues available (NRC, CAP, etc). This was evident by the large 4 Enclosure number of CAP items generated annually, which were reasonably distributed across the various departments. A shared computerized database was used for creating individual reports and for subsequent management of the processes of issue evaluation and response. This included determining the issue's significance, addressing such matters as regulatory compliance and reporting, and assigning any actions deemed necessary or appropriate.
However, there were some areas of concern that prevented the CAP from being an effective tool for performance improvement. There were examples where licensee staff failed to demonstrate a challenging, questioning attitude during issue screening and evaluation and where identified program weaknesses or vulnerabilities were accepted without a strong desire for change. Some specific examples were:
- The inspectors observed an IST meeting reviewing CAP Issue Reports 67034 and 67028, involving foreign material found in the condensate storage tank. Both issues were screened as conditions not adverse to quality (NCAQ) on the basis that the tank was non-safety related. However, the IST failed to consider the impact the foreign material could have on the safety related high pressure core injection system, which takes suction from the CST during the initial stage of a design-basis accident.
- The inspectors observed the MRC screening of CAP Issue Report 66544, regarding the potential overtorquing of the 'D' river supply pump mounting bolts. Although the report did not contain sufficient information to determine whether the pump was adequately mounted, this issue was not identified during the MRC screening. The pump is safety-related and is required to remain available during a seismic event.
- Corrective Action Program Report 63741, was not considered a condition adverse to quality (CAQ) even though it identified potential degradation of cabling associated with the high pressure core injection, main steam isolation valves and reactor core isolation systems (all safety-related and/or risk significant systems). The issue had been identified during the 2009 refueling outage and was screened by the MRC. Other examples were also identified by the team and were discussed with licensee staff. The licensee initiated CAP Reports 67083 and 67412 for the above examples. Ineffective trending has been a recurring issue since 2005, based on the results of NRC, industry and station assessments. However, fixing this problem does not appear to be a station priority. Although the pieces needed to have a successful program are largely in place, there does not appear to be a drive to actually implement the process. The inspectors observed the following:
- There was no stated expectation or procedural guidance regarding when to issue a trend (i.e., a minimum threshold);
- From May 2008 to May 2009, over 9100 items were issued into the CAP, yet only 24 trend CAPs were initiated. Of these, 12 came from Operations and at least one from NRC; and
- Some CAP evaluations (apparent cause evaluation (ACE) 1776, CAP 59216) had identified recurring events, yet there was no discussion or action to consider a common-cause evaluation.
5 Enclosure This licensee initiated CAP Report 67330 for the issues with the trend program. The inspectors also noted that the licensee's procedures didn't state how risk significant, but non-safety related issues were classified. Specifically, the CAP procedures precluded these issues as being either CAQs or NCAQs, based on the specific definitions of these terms. Licensee staff was conditioned to classify only safety-significant issues as CAQs and all non-safety issues as NCAQs, regardless of risk significance. For example, CAP Report 63613, concerning degraded cabling for the main generator protection logic and turbine electro-hydraulic control systems, was screened as an NCAQ, but there was no documentation of whether the issue was risk significant or a potential plant reliability concern. The licensee initiated CAP Report 67361 to address this issue. The inspectors identified that contrary to ACP 1410.12, "Operator Burden Program," Rev. 16, (Section 3.2(4)), the Operations Manager was not presenting the status of the operator burden program to the plant health committee on a monthly basis. The licensee initiated CAP Report 67440 to address this issue. Findings Failure to promptly identify and evaluate the degraded condition associated with the 'D' RWS pump mounting base bolted connectors
Introduction:
A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," was identified by the inspectors for a failure of the licensee to promptly identify and correct a condition adverse to quality associated with the safety-related 'D' RWS pump.
Description:
On April 5, 2009, the 'D' RWS pump tripped approximately 30 seconds after being started from the control room. The pump was declared inoperable and an investigation commenced. The pump was found to be mechanically bound, with the motor supply breaker tripped on an over-current condition. A work request card (CWO A96711) was written and formal troubleshooting started. On April 7 the 'D' RWS pump was removed from the intake structure for repair. The pump was re-installed on April 13. The work was done, in accordance with the equipment-specific maintenance procedure, PUMP-J105-03, "Aurora/Johnston River Water Pumps," Revision 9. In accordance with this procedure, the pump mounting and discharge head flange bolts were torqued to 424-464 ft-lbs.
During post-maintenance testing, the pump experienced high vibration readings, requiring removal and reinstallation of the pump bolts. During the reinstallation, one of the six bolts failed and the threads were stripped. The work was stopped and CAP Report No. 066544, was initiated. The CAP stated that one of the studs had stripped and that the other five studs were showing signs of thread degradation.
