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| number = ML061360218
| number = ML061360218
| issue date = 05/09/2006
| issue date = 05/09/2006
| title = Perry, Unit 1 - Response to Nuclear Regulatory Commission Inspection Report 05000440/2006007 - NRC Follow Up Inspection of IP 95002 Action Items
| title = Response to Nuclear Regulatory Commission Inspection Report 05000440/2006007 - NRC Follow Up Inspection of IP 95002 Action Items
| author name = Pearce L W
| author name = Pearce L
| author affiliation = FirstEnergy Nuclear Operating Co
| author affiliation = FirstEnergy Nuclear Operating Co
| addressee name =  
| addressee name =  
Line 14: Line 14:
| page count = 12
| page count = 12
}}
}}
See also: [[followed by::IR 05000440/2006007]]


=Text=
=Text=
{{#Wiki_filter:PENOC Perry Nuclear Power Station-"f 10 Center Road FirstEnergy  
{{#Wiki_filter:PENOC           -"f Perry Nuclear Power Station 10 Center Road FirstEnergy Nuclear Operating Company                                                                         Perry Ohio 44081 L William Pearce                                                                                                 440-280-5382 Vice President                                                                                             Fax: 440-280-8029 May 09, 2006 PY-CEI/NRR-2959L United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58
Nuclear Operating  
 
Company Perry Ohio 44081 L William Pearce 440-280-5382
==Subject:==
Vice President  
Response to Nuclear Regulatory Commission (NRC) Inspection Report 05000440/2006007 - NRC Follow up Inspection of IP 95002 Action Items Ladies and Gentlemen:
Fax: 440-280-8029
This letter provides the FirstEnergy Nuclear Operating Company (FENOC) response to the NRC Inspection Report 05000440/2006007 for the Perry Nuclear Power Plant (PNPP). The inspection report provided the results of the NRC Confirmatory Action Letter (CAL) follow-up inspection for Inspection Procedure (IP) 95002 action items. The letter, requests that FENOC respond within 30 days of receipt of the letter describing the specific actions that FENOC plans to take to address the issues raised during the inspection. The attached provides the requested response.
May 09, 2006 PY-CEI/NRR-2959L
There are no commitments contained in this letter. If you have any have questions or require additional information, please contact Mr. Jeffrey Lausberg, Manager, Regulatory Compliance at (440) 280-5940.
United States Nuclear Regulatory  
Very/trj ly yoP Attachment cc: NRC Region Ill Administrator NRC Project Manager NRC Resident Inspector
Commission
 
Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58 Subject: Response to Nuclear Regulatory  
PY-CEI/NRR-2959L Attachment 1 Page 1 of 11 Response to NRC Inspection Report (IR) 06000440/2006007 NRC Follow up Inspection of IP 95002 Action Items Overall, the inspection team concluded that FENOC had satisfactorily implemented the commitments and action items that they reviewed and therefore, the corrective actions to address maintenance procedure adequacy, Emergency Service Water (ESW) pump coupling assembly, and training were adequate. Notwithstanding this overall conclusion, the team identified some cases where the implementation of these actions was weak, which potentially impacts the overall ability to effectively resolve these issues. These issues are identified in the Findings and Observations of the inspection report.
Commission (NRC) Inspection  
The following provides the specific NRC Findings and Observations identified in Inspection Report 2006007 followed by the FENOC's response to those Findings and Observations:
Report 05000440/2006007  
SECTION 3.0 PROCEDURE ADEQUACY
-NRC Follow up Inspection  
: 1. 3.1.b.1, Technical Content Review Results, states: The inspectors reviewed 19 of the 119 revised maintenance procedures. Overall, the inspectors concluded that the maintenance procedures reviewed were an improvement on the previous revisions, both in content, formatting, and ease of use. However, the following weaknesses were identified:
of IP 95002 Action Items Ladies and Gentlemen:
One procedure was identified to contain a significant technical error. GMI-0050, "Residual Heat Removal Pump Overhaul," Revision 0, that was to be utilized for the overhaul of a Residual Heat Removal (RHR) pump, did not include steps to re-insert pump coupling keys that were removed during pump disassembly.
This letter provides the FirstEnergy  
Therefore, the pump overhaul activity, if performed as written, would not return the equipment to a condition in which it would properly function, which was considered a significant technical procedure deficiency. However, because this procedure had not actually been utilized, the inspectors considered this procedure deficiency to be of only minor significance.
Nuclear Operating  
* The inspectors noted numerous instances of typographical errors and improper references. While these errors did not significantly impact the ability to implement the procedures, it indicated a lack of attention to detail in the procedure development and review process.
Company (FENOC) response to the NRC Inspection  
FENOC RESPONSE:
Report 05000440/2006007  
As stated above, during the NRC inspection, an error was identified for procedure GMI-0050, "Residual Heat Removal Pump Overhaul." The error was the omission of specific instructions in the procedure for reassembly of the pump shaft for the placement of keys on the pump shaft keyway sleeve and placement of the split ring. This made the procedure deficient. The missing steps could have caused problems during the reassembly of the pump shaft. When this issue was discovered, GMI-0050 was put on hold pending resolution of the issue and Condition Report (CR) 06-00261 was generated to document the issue. Investigation found that the RHR pumps have not been overhauled using this procedure, but rather in the past the vendor manual had been used with the vendor present on site. Additionally,
for the Perry Nuclear Power Plant (PNPP). The inspection  
 
report provided the results of the NRC Confirmatory  
PY-CEI/NRR-2959L Attachment I Page 2 of 11 the procedure will be reviewed against the vendor manual to verify that no other omission exists.
Action Letter (CAL) follow-up inspection  
The upgraded procedures have been categorized into four (4) groups, with prioritization based on frequency of use, scheduled use, and document change request feedback received from users. The procedures will be reviewed for adequacy, starting with Group 1 and progressing through Group 4 (lowest priority). GMI-0050 is scheduled to be updated under Group 4 since it is utilized in a forced or refueling outage. It will not be used until it is updated.
for Inspection  
In regards to the administrative errors that were found in the upgraded maintenance procedures (e.g., typographical errors, inconsistent formatting, missing references, etc.), FENOC has generated CR 06-00418 to address the issue. This CR will collectively address the issue and capture the lessons-leamed as well as address the necessary re-verification and revalidation of the upgraded maintenance procedures. Corrective Action 06-00418-02 was developed to track the Maintenance Department re-review of the 119 procedures to correct the following potential discrepancies:
Procedure (IP) 95002 action items. The letter, requests that FENOC respond within 30 days of receipt of the letter describing  
Typographical errors Formatting inconsistencies Proper step sequencing Redundant steps Deficient direction Faulty references Missing technical Information Proper use/identification of critical steps Additional resources are being brought in to help complete the reviews.
the specific actions that FENOC plans to take to address the issues raised during the inspection.  
Discrepancies identified during the review process will be documented via the Corrective Action Program and addressed, as required, to support procedure use/plant operation/scheduled maintenance activities. Overall results of the review will be documented in the closure of Corrective Action 06-00418-02.
The attached provides the requested  
: 2. 3.1.b.2, Identification of Missing "Critical" Procedure Step Designation, states: The inspectors identified numerous maintenance procedure steps that warranted identification as critical steps in these procedures, but had not been properly identified as such. Specific examples included:
response.There are no commitments  
* CMI-0016, "Division I and 11Emergency Diesel Generator Starting Air Valve Repair," Revision 3, did not identify measurement and evaluation of cap bore and piston diameter as a critical step although an Improper clearance could result in a failure of the emergency diesel generator to start.
contained  
* PMI-0040, "Division IlIl Air Start Motor Maintenance," Revision 4, did not identify a rotation check of the air starter during air start motor reassembly as a critical step although improper rotation could result in damage to the component or a slow start.
in this letter. If you have any have questions  
 
