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{{#Wiki_filter: | {{#Wiki_filter:PENOC Perry Nuclear Power Station-"f 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 11 Emergency | |||
Diesel Generator | |||
Starting Air Valve Repair," Revision 3, did not identify measurement | |||
and evaluation | |||
of cap bore and piston diameter as a critical step although an Improper clearance | |||
could result in a failure of the emergency | |||
diesel generator | |||
to start.* PMI-0040, "Division | |||
IlIl Air Start Motor Maintenance," Revision 4, did not identify a rotation check of the air starter during air start motor reassembly | |||
as a critical step although improper rotation could result in damage to the component | |||
or a slow start. | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
I Page 3 of 11* GMI-0002, "Maintenance | |||
of the Control Rod Drive Pumps," Revision 2, did not identify the measurement | |||
of run out clearances | |||
as a critical step although improper clearances | |||
could lead to premature | |||
bearing failure.MAI-0507 also prescribed | |||
that if possible, Critical Steps should be identified | |||
and mitigated | |||
by using one of the following | |||
methods:* Add a step for breakpoint | |||
review.* Add independent | |||
verification. | |||
* Add a step for peer-check. | |||
* Add a step 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 1 1 The issue with poorly worded steps in the maintenance | |||
procedure | |||
that hampered the maintenance | |||
workers ability to complete the MOV maintenance | |||
procedure | |||
is related to the issue raised in Item 2 above. This issue is being addressed | |||
as part of CR 06-00418.The issue with incorrect | |||
use of "N/A" during the performance | |||
of maintenance | |||
activity for ABB low voltage circuit breakers is addressed | |||
in Item 4 below.This issue was observed during the review of completed | |||
maintenance | |||
work package that utilized maintenance | |||
procedure | |||
GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance" and is being addressed | |||
in CR 06-00283.4. (a) 3.1.b.4, Inappropriate | |||
Use of Not Applicable (N/A) in Procedure | |||
Steps, states: The inspectors | |||
identified | |||
that many of the revised maintenance | |||
procedures | |||
applied to multiple different | |||
styles of components. | |||
As a result, these procedures | |||
required that maintenance | |||
workers determine | |||
the applicable | |||
steps of the procedure | |||
to be performed | |||
since all steps may not apply to a particular | |||
component. | |||
When a step was not performed, the worker would mark the step N/A [not applicable]. | |||
Based on the procedures | |||
reviewed, the inspectors | |||
concluded | |||
that the typical number of N/As required during the implementation | |||
of a procedure | |||
represented | |||
a potential | |||
human performance | |||
trap. During the inspection, the inspectors | |||
identified | |||
the following specific example in which a procedure | |||
step was inappropriately | |||
N/A'd for which the Enforcement | |||
section is restated here for the example "Failure to Perform Required Steps Prescribed | |||
by Procedure | |||
GEI-0009". | |||
Enforcement: | |||
Technical | |||
Specification | |||
5.4, "Procedures," required, in part, that written procedures | |||
be implemented | |||
covering applicable | |||
procedures | |||
recommended | |||
by Regulatory | |||
Guide 1.33, "Quality Assurance | |||
Program Requirements (Operation),"Revision | |||
2, dated February 1978. Regulatory | |||
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance | |||
that can affect the performance | |||
of safety-related | |||
equipment should be properly pre-planned | |||
and performed | |||
in accordance | |||
with written procedures, documented | |||
instructions, or drawings appropriate | |||
to the circumstances." Contrary to this requirement, on January 19, 2006 [it was determined | |||
that], licensee personnel | |||
failed to perform required steps in procedure | |||
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 & K-600S Through K-3000 & K-3000S Maintenance," Revision 17. Specifically, licensee personnel | |||
failed to perform minimum operating | |||
voltage testing on the safety-related | |||
EF1A05 breaker that provided power to Division I Motor Control Center (MCC), Switchgear (SWGR), and Battery Room Supply Fan A. However, because of the very low safety significance | |||
and because the issue has been entered into the licensee's | |||
corrective | |||
action program (CR 06-00283), the issue is being treated as a non-cited | |||
violation (NCV)consistent | |||
with Section VI.A. 1 of the NRC Enforcement | |||
Policy (NCV 05000440/2006007-01). | |||
FENOC RESPONSE: During a review of work order (WO) 200038182, the NRC inspector | |||
identified | |||
that step 5.2.3, 'Minimum Operating | |||
Voltage and Anti-Pump | |||
Verification," of procedure | |||
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600& K-600S through K-3000 & K-3000S Maintenance," was marked N/A and not performed | |||
during the voltage testing of the non-safety | |||
related breaker that provides power to the condensate | |||
transfer pump A. When the issue | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
1 Page 6 of 11 was raised during the inspection, CR 06-00283 was written to document and to investigate | |||
the issue, The investigation | |||
revealed that step 5.2.3 of GEl-0009 was incorrectly | |||
marked N/A and not performed | |||
as required. | |||
The anti-pump functional | |||
verification | |||
was performed | |||
by a subsequent | |||
step within the procedure. | |||
Step 5.16, "Breaker Anti-Pump," requires that the functionality | |||
of the breaker be verified before it is restored to an operable condition. | |||
From an equipment | |||
perspective, the anti-pump | |||
feature on the breaker was verified to be acceptable | |||
before it was installed | |||
and placed in service. There are no hardware issues associated | |||
with this breaker pertaining | |||
to the NA'd step 5.2.3. The maintenance | |||
work performed | |||
on this breaker satisfied | |||
the purpose of procedure | |||