The licensee identified that the actual, installed bolts (per the construction drawings) differed from those referenced in the maintenance procedure. This meant that the torque value stated in the procedure (424-464 ft-lbs) was incorrect. The correct value (based on the actual bolts installed) was 190-210 ft-lbs. Therefore, the pump mounting and discharge head flange bolts had been overtorqued.
6 Enclosure The stripped stud was repaired and the remaining five studs were re-torqued to the correct value. However, these studs were not removed or inspected for thread degradation prior to being re-torqued. Following post-maintenance testing, the pump was declared operable on April 17 and the CWO was closed. A procedural change request was initiated to change the referenced torque value in the pump maintenance procedure. Corrective Action Program 066544 was reviewed by the MRC on April 16. The issue was properly characterized as a condition adverse to quality and the Engineering Department was tasked to perform a condition evaluation (CE 7353) addressing the extent of condition of the other RWS pumps. The completed CE was reviewed by the MRC on May 19. The MRC approved the CE, as documented, with no additional questions or changes. The inspectors noted that while the CE adequately addressed the condition of the other RWS pumps, it did not address the overtorquing of the five remaining studs on the 'D' RWS pump, specifically, whether any thread degradation had occurred which may impact the pump operability. The inspectors asked to review the documentation of the condition of the remaining five studs, specifically, whether the seismic qualification for the 'D' RWS pump was still within design bases. The licensee stated a visual examination of the studs was performed by the mechanical maintenance personnel during the final pump re-assembly and that the only documentation was the description in CAP 66544. The licensee also stated that an evaluation of the seismic qualification of the pump mounting had not been performed. The licensee initiated CAP 67412 to address the inspectors' concerns. Subsequently, the Shift Manager requested a prompt operability determination from the engineering department and the licensee initiated a work order (CWO A101663) to inspect and document the actual condition of the 'D' RWS pump mounting studs. The inspection identified no cracks, but found that all of the studs had from 3 to 5 degraded threads on each stud, amounting to anywhere from 100 percent (no thread available for engagement) to 25 percent of the thread missing. A subsequent licensee evaluation identified that the degradation significantly challenged the ability of the studs to meet the original design basis stress limits during either an operational or a design basis earthquake. Since calculations showed that the mounting stud threads would still meet the Appendix F ASME Section III code maximum allowable values, the 'D' RWS pump was declared Operable but degraded. A CAP item was initiated (OBD 000317) to ensure that the studs would be repaired no later than the next refueling outage.
Analysis:
The licensee's failure to evaluate the operability of the 'D' RWS pump due to the degraded bolting was considered a performance deficiency. By not performing this evaluation, the licensee failed to recognize that the affected studs had significant thread wear, and required replacement in order to restore the pump to full operability.
Traditional enforcement did not apply since there were no actual safety consequences or potential for impacting the NRC's regulatory function, and the finding was not the result of any willful violation. The performance deficiency was more than minor because the issue was associated with the Mitigating Systems cornerstone attribute of equipment performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences.
Specifically, by not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately 7 Enclosure evaluate the impact the condition had on the seismic qualification of this safety-related component. The inspectors evaluated this finding using the SDP in accordance with IMC 0609, "Significance Determination Process," Attachment 0609.04, "Phase 1 - Initial Screening and Characterization of findings," Table 4a for the Mitigating Systems cornerstone. Since this finding is a design or qualification deficiency that did not result in a loss of operability of the safety component, the finding was determined to be of very low safety significance (Green). The failure to accurately and completely characterize the actual as-left condition of the studs precluded the ability to evaluate the potential impact the condition had on the seismic qualification of the safety-related component. The inspectors determined that this finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the licensee did not promptly and completely identify an adverse condition in the CAP in a timely manner commensurate with its safety significance. P.1(a)
Enforcement:
The 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, between April 14, 2009, and May 19, 2009, the licensee's initial identification, screening, evaluation, and implemented corrective actions associated with the over-torquing of the 'D' RWS pump mounting base bolted connectors, failed to promptly identify and correct a condition adverse to quality regarding the seismic qualification of safety related components. Specifically, by not examining the thread degradation documented on the overtorqued 'D' RWS pump mounting base bolted connectors, the licensee was unable to adequately identify the as-left condition of the stud threads, evaluate the impact that condition had on the seismic qualification of the pump, and implement appropriate corrective actions to resolve the degraded condition. Once this issue was identified by the inspectors, the licensee entered this issue into the CAP, examined the pump mounting connectors, and initiated a prompt operability determination to evaluate the seismic qualification. The 'D' RWS pump was subsequently declared Operable but degraded and a CAP tracking item was initiated to return the pump to the fully operable condition. Because this violation was of very low safety significance and issue was entered into the licensee's CAP, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000331/2009007-01). (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors observed that the majority of issues were of low level and were either closed to trend or at a level appropriate for a condition evaluation. Some of these issues were closed to a work request or to another CAP report, but the inspectors noted that both the parent and daughter documents had the necessary verbiage to document the interrelationship. Although fewer in number, the inspectors did not have any concerns with those issues assigned an ACE or root cause evaluation. There were no items in the operations, engineering, or maintenance backlogs that were risk significant, individually or collectively. The inspectors also identified no issues during the review of the ODMI process.