or require additional  
PY-CEI/NRR-2959L Attachment I Page 3 of 11
information, please contact Mr. Jeffrey Lausberg, Manager, Regulatory
* GMI-0002, "Maintenance of the Control Rod Drive Pumps," Revision 2, did not identify the measurement of run out clearances as a critical step although improper clearances could lead to premature bearing failure.
Compliance  
MAI-0507 also prescribed that if possible, Critical Steps should be identified and mitigated by using one of the following methods:
at (440) 280-5940.Very/trj ly yoP Attachment
* Add a step for breakpoint review.
cc: NRC Region Ill Administrator
* Add independent verification.
NRC Project Manager NRC Resident Inspector  
PY-CEI/NRR-2959L
Attachment  
1 Page 1 of 11 Response to NRC Inspection  
Report (IR) 06000440/2006007
NRC Follow up Inspection  
of IP 95002 Action Items Overall, the inspection  
team concluded  
that FENOC had satisfactorily  
implemented  
the commitments  
and action items that they reviewed and therefore, the corrective  
actions to address maintenance  
procedure  
adequacy, Emergency  
Service Water (ESW) pump coupling assembly, and training were adequate.  
Notwithstanding  
this overall conclusion, the team identified  
some cases where the implementation  
of these actions was weak, which potentially  
impacts the overall ability to effectively  
resolve these issues. These issues are identified  
in the Findings and Observations  
of the inspection  
report.The following  
provides the specific NRC Findings and Observations  
identified  
in Inspection
Report 2006007 followed by the FENOC's response to those Findings and Observations:
SECTION 3.0 PROCEDURE  
ADEQUACY 1. 3.1.b.1, Technical  
Content Review Results, states: The inspectors  
reviewed 19 of the 119 revised maintenance  
procedures.  
Overall, the inspectors  
concluded  
that the maintenance  
procedures  
reviewed were an improvement  
on the previous revisions, both in content, formatting, and ease of use. However, the following  
weaknesses
were identified:
One procedure  
was identified  
to contain a significant  
technical  
error. GMI-0050,"Residual  
Heat Removal Pump Overhaul," Revision 0, that was to be utilized for the overhaul of a Residual Heat Removal (RHR) pump, did not include steps to re-insert  
pump coupling keys that were removed during pump disassembly.
Therefore, the pump overhaul activity, if performed  
as written, would not return the equipment  
to a condition  
in which it would properly function, which was considered  
a significant  
technical  
procedure  
deficiency.  
However, because this procedure  
had not actually been utilized, the inspectors  
considered  
this procedure  
deficiency  
to be of only minor significance.
* The inspectors  
noted numerous instances  
of typographical  
errors and improper references.  
While these errors did not significantly  
impact the ability to implement  
the procedures, it indicated  
a lack of attention  
to detail in the procedure  
development  
and review process.FENOC RESPONSE: As stated above, during the NRC inspection, an error was identified  
for procedure  
GMI-0050, "Residual  
Heat Removal Pump Overhaul." The error was the omission of specific instructions  
in the procedure  
for reassembly  
of the pump shaft for the placement  
of keys on the pump shaft keyway sleeve and placement  
of the split ring. This made the procedure  
deficient.  
The missing steps could have caused problems during the reassembly  
of the pump shaft. When this issue was discovered, GMI-0050 was put on hold pending resolution  
of the issue and Condition  
Report (CR) 06-00261 was generated  
to document the issue. Investigation  
found that the RHR pumps have not been overhauled  
using this procedure, but rather in the past the vendor manual had been used with the vendor present on site. Additionally,  
PY-CEI/NRR-2959L
Attachment  
I Page 2 of 11 the procedure  
will be reviewed against the vendor manual to verify that no other omission exists.The upgraded procedures  
have been categorized  
into four (4) groups, with prioritization  
based on frequency  
of use, scheduled  
use, and document change request feedback received from users. The procedures  
will be reviewed for adequacy, starting with Group 1 and progressing  
through Group 4 (lowest priority).  
GMI-0050 is scheduled  
to be updated under Group 4 since it is utilized in a forced or refueling  
outage. It will not be used until it is updated.In regards to the administrative  
errors that were found in the upgraded maintenance  
procedures (e.g., typographical  
errors, inconsistent  
formatting, missing references, etc.), FENOC has generated  
CR 06-00418 to address the issue. This CR will collectively  
address the issue and capture the lessons-leamed  
as well as address the necessary  
re-verification  
and revalidation  
of the upgraded maintenance  
procedures.  
Corrective
Action 06-00418-02  
was developed  
to track the Maintenance  
Department
re-review  
of the 119 procedures  
to correct the following  
potential discrepancies:
Typographical  
errors Formatting  
inconsistencies
Proper step sequencing
Redundant  
steps Deficient  
direction Faulty references
Missing technical  
Information
Proper use/identification  
of critical steps Additional  
resources  
are being brought in to help complete the reviews.Discrepancies  
identified  
during the review process will be documented  
via the Corrective  
Action Program and addressed, as required, to support procedure  
use/plant  
operation/scheduled  
maintenance  
activities.  
Overall results of the review will be documented  
in the closure of Corrective
Action 06-00418-02.
2. 3.1.b.2, Identification  
of Missing "Critical" Procedure  
Step Designation, states: The inspectors  
identified  
numerous maintenance  
procedure  
steps that warranted identification  
as critical steps in these procedures, but had not been properly identified  
as such. Specific examples included:* CMI-0016, "Division  
I and 11 Emergency
Diesel Generator  
Starting Air Valve Repair," Revision 3, did not identify measurement  
and evaluation  
of cap bore and piston diameter as a critical step although an Improper clearance  
could result in a failure of the emergency  
diesel generator  
to start.* PMI-0040, "Division  
IlIl Air Start Motor Maintenance," Revision 4, did not identify a rotation check of the air starter during air start motor reassembly  
as a critical step although improper rotation could result in damage to the component  
or a slow start.  
PY-CEI/NRR-2959L
Attachment  
I Page 3 of 11* GMI-0002, "Maintenance  
of the Control Rod Drive Pumps," Revision 2, did not identify the measurement  
of run out clearances  
as a critical step although improper clearances  
could lead to premature  
bearing failure.MAI-0507 also prescribed  
that if possible, Critical Steps should be identified  
and mitigated  
by using one of the following  
methods:* Add a step for breakpoint  
review.* Add independent  
verification.
* Add a step for peer-check.
* Add a step for peer-check.
* Add a step to contact the supervisor.
* Add a step to contact the supervisor.
* Add a step to contact the Control Room to verify a condition  
* Add a step to contact the Control Room to verify a condition before continuing to the next action.
before continuing  
However, contrary to MAI-0507, no examples of mitigation strategies for critical steps could be found in any of the revised procedures. These mitigation strategies were intended to provide additional assurance of proper step completion. Follow up discussions with work management personnel indicated that these strategies were intended to be added during the work package development process. However, only one example was identified in which a mitigation strategy was included with a work order containing a critical step. The inspectors concluded that the licensee had not adequately implemented this procedural requirement. However, since the inspectors did not identify any instance where the omission of a mitigating strategy had resulted in improper procedure implementation, the inspectors concluded the issue was of only minor significance.
to the next action.However, contrary to MAI-0507, no examples of mitigation  
FENOC RESPONSE:
strategies  
FENOC acknowledges that inconsistencies exist in application of the critical steps in the upgraded maintenance procedures. When this issue was identified, several condition reports were generated to document the issues (i.e., CR 06-00181, 06-00276 and 06-00418). Condition Report 06-00418 documents the investigation summary and provides the corrective action to address the issue going forward. Since the CR was generated, MAI-0507, "Maintenance Procedures Writer's Guide," has been superseded by a new technical procedure guide PAP-0500, "Perry Technical Procedure Writer's Guide," Revision 0, that provides improved guidance for mitigation and application of critical steps.
for critical steps could be found in any of the revised procedures.  
The investigation found that the inconsistencies in the application of the critical steps in the upgraded maintenance procedures were due to less than adequate oversight and participation by Perry personnel during the procedure upgrade process. The initial maintenance procedure upgrade project was mainly supported by outside contract personnel utilizing a format obtained from another site that did not meet FENOC standards. Additionally, when the maintenance procedure upgrade project was initiated in late 2004, the maintenance procedure writers guide, MAI-0507 was not issued yet, which contributed to the issue.
These mitigation  
 
strategies  
PY-CEI/NRR-2959L Attachment 1 Page 4 of 11 As a result of the issues discussed above, the upgraded maintenance procedures will be reviewed for the consistent application of critical steps, formatting and consistency. Corrective actions will be taken to address issues found during the reviews. As stated above, this action is being tracked as CA 06-00418-02.
were intended to provide additional  
: 3. 3.1.b.3, Weaknesses in the use of Placekeeping Tools and Human Factoring, states:
assurance  
The inspectors confirmed that the licensee added placekeeping blocks to the revised procedures and had reformatted the procedures to address human factoring considerations. The inspectors supplemented this review with in-field observations of the implementation of the revised maintenance procedures. The inspectors noted performance of one procedure with improper use of placekeeping techniques:
of proper step completion.  
* During hydramotor work, the inspectors noted that technicians performed multiple steps in rapid succession without using proper placekeeping.
Follow up discussions  
* In the same procedure, the technicians performed several steps multiple times without using peacekeeping for each Performance of the step. By procedure, a step may be performed multiple times, but each Performance requires separate placekeeping.
with work management  
In addition, the inspectors noted multiple instances of poorly worded steps that hampered the maintenance worker's ability to successfully complete the procedure.
personnel  
For example:
indicated  
* The inspectors observed the performance of a motor-operated valve (MOV) maintenance activity. Although the maintenance procedure utilized for this activity had been previously performed more than 100 times on other valves, the workers stopped several times to obtain clarification on the requirements of the procedure.
that these strategies  
* The inspectors reviewed a completed work package that utilized maintenance procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance." The inspectors identified that workers had incorrectly N/A'd a section of the procedure. The inspectors noted that the procedural directions regarding performance of that section of the procedure were unclear. (Section b.4)
were intended to be added during the work package development  
The inspectors observed the performance of maintenance procedure ICI-B12-001, "ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration."
process. However, only one example was identified  
During implementation of the procedure, maintenance workers failed to remove all required access covers to the hydramotor. The inspectors noted that the procedure did not specifically identify the covers to be removed. (Section b.5)
in which a mitigation  
FENOC RESPONSE:
strategy was included with a work order containing  
The issue with improper use of peacekeeping during the hydramotor work activity is addressed in Item 5 below. This observation was noted during calibration check of a Division IlIl EDG Exhaust Air Damper using procedure ICI-B12-0001, -ITT NH90 Series Millampere Proportional/On-Off Hydramotor Actuator Calibration" and is being addressed in CR 06-01765.
a critical step. The inspectors  
 
concluded  
PY-CEI/NRR-2959L Attachment 1 Page 5 of 11 The issue with poorly worded steps in the maintenance procedure that hampered the maintenance workers ability to complete the MOV maintenance procedure is related to the issue raised in Item 2 above. This issue is being addressed as part of CR 06-00418.
that the licensee had not adequately  
The issue with incorrect use of "N/A" during the performance of maintenance activity for ABB low voltage circuit breakers is addressed in Item 4 below.
implemented  
This issue was observed during the review of completed maintenance work package that utilized maintenance procedure GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance" and is being addressed in CR 06-00283.
this procedural  
: 4. (a) 3.1.b.4, Inappropriate Use of Not Applicable (N/A) in Procedure Steps, states:
requirement.  
The inspectors identified that many of the revised maintenance procedures applied to multiple different styles of components. As a result, these procedures required that maintenance workers determine the applicable steps of the procedure to be performed since all steps may not apply to a particular component. When a step was not performed, the worker would mark the step N/A [not applicable]. Based on the procedures reviewed, the inspectors concluded that the typical number of N/As required during the implementation of a procedure represented a potential human performance trap. During the inspection, the inspectors identified the following specific example in which a procedure step was inappropriately N/A'd for which the Enforcement section is restated here for the example "Failure to Perform Required Steps Prescribed by Procedure GEI-0009".
However, since the inspectors
Enforcement: Technical Specification 5.4, "Procedures," required, in part, that written procedures be implemented covering applicable procedures recommended by Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operation),
did not identify any instance where the omission of a mitigating  
  "Revision 2, dated February 1978. Regulatory Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance that can affect the performanceof safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances."
strategy had resulted in improper procedure  
Contrary to this requirement, on January 19, 2006 [it was determined that], licensee personnel failed to perform required steps in procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 & K-600S Through K-3000 & K-3000S Maintenance," Revision 17. Specifically, licensee personnel failed to perform minimum operating voltage testing on the safety-related EF1A05 breaker that provided power to Division I Motor Control Center (MCC), Switchgear (SWGR), and Battery Room Supply Fan A. However, because of the very low safety significance and because the issue has been entered into the licensee's corrective action program (CR 06-00283), the issue is being treated as a non-cited violation (NCV) consistent with Section VI.A. 1 of the NRC Enforcement Policy (NCV 05000440/2006007-01).
implementation, the inspectors  
FENOC RESPONSE:
concluded  
During a review of work order (WO) 200038182, the NRC inspector identified that step 5.2.3, 'Minimum Operating Voltage and Anti-Pump Verification," of procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600
the issue was of only minor significance.
          & K-600S through K-3000 & K-3000S Maintenance," was marked N/A and not performed during the voltage testing of the non-safety related breaker that provides power to the condensate transfer pump A. When the issue
FENOC RESPONSE: FENOC acknowledges  
 
