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| number = ML061360218 | | number = ML061360218 | ||
| issue date = 05/09/2006 | | issue date = 05/09/2006 | ||
| title = | | title = Response to Nuclear Regulatory Commission Inspection Report 05000440/2006007 - NRC Follow Up Inspection of IP 95002 Action Items | ||
| author name = Pearce L | | 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 | ||
}} | }} | ||
=Text= | =Text= | ||
{{#Wiki_filter:PENOC Perry Nuclear Power Station | {{#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 | |||
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 | |||
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 | |||
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 | |||
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 | |||
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 | |||
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
ML061360218 | |
Person / Time | |
---|---|
Site: | Perry |
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.