GEI-0009 yet, as stated above, was not performed | |||
in full compliance | |||
with the requirements. | |||
The breaker was installed | |||
and placed in service on September | |||
9, 2005 and there have not been any operational | |||
issues since that time. This breaker is presently | |||
scheduled | |||
for refurbishment | |||
in June 2006 (with a maximum due date of June 2007). Additionally, an immediate | |||
investigation | |||
was performed | |||
to determine | |||
if any other safety related, electrically | |||
operated breakers had been installed | |||
during 2005 without verification | |||
of their anti-pump | |||
feature. The investigation | |||
determined | |||
that the safety-related | |||
breakers overhauled | |||
during 2005 adequately | |||
met the steps 5.2.3 and 5.16 of procedure | |||
GEI-0009 for proper breaker operation. | |||
Individual | |||
performance | |||
issues associated | |||
with this condition | |||
were referred to line management | |||
for appropriate | |||
actions in accordance | |||
with the FENOC Performance | |||
Management | |||
System.It is noted that for the safety related breaker that provides power to the division 1 motor control center (MCC), switchgear (SWGR) and battery room supply fan A, step 5.2.3 was left blank on the data sheet. However, since this breaker failed as-found, CR 05-04796 was written and the replacement | |||
breaker function was verified as acceptable.(b) 3.1.b.4, In addition to this example, the inspectors | |||
observed a nonsafety-related | |||
air-operated | |||
valve (AOV) rebuild activity during which maintenance | |||
workers improperly | |||
N/A'd a step that prescribed | |||
a valve stem inspection. | |||
FENOC RESPONSE: During performance | |||
of changing the packing for feedwater | |||
heater drain valve, I N25F0290A, step 5.3.2 of the valve packing instruction | |||
per procedure | |||
GMI-0061,"Valve | |||
Packing Instruction," was marked not applicable (N/A). The step states: "IF damage is found, THEN DETERMINE | |||
where information | |||
is available | |||
in Valveman Data Program or Order." The Valveman datasheet | |||
provides the information | |||
that addresses | |||
the packing configuration | |||
to be used. This step was incorrectly | |||
marked N/A while it was applicable. | |||
Step 5.3.2 was subsequently | |||
performed | |||
satisfactorily. | |||
This issue was documented | |||
in CR 06-00269. | |||
The investigation | |||
revealed that the individuals, although qualified | |||
to perform the task, had not performed | |||
the task regularly. | |||
Since the procedure | |||
was of a new format, the individuals | |||
misunderstood | |||
the steps and requirements | |||
of the datasheet. | |||
The use of training along with the procedure | |||
provides the individuals | |||
with sufficient | |||
information | |||
needed to perform the task. Had the individuals | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
I Page 7 of 1 1 followed the procedure | |||
they would have discovered | |||
the data was contained in the Valveman data package. This was a human performance | |||
issue rather than a procedure | |||
deficiency. | |||
Individual | |||
performance | |||
issues associated | |||
with this condition | |||
were referred to line management | |||
for appropriate | |||
actions in accordance | |||
with the FENOC Performance | |||
Management | |||
System.Elimination | |||
of human performance | |||
issues, including "procedure | |||
traps," has been given a high priority. | |||
The Maintenance | |||
Training Review Committee (TRC) is tracking actions for the maintenance | |||
organization | |||
to complete"Procedure | |||
Use And Adherence" classroom | |||
and laboratory | |||
training. | |||
At the end of March, 2006, the classroom | |||
portion had been completed | |||
by all maintenance | |||
supervisors | |||
and worker personnel. | |||
Laboratory | |||
practical training has been captured as an action that is scheduled | |||
to be completed next. The lesson material specifically | |||
includes training on "when procedure steps do not apply." 5. 3.1.b.5, Failure to Perform Required Steps Prescribed | |||
by Procedure | |||
ICI-B12-0001, states: Technical | |||
Specification | |||
5.4, "Procedures," required, in part, that written procedures | |||
be implemented | |||
covering applicable | |||
procedures | |||
recommended | |||
by Regulatory | |||
Guide 1.33, "Quality Assurance | |||
Program Requirements (Operation),"Revision | |||
2, dated February 1978. Regulatory | |||
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance | |||
that can affect the performance | |||
of safety-related | |||
equipment should be properly pre-planned | |||
and performed | |||
in accordance | |||
with written procedures, documented | |||
instructions, or drawings appropriate | |||
to the circumstances." Contrary to this requirement, on January 10, 2006, during a calibration | |||
check of a Division IlIl EDG Exhaust Air Damper, licensee personnel | |||
failed to perform required steps prescribed | |||
by procedure | |||
ICI-B12-0001, "ITT NH90 Series Milliampere | |||
Proportional/On-Off | |||
Hydramotor | |||
Actuator Calibration," Revision 4. However, because of the very low safety significance | |||
and because the issue has been entered into the licensee's | |||
corrective | |||
action program (CR 06-00125), the issue is being treated as a non-cited | |||
violation (NCV) consistent | |||
with Section VI.A. 1 of the NRC Enforcement | |||
Policy (NCV 05000440/2006007-02). | |||
FENOC RESPONSE: On January 10, 2006, the NRC inspector | |||
observed the implementation | |||
of upgraded maintenance | |||
procedure | |||
ICI-B12-0001, 'ITT NH90 Series Milliampere | |||
Proportional/On-Off | |||
Hydramotor | |||
Actuator Calibration," Revision 4, during a calibration | |||
check of a Division IlIl Emergency | |||
Diesel Generator Exhaust Air Damper Hydramotor. | |||
This procedure | |||
was categorized | |||
as Step-by-Step Use and in accordance | |||
with procedure | |||
NOP-LP-2601, 'Procedure | |||
Use and Adherence." During the performance | |||
of ICI-B12-0001, several instances | |||
were identified | |||
where procedure | |||
adherence | |||