that inconsistencies  
PY-CEI/NRR-2959L Attachment 1 Page 6 of 11 was raised during the inspection, CR 06-00283 was written to document and to investigate the issue, The investigation revealed that step 5.2.3 of GEl-0009 was incorrectly marked N/A and not performed as required. The anti-pump functional verification was performed by a subsequent step within the procedure. Step 5.16, "Breaker Anti-Pump," requires that the functionality of the breaker be verified before it is restored to an operable condition. From an equipment perspective, the anti-pump feature on the breaker was verified to be acceptable before it was installed and placed in service. There are no hardware issues associated with this breaker pertaining to the NA'd step 5.2.3. The maintenance work performed on this breaker satisfied the purpose of procedure GEI-0009 yet, as stated above, was not performed in full compliance with the requirements. The breaker was installed and placed in service on September 9, 2005 and there have not been any operational issues since that time. This breaker is presently scheduled for refurbishment in June 2006 (with a maximum due date of June 2007). Additionally, an immediate investigation was performed to determine if any other safety related, electrically operated breakers had been installed during 2005 without verification of their anti-pump feature. The investigation determined that the safety-related breakers overhauled during 2005 adequately met the steps 5.2.3 and 5.16 of procedure GEI-0009 for proper breaker operation.
exist in application  
Individual performance issues associated with this condition were referred to line management for appropriate actions in accordance with the FENOC Performance Management System.
of the critical steps in the upgraded maintenance  
It is noted that for the safety related breaker that provides power to the division 1 motor control center (MCC), switchgear (SWGR) and battery room supply fan A, step 5.2.3 was left blank on the data sheet. However, since this breaker failed as-found, CR 05-04796 was written and the replacement breaker function was verified as acceptable.
procedures.  
(b) 3.1.b.4, In addition to this example, the inspectors observed a nonsafety-related air-operated valve (AOV) rebuild activity during which maintenance workers improperly N/A'd a step that prescribed a valve stem inspection.
When this issue was identified, several condition  
FENOC RESPONSE:
reports were generated  
During performance of changing the packing for feedwater heater drain valve, I N25F0290A, step 5.3.2 of the valve packing instruction per procedure GMI-0061,"Valve Packing Instruction," was marked not applicable (N/A). The step states: "IF damage is found, THEN DETERMINE where information is available in Valveman Data Program or Order." The Valveman datasheet provides the information that addresses the packing configuration to be used. This step was incorrectly marked N/A while it was applicable. Step 5.3.2 was subsequently performed satisfactorily. This issue was documented in CR 06-00269. The investigation revealed that the individuals, although qualified to perform the task, had not performed the task regularly. Since the procedure was of a new format, the individuals misunderstood the steps and requirements of the datasheet.
to document the issues (i.e., CR 06-00181, 06-00276 and 06-00418).  
The use of training along with the procedure provides the individuals with sufficient information needed to perform the task. Had the individuals
Condition  
 
Report 06-00418 documents  
PY-CEI/NRR-2959L Attachment I Page 7 of 11 followed the procedure they would have discovered the data was contained in the Valveman data package. This was a human performance issue rather than a procedure deficiency. Individual performance issues associated with this condition were referred to line management for appropriate actions in accordance with the FENOC Performance Management System.
the investigation  
Elimination of human performance issues, including "procedure traps," has been given a high priority. The Maintenance Training Review Committee (TRC) is tracking actions for the maintenance organization to complete "Procedure Use And Adherence" classroom and laboratory training. At the end of March, 2006, the classroom portion had been completed by all maintenance supervisors and worker personnel. Laboratory practical training has been captured as an action that is scheduled to be completed next. The lesson material specifically includes training on "when procedure steps do not apply."
summary and provides the corrective  
: 5. 3.1.b.5, Failure to Perform Required Steps Prescribed by Procedure ICI-B12-0001, states: Technical Specification 5.4, "Procedures," required, in part, that written procedures be implemented covering applicable procedures recommended by Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operation),
action to address the issue going forward. Since the CR was generated, MAI-0507,"Maintenance  
  "Revision 2, dated February 1978. Regulatory Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance that can affect the performance of safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances."
Procedures  
Contrary to this requirement, on January 10, 2006, during a calibration check of a Division IlIl EDG Exhaust Air Damper, licensee personnel failed to perform required steps prescribed by procedure ICI-B12-0001, "ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration," Revision 4. However, because of the very low safety significance and because the issue has been entered into the licensee's corrective action program (CR 06-00125), the issue is being treated as a non-cited violation (NCV) consistent with Section VI.A. 1 of the NRC Enforcement Policy (NCV 05000440/2006007-02).
Writer's Guide," has been superseded  
FENOC RESPONSE:
by a new technical  
On January 10, 2006, the NRC inspector observed the implementation of upgraded maintenance procedure ICI-B12-0001, 'ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration," Revision 4, during a calibration check of a Division IlIl Emergency Diesel Generator Exhaust Air Damper Hydramotor. This procedure was categorized as Step-by-Step Use and in accordance with procedure NOP-LP-2601, 'Procedure Use and Adherence." During the performance of ICI-B12-0001, several instances were identified where procedure adherence was not followed in accordance with NOP-LP-2601.
procedure  
As discussed in the NRC inspection report:
guide PAP-0500, "Perry Technical  
* Step 5.9.2 of ICI-B12-0001 directed the user to verify the subject hydramotor had been full-stroke cycled a minimum of five times.
Procedure  
Although procedure steps which prescribe this type of verification permit the re-positioning of plant components, in accordance with
Writer's Guide," Revision 0, that provides improved guidance for mitigation  
 
and application  
PY-CEI/NRR-2959L Attachment I Page 8 of I1 NOP-LP-2601, these actions must be specifically authorized by plant procedures. In this case, and as observed by the inspectors, although this guidance did not exist, personnel performed future procedure steps out-of-sequence in order to accomplish Step 5.9.2.
of critical steps.The investigation  
* Step 5.9.3 of ICI-B12-0001 directed that screw-on covers be removed to support testing. In this case, personnel failed to remove the necessary covers to continue with the proper testing.
found that the inconsistencies  
* Step 5.9.4 of ICI-B12-0001 directed the connection of a multi-meter to a limit switch in accordance with Attachment 7, Figure 1. Contrary to this, personnel connected the multi-meter in accordance with Attachment 10 and continued with the calibration check. This error was identified by the inspectors observing the test when conflicts were discovered at a later procedure step.
in the application  
* Steps 5.9.5 through 5.9.9 of ICI-B12-0001 directed the manipulation of the hydramotor actuator for verification and recording of proper valve seating and stem travel. Contrary to procedure use guidance, personnel did not complete these steps via the read-then-perform approach. Additionally, NOP-LP-2601 directed that repeated steps shall be provided with "separate documentation" and "peacekeeping on the steps". These steps were repeated to satisfy the requirements of Step 5.9.2 without separate documentation and placekeeping annotation.
of the critical steps in the upgraded maintenance  
* Step 5.9.10, 5.9.10.a and 5.9.10.b of ICI-B12-0001 directed the connection of a multi-meter to position switches followed by actuator manipulation until such switches actuate. Contrary to procedure use guidance, steps were marked as complete concurrently without verifying individually that each step had been completed.
procedures  
As part of the immediate corrective action, personnel stopped the work activity and revised ICI-B12-0001 to clarify the requirements in Section 5.9 of the procedure. A second attempt was made to calibrate the hydramotor, but the procedure needed another revision to the steps. The procedure category was also revised from 'Step-by-Step" to "In-Field Reference," a more appropriate category for this procedure. Upon completion of the second procedure revision, the calibration was completed satisfactorily and the hydramotor was returned to service.
were due to less than adequate oversight  
Condition reports 06-00125 and 06-01765 address the above inspection report issues as follows:
and participation  
The first example of Step 5.9.2 of ICI-B12-0001 directed the user to verify that the hydramotor had been run through full stroke at least five times. Per NOP-LP-2601, the performer is allowed to reposition this hydramotor if authorized by plant procedures. The approval to stroke this valve was authorized by the order which was released by operations to allow calibration of the hydramotor. Note: The act of stroking the hydramotor is a skill that is obtained by a qualified technician during their on-the-job training/task performance evaluation (OJT/TPE) training.
by Perry personnel  
 
during the procedure  
PY-CEI/NRR-2959L Attachment I Page 9 of I1 Step 5.9.3 of ICI-B12-0001 directed the removal of control and electrical screw on covers for the PCD actuator. The technicians were working to calibrate the position limit switches instead of the travel limit switch so the correct cover was not removed. The technician made an error in not removing all of the covers needed for this calibration.
upgrade process. The initial maintenance  
Step 5.9.4 of ICI-B12-0001 directed the connection of a multi-meter to an actuator travel limit switch shown on attachment 7, but went to attachment 10 (this issue was addressed solely by CR 06-00125). The error was failure to follow the procedure. The procedures were revised, the calibration completed, the hydramotor was returned to service, and the potential limiting condition for operation (PLCO) cleared.
procedure  
Steps 5.9.5 through 5.9.9 of ICI-B12-0001 directed the manipulation of the hydramotor actuator for verification and recording of proper valve seating and stem travel. The steps were all performed and then signed off which violates procedure NOP-LP-2601 for use of a step-by-step procedure. Also, as the steps were repeated, the technicians failed to provide the separate documentation and placekeeping as required by NOP-LP-2601. Although this may be accomplished by different methods, the performers must follow the procedure requirements. These were human performance errors.
upgrade project was mainly supported  
Steps 5.9.10, 5.9.10a, and 5.9.10b of ICI-B12-0001 directed the connection of a multi-meter to position switches followed by actuator manipulation until such switches actuate. The steps were performed concurrently and then signed off after completed which is contrary to the requirements of NOP-LP-2601 for a Step-by-Step procedure.
by outside contract personnel  
The roll-up of these issues again emphasizes the failure to follow proper procedure use and adherence expectations. This issue was addressed in CR-06-00125. I&C, Electrical, Mechanical and Services sections of Maintenance have completed a procedure use and adherence class. The requirements and the expectations for procedure use and adherence were emphasized during the class.
utilizing  
As discussed above, procedure adherence and quality of the procedure contributed to this issue. Corrective actions were taken in accordance with the FENOC Performance Management Process.
a format obtained from another site that did not meet FENOC standards.  
: 6. 3.2, Commitment Item 1.b/DAMP Item B2.2.3.2, states: The inspectors concluded that NQI-1001, Revision 5, appropriately incorporated the consideration of failure history, risk significance, and failure probability in assigning QC inspection hold points. However, the inspectors identified that the methods Identified and in use did not take full advantage of all site programs. In particular, the procedure did not prescribe the review of the maintenance rule database, which collects pertinent component failure data, nor did it integrate the probabilistic risk assessment (PRA) model, which provides component-specific risk information.
Additionally, when the maintenance  
 
