IR 05000528/2018008: Difference between revisions

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=Text=
=Text=
{{#Wiki_filter:ber 16, 2018
{{#Wiki_filter:October 16, 2018


==SUBJECT:==
==SUBJECT:==
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Sincerely,
Sincerely,
/RA Gerond George Acting for/
/RA Gerond George Acting for/  
Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Docket Nos. 50-528, 50-529, and 50-530 License Nos. NPF-41, NPF-51, and NPF-74 Enclosure:
Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 w/ attachment: Information Requests


U.S. NUCLEAR REGULATORY COMMISSION
Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety
 
Docket Nos. 50-528, 50-529, and 50-530 License Nos. NPF-41, NPF-51, and NPF-74
 
Enclosure:
Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 w/ attachment: Information Requests
 
Enclosure U.S. NUCLEAR REGULATORY COMMISSION  


==Inspection Report==
==Inspection Report==
Docket Number(s): 05000528, 05000529, 05000530 License Number(s): NPF-41, NPF-51, NPF-74 Report Number(s): 05000528/2018008, 05000529/2018008, and 05000530/2018008 Enterprise Identifier: I-2018-008-0001 Licensee: Arizona Public Service Company Facility: Palo Verde Nuclear Generating Station Location: Tonopah, Arizona Inspection Dates: August 27, 2018, to September 14, 2018 Inspectors: E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead)
Docket Number(s):
P. Jayroe, Reactor Inspector G. Kolcum, Sr. Resident Inspector D. Reinert, Resident Inspector Approved By: Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Enclosure
05000528, 05000529, 05000530  
 
License Number(s):
NPF-41, NPF-51, NPF-74  
 
Report Number(s):
05000528/2018008, 05000529/2018008, and 05000530/2018008  
 
Enterprise Identifier: I-2018-008-0001  
 
Licensee:
Arizona Public Service Company  
 
Facility:
Palo Verde Nuclear Generating Station  
 
Location:
Tonopah, Arizona  
 
Inspection Dates:
August 27, 2018, to September 14, 2018  
 
Inspectors:
E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead)  
 
P. Jayroe, Reactor Inspector  
 
G. Kolcum, Sr. Resident Inspector  
 
D. Reinert, Resident Inspector  
 
Approved By:
Geoffrey B. Miller, Team Leader  
 
Inspection Program and Assessment Team  
 
Division of Reactor Safety  


=SUMMARY=
=SUMMARY=
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Palo Verde Nuclear Generating Station, Units 1, 2, and 3, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. A licensee-identified non-cited violation is discussed in report section 71152.
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Palo Verde Nuclear Generating Station, Units 1, 2, and 3, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. A licensee-identified non-cited violation is discussed in report section 7115


List of Findings and Violations Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance                                   Cross-cutting       Report Section Aspect Mitigating     Green                                       H.12                71152Problem Systems        NCV 05000528, 05000529,                                         Identification and 05000530/2018008-01                                             Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50,
===List of Findings and Violations===
Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Aspect Report Section Mitigating Systems Green NCV 05000528, 05000529, 05000530/2018008-01 Closed H.12 71152Problem Identification and Resolution The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50,
Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct the failures of multiple control room hand-switch operator knobs.
Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct the failures of multiple control room hand-switch operator knobs.


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==OTHER ACTIVITIES - BASELINE==
==OTHER ACTIVITIES - BASELINE==
===71152Problem Identification and Resolution Biennial Team Inspection===
{{IP sample|IP=IP 71152|count=1}}


===71152Problem Identification and Resolution Biennial Team Inspection ===
{{IP sample|IP=IP 71152|count=1}}
The team performed a biennial assessment of the licensees corrective action program (CAP),use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below.
The team performed a biennial assessment of the licensees corrective action program (CAP),use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below.
: (1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports and associated records, and an in-depth 5-year review of condition reports associated with the safety injection and shutdown cooling systems.
: (1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports and associated records, and an in-depth 5-year review of condition reports associated with the safety injection and shutdown cooling systems.
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: (3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, engineering, organizational effectiveness and performance improvement, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey.
: (3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, engineering, organizational effectiveness and performance improvement, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey.


===71153Follow-up of Events and Notices of Enforcement Discretion     Licensee Event Reports ===
===71153Follow-up of Events and Notices of Enforcement Discretion Licensee Event Reports===
{{IP sample|IP=IP 71153|count=1}}
{{IP sample|IP=IP 71153|count=1}}
The team evaluated licensee event report (LER) 05000528/2018-002: Condition Prohibited by Technical Specification for Inoperable Excore Instrument Channel (ADAMS Accession Number ML18130A986). The team reviewed two licensee-identified non-cited violations associated with the LER, described in the inspection results below.
The team evaluated licensee event report (LER) 05000528/2018-002: Condition Prohibited by Technical Specification for Inoperable Excore Instrument Channel (ADAMS Accession Number ML18130A986). The team reviewed two licensee-identified non-cited violations associated with the LER, described in the inspection results below.


==INSPECTION RESULTS==
==INSPECTION RESULTS==
- OBSERVATIONS/ASSESSMENT Corrective Action Program Assessment                 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems was adequate to support nuclear safety, though some challenges were noted. In particular, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues. These are described in observations, findings, and violations below.
- OBSERVATIONS/ASSESSMENT  
 
Corrective Action Program Assessment 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems was adequate to support nuclear safety, though some challenges were noted. In particular, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues. These are described in observations, findings, and violations below.


Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues was adequate to support nuclear safety. The licensee continues to work to improve management oversight of the corrective action program, which has been consistently identified as an area for improvement by both third party and internal reviews. The team noted that the licensees actions appear to have improved management oversight, including improvements to quality and consistency of evaluation products through enhanced CARB oversight, and the addition of new tools for scoping the evaluation. However, these actions were too recently completed for the team to determine whether they have been fully successful. Additionally, the team noted that while individual problems were generally fixed, the licensee did not always expand evaluations to determine the cause or aggregate impact of multiple similar conditions. Examples are discussed below.
Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues was adequate to support nuclear safety. The licensee continues to work to improve management oversight of the corrective action program, which has been consistently identified as an area for improvement by both third party and internal reviews. The team noted that the licensees actions appear to have improved management oversight, including improvements to quality and consistency of evaluation products through enhanced CARB oversight, and the addition of new tools for scoping the evaluation. However, these actions were too recently completed for the team to determine whether they have been fully successful. Additionally, the team noted that while individual problems were generally fixed, the licensee did not always expand evaluations to determine the cause or aggregate impact of multiple similar conditions. Examples are discussed below.
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Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of conditions adverse to quality that were classified as nonconformances, this is discussed below as a minor violation.
Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of conditions adverse to quality that were classified as nonconformances, this is discussed below as a minor violation.