was not followed in accordance | |||
with NOP-LP-2601. | |||
As discussed | |||
in the NRC inspection | |||
report:* Step 5.9.2 of ICI-B12-0001 | |||
directed the user to verify the subject hydramotor | |||
had been full-stroke | |||
cycled a minimum of five times.Although procedure | |||
steps which prescribe | |||
this type of verification | |||
permit the re-positioning | |||
of plant components, in accordance | |||
with | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
I Page 8 of I1 NOP-LP-2601, these actions must be specifically | |||
authorized | |||
by plant procedures. | |||
In this case, and as observed by the inspectors, although this guidance did not exist, personnel | |||
performed | |||
future procedure | |||
steps out-of-sequence | |||
in order to accomplish | |||
Step 5.9.2.* Step 5.9.3 of ICI-B12-0001 | |||
directed that screw-on covers be removed to support testing. In this case, personnel | |||
failed to remove the necessary | |||
covers to continue with the proper testing.* Step 5.9.4 of ICI-B12-0001 | |||
directed the connection | |||
of a multi-meter | |||
to a limit switch in accordance | |||
with Attachment | |||
7, Figure 1. Contrary to this, personnel | |||
connected | |||
the multi-meter | |||
in accordance | |||
with Attachment | |||
10 and continued | |||
with the calibration | |||
check. This error was identified | |||
by the inspectors | |||
observing | |||
the test when conflicts were discovered | |||
at a later procedure | |||
step.* Steps 5.9.5 through 5.9.9 of ICI-B12-0001 | |||
directed the manipulation | |||
of the hydramotor | |||
actuator for verification | |||
and recording | |||
of proper valve seating and stem travel. Contrary to procedure | |||
use guidance, personnel | |||
did not complete these steps via the read-then-perform | |||
approach. | |||
Additionally, NOP-LP-2601 | |||
directed that repeated steps shall be provided with "separate | |||
documentation" and "peacekeeping | |||
on the steps". These steps were repeated to satisfy the requirements | |||
of Step 5.9.2 without separate documentation | |||
and placekeeping | |||
annotation. | |||
* Step 5.9.10, 5.9.10.a and 5.9.10.b of ICI-B12-0001 | |||
directed the connection | |||
of a multi-meter | |||
to position switches followed by actuator manipulation | |||
until such switches actuate. Contrary to procedure | |||
use guidance, steps were marked as complete concurrently | |||
without verifying | |||
individually | |||
that each step had been completed. | |||
As part of the immediate | |||
corrective | |||
action, personnel | |||
stopped the work activity and revised ICI-B12-0001 | |||
to clarify the requirements | |||
in Section 5.9 of the procedure. | |||
A second attempt was made to calibrate | |||
the hydramotor, but the procedure | |||
needed another revision to the steps. The procedure | |||
category was also revised from 'Step-by-Step" to "In-Field | |||
Reference," a more appropriate | |||
category for this procedure. | |||
Upon completion | |||
of the second procedure | |||
revision, the calibration | |||
was completed | |||
satisfactorily | |||
and the hydramotor | |||
was returned to service.Condition | |||
reports 06-00125 and 06-01765 address the above inspection | |||
report issues as follows: The first example of Step 5.9.2 of ICI-B12-0001 | |||
directed the user to verify that the hydramotor | |||
had been run through full stroke at least five times. Per NOP-LP-2601, the performer | |||
is allowed to reposition | |||
this hydramotor | |||
if authorized | |||
by plant procedures. | |||
The approval to stroke this valve was authorized | |||
by the order which was released by operations | |||
to allow calibration | |||
of the hydramotor. | |||
Note: The act of stroking the hydramotor | |||
is a skill that is obtained by a qualified | |||
technician | |||
during their on-the-job | |||
training/task | |||
performance | |||
evaluation (OJT/TPE) | |||
training. | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
I Page 9 of I1 Step 5.9.3 of ICI-B12-0001 | |||
directed the removal of control and electrical | |||
screw on covers for the PCD actuator. | |||
The technicians | |||
were working to calibrate | |||
the position limit switches instead of the travel limit switch so the correct cover was not removed. The technician | |||
made an error in not removing all of the covers needed for this calibration. | |||
Step 5.9.4 of ICI-B12-0001 | |||
directed the connection | |||
of a multi-meter | |||
to an actuator travel limit switch shown on attachment | |||
7, but went to attachment | |||
10 (this issue was addressed | |||
solely by CR 06-00125). | |||
The error was failure to follow the procedure. | |||
The procedures | |||
were revised, the calibration | |||
completed, the hydramotor | |||
was returned to service, and the potential | |||
limiting condition | |||
for operation (PLCO) cleared.Steps 5.9.5 through 5.9.9 of ICI-B12-0001 | |||
directed the manipulation | |||
of the hydramotor | |||
actuator for verification | |||
and recording | |||
of proper valve seating and stem travel. The steps were all performed | |||
and then signed off which violates procedure | |||
NOP-LP-2601 | |||
for use of a step-by-step | |||
procedure. | |||
Also, as the steps were repeated, the technicians | |||
failed to provide the separate documentation | |||
and placekeeping | |||
as required by NOP-LP-2601. | |||
Although this may be accomplished | |||
by different | |||
methods, the performers | |||
must follow the procedure | |||
requirements. | |||
These were human performance | |||
errors.Steps 5.9.10, 5.9.10a, and 5.9.10b of ICI-B12-0001 | |||
directed the connection | |||
of a multi-meter | |||
to position switches followed by actuator manipulation | |||
until such switches actuate. The steps were performed | |||
concurrently | |||
and then signed off after completed | |||
which is contrary to the requirements | |||
of NOP-LP-2601 for a Step-by-Step | |||
procedure. | |||
The roll-up of these issues again emphasizes | |||
the failure to follow proper procedure | |||
use and adherence | |||
expectations. | |||
This issue was addressed | |||
in CR-06-00125. | |||
I&C, Electrical, Mechanical | |||
and Services sections of Maintenance | |||
have completed | |||