8 Enclosure The inspectors observed that standards for performing cause evaluations were not being reinforced. There were several examples where the review of the extent of condition, applicability of operating experience, or the basis for the conclusion were either limited or not well documented. There was a tendency to perform myopic reviews focusing on the specific issue being evaluated rather than the underlying performance concern.
- Apparent Cause Evaluation 1922 was written to investigate higher than expected dose rates in the radwaste surge tank following a water transfer. Although the ACE identified some issues with how water transfers were conducted in general, it only focused on the specific circumstances. Additionally, the ACE failed to consider whether previously identified operating experience could have prevented this event.
- Apparent Cause Evaluation 1833 was written to investigate why one security crew did not have the necessary fire brigade trained personnel. Although the ACE identified a similar, prior event, there was no discussion of why the corrective actions from that event failed to prevent recurrence.
- Apparent Cause Evaluation 1776 was written to investigate why a degraded cable issue had not been captured in the CAP. However, the ACE did not evaluate this issue, but only addressed the operability impact of the degraded cable. Additionally, the ACE identified several, similar prior events, but did not evaluate whether a common-cause evaluation was warranted.
- Apparent Cause Evaluation 1780 was written to investigate an unposted high radiation area identified on the torus catwalk. The ACE had a very limited extent-of-condition evaluation and failed to consider whether previously identified operating experience could have prevented this event.
- Apparent Cause Evaluation 1802 was written to investigate events where operating crews failed to maintain critical parameters within prescribed limits. The extent of condition was limited to a listing of internal operating experience and did not address other areas of plant operations where a similar condition could exist. Each of the above ACEs had been graded by the respective, initiating departments prior to issuance.
In some cases, these issues were identified during the grading, but there was no expectation or impetus to change the "incorrect" behavior, as the ACEs received passing scores. The licensee initiated CAP Reports 67100, 67307, and 67331 to address the issues identified by the inspectors. Corrective Action Program Report 58355 was initiated after the licensee identified that the 'B' standby diesel generator lube oil temperature was high due to a failed switch.
The MRC concluded that an ACE was not required as the cause of the issue was simple and known and that the extent of condition was understood. However, the inspectors noted that there was no causal analysis regarding why the switch failed. The licensee initiated CAP Report 58355 to evaluate why the cause of the switch failure was not evaluated. Findings No findings of significance were identified.
9 Enclosure (3) Effectiveness of Corrective Actions The inspectors concluded that over the 2 year period encompassed by the inspection, the licensee implemented effective corrective actions. The inspectors identified no significant examples where problems recurred. However, the inspectors identified some examples where issues identified in CAP evaluations were not fully addressed by corrective actions. For example:
- Root cause evaluations 1074 and 1075 addressed weaknesses in the CAP program identified by an industry audit. The evaluations identified several items of concern, yet there were no clearly identified corrective actions associated with each of these items.
- Corrective Action Program Report 62896 was written to address an unexpected alarm on an average power range monitor (APRM) due to age related degradation of a relay. Although the CAP evaluation identified other, similar relays susceptible to similar failure in the APRM system (which was safety-related), there were no corrective actions to evaluate the plant risk in order to prioritize repairs. The above examples were due, in part, to the issues with the quality of the cause evaluations discussed above, and will be addressed in the associated CAP report items. However, the licensee did initiate CAP Report 67237 to evaluate the issues with root cause evaluations 1074 and 1075. The inspectors also identified numerous examples where extensions for corrective actions were granted without having an adequate basis or documenting the justification.
The licensee issued CAP Report 65894 to address this issue. Findings No findings of significance were identified.
.2 Assessment of the Use of Operating Experience
a. Inspection Scope
The inspectors reviewed the licensee's implementation of the facility's Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, observed daily station and pre-job briefings to observe the use of OE information, and reviewed completed evaluations of OE issues and events. The inspectors' review was to determine whether the licensee was effectively integrating OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensee's program was sufficient to prevent future occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and effectively and timely implemented.
10 Enclosure b. Assessment In general, OE was effectively used at the station. The inspectors observed that OE was discussed as part of the daily station and pre-job briefings. Industry OE was effectively disseminated across the various plant departments and no issues were identified during the inspectors' review of licensee OE evaluations. During interviews, several licensee personnel commented favorably on the use of OE in their daily activities.