procedure  
PY-CEI/NRR-2959L Attachment 1 Page 10 of II FENOC RESPONSE:
upgrade project was initiated  
To address the above observations, CR 06-00366 was generated. It should be noted that NQI-I001 was superseded by Nuclear Operating Procedure NOP-LP-2018, "Quality Control Inspection of Maintenance and Modification Activities," on December 19, 2005. The CR investigation was focused on addressing the following enhancement actions to procedure NOP-LP-2018:
in late 2004, the maintenance  
* Assignment of hold/witness points to procedure steps that are identified as "critical steps."
procedure  
* Use of Probabilistic Safety Assessment (PSA) risk significance for component level equipment and non-safety risk significance equipment.
writers guide, MAI-0507 was not issued yet, which contributed  
* Use of Maintenance Rule database for the identification of repeat failure items for potential assignment of hold/witness points.
to the issue.  
The investigation determined that use of the Maintenance Rule database as a means to identify additional QC hold/witness points is not an optimum method. Since the condition reports drive the maintenance rule evaluation through the corrective actions, historical failure data can be obtained through the review of condition reports for those components that are considered to be a maintenance rule failure. Therefore, historical data from the condition reporting system will be used for the identification of repeat failures items for potential assignment of hold/witness points.
PY-CEI/NRR-2959L
The following enhancements were added to procedure NOP-LP-2018:
Attachment  
* Use of pre-established "Critical Steps" as a factor when assigning QC Hold/Witness points.
1 Page 4 of 11 As a result of the issues discussed  
* Use of risk significance assessment tool at a component level as a factor when assigning Hold/Witness points.
above, the upgraded maintenance
* Use of Risk Significance (PSA), Maintenance Rule, Critical Components, and Maintenance Modifications as factors that the QC supervisor will utilize when assigning process monitoring.
procedures  
SECTION 5.0 TRAINING 5.3, Review of Human Performance Tools to Reinforce Human Performance Under Stress, states: While observing the rebuild of a fire protection deluge valve, a procedure step in the work package required the inspection of valve internals to evaluate the condition of the valve, including the condition of internal moving parts.
will be reviewed for the consistent  
When questioned about the presence of moving parts, licensee personnel were unsure if the valve contained moving parts. Despite this lack of knowledge, licensee personnel signed off the step as complete. Upon further review, the inspectors determined that the work package was incorrect and referenced a section of the technical manual for a valve that contained moving parts although the valve inspected did not contain moving parts.
application  
However, since this error had no actual adverse impact on the deluge valve inspection results, the inspectors concluded the issue was of only minor significance.
of critical steps, formatting  
 