Observations on the Corrective Action Program             71152Problem Identification and Resolution The team reviewed the engineering design change process and impact review process, and found it to be adequate and in line with industry standards. The team also screened a sample of condition reports that originated over the past 2 years and found several examples of misses tied to the design change process and impact reviews where the required updates to documentation were not completed or were incorrect. Personnel interviewed by the team indicated that these misses were sometimes identified by workers being unable to perform work activities as directed by work orders or unable to draft clearance orders due to incorrect drawings. In all examples reviewed by the team, the licensee revised or updated affected documentation after the condition report was written; however the team did not note any significant efforts to evaluate or improve the engineering design change impact review process. The team reviewed the stations use of trend codes to track these examples and identified several instances where expected trend codes were incorrectly applied or not applied at all. One particular trend code (CM 3.10) is applied to condition reports which are created in advance or just recently after a plant modification to create a tracking item for required updates to various documents; the team noted examples of documentation revisions tied to legacy modifications lumped in under this trend code. Liberal use of this particular trend code in coincidence with restricted use of more applicable trend codes may be masking potential trends in documentation revisions missed by the impact review process. The licensee documented this observation in Condition Report 18-14427.
Observations on the Corrective Action Program 71152Problem Identification and Resolution The team reviewed the engineering design change process and impact review process, and found it to be adequate and in line with industry standards. The team also screened a sample of condition reports that originated over the past 2 years and found several examples of misses tied to the design change process and impact reviews where the required updates to documentation were not completed or were incorrect. Personnel interviewed by the team indicated that these misses were sometimes identified by workers being unable to perform work activities as directed by work orders or unable to draft clearance orders due to incorrect drawings. In all examples reviewed by the team, the licensee revised or updated affected documentation after the condition report was written; however the team did not note any significant efforts to evaluate or improve the engineering design change impact review process. The team reviewed the stations use of trend codes to track these examples and identified several instances where expected trend codes were incorrectly applied or not applied at all. One particular trend code (CM 3.10) is applied to condition reports which are created in advance or just recently after a plant modification to create a tracking item for required updates to various documents; the team noted examples of documentation revisions tied to legacy modifications lumped in under this trend code. Liberal use of this particular trend code in coincidence with restricted use of more applicable trend codes may be masking potential trends in documentation revisions missed by the impact review process. The licensee documented this observation in Condition Report 18-14427.


The team observed that the licensees condition report classification committees (the Screening Committee and the Condition Review Group) did not always consistently apply the corrective action program (CAP) definitions of condition adverse to quality (CAQ) and non-condition adverse to quality. In particular, a lack of guidance or familiarity in what constituted an adverse trend in a quality process CAQ versus a potential adverse trend (non-condition adverse to quality until evaluated and confirmed) led to inconsistency in classification of condition reports documenting aggregate issues. The licensee documented this observation in Condition Reports 18-13648 and 18-14334.
The team observed that the licensees condition report classification committees (the Screening Committee and the Condition Review Group) did not always consistently apply the corrective action program (CAP) definitions of condition adverse to quality (CAQ) and non-condition adverse to quality. In particular, a lack of guidance or familiarity in what constituted an adverse trend in a quality process CAQ versus a potential adverse trend (non-condition adverse to quality until evaluated and confirmed) led to inconsistency in classification of condition reports documenting aggregate issues. The licensee documented this observation in Condition Reports 18-13648 and 18-14334.
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Additionally, some identified deficiencies in quality programs were classified as non-condition adverse to quality. For example, on January 2, 2018, the licensees organizational effectiveness department issued a Corrective Action Program Elevation Letter, which identified, inconsistent identification of issues entered into the condition reporting process, CAP product quality decline, inappropriate closure of CAP actions, and rejection of CAP products including causal evaluation. The condition report associated with this letter, Condition Report 18-00055, was classified as non-condition adverse to quality. In procedure 01DP-0AP12, Condition Reporting Process the licensee defines CAQ to include, failures to comply with procedures that implement the current licensing basis (CLB), where CLB is defined to include both 10 CFR Part 50 and the licensees quality assurance program, both of which contain requirements implemented by CAP. In these examples and others reviewed by the team, the conditions adverse to quality were timely addressed, even when classified as non-condition adverse to quality. Therefore there was no violation of NRC regulations. The licensee documented this issue in Condition Report 18-13739.
Additionally, some identified deficiencies in quality programs were classified as non-condition adverse to quality. For example, on January 2, 2018, the licensees organizational effectiveness department issued a Corrective Action Program Elevation Letter, which identified, inconsistent identification of issues entered into the condition reporting process, CAP product quality decline, inappropriate closure of CAP actions, and rejection of CAP products including causal evaluation. The condition report associated with this letter, Condition Report 18-00055, was classified as non-condition adverse to quality. In procedure 01DP-0AP12, Condition Reporting Process the licensee defines CAQ to include, failures to comply with procedures that implement the current licensing basis (CLB), where CLB is defined to include both 10 CFR Part 50 and the licensees quality assurance program, both of which contain requirements implemented by CAP. In these examples and others reviewed by the team, the conditions adverse to quality were timely addressed, even when classified as non-condition adverse to quality. Therefore there was no violation of NRC regulations. The licensee documented this issue in Condition Report 18-13739.


Assessment of Use of Operating Experience                 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analysis and apparent cause evaluations. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs.
Assessment of Use of Operating Experience 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analysis and apparent cause evaluations. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs.


Self-Assessments and Audits Assessment               71152Problem Identification and Resolution Based on the samples reviewed, the team determined that station performance in these areas adequately supported nuclear safety. Generally, self-assessments and audits were effective at identifying deficiencies and enhancements. In all cases, deficiencies were documented in condition reports for both self-assessments and audits. Audits, in particular, were highly effective in identifying and documenting deficiencies. One self-assessment (16-10139) did not appear to have a tracking item (i.e. condition report) for an enhancement.
Self-Assessments and Audits Assessment 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that station performance in these areas adequately supported nuclear safety. Generally, self-assessments and audits were effective at identifying deficiencies and enhancements. In all cases, deficiencies were documented in condition reports for both self-assessments and audits. Audits, in particular, were highly effective in identifying and documenting deficiencies. One self-assessment (16-10139) did not appear to have a tracking item (i.e. condition report) for an enhancement.


Safety-Conscious Work Environment Assessment             71152Problem Identification and Resolution The team found no evidence of challenges to the safety-conscious work environment of station work groups. Individuals appeared willing to raise nuclear safety concerns through at least one of the several means available.
Safety-Conscious Work Environment Assessment 71152Problem Identification and Resolution The team found no evidence of challenges to the safety-conscious work environment of station work groups. Individuals appeared willing to raise nuclear safety concerns through at least one of the several means available.


==INSPECTION RESULTS==
==INSPECTION RESULTS==
- ISSUES/FINDINGS Minor Violation                         71152Problem Identification and Resolution Performance Deficiency: Failure to promptly identify and correct conditions adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI.
- ISSUES/FINDINGS  
 
Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to promptly identify and correct conditions adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI.