a procedure | |||
use and adherence | |||
class. The requirements | |||
and the expectations | |||
for procedure | |||
use and adherence | |||
were emphasized | |||
during the class.As discussed | |||
above, procedure | |||
adherence | |||
and quality of the procedure contributed | |||
to this issue. Corrective | |||
actions were taken in accordance | |||
with the FENOC Performance | |||
Management | |||
Process.6. 3.2, Commitment | |||
Item 1.b/DAMP Item B2.2.3.2, states: The inspectors | |||
concluded that NQI-1001, Revision 5, appropriately | |||
incorporated | |||
the consideration | |||
of failure history, risk significance, and failure probability | |||
in assigning | |||
QC inspection | |||
hold points. However, the inspectors | |||
identified | |||
that the methods Identified | |||
and in use did not take full advantage | |||
of all site programs. | |||
In particular, the procedure | |||
did not prescribe | |||
the review of the maintenance | |||
rule database, which collects pertinent component | |||
failure data, nor did it integrate | |||
the probabilistic | |||
risk assessment (PRA)model, which provides component-specific | |||
risk information. | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
1 Page 10 of II FENOC RESPONSE: To address the above observations, CR 06-00366 was generated. | |||
It should be noted that NQI- I001 was superseded | |||
by Nuclear Operating | |||
Procedure NOP-LP-2018, "Quality Control Inspection | |||
of Maintenance | |||
and Modification | |||
Activities," on December 19, 2005. The CR investigation | |||
was focused on addressing | |||
the following | |||
enhancement | |||
actions to procedure | |||
NOP-LP-2018: | |||
* Assignment | |||
of hold/witness | |||
points to procedure | |||
steps that are identified | |||
as "critical | |||
steps."* Use of Probabilistic | |||
Safety Assessment (PSA) risk significance | |||
for component | |||
level equipment | |||
and non-safety | |||
risk significance | |||
equipment. | |||
* Use of Maintenance | |||
Rule database for the identification | |||
of repeat failure items for potential | |||
assignment | |||
of hold/witness | |||
points.The investigation | |||
determined | |||
that use of the Maintenance | |||
Rule database as a means to identify additional | |||
QC hold/witness | |||
points is not an optimum method. Since the condition | |||
reports drive the maintenance | |||
rule evaluation | |||
through the corrective | |||
actions, historical | |||
failure data can be obtained through the review of condition | |||
reports for those components | |||
that are considered | |||
to be a maintenance | |||
rule failure. Therefore, historical | |||
data from the condition reporting | |||
system will be used for the identification | |||
of repeat failures items for potential | |||
assignment | |||
of hold/witness | |||
points.The following | |||
enhancements | |||
were added to procedure | |||
NOP-LP-2018: | |||
* Use of pre-established "Critical | |||
Steps" as a factor when assigning | |||
QC Hold/Witness | |||
points.* Use of risk significance | |||
assessment | |||
tool at a component | |||
level as a factor when assigning | |||
Hold/Witness | |||
points.* Use of Risk Significance (PSA), Maintenance | |||
Rule, Critical Components, and Maintenance | |||
Modifications | |||
as factors that the QC supervisor | |||
will utilize when assigning | |||
process monitoring. | |||
SECTION 5.0 TRAINING 5.3, Review of Human Performance | |||
Tools to Reinforce | |||
Human Performance | |||
Under Stress, states: While observing | |||
the rebuild of a fire protection | |||
deluge valve, a procedure | |||
step in the work package required the inspection | |||
of valve internals | |||
to evaluate the condition | |||
of the valve, including | |||
the condition | |||
of internal moving parts.When questioned | |||
about the presence of moving parts, licensee personnel | |||
were unsure if the valve contained | |||
moving parts. Despite this lack of knowledge, licensee personnel | |||
signed off the step as complete. | |||
Upon further review, the inspectors | |||
determined | |||
that the work package was incorrect | |||
and referenced | |||
a section of the technical | |||
manual for a valve that contained | |||
moving parts although the valve inspected | |||
did not contain moving parts.However, since this error had no actual adverse impact on the deluge valve inspection | |||
results, the inspectors | |||
concluded | |||
the issue was of only minor significance. | |||
PY-CEI/NRR-2959L | |||
Attachment | |||
1 Page 11 of 11 FENOC RESPONSE: To address the above observation, FENOC generated | |||
CRs 06-00178 and 06-01764. | |||
CR 06-00178 investigated | |||
the issue concerning | |||
the communication | |||
that took place between the inspector | |||
and responsible | |||
system engineer (RSE) during inspection | |||
of the fire protection | |||
deluge valve.The inspector | |||
questioned | |||
what moving parts were inspected | |||
for the valve in accordance | |||
with the work order and whether a vendor manual was reviewed during the valve inspection. | |||
The RSE's initial response was that the valve did not have the same spring arrangement | |||
like the other valves being inspected. | |||
This was confirmed | |||
by the maintenance | |||
personnel | |||
during the inspection. | |||
The proper response should have been that the valve flapper was inspected | |||
during the valve internal inspection | |||
and there was no spring arrangement | |||
for this particular | |||
valve model. This communication | |||
issue was subsequently | |||
clarified | |||
with the inspector. | |||
The investigation | |||
determined | |||
that the initial response by the RSE to the inspectors | |||
question was not clearly communicated. | |||
Condition | |||
report 06-01764 investigated | |||
the issue with potential | |||
for lack of knowledge | |||
and incorrect | |||
work package. During the initial inspection | |||
of the deluge valve, the RSE examined the valve internals | |||
to include flapper, seating surfaces, and body conditions. | |||
After inspection | |||
of the valve, the RSE confirmed | |||
by way of the maintenance | |||
personnel | |||