and consistency.  
PY-CEI/NRR-2959L Attachment 1 Page 11 of 11 FENOC RESPONSE:
Corrective  
To address the above observation, FENOC generated CRs 06-00178 and 06-01764. CR 06-00178 investigated the issue concerning the communication that took place between the inspector and responsible system engineer (RSE) during inspection of the fire protection deluge valve.
actions will be taken to address issues found during the reviews. As stated above, this action is being tracked as CA 06-00418-02.
The inspector questioned what moving parts were inspected for the valve in accordance with the work order and whether a vendor manual was reviewed during the valve inspection. The RSE's initial response was that the valve did not have the same spring arrangement like the other valves being inspected. This was confirmed by the maintenance personnel during the inspection. The proper response should have been that the valve flapper was inspected during the valve internal inspection and there was no spring arrangement for this particular valve model. This communication issue was subsequently clarified with the inspector. The investigation determined that the initial response by the RSE to the inspectors question was not clearly communicated.
3. 3.1.b.3, Weaknesses  
Condition report 06-01764 investigated the issue with potential for lack of knowledge and incorrect work package. During the initial inspection of the deluge valve, the RSE examined the valve internals to include flapper, seating surfaces, and body conditions. After inspection of the valve, the RSE confirmed by way of the maintenance personnel that this model valve did not have a spring. When questioned by the inspector as to what moving parts were inspected, the RSE identified that the internals and seating surface were inspected. The RSE went on to explain that this model did not contain a spring. The inspector asked if the vendor manual had been reviewed. The RSE responded no (note that this was the fourth deluge valve inspected by the RSE with some models containing the spring while others do not). In the subsequent meeting with the inspector, the RSE was more precise in specifically identifying that the flapper (moving part) was inspected and indicated that he had a conversation with the mechanic regarding this particular model not having a spring. The inspector was not aware of the conversation between the RSE and the maintenance personnel during the inspection. The work order package issue was associated with one of the two models with the manual/drawing (model without spring) not being in the package. The order was for the inspection of multiple deluge valves that consisted of both models. The SAP data for the valve being inspected at the time of this event did not identify the valve correctly and the proper vendor manual section/drawing was not provided. The package only contained a vendor manual/drawing of the model with a spring. This oversight was corrected by adding the appropriate manual section/drawing to the package and changing the SAP data base model number. Therefore, this issue is not a result of lack of RSE knowledge, but rather less than effective communications and an issue with the work package.}}
in the use of Placekeeping  
Tools and Human Factoring, states: The inspectors  
confirmed  
that the licensee added placekeeping  
blocks to the revised procedures  
and had reformatted  
the procedures  
to address human factoring considerations.  
The inspectors  
supplemented  
this review with in-field observations
of the implementation  
of the revised maintenance  
procedures.  
The inspectors  
noted performance  
of one procedure  
with improper use of placekeeping  
techniques:
* During hydramotor  
work, the inspectors  
noted that technicians  
performed multiple steps in rapid succession  
without using proper placekeeping.
* In the same procedure, the technicians  
performed  
several steps multiple times without using peacekeeping  
for each Performance  
of the step. By procedure, a step may be performed  
multiple times, but each Performance  
requires separate placekeeping.
In addition, the inspectors  
noted multiple instances  
of poorly worded steps that hampered the maintenance  
worker's ability to successfully  
complete the procedure.
For example:* The inspectors  
observed the performance  
of a motor-operated  
valve (MOV)maintenance  
activity.  
Although the maintenance  
procedure  
utilized for this activity had been previously  
performed  
more than 100 times on other valves, the workers stopped several times to obtain clarification  
on the requirements  
of the procedure.
* The inspectors  
reviewed a completed  
work package that utilized maintenance
procedure  
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance." The inspectors  
identified
that workers had incorrectly  
N/A'd a section of the procedure.  
The inspectors
noted that the procedural  
directions  
regarding  
performance  
of that section of the procedure  
were unclear. (Section b.4)The inspectors  
observed the performance  
of maintenance  
procedure  
ICI-B12-001,"ITT NH90 Series Milliampere  
Proportional/On-Off  
Hydramotor  
Actuator Calibration." During implementation  
of the procedure, maintenance  
workers failed to remove all required access covers to the hydramotor.  
The inspectors  
noted that the procedure did not specifically  
identify the covers to be removed. (Section b.5)FENOC RESPONSE: The issue with improper use of peacekeeping  
during the hydramotor  
work activity is addressed  
in Item 5 below. This observation  
was noted during calibration  
check of a Division IlIl EDG Exhaust Air Damper using procedure ICI-B12-0001, -ITT NH90 Series Millampere  
Proportional/On-Off  
Hydramotor
Actuator Calibration" and is being addressed  
in CR 06-01765.  
PY-CEI/NRR-2959L
Attachment  
1 Page 5 of 1 1 The issue with poorly worded steps in the maintenance  
procedure  
that hampered the maintenance  
workers ability to complete the MOV maintenance  
procedure  
is related to the issue raised in Item 2 above. This issue is being addressed  
as part of CR 06-00418.The issue with incorrect  
use of "N/A" during the performance  
of maintenance
activity for ABB low voltage circuit breakers is addressed  
in Item 4 below.This issue was observed during the review of completed  
maintenance  
work package that utilized maintenance  
procedure  
GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance" and is being addressed  
in CR 06-00283.4. (a) 3.1.b.4, Inappropriate  
Use of Not Applicable (N/A) in Procedure  
Steps, states: The inspectors  
identified  
that many of the revised maintenance  
procedures  
applied to multiple different  
styles of components.  
As a result, these procedures  
required that maintenance  
workers determine  
the applicable  
steps of the procedure  
to be performed  
since all steps may not apply to a particular  
component.  
When a step was not performed, the worker would mark the step N/A [not applicable].  
Based on the procedures  
reviewed, the inspectors  
concluded  
that the typical number of N/As required during the implementation  
of a procedure  
represented  
a potential  
human performance  
trap. During the inspection, the inspectors  
identified  
the following specific example in which a procedure  
step was inappropriately  
N/A'd for which the Enforcement  
section is restated here for the example "Failure to Perform Required Steps Prescribed  
by Procedure  
GEI-0009".
Enforcement:  
Technical  
Specification  
5.4, "Procedures," required, in part, that written procedures  
be implemented  
covering applicable  
procedures  
recommended
by Regulatory  
Guide 1.33, "Quality Assurance  
Program Requirements (Operation),"Revision  
2, dated February 1978. Regulatory  
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance  
that can affect the performance
of safety-related  
equipment should be properly pre-planned  
and performed  
in accordance  
with written procedures, documented  
instructions, or drawings appropriate  
to the circumstances." Contrary to this requirement, on January 19, 2006 [it was determined  
that], licensee personnel  
failed to perform required steps in procedure  
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 & K-600S Through K-3000 & K-3000S Maintenance," Revision 17. Specifically, licensee personnel  
failed to perform minimum operating  
voltage testing on the safety-related  
EF1A05 breaker that provided power to Division I Motor Control Center (MCC), Switchgear (SWGR), and Battery Room Supply Fan A. However, because of the very low safety significance
and because the issue has been entered into the licensee's  
corrective  
action program (CR 06-00283), the issue is being treated as a non-cited  
violation (NCV)consistent  
with Section VI.A. 1 of the NRC Enforcement  
Policy (NCV 05000440/2006007-01).
FENOC RESPONSE: During a review of work order (WO) 200038182, the NRC inspector  
identified
that step 5.2.3, 'Minimum Operating  
Voltage and Anti-Pump  
Verification," of procedure  
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600& K-600S through K-3000 & K-3000S Maintenance," was marked N/A and not performed  
during the voltage testing of the non-safety  
related breaker that provides power to the condensate  
transfer pump A. When the issue  
PY-CEI/NRR-2959L
Attachment  
1 Page 6 of 11 was raised during the inspection, CR 06-00283 was written to document and to investigate  
the issue, The investigation  
revealed that step 5.2.3 of GEl-0009 was incorrectly  
marked N/A and not performed  
as required.  
The anti-pump functional  
verification  
was performed  
by a subsequent  
step within the procedure.  
Step 5.16, "Breaker Anti-Pump," requires that the functionality  
of the breaker be verified before it is restored to an operable condition.  
From an equipment  
perspective, the anti-pump  
feature on the breaker was verified to be acceptable  
before it was installed  
and placed in service. There are no hardware issues associated  
with this breaker pertaining  
to the NA'd step 5.2.3. The maintenance  
work performed  
on this breaker satisfied  
the purpose of procedure  
GEI-0009 yet, as stated above, was not performed  
in full compliance  
with the requirements.  
The breaker was installed  
and placed in service on September  
9, 2005 and there have not been any operational
issues since that time. This breaker is presently  
scheduled  
for refurbishment
in June 2006 (with a maximum due date of June 2007). Additionally, an immediate  
investigation  
was performed  
to determine  
if any other safety related, electrically  
operated breakers had been installed  
during 2005 without verification  
of their anti-pump  
feature. The investigation  
determined  
that the safety-related  
breakers overhauled  
during 2005 adequately  
met the steps 5.2.3 and 5.16 of procedure  
GEI-0009 for proper breaker operation.
Individual  
performance  
issues associated  
with this condition  
were referred to line management  
for appropriate  
actions in accordance  
with the FENOC Performance  
Management  
System.It is noted that for the safety related breaker that provides power to the division 1 motor control center (MCC), switchgear (SWGR) and battery room supply fan A, step 5.2.3 was left blank on the data sheet. However, since this breaker failed as-found, CR 05-04796 was written and the replacement
breaker function was verified as acceptable.(b) 3.1.b.4, In addition to this example, the inspectors  
observed a nonsafety-related
air-operated  
valve (AOV) rebuild activity during which maintenance  
workers improperly  
N/A'd a step that prescribed  
a valve stem inspection.
FENOC RESPONSE: During performance  
of changing the packing for feedwater  
heater drain valve, I N25F0290A, step 5.3.2 of the valve packing instruction  
per procedure  
GMI-0061,"Valve  
Packing Instruction," was marked not applicable (N/A). The step states: "IF damage is found, THEN DETERMINE  
where information  
is available  
in Valveman Data Program or Order." The Valveman datasheet  
provides the information  
that addresses  
the packing configuration  
to be used. This step was incorrectly  
marked N/A while it was applicable.  
Step 5.3.2 was subsequently  
performed  
satisfactorily.  
This issue was documented  
in CR 06-00269.  
The investigation  
revealed that the individuals, although qualified  
to perform the task, had not performed  
the task regularly.  
Since the procedure  
was of a new format, the individuals
misunderstood  
the steps and requirements  
of the datasheet.
The use of training along with the procedure  
provides the individuals  
with sufficient  
information  
needed to perform the task. Had the individuals  
PY-CEI/NRR-2959L
Attachment  
I Page 7 of 1 1 followed the procedure  
they would have discovered  
the data was contained in the Valveman data package. This was a human performance  
issue rather than a procedure  
deficiency.  
Individual  
performance  
issues associated  
with this condition  
were referred to line management  
for appropriate  
actions in accordance  
with the FENOC Performance  
Management  
System.Elimination  
of human performance  
issues, including "procedure  
traps," has been given a high priority.  
The Maintenance  
Training Review Committee (TRC) is tracking actions for the maintenance  
organization  
to complete"Procedure  
Use And Adherence" classroom  
and laboratory  
training.  
At the end of March, 2006, the classroom  
portion had been completed  
by all maintenance  
supervisors  
and worker personnel.  
Laboratory  
practical training has been captured as an action that is scheduled  
to be completed next. The lesson material specifically  
includes training on "when procedure steps do not apply." 5. 3.1.b.5, Failure to Perform Required Steps Prescribed  
by Procedure  
ICI-B12-0001, states: Technical  
Specification  
5.4, "Procedures," required, in part, that written procedures  
be implemented  
covering applicable  
procedures  
recommended  
by Regulatory  
Guide 1.33, "Quality Assurance  
Program Requirements (Operation),"Revision  
2, dated February 1978. Regulatory  
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance  
that can affect the performance  
of safety-related  
equipment should be properly pre-planned  
and performed  
in accordance  
with written procedures, documented  
instructions, or drawings appropriate  
to the circumstances." Contrary to this requirement, on January 10, 2006, during a calibration  
check of a Division IlIl EDG Exhaust Air Damper, licensee personnel  
failed to perform required steps prescribed  
by procedure  
ICI-B12-0001, "ITT NH90 Series Milliampere
Proportional/On-Off  
Hydramotor  
Actuator Calibration," Revision 4. However, because of the very low safety significance  
and because the issue has been entered into the licensee's  
corrective  
action program (CR 06-00125), the issue is being treated as a non-cited  
violation (NCV) consistent  
with Section VI.A. 1 of the NRC Enforcement  
Policy (NCV 05000440/2006007-02).
FENOC RESPONSE: On January 10, 2006, the NRC inspector  
observed the implementation  
of upgraded maintenance  
procedure  
ICI-B12-0001, 'ITT NH90 Series Milliampere  
Proportional/On-Off  
Hydramotor  
Actuator Calibration," Revision 4, during a calibration  
check of a Division IlIl Emergency  
Diesel Generator Exhaust Air Damper Hydramotor.  
This procedure  
was categorized  
as Step-by-Step Use and in accordance  
with procedure  
NOP-LP-2601, 'Procedure
Use and Adherence." During the performance  
of ICI-B12-0001, several instances  
were identified  
where procedure  
adherence  
was not followed in accordance  
with NOP-LP-2601.
As discussed  
in the NRC inspection  
report:* Step 5.9.2 of ICI-B12-0001  
directed the user to verify the subject hydramotor  
had been full-stroke  
cycled a minimum of five times.Although procedure  
steps which prescribe  
this type of verification
permit the re-positioning  
of plant components, in accordance  
with
PY-CEI/NRR-2959L
Attachment  
I Page 8 of I1 NOP-LP-2601, these actions must be specifically  
authorized  
by plant procedures.  
In this case, and as observed by the inspectors, although this guidance did not exist, personnel  
performed  
future procedure  
steps out-of-sequence  
in order to accomplish  
Step 5.9.2.* Step 5.9.3 of ICI-B12-0001  
directed that screw-on covers be removed to support testing. In this case, personnel  
failed to remove the necessary  
covers to continue with the proper testing.* Step 5.9.4 of ICI-B12-0001  
directed the connection  
of a multi-meter  
to a limit switch in accordance  
with Attachment  
7, Figure 1. Contrary to this, personnel  
connected  
the multi-meter  
in accordance  
with Attachment  
10 and continued  
with the calibration  
check. This error was identified  
by the inspectors  
observing  
the test when conflicts were discovered  
at a later procedure  
step.* Steps 5.9.5 through 5.9.9 of ICI-B12-0001  
directed the manipulation
of the hydramotor  
actuator for verification  
and recording  
of proper valve seating and stem travel. Contrary to procedure  
use guidance, personnel  
did not complete these steps via the read-then-perform
approach.  
Additionally, NOP-LP-2601  
directed that repeated steps shall be provided with "separate  
documentation" and "peacekeeping
on the steps". These steps were repeated to satisfy the requirements
of Step 5.9.2 without separate documentation  
and placekeeping
annotation.
* Step 5.9.10, 5.9.10.a and 5.9.10.b of ICI-B12-0001  
directed the connection  
of a multi-meter  
to position switches followed by actuator manipulation  
until such switches actuate. Contrary to procedure  
use guidance, steps were marked as complete concurrently  
without verifying  
individually  
that each step had been completed.
As part of the immediate  
corrective  
action, personnel  
stopped the work activity and revised ICI-B12-0001  
to clarify the requirements  
in Section 5.9 of the procedure.  
A second attempt was made to calibrate  
the hydramotor, but the procedure  
needed another revision to the steps. The procedure  
category was also revised from 'Step-by-Step" to "In-Field  
Reference," a more appropriate  
category for this procedure.  
Upon completion  
of the second procedure  
revision, the calibration  
was completed  
satisfactorily  
and the hydramotor  
was returned to service.Condition  
reports 06-00125 and 06-01765 address the above inspection
report issues as follows: The first example of Step 5.9.2 of ICI-B12-0001  
directed the user to verify that the hydramotor  
had been run through full stroke at least five times. Per NOP-LP-2601, the performer  
is allowed to reposition  
this hydramotor  
if authorized  
by plant procedures.  
The approval to stroke this valve was authorized  
by the order which was released by operations  
to allow calibration
of the hydramotor.  
Note: The act of stroking the hydramotor  
is a skill that is obtained by a qualified  
technician  
during their on-the-job  
training/task
performance  
evaluation (OJT/TPE)  
training.  
PY-CEI/NRR-2959L
Attachment  
I Page 9 of I1 Step 5.9.3 of ICI-B12-0001  
directed the removal of control and electrical
screw on covers for the PCD actuator.  
The technicians  
were working to calibrate  
the position limit switches instead of the travel limit switch so the correct cover was not removed. The technician  
made an error in not removing all of the covers needed for this calibration.
Step 5.9.4 of ICI-B12-0001  
directed the connection  
of a multi-meter  
to an actuator travel limit switch shown on attachment  
7, but went to attachment  
10 (this issue was addressed  
solely by CR 06-00125).  
The error was failure to follow the procedure.  
The procedures  
were revised, the calibration
completed, the hydramotor  
was returned to service, and the potential  
limiting condition  
for operation (PLCO) cleared.Steps 5.9.5 through 5.9.9 of ICI-B12-0001  
directed the manipulation  
of the hydramotor  
actuator for verification  
and recording  
of proper valve seating and stem travel. The steps were all performed  
and then signed off which violates procedure  
NOP-LP-2601  
for use of a step-by-step  
procedure.  
Also, as the steps were repeated, the technicians  
failed to provide the separate documentation  
and placekeeping  
as required by NOP-LP-2601.  
Although this may be accomplished  
by different  
methods, the performers  
must follow the procedure  
requirements.  
These were human performance  
errors.Steps 5.9.10, 5.9.10a, and 5.9.10b of ICI-B12-0001  
directed the connection
of a multi-meter  
to position switches followed by actuator manipulation  
until such switches actuate. The steps were performed  
concurrently  
and then signed off after completed  
which is contrary to the requirements  
of NOP-LP-2601 for a Step-by-Step  
procedure.
The roll-up of these issues again emphasizes  
the failure to follow proper procedure  
use and adherence  
expectations.  
This issue was addressed  
in CR-06-00125.  
I&C, Electrical, Mechanical  
and Services sections of Maintenance  
have completed  
a procedure  
use and adherence  
class. The requirements  
and the expectations  
for procedure  
use and adherence  
were emphasized  
during the class.As discussed  
above, procedure  
adherence  
and quality of the procedure contributed  
to this issue. Corrective  
actions were taken in accordance  
with the FENOC Performance  
Management  
Process.6. 3.2, Commitment  
Item 1.b/DAMP Item B2.2.3.2, states: The inspectors  
concluded that NQI-1001, Revision 5, appropriately  
incorporated  
the consideration  
of failure history, risk significance, and failure probability  
in assigning  
QC inspection  
hold points. However, the inspectors  
identified  
that the methods Identified  
and in use did not take full advantage  
of all site programs.  
In particular, the procedure  
did not prescribe  
the review of the maintenance  
rule database, which collects pertinent component  
failure data, nor did it integrate  
the probabilistic  
risk assessment (PRA)model, which provides component-specific  
risk information.  
PY-CEI/NRR-2959L
Attachment  
1 Page 10 of II FENOC RESPONSE: To address the above observations, CR 06-00366 was generated.  
It should be noted that NQI- I001 was superseded  
by Nuclear Operating  
Procedure NOP-LP-2018, "Quality Control Inspection  
of Maintenance  
and Modification
Activities," on December 19, 2005. The CR investigation  
was focused on addressing  
the following  
enhancement  
actions to procedure  
NOP-LP-2018:
* Assignment  
of hold/witness  
points to procedure  
steps that are identified  
as "critical  
steps."* Use of Probabilistic  
Safety Assessment (PSA) risk significance  
for component  
level equipment  
and non-safety  
risk significance
equipment.
* Use of Maintenance  
Rule database for the identification  
of repeat failure items for potential  
assignment  
of hold/witness  
points.The investigation  
determined  
that use of the Maintenance  
Rule database as a means to identify additional  
QC hold/witness  
points is not an optimum method. Since the condition  
reports drive the maintenance  
rule evaluation
through the corrective  
actions, historical  
failure data can be obtained through the review of condition  
reports for those components  
that are considered  
to be a maintenance  
rule failure. Therefore, historical  
data from the condition reporting  
system will be used for the identification  
of repeat failures items for potential  
assignment  
of hold/witness  
points.The following  
enhancements  
were added to procedure  
NOP-LP-2018:
* Use of pre-established "Critical  
Steps" as a factor when assigning  
QC Hold/Witness  
points.* Use of risk significance  
assessment  
tool at a component  
level as a factor when assigning  
Hold/Witness  
points.* Use of Risk Significance (PSA), Maintenance  
Rule, Critical Components, and Maintenance  
Modifications  
as factors that the QC supervisor  
will utilize when assigning  
process monitoring.
SECTION 5.0 TRAINING 5.3, Review of Human Performance  
Tools to Reinforce  
Human Performance  
Under Stress, states: While observing  
the rebuild of a fire protection  
deluge valve, a procedure  
step in the work package required the inspection  
of valve internals  
to evaluate the condition  
of the valve, including  
the condition  
of internal moving parts.When questioned  
about the presence of moving parts, licensee personnel  
were unsure if the valve contained  
moving parts. Despite this lack of knowledge, licensee personnel  
signed off the step as complete.  
Upon further review, the inspectors
determined  
that the work package was incorrect  
and referenced  
a section of the technical  
manual for a valve that contained  
moving parts although the valve inspected  
did not contain moving parts.However, since this error had no actual adverse impact on the deluge valve inspection  
results, the inspectors  
concluded  
the issue was of only minor significance.  
PY-CEI/NRR-2959L
Attachment  
1 Page 11 of 11 FENOC RESPONSE: To address the above observation, FENOC generated  
CRs 06-00178 and 06-01764.  
CR 06-00178 investigated  
the issue concerning  
the communication  
that took place between the inspector  
and responsible
system engineer (RSE) during inspection  
of the fire protection  
deluge valve.The inspector  
questioned  
what moving parts were inspected  
for the valve in accordance  
with the work order and whether a vendor manual was reviewed during the valve inspection.  
The RSE's initial response was that the valve did not have the same spring arrangement  
like the other valves being inspected.  
This was confirmed  
by the maintenance  
personnel  
during the inspection.  
The proper response should have been that the valve flapper was inspected  
during the valve internal inspection  
and there was no spring arrangement  
for this particular  
valve model. This communication  
issue was subsequently  
clarified  
with the inspector.  
The investigation  
determined  
that the initial response by the RSE to the inspectors  
question was not clearly communicated.
Condition  
report 06-01764 investigated  
the issue with potential  
for lack of knowledge  
and incorrect  
work package. During the initial inspection  
of the deluge valve, the RSE examined the valve internals  
to include flapper, seating surfaces, and body conditions.  
After inspection  
of the valve, the RSE confirmed  
by way of the maintenance  
personnel  
that this model valve did not have a spring. When questioned  
by the inspector  
as to what moving parts were inspected, the RSE identified  
that the internals  
and seating surface were inspected.  
The RSE went on to explain that this model did not contain a spring. The inspector  
asked if the vendor manual had been reviewed.  
The RSE responded  
no (note that this was the fourth deluge valve inspected  
by the RSE with some models containing  
the spring while others do not). In the subsequent  
meeting with the inspector, the RSE was more precise in specifically  
identifying  
that the flapper (moving part) was inspected  
and indicated  
that he had a conversation  
with the mechanic regarding  
this particular  
model not having a spring. The inspector  
was not aware of the conversation  
between the RSE and the maintenance  
personnel  
during the inspection.  
The work order package issue was associated  
with one of the two models with the manual/drawing (model without spring) not being in the package. The order was for the inspection  
of multiple deluge valves that consisted  
of both models. The SAP data for the valve being inspected  
at the time of this event did not identify the valve correctly  
and the proper vendor manual section/drawing  
was not provided.  
The package only contained  
a vendor manual/drawing  
of the model with a spring. This oversight  
was corrected  
by adding the appropriate  
manual section/drawing  
to the package and changing the SAP data base model number. Therefore, this issue is not a result of lack of RSE knowledge, but rather less than effective communications  
and an issue with the work package.
}}