The team identified a backlog of conditions adverse to quality that the licensee had failed to timely correct. The oldest of these conditions was approximately 10 years old, with several hundred having been identified at least two operating cycles prior to the inspection. The team determined that the licensee was appropriately addressing degraded components that had an impact on safety or security, but was not always tracking or timely correcting nonconformances with its design bases in cases where these nonconformances had been assessed as not impacting safety-related functions. Further, the licensee was unable to initially determine the scope of its nonconformance backlog. The licensee documented this deficiency as Condition Reports 18-13549 and 18-14426.
The team identified a backlog of conditions adverse to quality that the licensee had failed to timely correct. The oldest of these conditions was approximately 10 years old, with several hundred having been identified at least two operating cycles prior to the inspection. The team determined that the licensee was appropriately addressing degraded components that had an impact on safety or security, but was not always tracking or timely correcting nonconformances with its design bases in cases where these nonconformances had been assessed as not impacting safety-related functions. Further, the licensee was unable to initially determine the scope of its nonconformance backlog. The licensee documented this deficiency as Condition Reports 18-13549 and 18-14426.
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This failure to comply with 10 CFR 50, Appendix B, Criterion XVI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.
This failure to comply with 10 CFR 50, Appendix B, Criterion XVI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.


Minor Violation                         71152Problem Identification and Resolution Performance Deficiency: Failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR 50, Appendix B, Criterion VI.
Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR 50, Appendix B, Criterion VI.


The team identified that the CAP procedure directed the use of the Cause Analysis Manual in performing some cause evaluations. This cause evaluation process is an activity affecting quality required by 10 CFR 50, Appendix B and the licensees Quality Assurance Program.
The team identified that the CAP procedure directed the use of the Cause Analysis Manual in performing some cause evaluations. This cause evaluation process is an activity affecting quality required by 10 CFR 50, Appendix B and the licensees Quality Assurance Program.
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This failure to comply with 10 CFR 50, Appendix B, Criterion VI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.
This failure to comply with 10 CFR 50, Appendix B, Criterion VI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.


Licensee-Identified Non-Cited Violation               71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.


Violation: 10 CFR Part 50, Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Violation: 10 CFR Part 50, Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
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Significance/Severity Level: The team determined this finding was of very low safety significance (Green) because a minimum of two excore detector channels always remained available to trip the reactor during a main steam line break. Redundant channels were not affected and were available to perform the required safety function to trip the reactor.
Significance/Severity Level: The team determined this finding was of very low safety significance (Green) because a minimum of two excore detector channels always remained available to trip the reactor during a main steam line break. Redundant channels were not affected and were available to perform the required safety function to trip the reactor.


Corrective Action Reference(s): Condition Report 18-12217 Licensee-Identified Non-Cited Violation               71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Corrective Action Reference(s): Condition Report 18-12217 Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.


Violation: 10 CFR 50.73(a)(2)(i)(B) requires, in part, that the holder of an operating license shall submit an licensee event report within 60 days of discovery of the event, which includes any operation or condition which was prohibited by technical specifications.
Violation: 10 CFR 50.73(a)(2)(i)(B) requires, in part, that the holder of an operating license shall submit an licensee event report within 60 days of discovery of the event, which includes any operation or condition which was prohibited by technical specifications.
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Significance/Severity Level: This violation was considered as traditional enforcement because the failure to notify the NRC had the potential for impacting the NRCs ability to perform its regulatory function. Consistent with the guidance in Section 6.9, Paragraph d.9, of the NRC Enforcement Policy, the failure to report the condition prohibited by technical specifications was determined to be a Severity Level IV violation.
Significance/Severity Level: This violation was considered as traditional enforcement because the failure to notify the NRC had the potential for impacting the NRCs ability to perform its regulatory function. Consistent with the guidance in Section 6.9, Paragraph d.9, of the NRC Enforcement Policy, the failure to report the condition prohibited by technical specifications was determined to be a Severity Level IV violation.


Corrective Action Reference(s): Condition Report 18-02569 Non-Cited Violation (NCV): Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone         Significance                               Cross-cutting Report Section Aspect Mitigating         Green                                       None            71152Problem Systems            NCV 05000528; 05000529;                                     Identification and 05000530/2018008-01                                         Resolution Closed The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action for failure to promptly correct a condition adverse to quality. Specifically, since October 30, 2014, the licensee failed to implement prompt corrective actions to correct an adverse condition related to the failure of control room hand-switch operator knobs.
Corrective Action Reference(s): Condition Report 18-02569  
 
Non-Cited Violation (NCV): Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Aspect Report Section Mitigating Systems Green NCV 05000528; 05000529; 05000530/2018008-01 Closed None 71152Problem Identification and Resolution The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action for failure to promptly correct a condition adverse to quality. Specifically, since October 30, 2014, the licensee failed to implement prompt corrective actions to correct an adverse condition related to the failure of control room hand-switch operator knobs.


=====Description:=====
=====Description:=====
While performing control room observations on August 28, 2018, the team identified that various control room hand-switches were missing operator knobs. The control room switches are Coordinated Manual Controls 910 series currently manufactured and supported by Senasys. The switches are operated by turning the selector knob, which rotates a cam at the end of the knob shaft, pushing a set of plungers which will make or break electrical contact continuity within the contact block. The primary purpose of the knob is to allow operators to change the status of equipment in the plant.
While performing control room observations on August 28, 2018, the team identified that various control room hand-switches were missing operator knobs. The control room switches are Coordinated Manual Controls 910 series currently manufactured and supported by Senasys. The switches are operated by turning the selector knob, which rotates a cam at the end of the knob shaft, pushing a set of plungers which will make or break electrical contact continuity within the contact block. The primary purpose of the knob is to allow operators to change the status of equipment in the plant.


The team identified a total of eighteen missing operator knobs among the three unit control rooms. Fourteen of these controlled safety-related, technical specification (TS)-related, or emergency operating procedure (EOP)-related components:1 Broken           Number            Number            Number       Oldest switches      safety-related     TS-related       EOP-related Unit 1           5                4                2                  2         October 30, 2014 Unit 2           7                6                3                  2         October 18, 2015 Unit 3           6                1                0                  2         April 27, 2018 Total         18                11                5                  6 The licensee had provided one or two spare operator knobs in each control room that could be used to operate a hand-switch when necessary during routine, alarm, abnormal, or emergency events. However, the licensee had performed no formal evaluation of the use of these spare knobs as a compensatory action or of the aggregate impact to each control room during off-normal or emergency scenarios. The licensee did not control the spare knobs despite having dedicated them as basic components for use in safety-related applications. All equivalent knobs in the plant reference simulators were intact. The licensee did not model or brief this discrepancy between the simulator and the plant during training scenarios. Neither did the licensee list the missing knobs on the simulator differences list or evaluate the missing knobs in the overall simulator program of maintenance, testing, and correction of discrepancies with the actual plant.
The team identified a total of eighteen missing operator knobs among the three unit control rooms. Fourteen of these controlled safety-related, technical specification (TS)-related, or emergency operating procedure (EOP)-related components:1  
 
Broken switches Number safety-related Number TS-related Number EOP-related Oldest Unit 1  
 
2 October 30, 2014 Unit 2  
 
2 October 18, 2015 Unit 3  
 
2 April 27, 2018 Total  
 
The licensee had provided one or two spare operator knobs in each control room that could be used to operate a hand-switch when necessary during routine, alarm, abnormal, or emergency events. However, the licensee had performed no formal evaluation of the use of these spare knobs as a compensatory action or of the aggregate impact to each control room during off-normal or emergency scenarios. The licensee did not control the spare knobs despite having dedicated them as basic components for use in safety-related applications. All equivalent knobs in the plant reference simulators were intact. The licensee did not model or brief this discrepancy between the simulator and the plant during training scenarios. Neither did the licensee list the missing knobs on the simulator differences list or evaluate the missing knobs in the overall simulator program of maintenance, testing, and correction of discrepancies with the actual plant.