that this model valve did not have a spring. When questioned | |||
by the inspector | |||
as to what moving parts were inspected, the RSE identified | |||
that the internals | |||
and seating surface were inspected. | |||
The RSE went on to explain that this model did not contain a spring. The inspector | |||
asked if the vendor manual had been reviewed. | |||
The RSE responded | |||
no (note that this was the fourth deluge valve inspected | |||
by the RSE with some models containing | |||
the spring while others do not). In the subsequent | |||
meeting with the inspector, the RSE was more precise in specifically | |||
identifying | |||
that the flapper (moving part) was inspected | |||
and indicated | |||
that he had a conversation | |||
with the mechanic regarding | |||
this particular | |||
model not having a spring. The inspector | |||
was not aware of the conversation | |||
between the RSE and the maintenance | |||
personnel | |||
during the inspection. | |||
The work order package issue was associated | |||
with one of the two models with the manual/drawing (model without spring) not being in the package. The order was for the inspection | |||
of multiple deluge valves that consisted | |||
of both models. The SAP data for the valve being inspected | |||
at the time of this event did not identify the valve correctly | |||
and the proper vendor manual section/drawing | |||
was not provided. | |||
The package only contained | |||
a vendor manual/drawing | |||
of the model with a spring. This oversight | |||
was corrected | |||
by adding the appropriate | |||
manual section/drawing | |||
to the package and changing the SAP data base model number. Therefore, this issue is not a result of lack of RSE knowledge, but rather less than effective communications | |||
and an issue with the work package. | |||
}} | }} |
Revision as of 13:16, 11 November 2018
ML061360218 | |
Person / Time | |
---|---|
Site: | Perry |
Issue date: | 05/09/2006 |
From: | Pearce L W FirstEnergy Nuclear Operating Co |
To: | Document Control Desk, NRC/RGN-III |
References | |
IR-06-007, PY-CEI/NRR-2959L | |
Download: ML061360218 (12) | |
See also: IR 05000440/2006007
Text
PENOC Perry Nuclear Power Station-"f 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 11 Emergency
Diesel Generator
Starting Air Valve Repair," Revision 3, did not identify measurement
and evaluation
of cap bore and piston diameter as a critical step although an Improper clearance
could result in a failure of the emergency
diesel generator
to start.* PMI-0040, "Division
IlIl Air Start Motor Maintenance," Revision 4, did not identify a rotation check of the air starter during air start motor reassembly
as a critical step although improper rotation could result in damage to the component
or a slow start.
PY-CEI/NRR-2959L
Attachment
I Page 3 of 11* GMI-0002, "Maintenance
of the Control Rod Drive Pumps," Revision 2, did not identify the measurement
of run out clearances
as a critical step although improper clearances
could lead to premature
bearing failure.MAI-0507 also prescribed
that if possible, Critical Steps should be identified
and mitigated
by using one of the following
methods:* Add a step for breakpoint
review.* Add independent
verification.
- Add a step for peer-check.
- Add a step 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 1 1 The issue with poorly worded steps in the maintenance
procedure
that hampered the maintenance
workers ability to complete the MOV maintenance
procedure
is related to the issue raised in Item 2 above. This issue is being addressed
as part of CR 06-00418.The issue with incorrect
use of "N/A" during the performance
of maintenance
activity for ABB low voltage circuit breakers is addressed
in Item 4 below.This issue was observed during the review of completed
maintenance
work package that utilized maintenance
procedure
GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600S Through K-3000 and K-3000S Maintenance" and is being addressed
in CR 06-00283.4. (a) 3.1.b.4, Inappropriate
Use of Not Applicable (N/A) in Procedure
Steps, states: The inspectors
identified
that many of the revised maintenance
procedures
applied to multiple different
styles of components.
As a result, these procedures
required that maintenance
workers determine
the applicable
steps of the procedure
to be performed
since all steps may not apply to a particular
component.
When a step was not performed, the worker would mark the step N/A [not applicable].
Based on the procedures
reviewed, the inspectors
concluded
that the typical number of N/As required during the implementation
of a procedure
represented
a potential
human performance
trap. During the inspection, the inspectors
identified
the following specific example in which a procedure
step was inappropriately
N/A'd for which the Enforcement
section is restated here for the example "Failure to Perform Required Steps Prescribed
by Procedure
GEI-0009".
Enforcement:
Technical
Specification
5.4, "Procedures," required, in part, that written procedures
be implemented
covering applicable
procedures
recommended
by Regulatory
Guide 1.33, "Quality Assurance
Program Requirements (Operation),"Revision
2, dated February 1978. Regulatory
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance
that can affect the performance
of safety-related
equipment should be properly pre-planned
and performed
in accordance
with written procedures, documented
instructions, or drawings appropriate
to the circumstances." Contrary to this requirement, on January 19, 2006 [it was determined
that], licensee personnel
failed to perform required steps in procedure
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600 & K-600S Through K-3000 & K-3000S Maintenance," Revision 17. Specifically, licensee personnel
failed to perform minimum operating
voltage testing on the safety-related
EF1A05 breaker that provided power to Division I Motor Control Center (MCC), Switchgear (SWGR), and Battery Room Supply Fan A. However, because of the very low safety significance
and because the issue has been entered into the licensee's
corrective
action program (CR 06-00283), the issue is being treated as a non-cited
violation (NCV)consistent
with Section VI.A. 1 of the NRC Enforcement
Policy (NCV 05000440/2006007-01).