Findings No findings of significance were identified.
.3 Assessment of Self-Assessments and Audits
a. Inspection Scope
The inspectors assessed the licensee staff's ability to identify and enter issues into the CAP program, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits.
b. Assessment The inspectors considered the quality of the NOS audits to be thorough and critical. The self-assessments were acceptable but, as expected, they were not at the same level of quality as the audits. The inspectors observed that CAP items had been initiated for issues identified through the NOS audits and self-assessments. The inspectors identified that the maintenance department, contrary to the other plant departments, had not performed a "quick-hit" self-assessment in the past 2 years. The licensee initiated CAP Report 67376 to address this issue. Findings No findings of significance were identified.
.4 Assessment of Safety-Conscious Work Environment
a. Inspection Scope
The inspectors assessed the licensee's safety-conscious work environment through the reviews of the facility's ECP implementing procedures, discussions with ECP coordinators, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results of licensee safety culture surveys. The inspectors reviewed the following ECP case files (titles redacted): 09-06R, 06-03, 07-06,07-03R, 08-05, 08-08, and 08-02. These files involved potential cases of harassment and intimidation for raising safety issues. b. Assessment The inspectors determined that the plant staff were aware of the importance of having a strong SCWE and expressed a willingness to raise safety issues. No one interviewed 11 Enclosure had experienced retaliation for safety issues raised, or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP process.
These results were similar with the findings of the licensee's safety culture surveys. Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable SCWE.
The inspectors determined that the ECP process was being effectively implemented. The inspectors review of several, selected case files (generated from 2006-2009) concerning apparent cases of harassment and intimidation for raising safety concerns determined that the licensee had appropriately investigated and taken effective action to address the individual issues and promote a strong SCWE. However, during the interviews, several individuals did not know who the site ECP coordinator was nor were familiar with the site Differing Professional Opinion process (which was another forum, similar to the ECP, for raising safety issues). The inspectors also identified a potential vulnerability in the ECP process based on how issues were classified. Specifically, the inspectors noted that based on the classification, some issues had more relaxed requirements regarding documentation and feedback to the originator which may lead individuals to believe that the ECP was not effectively addressing issues. The licensee initiated CAP Report 67378 to address this concern. Findings No findings of significance were identified.
4OA6 Management Meetings
.1 Exit Meeting Summary
- On May 22, 2009, the inspectors presented the inspection results to Mr. Anderson and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.
- On June 16, 2009, the inspectors held a teleconference with Mr. Anderson and other members of his staff, to discuss the finding and NCV for the failure to identify and correct a CAQ associated with the 'D' RWS pump. ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee *
- R. Anderson, Site Vice President *
- R. Murrell, Licensing Engineer
- D. Brigl, Employee Concerns Investigator
- S. Catron, Licensing Manager
- D. Curtland, General Plant Manager
- M. Davis, Emergency Preparedness Manager
- P. Dutcher, Maintenance Support General Supervisor
- P. Giroir, Operations Support Manager
- B. Porter, Radiation Protection/Chemistry Manager
- G. Rushworth, Assistant Operations Manager
- J. Schwertfeger, Security Operations Supervisor
- J. Swales, Mechanical Design Supervisor
- Present during the June 16, 2009, teleconference
Nuclear Regulatory Commission
- K. Riemer, Chief, Branch 2, Division of Reactor Projects
LIST OF ITEMS
OPENED, CLOSED AND DISCUSSED
Opened and Closed
- 05000331/2009007-01 NCV Failure to promptly identify and evaluate the degraded condition associated with the 'D' RWS pump mounting
base bolted connectors (Section 4OA2.1b.(1))
Attachment
LIST OF DOCUMENTS REVIEWED
The following is a list of documents reviewed during the inspection.
- Inclusion on this list does not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that selected sections of portions of the documents were evaluated as part of the overall inspection effort.
- Inclusion of a document on this list does not imply NRC acceptance of the document or any part of it, unless this is stated in the body of the inspection report.