Corrective Action(s): As an immediate corrective action, the licensee provided five additional knobs for each control room and provided a formal communication to control room staff regarding their use.
Corrective Action(s): As an immediate corrective action, the licensee provided five additional knobs for each control room and provided a formal communication to control room staff regarding their use.
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Significance: The team performed the initial significance determination using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.
Significance: The team performed the initial significance determination using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.


Four of the eighteen switches met none of these criteria, though one of those four controlled a breaker that was included in the probabilistic risk model. The other fourteen switches variously met one or more of the criteria. Because of this overlap, the numbers in the table to not sum horizontally.
1 Four of the eighteen switches met none of these criteria, though one of those four controlled a breaker that was included in the probabilistic risk model. The other fourteen switches variously met one or more of the criteria. Because of this overlap, the numbers in the table to not sum horizontally.


Cross Cutting Aspect: This finding had a cross-cutting aspect in the area of human performance, avoid complacency, in that the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee did not implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control room (H.12).
Cross Cutting Aspect: This finding had a cross-cutting aspect in the area of human performance, avoid complacency, in that the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee did not implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control room (H.12).
Line 165: Line 224:
Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.
Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.


Licensee Event     Condition Prohibited by Technical         71153 Follow-up of Events Report        Specifications for an Inoperable           and Notices of Enforcement (Closed)        Excore Instrument Channel                 Discretion (LER 05000528/2018-002)
Licensee Event Report (Closed)
Condition Prohibited by Technical Specifications for an Inoperable Excore Instrument Channel (LER 05000528/2018-002)71153 Follow-up of Events and Notices of Enforcement Discretion


==EXIT MEETINGS AND DEBRIEFS==
==EXIT MEETINGS AND DEBRIEFS==
Line 173: Line 233:


Condition Reports
Condition Reports
10-00424       16-04624       17-12748         18-00837       18-06960         16-19560
10-00424
2-00391       16-04625       17-13751         18-00869       18-07751         16-19864
16-04624
13-00349       16-04628       17-13780         18-01277       16-13267         16-20048
17-12748
13-00736       16-04646       17-14018         18-01512       16-13529         16-20333
18-00837
14-01375       17-08432       17-14219         18-01657       16-13896         16-20383
18-06960
14-01904       17-08633       17-14504         18-01685       16-14370         16-20395
16-19560
14-02854       17-08634       17-15012         18-01702       16-14791         18-12743
2-00391
15-02470       17-08636       17-15793         18-01737       16-14896         18-13345
16-04625
15-02897       17-08672       17-16181         16-10666       16-15709         18-13446
17-13751
15-06128       17-08818       17-16495         16-10742       16-16024         18-13575
18-00869
15-07118       17-09022       17-16497         16-11578       16-16585         18-13996
18-07751
16-03489       17-09222       17-16552         16-11605       16-16995         18-14126
16-19864
16-03566       17-09257       17-16563         16-12160       18-07903         18-14201
13-00349
16-03843       17-09326       17-17371         16-12430       18-07964         18-14212
16-04628
16-03914       17-09336       16-07329         16-12465       18-08156         18-14215
17-13780
16-04598       17-09524       16-07589         16-12783       18-08409         18-14218
18-01277
17-16181       17-09656       16-07632         16-12797       18-08466         18-14222
16-13267
17-16495       17-10518       16-08413         16-13128       18-08815         18-14223
16-20048
17-16497       17-11997       16-09123         18-02462       18-09130         18-14224
13-00736
17-16552       17-12205       16-09548         18-02960       18-09679         18-14226
16-04646
17-16563       16-04677       16-09997         18-03038       18-10024         18-14372
17-14018
17-17371       16-04977       16-10139         18-03154       18-10995
18-01512
17-17791       16-04980       16-10173         18-03173       18-11453
16-13529
17-17965       16-04982       16-10185         18-03177       18-12086
16-20333
17-18155       16-04984       17-17791         18-03346       18-12157
14-01375
18-00055       16-05436       17-17965         18-04528       18-12174
17-08432
15-07118       16-05926       17-18155         18-04994       18-12217
17-14219
16-03489       16-05966       18-00055         18-05015       18-12423
18-01657
16-03566       16-06026       18-00055         18-05879       16-18951
16-13896
16-03843       16-06578       18-00086         18-06317       16-19295
16-20383
16-03914       17-12265       18-00194         18-06774       16-19296
14-01904
16-04598       17-12466       18-00202         18-06912       16-19554
17-08633
17-14504
18-01685
16-14370
16-20395
14-02854
17-08634
17-15012
18-01702
16-14791
18-12743
15-02470
17-08636
17-15793
18-01737
16-14896
18-13345
15-02897
17-08672
17-16181
16-10666
16-15709
18-13446
15-06128
17-08818
17-16495
16-10742
16-16024
18-13575
15-07118
17-09022
17-16497
16-11578
16-16585
18-13996
16-03489
17-09222
17-16552
16-11605
16-16995
18-14126
16-03566
17-09257
17-16563
16-12160
18-07903
18-14201
16-03843
17-09326
17-17371
16-12430
18-07964
18-14212
16-03914
17-09336
16-07329
16-12465
18-08156
18-14215
16-04598
17-09524
16-07589
16-12783
18-08409
18-14218
17-16181
17-09656
16-07632
16-12797
18-08466
18-14222
17-16495
17-10518
16-08413
16-13128
18-08815
18-14223
17-16497
17-11997
16-09123
18-02462
18-09130
18-14224
17-16552
17-12205
16-09548
18-02960
18-09679
18-14226
17-16563
16-04677
16-09997
18-03038
18-10024
18-14372
17-17371
16-04977
16-10139
18-03154
18-10995
17-17791
16-04980
16-10173
18-03173
18-11453
17-17965
16-04982
16-10185
18-03177
18-12086
17-18155
16-04984
17-17791
18-03346
18-12157
18-00055
16-05436
17-17965
18-04528
18-12174
15-07118
16-05926
17-18155
18-04994
18-12217
16-03489
16-05966
18-00055
18-05015
18-12423
16-03566
16-06026
18-00055
18-05879
16-18951
16-03843
16-06578
18-00086
18-06317
16-19295
16-03914
17-12265
18-00194
18-06774
16-19296
16-04598
17-12466
18-00202
18-06912
16-19554
Plus approximately 100 anonymous condition reports initiated between January 1, 2018, and
Plus approximately 100 anonymous condition reports initiated between January 1, 2018, and
August 7, 2018, and the text of most of the several hundred condition reports issued while the
August 7, 2018, and the text of most of the several hundred condition reports issued while the
team was on site.
team was on site.
Work Orders
Work Orders
24481         4340548       4616104       4699032       4842349
24481
4316976       4412917       4699031       4699034       4857178
4340548
4616104
4699032
4842349  
 