Latest revision as of 18:32, 23 November 2019

Response to Nuclear Regulatory Commission Inspection Report 05000440/2006007 - NRC Follow Up Inspection of IP 95002 Action Items
ML061360218
Person / Time
Site: Perry FirstEnergy icon.png
Issue date: 05/09/2006
From: Pearce L
FirstEnergy Nuclear Operating Co
To:
Document Control Desk, NRC/RGN-III
References
IR-06-007, PY-CEI/NRR-2959L
Download: ML061360218 (12)


Text

PENOC -"f Perry Nuclear Power Station 10 Center Road FirstEnergy Nuclear Operating Company Perry Ohio 44081 L William Pearce 440-280-5382 Vice President Fax: 440-280-8029 May 09, 2006 PY-CEI/NRR-2959L United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58

Subject:

Response to Nuclear Regulatory Commission (NRC) Inspection Report 05000440/2006007 - NRC Follow up Inspection of IP 95002 Action Items Ladies and Gentlemen:

This letter provides the FirstEnergy Nuclear Operating Company (FENOC) response to the NRC Inspection Report 05000440/2006007 for the Perry Nuclear Power Plant (PNPP). The inspection report provided the results of the NRC Confirmatory Action Letter (CAL) follow-up inspection for Inspection Procedure (IP) 95002 action items. The letter, requests that FENOC respond within 30 days of receipt of the letter describing the specific actions that FENOC plans to take to address the issues raised during the inspection. The attached provides the requested response.

There are no commitments contained in this letter. If you have any have questions or require additional information, please contact Mr. Jeffrey Lausberg, Manager, Regulatory Compliance at (440) 280-5940.

Very/trj ly yoP Attachment cc: NRC Region Ill Administrator NRC Project Manager NRC Resident Inspector

PY-CEI/NRR-2959L Attachment 1 Page 1 of 11 Response to NRC Inspection Report (IR) 06000440/2006007 NRC Follow up Inspection of IP 95002 Action Items Overall, the inspection team concluded that FENOC had satisfactorily implemented the commitments and action items that they reviewed and therefore, the corrective actions to address maintenance procedure adequacy, Emergency Service Water (ESW) pump coupling assembly, and training were adequate. Notwithstanding this overall conclusion, the team identified some cases where the implementation of these actions was weak, which potentially impacts the overall ability to effectively resolve these issues. These issues are identified in the Findings and Observations of the inspection report.

The following provides the specific NRC Findings and Observations identified in Inspection Report 2006007 followed by the FENOC's response to those Findings and Observations:

SECTION 3.0 PROCEDURE ADEQUACY

1. 3.1.b.1, Technical Content Review Results, states: The inspectors reviewed 19 of the 119 revised maintenance procedures. Overall, the inspectors concluded that the maintenance procedures reviewed were an improvement on the previous revisions, both in content, formatting, and ease of use. However, the following weaknesses were identified:

One procedure was identified to contain a significant technical error. GMI-0050, "Residual Heat Removal Pump Overhaul," Revision 0, that was to be utilized for the overhaul of a Residual Heat Removal (RHR) pump, did not include steps to re-insert pump coupling keys that were removed during pump disassembly.

Therefore, the pump overhaul activity, if performed as written, would not return the equipment to a condition in which it would properly function, which was considered a significant technical procedure deficiency. However, because this procedure had not actually been utilized, the inspectors considered this procedure deficiency to be of only minor significance.

  • The inspectors noted numerous instances of typographical errors and improper references. While these errors did not significantly impact the ability to implement the procedures, it indicated a lack of attention to detail in the procedure development and review process.

FENOC RESPONSE:

As stated above, during the NRC inspection, an error was identified for procedure GMI-0050, "Residual Heat Removal Pump Overhaul." The error was the omission of specific instructions in the procedure for reassembly of the pump shaft for the placement of keys on the pump shaft keyway sleeve and placement of the split ring. This made the procedure deficient. The missing steps could have caused problems during the reassembly of the pump shaft. When this issue was discovered, GMI-0050 was put on hold pending resolution of the issue and Condition Report (CR) 06-00261 was generated to document the issue. Investigation found that the RHR pumps have not been overhauled using this procedure, but rather in the past the vendor manual had been used with the vendor present on site. Additionally,

PY-CEI/NRR-2959L Attachment I Page 2 of 11 the procedure will be reviewed against the vendor manual to verify that no other omission exists.

The upgraded procedures have been categorized into four (4) groups, with prioritization based on frequency of use, scheduled use, and document change request feedback received from users. The procedures will be reviewed for adequacy, starting with Group 1 and progressing through Group 4 (lowest priority). GMI-0050 is scheduled to be updated under Group 4 since it is utilized in a forced or refueling outage. It will not be used until it is updated.

In regards to the administrative errors that were found in the upgraded maintenance procedures (e.g., typographical errors, inconsistent formatting, missing references, etc.), FENOC has generated CR 06-00418 to address the issue. This CR will collectively address the issue and capture the lessons-leamed as well as address the necessary re-verification and revalidation of the upgraded maintenance procedures. Corrective Action 06-00418-02 was developed to track the Maintenance Department re-review of the 119 procedures to correct the following potential discrepancies:

Typographical errors Formatting inconsistencies Proper step sequencing Redundant steps Deficient direction Faulty references Missing technical Information Proper use/identification of critical steps Additional resources are being brought in to help complete the reviews.

Discrepancies identified during the review process will be documented via the Corrective Action Program and addressed, as required, to support procedure use/plant operation/scheduled maintenance activities. Overall results of the review will be documented in the closure of Corrective Action 06-00418-02.