- PLANT PROCEDURES Number Description or Title Date or Revision
- NA-AA-200 Employee Concerns Program Process Description Revision 0
- PA-AA-102 Operating Experience Program Revision 0
- PI-AA-204 Condition Identification and Screening Process Revision 2
- PI-AA-205 Condition Evaluation and Corrective Action Revision 1
- NP-809 Nuclear Policy:
- Safety Conscious Work Environment Revision 0
- NAP-412 Operational Decision-Making Revision 6
- NAP-424 Employee Concerns Program Revision 2
- CP 0060 Differing Professional Opinions Revision 0
- OP-001 Operator burden and clearance audit Revision 43
- ACP 101.01 Procedure use and adherence Revision 45
- ACP 102.35 Performance Monitoring and Improvement Revision 11
- ACP 114.8 Action Request Trending Revision 6
- ACP 1208.6 Equipment Reliability Process Description Revision 7
- ACP 1410.12 Operator burden program Revision 16
- MD-042 Bolting Practices Revision 9
- PUMP-J105-03 Equipment-Specific Maintenance Procedure AURORA/JOHNSTON River Water Pumps Revision 9 & 10 & 11
- Root Cause Evaluation Manual Revision 17
- Apparent Cause Evaluation Manual Revision 10
- CAP Trend Code Manual Revision 5
- Common Cause Effectiveness Manual Revision 3
- Corrective Action Effectiveness Manual Revision 3
- CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 042926
- CAQ-Upward Step Change in 'B' Recirc MG on 6/25/2006 6/16/2006
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 047115
- CAP 048889 Turbine Vibrations Not Returning to Expected Values 4/6/2007
- CAP 049684 NCAQ Inaccuracies in the 2006 Annual Radiological Environmental Operating Report 5/10/2007
- CAP 049725 NRC weekly debrief 5/11/2007
- CAP 050594 Unplanned risk level of yellow due to severe thunderstorm watch 6/22/2007
- CAP 051042 DAEC emergency plan table B-1 7/12/2007
- CAP 051129
- CAQ-CAs of
- CAP 051288
- CAQ-DAEC Year-to-Date Dose Increased Over 3000 millirem on Daily Exposure Rep. 7/24/2007
- CAP 051343 Focused Self Assessment of Design and Reliability of Intake Structures and Equipment 7/26/2007
- CAP 052776
- CAQ-Potential MOV Stroke Delay Times are Not Accounted For 9/26/2007
- CAP 053115
- CAQ-Degraded Condition Not Documented in
- CAP 10/12/2007
- CAP 053208 CAQ - CAP052817 did not consider past operability 10/16/2007
- CAP 053487
- NCAQ-Decrease in Indicated Core Flow 10/28/2007
- CAP 053759 NCAQ - Declining Trend in Training for CA Extension 11/9/2007
- DRUM-Increase in Clock Resets for the Quarter 11/16/2007
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 054053 CAQ - 'A' and 'B' SBDG Auto Start Due to 161KV Breaker Cycling (DAEC to Fairfax) 12/1/2007
- CAP 054293
- CAQ-Reactor Level Lowered 2 Inches Without Operator Action 12/14/2007
- CAP 055211
- CAQ-B Recirc Pump Seal Pressure Increase 2/1/2008
- CAP 055300 NCAQ - NOS Identified Negative Trend in Blocked Access to Fire Protection Equipment 2/5/2008
- CAP 055441
- CAQ-STREAM Analysis Driver-Management Tolerance of Performance 2/11/2008
- CAP 055559
- CAQ-NRC Identified Concern During CDBI 2/14/2008
- CAP 055801
- CAQ-Security Department Without Fire Brigade Personnel for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> 2/25/2008
- CAP 057678
- NCAQ-CV1569 Appears to Have Partially Cycled Based on Downstream Temperatures 5/18/2008
- CAP 057717 Confusion on Concurrent and Independent Verification 5/20/2008
- CAP 057980 CAQ - NRC commitment not met in past operability calculation 5/28/2008
- CAP 058085 1P205A and B Decreasing Vane Pass Trends 7/25/2008
- CAP 058097
- CAQ-1X001 Main Transformer Hot Connection 6/3/2008
- CAP 058142 'A' SBLC Pump Momentary Pressure Drop 6/4/2008
- CAP 058928 Fermanite Valve V07-0247 Repair 8/26/2008
- CAP 059090 NCAQ - Ops burdens review meetings 7/24/2008
- CAP 059294 'A' SFU Unit Required 1 Bolt & Nut to be Replaced 8/4/2008
- CAP 059308 Main Steam Line Temperatures Approaching Upper Limit 8/5/2008