4316976
4412917
4699031
4699034
4857178  
 
Audit Reports
Audit Reports
2016-007     2016-010     2017-009     2018-003
2016-007
2016-009     2017-003     2018-002
2016-010
2017-009
2018-003  
 
2016-009
2017-003
2018-002  
 
Procedures
Procedures
Number       Title                                                 Revision
Number
01DP-0AP01   Procedure Process                                     59
Title
01DP-0AP12   Condition Reporting Process                           23, 24, 29, 30
Revision
01DP-0AP22   Procedure Writers Guide                               10
01DP-0AP01
01DP-0AP58-01 Trend Analysis and Coding Administrative Guideline     1
Procedure Process
2DP-0AP01   Plant Review Board                                     22
01DP-0AP12
2DP-0MC08,   Control of Purchasing Material and Equipment
Condition Reporting Process
5DP-0CC05     Simulator Instructors Guide and Reporting             0
23, 24, 29, 30
15DP-0TR08   Systematic Approach to Training                       14
01DP-0AP22
30DP-0AC02   Station Rework Reduction                               5
Procedure Writers Guide
30DP-0WM15   Fix-It-Now Multi-Discipline Team                       13
01DP-0AP58-01
31MT-9SI02   High Pressure Safety Injection Pump Disassembly,       32
Trend Analysis and Coding Administrative Guideline
2DP-0AP01
Plant Review Board
2DP-0MC08,
Control of Purchasing Material and Equipment
5DP-0CC05
Simulator Instructors Guide and Reporting
15DP-0TR08
Systematic Approach to Training
30DP-0AC02
Station Rework Reduction
30DP-0WM15
Fix-It-Now Multi-Discipline Team
31MT-9SI02
High Pressure Safety Injection Pump Disassembly,
Examination, and Assembly
Examination, and Assembly
40AL-9RK6A   Panel B06A Alarm Responses                             19
40AL-9RK6A
40AO-9ZZ21   Acts of Nature                                         38
Panel B06A Alarm Responses
40DP-9OP15   Operator Challenges and Discrepancy Tracking           29
40AO-9ZZ21
40DP-9OP20   Watch Standing Practices                               48
Acts of Nature
40DP-9OP26   Operations Condition Reporting Process and Operability 45
40DP-9OP15
Operator Challenges and Discrepancy Tracking
40DP-9OP20
Watch Standing Practices
40DP-9OP26
Operations Condition Reporting Process and Operability
Determination / Functional Assessment
Determination / Functional Assessment
40DP-9OP33   Shift Turnover                                         35
40DP-9OP33
40DP-9WP01   Operations Processing of Work Orders                   34
Shift Turnover
40DP-9ZZ04   Time Critical Action (TCA) Program                     13
40DP-9WP01
40OP-9AF02   Non-Essential Auxiliary Feedwater Pump Operation       20
Operations Processing of Work Orders
40OP-9CH03   RCP Seal Injection System                             30
40DP-9ZZ04
60DP-0QQ02   Trend Analysis and Coding                             27
Time Critical Action (TCA) Program
65DP-0QQ01   Industry Operating Experience Review                   41
40OP-9AF02
73TD-0ZZ03   System Engineering Handbook                           25
Non-Essential Auxiliary Feedwater Pump Operation
75RP-9RP20   Use and Control of HEPA Filtration and Vacuum         5
40OP-9CH03
RCP Seal Injection System
60DP-0QQ02
Trend Analysis and Coding
65DP-0QQ01
Industry Operating Experience Review
73TD-0ZZ03
System Engineering Handbook
75RP-9RP20
Use and Control of HEPA Filtration and Vacuum
Equipment
Equipment
81DP-0EE10   Design Change Process                                 45
81DP-0EE10
Design Change Process  
 
Procedures
Procedures
Number           Title                                               Revision
Number
93DP-0LC18       Part 21 Reporting Process                           2
Title
Revision
93DP-0LC18
Part 21 Reporting Process  
 
Miscellaneous
Miscellaneous
Documents                                                             Revision
Documents
Number           Title                                               or Date
Number  
2018 PVNGS Condition Reports CRG Refuse Back to     August 27, 2018
 
Title
Revision
or Date
2018 PVNGS Condition Reports CRG Refuse Back to
SC Rate / Through Rate Performance
SC Rate / Through Rate Performance
Active Night Orders                                 August 10, 2017
August 27, 2018
Active Standing Orders                             August 10, 2017
Active Night Orders
Control Room Discrepancies                         August 10, 2017
August 10, 2017
Open Operator Burdens                               August 10, 2017
Active Standing Orders
Operations Challenges List                         August 10, 2017
August 10, 2017
Operator Work Arounds                               August 10, 2017
Control Room Discrepancies
Organizational Effectiveness Monthly Performance   March 2018
August 10, 2017
Open Operator Burdens
August 10, 2017
Operations Challenges List
August 10, 2017
Operator Work Arounds
August 10, 2017
Organizational Effectiveness Monthly Performance
Summary: 2018 1st Quarter
Summary: 2018 1st Quarter
Organizational Effectiveness Quarterly Performance 2nd Quarter
March 2018
Summary                                            2018
Organizational Effectiveness Quarterly Performance
PRB Meeting Minutes: Monthly PRB (October 2017)     Oct 31, 2017
Summary
2nd Quarter
2018
PRB Meeting Minutes: Monthly PRB (October 2017)
and U1R20 Refueling Outage Restart
and U1R20 Refueling Outage Restart
PRB Monthly and U2R20 Startup Meeting Minutes       April 28, 2017
Oct 31, 2017
PVNGS Operations Quality Assurance Program         0, 0a
PRB Monthly and U2R20 Startup Meeting Minutes
April 28, 2017
PVNGS Operations Quality Assurance Program
Description (QAPD)
Description (QAPD)
Simulator to Unit Differences                       August 22, 2018
0, 0a
Training Slides: Introduction to Cause Analysis   November 16,
Simulator to Unit Differences
August 22, 2018
Training Slides: Introduction to Cause Analysis
November 16,
2016
2016
13-NS-C088       Mission Time Study                                 1
13-NS-C088
Design Equivalent Containment Construction Vent Concrete Cover Rework 0
Mission Time Study
Change 00462      and Design Drawing Detail Revision
Design Equivalent
Drawing 12-E-     Diesel Storage Tank Conduit Plan & Section          12
Change 00462
Containment Construction Vent Concrete Cover Rework
and Design Drawing Detail Revision
Drawing 12-E-
2YU-009
2YU-009
NLR17C030201     Licensed Operator Continuing Training               April 5, 2017
Diesel Storage Tank Conduit Plan & Section
NLR17C030201
Licensed Operator Continuing Training
April 5, 2017  
 