FENOC RESPONSE: During a review of work order (WO) 200038182, the NRC inspector
identified
that step 5.2.3, 'Minimum Operating
Voltage and Anti-Pump
Verification," of procedure
GEI-0009, "ABB Low Voltage Power Circuit Breaker Types K-600& K-600S through K-3000 & K-3000S Maintenance," was marked N/A and not performed
during the voltage testing of the non-safety
related breaker that provides power to the condensate
transfer pump A. When the issue
PY-CEI/NRR-2959L
Attachment
1 Page 6 of 11 was raised during the inspection, CR 06-00283 was written to document and to investigate
the issue, The investigation
revealed that step 5.2.3 of GEl-0009 was incorrectly
marked N/A and not performed
as required.
The anti-pump functional
verification
was performed
by a subsequent
step within the procedure.
Step 5.16, "Breaker Anti-Pump," requires that the functionality
of the breaker be verified before it is restored to an operable condition.
From an equipment
perspective, the anti-pump
feature on the breaker was verified to be acceptable
before it was installed
and placed in service. There are no hardware issues associated
with this breaker pertaining
to the NA'd step 5.2.3. The maintenance
work performed
on this breaker satisfied
the purpose of procedure
GEI-0009 yet, as stated above, was not performed
in full compliance
with the requirements.
The breaker was installed
and placed in service on September
9, 2005 and there have not been any operational
issues since that time. This breaker is presently
scheduled
for refurbishment
in June 2006 (with a maximum due date of June 2007). Additionally, an immediate
investigation
was performed
to determine
if any other safety related, electrically
operated breakers had been installed
during 2005 without verification
of their anti-pump
feature. The investigation
determined
that the safety-related
breakers overhauled
during 2005 adequately
met the steps 5.2.3 and 5.16 of procedure
GEI-0009 for proper breaker operation.
Individual
performance
issues associated
with this condition
were referred to line management
for appropriate
actions in accordance
with the FENOC Performance
Management
System.It is noted that for the safety related breaker that provides power to the division 1 motor control center (MCC), switchgear (SWGR) and battery room supply fan A, step 5.2.3 was left blank on the data sheet. However, since this breaker failed as-found, CR 05-04796 was written and the replacement
breaker function was verified as acceptable.(b) 3.1.b.4, In addition to this example, the inspectors
observed a nonsafety-related
air-operated
valve (AOV) rebuild activity during which maintenance
workers improperly
N/A'd a step that prescribed
a valve stem inspection.
FENOC RESPONSE: During performance
of changing the packing for feedwater
heater drain valve, I N25F0290A, step 5.3.2 of the valve packing instruction
per procedure
GMI-0061,"Valve
Packing Instruction," was marked not applicable (N/A). The step states: "IF damage is found, THEN DETERMINE
where information
is available
in Valveman Data Program or Order." The Valveman datasheet
provides the information
that addresses
the packing configuration
to be used. This step was incorrectly
marked N/A while it was applicable.
Step 5.3.2 was subsequently
performed
satisfactorily.
This issue was documented
in CR 06-00269.
The investigation
revealed that the individuals, although qualified
to perform the task, had not performed
the task regularly.
Since the procedure
was of a new format, the individuals
misunderstood
the steps and requirements
of the datasheet.
The use of training along with the procedure
provides the individuals
with sufficient
information
needed to perform the task. Had the individuals
PY-CEI/NRR-2959L
Attachment
I Page 7 of 1 1 followed the procedure
they would have discovered
the data was contained in the Valveman data package. This was a human performance
issue rather than a procedure
deficiency.
Individual
performance
issues associated
with this condition
were referred to line management
for appropriate
actions in accordance
with the FENOC Performance
Management
System.Elimination
of human performance
issues, including "procedure
traps," has been given a high priority.
The Maintenance
Training Review Committee (TRC) is tracking actions for the maintenance
organization
to complete"Procedure
Use And Adherence" classroom
and laboratory
training.
At the end of March, 2006, the classroom
portion had been completed
by all maintenance
supervisors
and worker personnel.
Laboratory
practical training has been captured as an action that is scheduled
to be completed next. The lesson material specifically
includes training on "when procedure steps do not apply." 5. 3.1.b.5, Failure to Perform Required Steps Prescribed
by Procedure
ICI-B12-0001, states: Technical
Specification
5.4, "Procedures," required, in part, that written procedures
be implemented
covering applicable
procedures
recommended
by Regulatory
Guide 1.33, "Quality Assurance
Program Requirements (Operation),"Revision
2, dated February 1978. Regulatory
Guide 1.33, Appendix A, paragraph 9a, stated, "Maintenance
that can affect the performance
of safety-related
equipment should be properly pre-planned
and performed
in accordance
with written procedures, documented
instructions, or drawings appropriate
to the circumstances." Contrary to this requirement, on January 10, 2006, during a calibration
check of a Division IlIl EDG Exhaust Air Damper, licensee personnel
failed to perform required steps prescribed
by procedure
ICI-B12-0001, "ITT NH90 Series Milliampere
Proportional/On-Off
Hydramotor
Actuator Calibration," Revision 4. However, because of the very low safety significance
and because the issue has been entered into the licensee's
corrective
action program (CR 06-00125), the issue is being treated as a non-cited
violation (NCV) consistent
with Section VI.A. 1 of the NRC Enforcement
Policy (NCV 05000440/2006007-02).