- CAP 059348 Discrepancy Between Pipe Support Drawing Load and Calculation Loads 8/6/2008
- CAP 059388
- CAQ-SECR Pipe Supports Appear to Have Missing Bolts 8/7/2008
- CAP 059395
- CAQ-Undersized Bolt on A SFU Housing Flange 8/7/2008
- CAP 059432 Undesired Recirc Flow Changes 8/8/2008
- CAP 059444 RWS
- STP-NS
- 100102 Indicates 1P117D Degrading 8/10/2008
- CAP 059468 Pipe Support Discrepancies 8/11/2008
- CAP 059495 NCAQ - High risk activities not on the risk report or discussed at production meet 8/12/2008
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 059731
- CAQ-RCE 1076 CATPR 2.1 Corrective Actions May Not Have Been Effectively Implemented 8/22/2008
- CAP 059783
- CAQ-Both MSR Second Stage Drain Tanks (1T092A and 1T092B) Have One Controller 8/25/2008
- CAP 059861
- CAQ-HPCI Steam Exhaust Breaker Drawing Discrepancy 8/27/2008
- CAP 059892
- CAQ-HPCI Steam Exhaust Vacuum Breaker Piping Configuration Does Not Match Design Calc 8/28/2008
- CAP 060140
- CAQ-Mistake Discovered In the HPCI Steam Exhaust Vacuum Breaker Piping Design Calc. 9/10/2008
- CAP 060168 CAQ - NRC inspector question regarding HPCI SR 3.5.1.1 9/11/2008
- CAP 060168
- CAQ-NRC Inspector Question Regarding HPCI SR 3.5.1.1 9/11/2008
- CAP 060283
- NCAQ-HPCI Operability Questioned During Performance of A77986 9/16/2008
- CAP 060388
- NCAQ-Missing Fasteners in MG SET Room 9/18/2008
- CAP 060543 CAQ - Functionality assessment not performed 9/24/2008
- CAP 060874 Valve Installed in the Plant Not per the Design Documents 10/9/2008
- CAP 061237 'B' Chiller Oil Pressure Continues to Degrade 10/23/2008
- CAP 061328
- NCAQ-Initiating an ODM Issue for Main Generator Low Frequency Alarms 10/27/2008
- CAP 061725
- CAQ-Bolt Missing From Hanger (next to MO2202) 11/13/2008
- CAP 062046
- CAQ-NRC Cross-Cutting Findings 12/2/2008
- CAP 062175
- CAQ-Main Turbine Bypass Valve BV1 Position Feedback Signal is Intermittent 12/7/2008
- CAP 062246 NCAQ -
- BV-1 False Open Signal-Need to Restore Reliability & Implement Bridge Strategy 12/10/2008
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 062602 'A' RWS Subsystem Inoperable Due to
- HSS-2911A Out of Position 12/31/2008
- CAP 062760
- NCAQ-Missing Fasteners-Drywell EQ Boxes 1/9/2009
- CAP 062896
- CAQ-APRM Inop Trip with No Back Panel Indications 1/15/2009
- CAP 062989 NCAQ - 4
th Quarter 2008 DAEC DRUMs to be Postponed 1/19/2009
- CAP 063486
- CAQ-Increased Dose Rates in Radwaste Surge Tank 2/3/2009
- CAP 063758 NCAQ - Potential trend in procedural use and compliance 2/7/2009
- CAP 063867
- CAQ-Perform Aggregate Review of
- CAP 063912 INR
- IVVI-09-04 & -05 Steam Dryer Indications 2/10/2009
- CAP 064512
- CAQ-Diver in Torus Received Accum. Dose and Dose Rate Alarms on Electronic Dosimeter 2/20/2009
- CAP 064644 CAQ - Rack Dwg M155-012<7> 1C08 Depicts Freq Meter & Volt Meter Term. Incorrectly 2/19/2009
- CAP 064746
- CAQ-LLRT Spill Causes Concern in Clean Area:
- RB 786' by Reactor Water Sample Valves 2/20/2009
- CAP 064786
- CAQ-Three Personnel Contaminations in the Hotwell 2/21/2009
- CAP 065300 NCAQ - Two risk reviews for the same evolution evaluated differently 2/27/2009
- CAP 065874
- NCAQ-FO Boxes Missing Cover Screws 3/17/2009
- CAP 066009 NCAQ - Initiating an ODMI for HP Turbine Steam Leak to Track Completion of Repair 3/23/2009
- CAP 066066 NCAQ - 1T93B Leak and CV1077B Observed cycling Full Open to Full Closed 3/25/2009
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- CAP 067433 Corrective Action Not Performed per
- CA 50628 5/21/2009
- CE 6419 Trend in General Maintenance Misposition Events 5/14/2008
- CE 7149 NCAQ - Refuel Bridge Outage Performance Improvement 2/21/2009
- ACE 1736 Required Simulator Testing Not Finished on Time Revision 0
- ACE 1737 Plant Modifications Installed Without Adequate Training 5/24/2007
- ACE 1740 Repetitive Failure to Provide Satisfactory Corrective Action 6/1/2007