INFORMATION REQUESTS
INFORMATION REQUESTS


ML18291A562
ML18291A562
SUNSI Review: ADAMS:       Non-Publicly Available Non-Sensitive     Keyword: NRC-002
SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002
By: EAR         Yes No   Publicly Available       Sensitive
By: EAR Yes No
OFFICE       RI/IPAT     SRI/PBA       RI/PBD     C/PBD         SRI/IPAT       TL/IPAT
Publicly Available Sensitive
NAME         PJayroe     GKolcum       DReinert   NOKeefe     ERuesch         GMiller
OFFICE
SIGNATURE         /RA-e/     /RA-e/         /RA-e/     /RA/           /RA/       /RA GAG for/
RI/IPAT
DATE           9/21/2018 9/21/2018     9/21/2018   10/16/2018     10/16/2018     10/16/2018
SRI/PBA
RI/PBD
C/PBD
SRI/IPAT
TL/IPAT
NAME
PJayroe
GKolcum
DReinert
NOKeefe
ERuesch
GMiller
SIGNATURE  
/RA-e/  
/RA-e/  
/RA-e/  
/RA/  
/RA/  
/RA GAG for/
DATE
9/21/2018
9/21/2018
9/21/2018
10/16/2018
10/16/2018
10/16/2018
}}
}}

Latest revision as of 11:02, 5 January 2025

NRC Biennial Problem Identification and Resolution Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008
ML18291A562
Person / Time
Site: Palo Verde  Arizona Public Service icon.png
Issue date: 10/16/2018
From: Geoffrey Miller
Division of Reactor Safety IV
To: Bement R
Arizona Public Service Co
Miller G
References
IR 2018008
Download: ML18291A562 (22)


Text

October 16, 2018

SUBJECT:

PALO VERDE NUCLEAR GENERATING STATION - NRC BIENNIAL PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000528/2018008, 05000529/2018008, AND 05000530/2018008

Dear Mr. Bement:

On September 14, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution inspection at your Palo Verde Nuclear Generating Station, Units 1, 2, and 3. The NRC inspection team discussed the results of this inspection with Ms. M. Lacal, Senior Vice President, Regulatory and Oversight, and other members of your staff. The results of this inspection are documented in the enclosed report.

The NRC inspection team reviewed the stations corrective action program and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems and to confirm that the station was complying with NRC regulations and licensee standards for corrective action programs. Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.

The team also evaluated the stations processes for use of industry and NRC operating experience information and the effectiveness of the stations audits and self-assessments.

Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.

Finally the team reviewed the stations programs to establish and maintain a safety-conscious work environment and interviewed station personnel to evaluate the effectiveness of these programs. Based on the teams observations and the results of these interviews, the team found no evidence of challenges to your organizations safety-conscious work environment.

Palo Verde Nuclear Generating Station employees appeared willing to raise nuclear safety concerns through at least one of the several means available.

The NRC inspectors documented one finding of very low safety significance (Green) in this report, which involved a violation of NRC requirements. Additionally, the team documented two licensee-identified violations that were determined to be of very low safety significance. The NRC is treating these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.

If you contest these violations or their significance, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the Palo Verde Nuclear Generating Station.

Likewise, if you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the Palo Verde Nuclear Generating Station.

This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA Gerond George Acting for/

Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety

Docket Nos. 50-528, 50-529, and 50-530 License Nos. NPF-41, NPF-51, and NPF-74

Enclosure:

Inspection Report 05000528/2018008, 05000529/2018008, and 05000530/2018008 w/ attachment: Information Requests

Enclosure U.S. NUCLEAR REGULATORY COMMISSION

Inspection Report

Docket Number(s):

05000528, 05000529, 05000530

License Number(s):

NPF-41, NPF-51, NPF-74

Report Number(s):

05000528/2018008, 05000529/2018008, and 05000530/2018008

Enterprise Identifier: I-2018-008-0001

Licensee:

Arizona Public Service Company

Facility:

Palo Verde Nuclear Generating Station

Location:

Tonopah, Arizona

Inspection Dates:

August 27, 2018, to September 14, 2018

Inspectors:

E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead)

P. Jayroe, Reactor Inspector

G. Kolcum, Sr. Resident Inspector

D. Reinert, Resident Inspector

Approved By:

Geoffrey B. Miller, Team Leader

Inspection Program and Assessment Team

Division of Reactor Safety

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Palo Verde Nuclear Generating Station, Units 1, 2, and 3, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. A licensee-identified non-cited violation is discussed in report section 7115

List of Findings and Violations

Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Aspect Report Section Mitigating Systems Green NCV 05000528, 05000529,05000530/2018008-01 Closed H.12 71152Problem Identification and Resolution The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50,

Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct the failures of multiple control room hand-switch operator knobs.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs)in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html.

Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The team reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

OTHER ACTIVITIES - BASELINE

71152Problem Identification and Resolution Biennial Team Inspection

The team performed a biennial assessment of the licensees corrective action program (CAP),use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below.

(1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports and associated records, and an in-depth 5-year review of condition reports associated with the safety injection and shutdown cooling systems.
(2) Operating Experience, Self-Assessments, and Audits - The team evaluated the stations processes for use of industry and NRC operating experience. The team also evaluated the effectiveness of the stations audits and self-assessments program by reviewing a sample of nine self-assessments (benchmark, simple, formal departmental) and seven audits.
(3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, engineering, organizational effectiveness and performance improvement, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey.

71153Follow-up of Events and Notices of Enforcement Discretion Licensee Event Reports

The team evaluated licensee event report (LER) 05000528/2018-002: Condition Prohibited by Technical Specification for Inoperable Excore Instrument Channel (ADAMS Accession Number ML18130A986). The team reviewed two licensee-identified non-cited violations associated with the LER, described in the inspection results below.

INSPECTION RESULTS

- OBSERVATIONS/ASSESSMENT

Corrective Action Program Assessment 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems was adequate to support nuclear safety, though some challenges were noted. In particular, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues. These are described in observations, findings, and violations below.

Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues was adequate to support nuclear safety. The licensee continues to work to improve management oversight of the corrective action program, which has been consistently identified as an area for improvement by both third party and internal reviews. The team noted that the licensees actions appear to have improved management oversight, including improvements to quality and consistency of evaluation products through enhanced CARB oversight, and the addition of new tools for scoping the evaluation. However, these actions were too recently completed for the team to determine whether they have been fully successful. Additionally, the team noted that while individual problems were generally fixed, the licensee did not always expand evaluations to determine the cause or aggregate impact of multiple similar conditions. Examples are discussed below.

Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of conditions adverse to quality that were classified as nonconformances, this is discussed below as a minor violation.