2. 3.1.b.2, Identification of Missing "Critical" Procedure Step Designation, states: The inspectors identified numerous maintenance procedure steps that warranted identification as critical steps in these procedures, but had not been properly identified as such. Specific examples included:
  • CMI-0016, "Division I and 11Emergency Diesel Generator Starting Air Valve Repair," Revision 3, did not identify measurement and evaluation of cap bore and piston diameter as a critical step although an Improper clearance could result in a failure of the emergency diesel generator to start.
  • PMI-0040, "Division IlIl Air Start Motor Maintenance," Revision 4, did not identify a rotation check of the air starter during air start motor reassembly as a critical step although improper rotation could result in damage to the component or a slow start.

PY-CEI/NRR-2959L Attachment I Page 3 of 11

  • GMI-0002, "Maintenance of the Control Rod Drive Pumps," Revision 2, did not identify the measurement of run out clearances as a critical step although improper clearances could lead to premature bearing failure.

MAI-0507 also prescribed that if possible, Critical Steps should be identified and mitigated by using one of the following methods:

  • Add a step for breakpoint review.
  • Add independent verification.
  • Add a step for peer-check.
  • Add a step to contact the supervisor.
  • Add a step to contact the Control Room to verify a condition before continuing to the next action.

However, contrary to MAI-0507, no examples of mitigation strategies for critical steps could be found in any of the revised procedures. These mitigation strategies were intended to provide additional assurance of proper step completion. Follow up discussions with work management personnel indicated that these strategies were intended to be added during the work package development process. However, only one example was identified in which a mitigation strategy was included with a work order containing a critical step. The inspectors concluded that the licensee had not adequately implemented this procedural requirement. However, since the inspectors did not identify any instance where the omission of a mitigating strategy had resulted in improper procedure implementation, the inspectors concluded the issue was of only minor significance.

FENOC RESPONSE:

FENOC acknowledges that inconsistencies exist in application of the critical steps in the upgraded maintenance procedures. When this issue was identified, several condition reports were generated to document the issues (i.e., CR 06-00181, 06-00276 and 06-00418). Condition Report 06-00418 documents the investigation summary and provides the corrective action to address the issue going forward. Since the CR was generated, MAI-0507, "Maintenance Procedures Writer's Guide," has been superseded by a new technical procedure guide PAP-0500, "Perry Technical Procedure Writer's Guide," Revision 0, that provides improved guidance for mitigation and application of critical steps.

The investigation found that the inconsistencies in the application of the critical steps in the upgraded maintenance procedures were due to less than adequate oversight and participation by Perry personnel during the procedure upgrade process. The initial maintenance procedure upgrade project was mainly supported by outside contract personnel utilizing a format obtained from another site that did not meet FENOC standards. Additionally, when the maintenance procedure upgrade project was initiated in late 2004, the maintenance procedure writers guide, MAI-0507 was not issued yet, which contributed to the issue.

PY-CEI/NRR-2959L Attachment 1 Page 4 of 11 As a result of the issues discussed above, the upgraded maintenance procedures will be reviewed for the consistent application of critical steps, formatting and consistency. Corrective actions will be taken to address issues found during the reviews. As stated above, this action is being tracked as CA 06-00418-02.

3. 3.1.b.3, Weaknesses in the use of Placekeeping Tools and Human Factoring, states:

The inspectors confirmed that the licensee added placekeeping blocks to the revised procedures and had reformatted the procedures to address human factoring considerations. The inspectors supplemented this review with in-field observations of the implementation of the revised maintenance procedures. The inspectors noted performance of one procedure with improper use of placekeeping techniques:

  • During hydramotor work, the inspectors noted that technicians performed multiple steps in rapid succession without using proper placekeeping.
  • In the same procedure, the technicians performed several steps multiple times without using peacekeeping for each Performance of the step. By procedure, a step may be performed multiple times, but each Performance requires separate placekeeping.

In addition, the inspectors noted multiple instances of poorly worded steps that hampered the maintenance worker's ability to successfully complete the procedure.

For example:

  • The inspectors observed the performance of a motor-operated valve (MOV) maintenance activity. Although the maintenance procedure utilized for this activity had been previously performed more than 100 times on other valves, the workers stopped several times to obtain clarification on the requirements of the procedure.
  • The inspectors reviewed a completed work package that utilized maintenance procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance." The inspectors identified that workers had incorrectly N/A'd a section of the procedure. The inspectors noted that the procedural directions regarding performance of that section of the procedure were unclear. (Section b.4)

The inspectors observed the performance of maintenance procedure ICI-B12-001, "ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration."

During implementation of the procedure, maintenance workers failed to remove all required access covers to the hydramotor. The inspectors noted that the procedure did not specifically identify the covers to be removed. (Section b.5)

FENOC RESPONSE:

The issue with improper use of peacekeeping during the hydramotor work activity is addressed in Item 5 below. This observation was noted during calibration check of a Division IlIl EDG Exhaust Air Damper using procedure ICI-B12-0001, -ITT NH90 Series Millampere Proportional/On-Off Hydramotor Actuator Calibration" and is being addressed in CR 06-01765.

PY-CEI/NRR-2959L Attachment 1 Page 5 of 11 The issue with poorly worded steps in the maintenance procedure that hampered the maintenance workers ability to complete the MOV maintenance procedure is related to the issue raised in Item 2 above. This issue is being addressed as part of CR 06-00418.

The issue with incorrect use of "N/A" during the performance of maintenance activity for ABB low voltage circuit breakers is addressed in Item 4 below.

This issue was observed during the review of completed maintenance work package that utilized maintenance procedure GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance" and is being addressed in CR 06-00283.

4. (a) 3.1.b.4, Inappropriate Use of Not Applicable (N/A) in Procedure Steps, states:

The inspectors identified that many of the revised maintenance procedures applied to multiple different styles of components. As a result, these procedures required that maintenance workers determine the applicable steps of the procedure to be performed since all steps may not apply to a particular component. When a step was not performed, the worker would mark the step N/A [not applicable]. Based on the procedures reviewed, the inspectors concluded that the typical number of N/As required during the implementation of a procedure represented a potential human performance trap. During the inspection, the inspectors identified the following specific example in which a procedure step was inappropriately N/A'd for which the Enforcement section is restated here for the example "Failure to Perform Required Steps Prescribed by Procedure GEI-0009".

Enforcement: Technical Specification 5.4, "Procedures," required, in part, that written procedures be implemented covering applicable procedures recommended by Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operation),

"Revision 2, dated February 1978. Regulatory Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance that can affect the performanceof safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances."

Contrary to this requirement, on January 19, 2006 [it was determined that], licensee personnel failed to perform required steps in procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 & K-600S Through K-3000 & K-3000S Maintenance," Revision 17. Specifically, licensee personnel failed to perform minimum operating voltage testing on the safety-related EF1A05 breaker that provided power to Division I Motor Control Center (MCC), Switchgear (SWGR), and Battery Room Supply Fan A. However, because of the very low safety significance and because the issue has been entered into the licensee's corrective action program (CR 06-00283), the issue is being treated as a non-cited violation (NCV) consistent with Section VI.A. 1 of the NRC Enforcement Policy (NCV 05000440/2006007-01).

FENOC RESPONSE:

During a review of work order (WO) 200038182, the NRC inspector identified that step 5.2.3, 'Minimum Operating Voltage and Anti-Pump Verification," of procedure GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600

& K-600S through K-3000 & K-3000S Maintenance," was marked N/A and not performed during the voltage testing of the non-safety related breaker that provides power to the condensate transfer pump A. When the issue

PY-CEI/NRR-2959L Attachment 1 Page 6 of 11 was raised during the inspection, CR 06-00283 was written to document and to investigate the issue, The investigation revealed that step 5.2.3 of GEl-0009 was incorrectly marked N/A and not performed as required. The anti-pump functional verification was performed by a subsequent step within the procedure. Step 5.16, "Breaker Anti-Pump," requires that the functionality of the breaker be verified before it is restored to an operable condition. From an equipment perspective, the anti-pump feature on the breaker was verified to be acceptable before it was installed and placed in service. There are no hardware issues associated with this breaker pertaining to the NA'd step 5.2.3. The maintenance work performed on this breaker satisfied the purpose of procedure GEI-0009 yet, as stated above, was not performed in full compliance with the requirements. The breaker was installed and placed in service on September 9, 2005 and there have not been any operational issues since that time. This breaker is presently scheduled for refurbishment in June 2006 (with a maximum due date of June 2007). Additionally, an immediate investigation was performed to determine if any other safety related, electrically operated breakers had been installed during 2005 without verification of their anti-pump feature. The investigation determined that the safety-related breakers overhauled during 2005 adequately met the steps 5.2.3 and 5.16 of procedure GEI-0009 for proper breaker operation.

Individual performance issues associated with this condition were referred to line management for appropriate actions in accordance with the FENOC Performance Management System.

It is noted that for the safety related breaker that provides power to the division 1 motor control center (MCC), switchgear (SWGR) and battery room supply fan A, step 5.2.3 was left blank on the data sheet. However, since this breaker failed as-found, CR 05-04796 was written and the replacement breaker function was verified as acceptable.

(b) 3.1.b.4, In addition to this example, the inspectors observed a nonsafety-related air-operated valve (AOV) rebuild activity during which maintenance workers improperly N/A'd a step that prescribed a valve stem inspection.

FENOC RESPONSE:

During performance of changing the packing for feedwater heater drain valve, I N25F0290A, step 5.3.2 of the valve packing instruction per procedure GMI-0061,"Valve Packing Instruction," was marked not applicable (N/A). The step states: "IF damage is found, THEN DETERMINE where information is available in Valveman Data Program or Order." The Valveman datasheet provides the information that addresses the packing configuration to be used. This step was incorrectly marked N/A while it was applicable. Step 5.3.2 was subsequently performed satisfactorily. This issue was documented in CR 06-00269. The investigation revealed that the individuals, although qualified to perform the task, had not performed the task regularly. Since the procedure was of a new format, the individuals misunderstood the steps and requirements of the datasheet.

The use of training along with the procedure provides the individuals with sufficient information needed to perform the task. Had the individuals

PY-CEI/NRR-2959L Attachment I Page 7 of 11 followed the procedure they would have discovered the data was contained in the Valveman data package. This was a human performance issue rather than a procedure deficiency. Individual performance issues associated with this condition were referred to line management for appropriate actions in accordance with the FENOC Performance Management System.

Elimination of human performance issues, including "procedure traps," has been given a high priority. The Maintenance Training Review Committee (TRC) is tracking actions for the maintenance organization to complete "Procedure Use And Adherence" classroom and laboratory training. At the end of March, 2006, the classroom portion had been completed by all maintenance supervisors and worker personnel. Laboratory practical training has been captured as an action that is scheduled to be completed next. The lesson material specifically includes training on "when procedure steps do not apply."