- ACE 1741 Trend in Configuration Control Loss During Fabrication & Welding 6/4/2007
- ACE 1767 Newly Installed RWS Check Valve Weight is Greater than Analyzed 9/18/2007
- ACE 1776
- CAQ-Degraded Condition Not Documented in
- CAP 11/26/2007
- ACE 1780
- ACE 1788 NCAQ - Perform Common Cause Evaluation as Noted in Activity Description 8/31/2007
- ACE 1801 Evaluation of
- OP.1-2 - Critical parameter monitoring Revision 0
- EN.1-1 1/15/2008
- OR.2-2 Revision 0
- ACE 1824
- CV-4914 Failed to Open Within ASME Acceptance Criteria 2/12/2008
- ACE 1833
- CAQ-Security Department Without Fire Brigade Personnel for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> 3/24/2008
- ACE 1860 Unusual event declared based on loss of communications capability Revision 0
- ACE 1872 Unplanned technical specification LCO due to failure of FY2747 Revision 0
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- ACE 1878
- CAQ-RCE 1076 CATPR 2.1 Corrective Actions May Not Have Been Effectively Implemented 10/10/2008
- ACE 1882
- CAQ-NRC Inspector Question Regarding HPCI SR 3.5.1.1 9/11/2008
- ACE 1883 Isophase Bus Duct Project Scope Change 9/17/2008
- ACE 1891 CCE - Five clearance preparation issues were identified between 9/24/08-9/29/08 Revision 0
- ACE 1901 Common Cause Evaluation
- CAQ-NRC Cross-Cutting Findings 1/5/2009
- ACE 1904
- CAQ-Main Turbine Bypass Valve BV1 Position Feedback Signal is Intermittent 1/15/2009
- ACE 1909 'A' RWS Subsystem Inoperable Due to
- HSS-2911A Out of Position 12/31/2008
- ACE 1910 NCAQ - Adverse Trend in Missed Surveillances 1/16/2009
- ACE 1913
- CAQ-APRM Inop Trip with No Back Panel Indications 3/22/2009
- ACE 1918
- CAQ-Perform Aggregate Review of
- ACE 1919
- CAQ-Perform Aggregate Review-ECP 1748-SBDG Governor Modification Activity Issues Common Cause Evaluation Due After the RFO
(3/31/2009) 2/12/2009
- ACE 1922
- CAQ-Increased Dose Rates In Radwaste Surge Tank 2/24/2009
- ACE 1926 Three Personnel Contaminations in the Hotwell 2/21/2009
- ACE 1927 Common Cause Evaluation
- CAQ-LLRT Spill Causes Concern in Clean Area:
- RB 786' by Reactor Water Sample Valves 3/30/2009
- ACE 1928
- CAQ-Diver in Torus Received Accum. Dose and Dose Rate Alarms on Electronic Dosimeter 4/29/2009
- RCE 1050 1K004 Compressor Overheats-Unplanned LCO 3/13/2006
- EFR 044304 Effectiveness Review for
- RCE 1053 7/16/2008
- RCE 1069 Organizational Responses Not Meeting Expectations 5/2/2007
- RCE 1070 Root cause analysis of control room simulator fidelity issues 6/27/2007
- Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision
- RCE 1072 Damage to 1B42 Bus Bars When Tagging Out
- 1B4234A 10/9/2007
- RCE 1072 A Loss of Vital Bus 1B42 (480 VAC) Revision 1
- RCE 1074 STREAM Analysis Driver-Ineffective Corrective Actions 4/24/2008
- EFR 049673
- CAQ-EFR for RC1 CATPR1 Ineffective Corrective Actions
- RCE 1074 4/24/2008
- RCE 1075 Organization Tolerance of Performance 2/25/2008
- RCE 1079 'B' Cooling Tower West Riser Failure Revision 0
- RCE 1080 RFO21 Electrical Configuration Errors Revision 1
- OPERATING EXPERIENCE Number Description or TitleDate or Revision
- CAP 018948 Deficiencies Identified Pertaining to Source Control 10/6/1997
- CAP 055830
- NCAQ-Rapid FPL Internal
- OE-Turkey Point Clock Reset 2/26/2008
- CAP 057420
- NCAQ-Rapid OE PTN Valve Out-of-position 5/6/2008
- CE 6224 Rapid
- OE-Turkey Point Site Clock Reset:
- CE 6293
- NCAQ-Rapid
- OE-Turkey Point Configuration Control Issue and Potential HU Event 3/21/2008
- OE 21336 External Operating Experience 8/13/2007
- TIL 1588 Explosive Gas Mixture in Stator Water Tanks 10/31/2007
- OE 27315 Perform OE Evaluation-A 10CFR Part 21 Replacement Relief Valve Spring 3/21/2008
- IN 2008-11, Service Water Degradations at Brunswick 6/23/2008
- OTH 20109 Source Control-I&C Use of Calibration 10/14/1997
- Attachment AUDITS, ASSESSMENTS AND