Observations on the Corrective Action Program 71152Problem Identification and Resolution The team reviewed the engineering design change process and impact review process, and found it to be adequate and in line with industry standards. The team also screened a sample of condition reports that originated over the past 2 years and found several examples of misses tied to the design change process and impact reviews where the required updates to documentation were not completed or were incorrect. Personnel interviewed by the team indicated that these misses were sometimes identified by workers being unable to perform work activities as directed by work orders or unable to draft clearance orders due to incorrect drawings. In all examples reviewed by the team, the licensee revised or updated affected documentation after the condition report was written; however the team did not note any significant efforts to evaluate or improve the engineering design change impact review process. The team reviewed the stations use of trend codes to track these examples and identified several instances where expected trend codes were incorrectly applied or not applied at all. One particular trend code (CM 3.10) is applied to condition reports which are created in advance or just recently after a plant modification to create a tracking item for required updates to various documents; the team noted examples of documentation revisions tied to legacy modifications lumped in under this trend code. Liberal use of this particular trend code in coincidence with restricted use of more applicable trend codes may be masking potential trends in documentation revisions missed by the impact review process. The licensee documented this observation in Condition Report 18-14427.

The team observed that the licensees condition report classification committees (the Screening Committee and the Condition Review Group) did not always consistently apply the corrective action program (CAP) definitions of condition adverse to quality (CAQ) and non-condition adverse to quality. In particular, a lack of guidance or familiarity in what constituted an adverse trend in a quality process CAQ versus a potential adverse trend (non-condition adverse to quality until evaluated and confirmed) led to inconsistency in classification of condition reports documenting aggregate issues. The licensee documented this observation in Condition Reports 18-13648 and 18-14334.

Additionally, some identified deficiencies in quality programs were classified as non-condition adverse to quality. For example, on January 2, 2018, the licensees organizational effectiveness department issued a Corrective Action Program Elevation Letter, which identified, inconsistent identification of issues entered into the condition reporting process, CAP product quality decline, inappropriate closure of CAP actions, and rejection of CAP products including causal evaluation. The condition report associated with this letter, Condition Report 18-00055, was classified as non-condition adverse to quality. In procedure 01DP-0AP12, Condition Reporting Process the licensee defines CAQ to include, failures to comply with procedures that implement the current licensing basis (CLB), where CLB is defined to include both 10 CFR Part 50 and the licensees quality assurance program, both of which contain requirements implemented by CAP. In these examples and others reviewed by the team, the conditions adverse to quality were timely addressed, even when classified as non-condition adverse to quality. Therefore there was no violation of NRC regulations. The licensee documented this issue in Condition Report 18-13739.

Assessment of Use of Operating Experience 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analysis and apparent cause evaluations. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs.

Self-Assessments and Audits Assessment 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that station performance in these areas adequately supported nuclear safety. Generally, self-assessments and audits were effective at identifying deficiencies and enhancements. In all cases, deficiencies were documented in condition reports for both self-assessments and audits. Audits, in particular, were highly effective in identifying and documenting deficiencies. One self-assessment (16-10139) did not appear to have a tracking item (i.e. condition report) for an enhancement.

Safety-Conscious Work Environment Assessment 71152Problem Identification and Resolution The team found no evidence of challenges to the safety-conscious work environment of station work groups. Individuals appeared willing to raise nuclear safety concerns through at least one of the several means available.

INSPECTION RESULTS

- ISSUES/FINDINGS

Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to promptly identify and correct conditions adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI.

The team identified a backlog of conditions adverse to quality that the licensee had failed to timely correct. The oldest of these conditions was approximately 10 years old, with several hundred having been identified at least two operating cycles prior to the inspection. The team determined that the licensee was appropriately addressing degraded components that had an impact on safety or security, but was not always tracking or timely correcting nonconformances with its design bases in cases where these nonconformances had been assessed as not impacting safety-related functions. Further, the licensee was unable to initially determine the scope of its nonconformance backlog. The licensee documented this deficiency as Condition Reports 18-13549 and 18-14426.

Screening: The performance deficiency was minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.

Enforcement:

This failure to comply with 10 CFR 50, Appendix B, Criterion XVI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.

Minor Violation 71152Problem Identification and Resolution Performance Deficiency: Failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR 50, Appendix B, Criterion VI.

The team identified that the CAP procedure directed the use of the Cause Analysis Manual in performing some cause evaluations. This cause evaluation process is an activity affecting quality required by 10 CFR 50, Appendix B and the licensees Quality Assurance Program.

The licensee failed to control the Cause Analysis Manual in accordance with the Palo Verde Nuclear Generating Station Operations Quality Assurance Program Description, Revision 0, Section 2.6, Document Control. The licensee documented this violation in Condition Report 18-13996.

Screening: The performance deficiency is minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.

Enforcement:

This failure to comply with 10 CFR 50, Appendix B, Criterion VI constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.

Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

Violation: 10 CFR Part 50, Appendix B, Criterion V requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.

Contrary to the above, on May 24, 2007, the licensee failed to perform the installation of the Unit 1, channel C excore nuclear instrument preamplifier connection, an activity affecting quality, in accordance with these instructions, procedures, or drawings. The licensee determined that a human performance error occurred during the performance of the 2007 work order which explicitly stated that the o-rings were required for environmental qualification. As a result, the excore detector would not have performed its safety function during a design basis main steam line break.

Significance/Severity Level: The team determined this finding was of very low safety significance (Green) because a minimum of two excore detector channels always remained available to trip the reactor during a main steam line break. Redundant channels were not affected and were available to perform the required safety function to trip the reactor.

Corrective Action Reference(s): Condition Report 18-12217 Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

Violation: 10 CFR 50.73(a)(2)(i)(B) requires, in part, that the holder of an operating license shall submit an licensee event report within 60 days of discovery of the event, which includes any operation or condition which was prohibited by technical specifications.

Contrary to the above, the licensee failed to submit a licensee event report within 60 days of April 23, 2016, after discovering that the Unit 1 channel C excore was in a condition which was prohibited by technical specifications. The detector was found in a configuration without o-rings at two electrical connection interfaces. Condition Report 16-06735 documented the non-conforming condition, but was closed without performing a reportability review.

Significance/Severity Level: This violation was considered as traditional enforcement because the failure to notify the NRC had the potential for impacting the NRCs ability to perform its regulatory function. Consistent with the guidance in Section 6.9, Paragraph d.9, of the NRC Enforcement Policy, the failure to report the condition prohibited by technical specifications was determined to be a Severity Level IV violation.

Corrective Action Reference(s): Condition Report 18-02569

Non-Cited Violation (NCV): Inadequate Corrective Actions For Missing Control Room Hand-Switch Operator Knobs Cornerstone Significance Cross-cutting Aspect Report Section Mitigating Systems Green NCV 05000528; 05000529;05000530/2018008-01 Closed None 71152Problem Identification and Resolution The team reviewed a Green, NRC identified, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action for failure to promptly correct a condition adverse to quality. Specifically, since October 30, 2014, the licensee failed to implement prompt corrective actions to correct an adverse condition related to the failure of control room hand-switch operator knobs.

Description:

While performing control room observations on August 28, 2018, the team identified that various control room hand-switches were missing operator knobs. The control room switches are Coordinated Manual Controls 910 series currently manufactured and supported by Senasys. The switches are operated by turning the selector knob, which rotates a cam at the end of the knob shaft, pushing a set of plungers which will make or break electrical contact continuity within the contact block. The primary purpose of the knob is to allow operators to change the status of equipment in the plant.