FENOC RESPONSE: On January 10, 2006, the NRC inspector
observed the implementation
of upgraded maintenance
procedure
ICI-B12-0001, 'ITT NH90 Series Milliampere
Proportional/On-Off
Hydramotor
Actuator Calibration," Revision 4, during a calibration
check of a Division IlIl Emergency
Diesel Generator Exhaust Air Damper Hydramotor.
This procedure
was categorized
as Step-by-Step Use and in accordance
with procedure
NOP-LP-2601, 'Procedure
Use and Adherence." During the performance
of ICI-B12-0001, several instances
were identified
where procedure
adherence
was not followed in accordance
with NOP-LP-2601.
As discussed
in the NRC inspection
report:* Step 5.9.2 of ICI-B12-0001
directed the user to verify the subject hydramotor
had been full-stroke
cycled a minimum of five times.Although procedure
steps which prescribe
this type of verification
permit the re-positioning
of plant components, in accordance
with
PY-CEI/NRR-2959L
Attachment
I Page 8 of I1 NOP-LP-2601, these actions must be specifically
authorized
by plant procedures.
In this case, and as observed by the inspectors, although this guidance did not exist, personnel
performed
future procedure
steps out-of-sequence
in order to accomplish
Step 5.9.2.* Step 5.9.3 of ICI-B12-0001
directed that screw-on covers be removed to support testing. In this case, personnel
failed to remove the necessary
covers to continue with the proper testing.* Step 5.9.4 of ICI-B12-0001
directed the connection
of a multi-meter
to a limit switch in accordance
with Attachment
7, Figure 1. Contrary to this, personnel
connected
the multi-meter
in accordance
with Attachment
10 and continued
with the calibration
check. This error was identified
by the inspectors
observing
the test when conflicts were discovered
at a later procedure
step.* Steps 5.9.5 through 5.9.9 of ICI-B12-0001
directed the manipulation
of the hydramotor
actuator for verification
and recording
of proper valve seating and stem travel. Contrary to procedure
use guidance, personnel
did not complete these steps via the read-then-perform
approach.
Additionally, NOP-LP-2601
directed that repeated steps shall be provided with "separate
documentation" and "peacekeeping
on the steps". These steps were repeated to satisfy the requirements
of Step 5.9.2 without separate documentation
and placekeeping
annotation.
- Step 5.9.10, 5.9.10.a and 5.9.10.b of ICI-B12-0001
directed the connection
of a multi-meter
to position switches followed by actuator manipulation
until such switches actuate. Contrary to procedure
use guidance, steps were marked as complete concurrently
without verifying
individually
that each step had been completed.
As part of the immediate
corrective
action, personnel
stopped the work activity and revised ICI-B12-0001
to clarify the requirements
in Section 5.9 of the procedure.
A second attempt was made to calibrate
the hydramotor, but the procedure
needed another revision to the steps. The procedure
category was also revised from 'Step-by-Step" to "In-Field
Reference," a more appropriate
category for this procedure.
Upon completion
of the second procedure
revision, the calibration
was completed
satisfactorily
and the hydramotor
was returned to service.Condition
reports 06-00125 and 06-01765 address the above inspection
report issues as follows: The first example of Step 5.9.2 of ICI-B12-0001
directed the user to verify that the hydramotor
had been run through full stroke at least five times. Per NOP-LP-2601, the performer
is allowed to reposition
this hydramotor
if authorized
by plant procedures.
The approval to stroke this valve was authorized
by the order which was released by operations
to allow calibration
of the hydramotor.
Note: The act of stroking the hydramotor
is a skill that is obtained by a qualified
technician
during their on-the-job
training/task
performance
evaluation (OJT/TPE)
training.
PY-CEI/NRR-2959L
Attachment
I Page 9 of I1 Step 5.9.3 of ICI-B12-0001
directed the removal of control and electrical
screw on covers for the PCD actuator.
The technicians
were working to calibrate
the position limit switches instead of the travel limit switch so the correct cover was not removed. The technician
made an error in not removing all of the covers needed for this calibration.
Step 5.9.4 of ICI-B12-0001
directed the connection
of a multi-meter
to an actuator travel limit switch shown on attachment
7, but went to attachment
10 (this issue was addressed
solely by CR 06-00125).
The error was failure to follow the procedure.
The procedures
were revised, the calibration
completed, the hydramotor
was returned to service, and the potential
limiting condition
for operation (PLCO) cleared.Steps 5.9.5 through 5.9.9 of ICI-B12-0001
directed the manipulation
of the hydramotor
actuator for verification
and recording
of proper valve seating and stem travel. The steps were all performed
and then signed off which violates procedure
NOP-LP-2601
for use of a step-by-step
procedure.
Also, as the steps were repeated, the technicians
failed to provide the separate documentation
and placekeeping
as required by NOP-LP-2601.
Although this may be accomplished
by different
methods, the performers
must follow the procedure
requirements.
These were human performance
errors.Steps 5.9.10, 5.9.10a, and 5.9.10b of ICI-B12-0001
directed the connection
of a multi-meter
to position switches followed by actuator manipulation
until such switches actuate. The steps were performed
concurrently
and then signed off after completed
which is contrary to the requirements
of NOP-LP-2601 for a Step-by-Step
procedure.
The roll-up of these issues again emphasizes
the failure to follow proper procedure
use and adherence
expectations.
This issue was addressed
in CR-06-00125.