- SELF-ASSESSMENTS Number Description or TitleDate or Revision
- SA 20302 SnapShot Evaluation of the DAEC Probabilistic Risk Assessment (PRA) Program 6/22/2007
- SA 24116 Mechanical Maintenance Benchmarking Trip for Relief Valve Test Bench 11/29/2007
- SA 25100 Self Assessment of Systems Engineering Trending 1/8/2008
- SA 25844 Quick Hit Self-Assessment on Transformer, Switchyard, and Grid Reliability 2/4/2008
- SA 26184 NCAQ - Conduct a Fleet Self-Assessment of the Corrective Action Program 2/14/2008
- SA 29192 This Action Supersedes/Replaces
- OTH 29156 and
- SA 48465 5/20/2008
- SA 32236 Concept of Department Fundamentals is Not Understood in All Areas 9/29/2008
- SA 33284 Industry Focused Self-Assessment of
- EPA 10/30/2008
- SA 34254 Evaluate station summer readiness Revision 1
- SA 37311 Post Outage Validation of PADS/Security Computer Active Personnel 3/31/2009
- SA 43996 Operating Experience Program 6/28/2007
- SA 44138 Conduct a Self-Assessment of the Conduct of Maintenance 10/3/2006
- SA 44139 Perform a Focused Self-Assessment for
- FME 10/3/2006
- SA 44237 Mod / 50.59 Self Assessment 10/23/2006
- SA 45808
- ACP 1408.1 and Work Order Screening Improvements 4/25/2007
- SA 46247 SOER 02-04 Self Assessment 5/29/2007
- SA 46257 Mechanical Maintenance Benchmarking for Relief Valve Test Bench 11/29/2007
- SA 48037 Conduct of operations/operations fundamentals Revision 0
- SA 48471 NCAQ - Perform Benchmarking of I&C Work Management, Scheduling, and Implementation 12/18/2007
- Attachment AUDITS, ASSESSMENTS AND
- SELF-ASSESSMENTS Number Description or TitleDate or Revision
- SA 48472 NCAQ - Perform Benchmarking of Electrical Safety and Flash Protection 12/18/2007
- SA 48474 NCAQ - Perform Benchmarking of Scaffold Control 12/18/2007
- PDA-08-011 2008 Radiation Protection Assessment 4/4/2008
- PDA-08-012 Systems Engineering 4/30/2008
- PDA-08-022 Corrective Actions 7/2/2008
- PDA-08-025 Corrective and Preventive Maintenance 8/14/2008
- PDA-08-040 Corrective Action Program 12/29/2008
- PDA-09-001 Security 1/27/2009
- PDA-09-005 Radiation Protection 4/20/2009
- PDA-09-013 Maintenance Planning and Scheduling 5/14/2009
- NG-07-0467 Quality Assurance Finding-"Corrective Program Deficiency Repetitive Failure to Provide Satisfactory Corrective Action" 5/29/2007
- CAP Problem Area Assessment August 2007
- CONDITION REPORTS GENERATED DURING INSPECTION Number Description or TitleDate or Revision
- CAP 067100
- NCAQ-ACE OE Review Quality 5/7/2009
- CAP 067237 Inconsistent use of Root Cause Evaluation Process 5/14/2009
- CAP 58355
- Did not have Causal Analysis of Switch Failure 5/20/2009
- CAP 067412 NRC P&IR Concerns with D River Water Pump Mounting 5/20/2009
- Attachment MISCELLANEOUS
- Number Description or TitleDate or Revision
- EMA A96711 1P117D 'D' RWS Pump Mounting Base Anchor Bolts Revision 0 CAL-IELP-M92-
- 106 Seismic-Stress Analysis of Johnston Vertical Pump (25
- NLC-1 Stage Revision 0
- BECH-C016 Drawing-Standard Details Equipment Foundation Schedule Revision 21
Work Orders
- Number Description or TitleDate or Revision
- CWO A80062 Replace 1P117D Pump-Indicated Degraded Condition 9/22/2008 CWO A96711 1P117D-Pull Pump-Repair Pump-Return Pump to Original Location 4/7/2009
- Department Roll-Up Meeting Reports Number Description or TitleDate or Revision
- 3Q2008 DAEC Station DRUM Report 12/18/2008 3Q2008 DAEC Chemistry/Environmental DRUM Report 11/20/2008 3Q2008 DAEC Radiation Protection DRUM Report 11/18/2008 3Q2008 DAEC Operations DRUM Report 11/12/2008 3Q2008 DAEC Training DRUM Report 11/3/2008 3Q2008 DAEC Maintenance DRUM Report 11/21/2008 3Q2008 DAEC Engineering DRUM Report 11/19/2008 4Q2008&1Q2009 DAEC Radiation Protection DRUM Report 4/28/2009 4Q2008&1Q2009 DAEC Training DRUM Report 4/29/2009 4Q2008&1Q2009 DAEC Maintenance DRUM Report 4/30/2009 1Q2009 DAEC Engineering DRUM Report 5/10/2009
- Attachment
LIST OF ACRONYMS
- USED [[]]