5. 3.1.b.5, Failure to Perform Required Steps Prescribed by Procedure ICI-B12-0001, states: Technical Specification 5.4, "Procedures," required, in part, that written procedures be implemented covering applicable procedures recommended by Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operation),

"Revision 2, dated February 1978. Regulatory Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance that can affect the performance of safety-related equipment should be properly pre-planned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances."

Contrary to this requirement, on January 10, 2006, during a calibration check of a Division IlIl EDG Exhaust Air Damper, licensee personnel failed to perform required steps prescribed by procedure ICI-B12-0001, "ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration," Revision 4. However, because of the very low safety significance and because the issue has been entered into the licensee's corrective action program (CR 06-00125), the issue is being treated as a non-cited violation (NCV) consistent with Section VI.A. 1 of the NRC Enforcement Policy (NCV 05000440/2006007-02).

FENOC RESPONSE:

On January 10, 2006, the NRC inspector observed the implementation of upgraded maintenance procedure ICI-B12-0001, 'ITT NH90 Series Milliampere Proportional/On-Off Hydramotor Actuator Calibration," Revision 4, during a calibration check of a Division IlIl Emergency Diesel Generator Exhaust Air Damper Hydramotor. This procedure was categorized as Step-by-Step Use and in accordance with procedure NOP-LP-2601, 'Procedure Use and Adherence." During the performance of ICI-B12-0001, several instances were identified where procedure adherence was not followed in accordance with NOP-LP-2601.

As discussed in the NRC inspection report:

  • Step 5.9.2 of ICI-B12-0001 directed the user to verify the subject hydramotor had been full-stroke cycled a minimum of five times.

Although procedure steps which prescribe this type of verification permit the re-positioning of plant components, in accordance with

PY-CEI/NRR-2959L Attachment I Page 8 of I1 NOP-LP-2601, these actions must be specifically authorized by plant procedures. In this case, and as observed by the inspectors, although this guidance did not exist, personnel performed future procedure steps out-of-sequence in order to accomplish Step 5.9.2.

  • Step 5.9.3 of ICI-B12-0001 directed that screw-on covers be removed to support testing. In this case, personnel failed to remove the necessary covers to continue with the proper testing.
  • Step 5.9.4 of ICI-B12-0001 directed the connection of a multi-meter to a limit switch in accordance with Attachment 7, Figure 1. Contrary to this, personnel connected the multi-meter in accordance with Attachment 10 and continued with the calibration check. This error was identified by the inspectors observing the test when conflicts were discovered at a later procedure step.
  • Steps 5.9.5 through 5.9.9 of ICI-B12-0001 directed the manipulation of the hydramotor actuator for verification and recording of proper valve seating and stem travel. Contrary to procedure use guidance, personnel did not complete these steps via the read-then-perform approach. Additionally, NOP-LP-2601 directed that repeated steps shall be provided with "separate documentation" and "peacekeeping on the steps". These steps were repeated to satisfy the requirements of Step 5.9.2 without separate documentation and placekeeping annotation.
  • Step 5.9.10, 5.9.10.a and 5.9.10.b of ICI-B12-0001 directed the connection of a multi-meter to position switches followed by actuator manipulation until such switches actuate. Contrary to procedure use guidance, steps were marked as complete concurrently without verifying individually that each step had been completed.

As part of the immediate corrective action, personnel stopped the work activity and revised ICI-B12-0001 to clarify the requirements in Section 5.9 of the procedure. A second attempt was made to calibrate the hydramotor, but the procedure needed another revision to the steps. The procedure category was also revised from 'Step-by-Step" to "In-Field Reference," a more appropriate category for this procedure. Upon completion of the second procedure revision, the calibration was completed satisfactorily and the hydramotor was returned to service.

Condition reports 06-00125 and 06-01765 address the above inspection report issues as follows:

The first example of Step 5.9.2 of ICI-B12-0001 directed the user to verify that the hydramotor had been run through full stroke at least five times. Per NOP-LP-2601, the performer is allowed to reposition this hydramotor if authorized by plant procedures. The approval to stroke this valve was authorized by the order which was released by operations to allow calibration of the hydramotor. Note: The act of stroking the hydramotor is a skill that is obtained by a qualified technician during their on-the-job training/task performance evaluation (OJT/TPE) training.

PY-CEI/NRR-2959L Attachment I Page 9 of I1 Step 5.9.3 of ICI-B12-0001 directed the removal of control and electrical screw on covers for the PCD actuator. The technicians were working to calibrate the position limit switches instead of the travel limit switch so the correct cover was not removed. The technician made an error in not removing all of the covers needed for this calibration.

Step 5.9.4 of ICI-B12-0001 directed the connection of a multi-meter to an actuator travel limit switch shown on attachment 7, but went to attachment 10 (this issue was addressed solely by CR 06-00125). The error was failure to follow the procedure. The procedures were revised, the calibration completed, the hydramotor was returned to service, and the potential limiting condition for operation (PLCO) cleared.

Steps 5.9.5 through 5.9.9 of ICI-B12-0001 directed the manipulation of the hydramotor actuator for verification and recording of proper valve seating and stem travel. The steps were all performed and then signed off which violates procedure NOP-LP-2601 for use of a step-by-step procedure. Also, as the steps were repeated, the technicians failed to provide the separate documentation and placekeeping as required by NOP-LP-2601. Although this may be accomplished by different methods, the performers must follow the procedure requirements. These were human performance errors.

Steps 5.9.10, 5.9.10a, and 5.9.10b of ICI-B12-0001 directed the connection of a multi-meter to position switches followed by actuator manipulation until such switches actuate. The steps were performed concurrently and then signed off after completed which is contrary to the requirements of NOP-LP-2601 for a Step-by-Step procedure.

The roll-up of these issues again emphasizes the failure to follow proper procedure use and adherence expectations. This issue was addressed in CR-06-00125. I&C, Electrical, Mechanical and Services sections of Maintenance have completed a procedure use and adherence class. The requirements and the expectations for procedure use and adherence were emphasized during the class.

As discussed above, procedure adherence and quality of the procedure contributed to this issue. Corrective actions were taken in accordance with the FENOC Performance Management Process.

6. 3.2, Commitment Item 1.b/DAMP Item B2.2.3.2, states: The inspectors concluded that NQI-1001, Revision 5, appropriately incorporated the consideration of failure history, risk significance, and failure probability in assigning QC inspection hold points. However, the inspectors identified that the methods Identified and in use did not take full advantage of all site programs. In particular, the procedure did not prescribe the review of the maintenance rule database, which collects pertinent component failure data, nor did it integrate the probabilistic risk assessment (PRA) model, which provides component-specific risk information.

PY-CEI/NRR-2959L Attachment 1 Page 10 of II FENOC RESPONSE:

To address the above observations, CR 06-00366 was generated. It should be noted that NQI-I001 was superseded by Nuclear Operating Procedure NOP-LP-2018, "Quality Control Inspection of Maintenance and Modification Activities," on December 19, 2005. The CR investigation was focused on addressing the following enhancement actions to procedure NOP-LP-2018:

  • Assignment of hold/witness points to procedure steps that are identified as "critical steps."
  • Use of Probabilistic Safety Assessment (PSA) risk significance for component level equipment and non-safety risk significance equipment.
  • Use of Maintenance Rule database for the identification of repeat failure items for potential assignment of hold/witness points.

The investigation determined that use of the Maintenance Rule database as a means to identify additional QC hold/witness points is not an optimum method. Since the condition reports drive the maintenance rule evaluation through the corrective actions, historical failure data can be obtained through the review of condition reports for those components that are considered to be a maintenance rule failure. Therefore, historical data from the condition reporting system will be used for the identification of repeat failures items for potential assignment of hold/witness points.

The following enhancements were added to procedure NOP-LP-2018:

  • Use of pre-established "Critical Steps" as a factor when assigning QC Hold/Witness points.
  • Use of risk significance assessment tool at a component level as a factor when assigning Hold/Witness points.
  • Use of Risk Significance (PSA), Maintenance Rule, Critical Components, and Maintenance Modifications as factors that the QC supervisor will utilize when assigning process monitoring.

SECTION 5.0 TRAINING 5.3, Review of Human Performance Tools to Reinforce Human Performance Under Stress, states: While observing the rebuild of a fire protection deluge valve, a procedure step in the work package required the inspection of valve internals to evaluate the condition of the valve, including the condition of internal moving parts.

When questioned about the presence of moving parts, licensee personnel were unsure if the valve contained moving parts. Despite this lack of knowledge, licensee personnel signed off the step as complete. Upon further review, the inspectors determined that the work package was incorrect and referenced a section of the technical manual for a valve that contained moving parts although the valve inspected did not contain moving parts.

However, since this error had no actual adverse impact on the deluge valve inspection results, the inspectors concluded the issue was of only minor significance.

PY-CEI/NRR-2959L Attachment 1 Page 11 of 11 FENOC RESPONSE:

To address the above observation, FENOC generated CRs 06-00178 and 06-01764. CR 06-00178 investigated the issue concerning the communication that took place between the inspector and responsible system engineer (RSE) during inspection of the fire protection deluge valve.

The inspector questioned what moving parts were inspected for the valve in accordance with the work order and whether a vendor manual was reviewed during the valve inspection. The RSE's initial response was that the valve did not have the same spring arrangement like the other valves being inspected. This was confirmed by the maintenance personnel during the inspection. The proper response should have been that the valve flapper was inspected during the valve internal inspection and there was no spring arrangement for this particular valve model. This communication issue was subsequently clarified with the inspector. The investigation determined that the initial response by the RSE to the inspectors question was not clearly communicated.

Condition report 06-01764 investigated the issue with potential for lack of knowledge and incorrect work package. During the initial inspection of the deluge valve, the RSE examined the valve internals to include flapper, seating surfaces, and body conditions. After inspection of the valve, the RSE confirmed by way of the maintenance personnel that this model valve did not have a spring. When questioned by the inspector as to what moving parts were inspected, the RSE identified that the internals and seating surface were inspected. The RSE went on to explain that this model did not contain a spring. The inspector asked if the vendor manual had been reviewed. The RSE responded no (note that this was the fourth deluge valve inspected by the RSE with some models containing the spring while others do not). In the subsequent meeting with the inspector, the RSE was more precise in specifically identifying that the flapper (moving part) was inspected and indicated that he had a conversation with the mechanic regarding this particular model not having a spring. The inspector was not aware of the conversation between the RSE and the maintenance personnel during the inspection. The work order package issue was associated with one of the two models with the manual/drawing (model without spring) not being in the package. The order was for the inspection of multiple deluge valves that consisted of both models. The SAP data for the valve being inspected at the time of this event did not identify the valve correctly and the proper vendor manual section/drawing was not provided. The package only contained a vendor manual/drawing of the model with a spring. This oversight was corrected by adding the appropriate manual section/drawing to the package and changing the SAP data base model number. Therefore, this issue is not a result of lack of RSE knowledge, but rather less than effective communications and an issue with the work package.