I&C, Electrical, Mechanical
and Services sections of Maintenance
have completed
a procedure
use and adherence
class. The requirements
and the expectations
for procedure
use and adherence
were emphasized
during the class.As discussed
above, procedure
adherence
and quality of the procedure contributed
to this issue. Corrective
actions were taken in accordance
with the FENOC Performance
Management
Process.6. 3.2, Commitment
Item 1.b/DAMP Item B2.2.3.2, states: The inspectors
concluded that NQI-1001, Revision 5, appropriately
incorporated
the consideration
of failure history, risk significance, and failure probability
in assigning
QC inspection
hold points. However, the inspectors
identified
that the methods Identified
and in use did not take full advantage
of all site programs.
In particular, the procedure
did not prescribe
the review of the maintenance
rule database, which collects pertinent component
failure data, nor did it integrate
the probabilistic
risk assessment (PRA)model, which provides component-specific
risk information.
PY-CEI/NRR-2959L
Attachment
1 Page 10 of II FENOC RESPONSE: To address the above observations, CR 06-00366 was generated.
It should be noted that NQI- I001 was superseded
by Nuclear Operating
Procedure NOP-LP-2018, "Quality Control Inspection
of Maintenance
and Modification
Activities," on December 19, 2005. The CR investigation
was focused on addressing
the following
enhancement
actions to procedure
NOP-LP-2018:
- Assignment
of hold/witness
points to procedure
steps that are identified
as "critical
steps."* Use of Probabilistic
Safety Assessment (PSA) risk significance
for component
level equipment
and non-safety
risk significance
equipment.
- Use of Maintenance
Rule database for the identification
of repeat failure items for potential
assignment
of hold/witness
points.The investigation
determined
that use of the Maintenance
Rule database as a means to identify additional
QC hold/witness
points is not an optimum method. Since the condition
reports drive the maintenance
rule evaluation
through the corrective
actions, historical
failure data can be obtained through the review of condition
reports for those components
that are considered
to be a maintenance
rule failure. Therefore, historical
data from the condition reporting
system will be used for the identification
of repeat failures items for potential
assignment
of hold/witness
points.The following
enhancements
were added to procedure
NOP-LP-2018:
- Use of pre-established "Critical
Steps" as a factor when assigning
QC Hold/Witness
points.* Use of risk significance
assessment
tool at a component
level as a factor when assigning
Hold/Witness
points.* Use of Risk Significance (PSA), Maintenance
Rule, Critical Components, and Maintenance
Modifications
as factors that the QC supervisor
will utilize when assigning
process monitoring.
SECTION 5.0 TRAINING 5.3, Review of Human Performance
Tools to Reinforce
Human Performance
Under Stress, states: While observing
the rebuild of a fire protection
deluge valve, a procedure
step in the work package required the inspection
of valve internals
to evaluate the condition
of the valve, including
the condition
of internal moving parts.When questioned
about the presence of moving parts, licensee personnel
were unsure if the valve contained
moving parts. Despite this lack of knowledge, licensee personnel
signed off the step as complete.
Upon further review, the inspectors
determined
that the work package was incorrect
and referenced
a section of the technical
manual for a valve that contained
moving parts although the valve inspected
did not contain moving parts.However, since this error had no actual adverse impact on the deluge valve inspection
results, the inspectors
concluded
the issue was of only minor significance.
PY-CEI/NRR-2959L
Attachment
1 Page 11 of 11 FENOC RESPONSE: To address the above observation, FENOC generated
CRs 06-00178 and 06-01764.
CR 06-00178 investigated
the issue concerning
the communication
that took place between the inspector
and responsible
system engineer (RSE) during inspection
of the fire protection
deluge valve.The inspector
questioned
what moving parts were inspected
for the valve in accordance
with the work order and whether a vendor manual was reviewed during the valve inspection.
The RSE's initial response was that the valve did not have the same spring arrangement
like the other valves being inspected.
This was confirmed
by the maintenance
personnel
during the inspection.
The proper response should have been that the valve flapper was inspected
during the valve internal inspection
and there was no spring arrangement
for this particular
valve model. This communication
issue was subsequently
clarified
with the inspector.
The investigation
determined
that the initial response by the RSE to the inspectors
question was not clearly communicated.
Condition
report 06-01764 investigated
the issue with potential
for lack of knowledge
and incorrect
work package. During the initial inspection
of the deluge valve, the RSE examined the valve internals
to include flapper, seating surfaces, and body conditions.
After inspection
of the valve, the RSE confirmed
by way of the maintenance
personnel
that this model valve did not have a spring. When questioned
by the inspector
as to what moving parts were inspected, the RSE identified
that the internals
and seating surface were inspected.
The RSE went on to explain that this model did not contain a spring. The inspector
asked if the vendor manual had been reviewed.
The RSE responded
no (note that this was the fourth deluge valve inspected
by the RSE with some models containing
the spring while others do not). In the subsequent
meeting with the inspector, the RSE was more precise in specifically
identifying
that the flapper (moving part) was inspected
and indicated
that he had a conversation
with the mechanic regarding
this particular
model not having a spring. The inspector
was not aware of the conversation
between the RSE and the maintenance
personnel
during the inspection.
The work order package issue was associated
with one of the two models with the manual/drawing (model without spring) not being in the package. The order was for the inspection
of multiple deluge valves that consisted
of both models. The SAP data for the valve being inspected
at the time of this event did not identify the valve correctly
and the proper vendor manual section/drawing
was not provided.
The package only contained
a vendor manual/drawing
of the model with a spring. This oversight
was corrected
by adding the appropriate
manual section/drawing
to the package and changing the SAP data base model number. Therefore, this issue is not a result of lack of RSE knowledge, but rather less than effective communications
and an issue with the work package.