The team identified a total of eighteen missing operator knobs among the three unit control rooms. Fourteen of these controlled safety-related, technical specification (TS)-related, or emergency operating procedure (EOP)-related components:1

Broken switches Number safety-related Number TS-related Number EOP-related Oldest Unit 1

2 October 30, 2014 Unit 2

2 October 18, 2015 Unit 3

2 April 27, 2018 Total

The licensee had provided one or two spare operator knobs in each control room that could be used to operate a hand-switch when necessary during routine, alarm, abnormal, or emergency events. However, the licensee had performed no formal evaluation of the use of these spare knobs as a compensatory action or of the aggregate impact to each control room during off-normal or emergency scenarios. The licensee did not control the spare knobs despite having dedicated them as basic components for use in safety-related applications. All equivalent knobs in the plant reference simulators were intact. The licensee did not model or brief this discrepancy between the simulator and the plant during training scenarios. Neither did the licensee list the missing knobs on the simulator differences list or evaluate the missing knobs in the overall simulator program of maintenance, testing, and correction of discrepancies with the actual plant.

Corrective Action(s): As an immediate corrective action, the licensee provided five additional knobs for each control room and provided a formal communication to control room staff regarding their use.

Corrective Action Reference(s): Condition Reports 18-13575 and 18-14201.

Performance Assessment:

Performance Deficiency: The failure to promptly identify and correct a condition adverse to quality related to the failure of control room hand-switch operator knobs as required by 10 CFR 50, Appendix B, Criterion XVI was a performance deficiency.

Screening: The performance deficiency was more than minor, and therefore a finding, because it affected the configuration control attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Since October 30, 2014, the licensee had failed to implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control rooms of all three units.

Significance: The team performed the initial significance determination using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.

1 Four of the eighteen switches met none of these criteria, though one of those four controlled a breaker that was included in the probabilistic risk model. The other fourteen switches variously met one or more of the criteria. Because of this overlap, the numbers in the table to not sum horizontally.

Cross Cutting Aspect: This finding had a cross-cutting aspect in the area of human performance, avoid complacency, in that the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee did not implement prompt corrective actions to correct an adverse condition of broken operator knobs in the control room (H.12).

Enforcement:

Violation: Title 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.

Contrary to this requirement, the licensee failed to assure that conditions adverse to quality were promptly corrected. Specifically, since October 30, 2014, the licensee failed to correct a condition adverse to quality related to broken operator knobs in the control room, to which 10 CFR Part 50, Appendix B, applies. Consequently, the licensees failure to implement prompt corrective actions to correct an adverse condition related to the broken operator knobs in the control room resulted in not returning the switch to the vendor drawing configuration and specifications.

Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.

Licensee Event Report (Closed)

Condition Prohibited by Technical Specifications for an Inoperable Excore Instrument Channel (LER 05000528/2018-002)71153 Follow-up of Events and Notices of Enforcement Discretion

EXIT MEETINGS AND DEBRIEFS

On September 14, 2018, the team presented the inspection results to Ms. M. Lacal, Senior Vice President, Regulatory & Oversight, and other members of the licensee staff. The team confirmed that any proprietary or sensitive information reviewed was controlled to protect from public disclosure.

DOCUMENTS REVIEWED

Condition Reports

10-00424

16-04624

17-12748

18-00837

18-06960

16-19560

2-00391

16-04625

17-13751

18-00869

18-07751

16-19864

13-00349

16-04628

17-13780

18-01277

16-13267

16-20048

13-00736

16-04646

17-14018

18-01512

16-13529

16-20333

14-01375

17-08432

17-14219

18-01657

16-13896

16-20383

14-01904

17-08633

17-14504

18-01685

16-14370

16-20395

14-02854

17-08634

17-15012

18-01702

16-14791

18-12743

15-02470

17-08636

17-15793

18-01737

16-14896

18-13345

15-02897

17-08672

17-16181

16-10666

16-15709

18-13446

15-06128

17-08818

17-16495

16-10742

16-16024

18-13575

15-07118

17-09022

17-16497

16-11578

16-16585

18-13996

16-03489

17-09222

17-16552

16-11605

16-16995

18-14126

16-03566

17-09257

17-16563

16-12160

18-07903

18-14201

16-03843

17-09326

17-17371

16-12430

18-07964

18-14212

16-03914

17-09336

16-07329

16-12465

18-08156

18-14215

16-04598

17-09524

16-07589

16-12783

18-08409

18-14218

17-16181

17-09656

16-07632

16-12797

18-08466

18-14222

17-16495

17-10518

16-08413

16-13128

18-08815

18-14223

17-16497

17-11997

16-09123

18-02462

18-09130

18-14224

17-16552

17-12205

16-09548

18-02960

18-09679

18-14226

17-16563

16-04677

16-09997

18-03038

18-10024

18-14372

17-17371

16-04977

16-10139

18-03154

18-10995

17-17791

16-04980

16-10173

18-03173

18-11453

17-17965

16-04982

16-10185

18-03177

18-12086

17-18155

16-04984

17-17791

18-03346

18-12157

18-00055

16-05436

17-17965

18-04528

18-12174

15-07118

16-05926

17-18155

18-04994

18-12217

16-03489

16-05966

18-00055

18-05015

18-12423

16-03566

16-06026

18-00055

18-05879

16-18951

16-03843

16-06578

18-00086

18-06317

16-19295

16-03914

17-12265

18-00194

18-06774

16-19296

16-04598

17-12466

18-00202

18-06912

16-19554

Plus approximately 100 anonymous condition reports initiated between January 1, 2018, and

August 7, 2018, and the text of most of the several hundred condition reports issued while the

team was on site.

Work Orders

24481

4340548

4616104

4699032

4842349

4316976

4412917

4699031

4699034

4857178

Audit Reports

2016-007

2016-010

2017-009

2018-003

2016-009

2017-003

2018-002

Procedures

Number

Title

Revision

01DP-0AP01

Procedure Process

01DP-0AP12

Condition Reporting Process

23, 24, 29, 30

01DP-0AP22

Procedure Writers Guide

01DP-0AP58-01

Trend Analysis and Coding Administrative Guideline

2DP-0AP01

Plant Review Board

2DP-0MC08,

Control of Purchasing Material and Equipment

5DP-0CC05

Simulator Instructors Guide and Reporting

15DP-0TR08

Systematic Approach to Training

30DP-0AC02

Station Rework Reduction

30DP-0WM15

Fix-It-Now Multi-Discipline Team

31MT-9SI02

High Pressure Safety Injection Pump Disassembly,

Examination, and Assembly

40AL-9RK6A

Panel B06A Alarm Responses

40AO-9ZZ21

Acts of Nature

40DP-9OP15

Operator Challenges and Discrepancy Tracking

40DP-9OP20

Watch Standing Practices

40DP-9OP26

Operations Condition Reporting Process and Operability

Determination / Functional Assessment

40DP-9OP33

Shift Turnover

40DP-9WP01

Operations Processing of Work Orders

40DP-9ZZ04

Time Critical Action (TCA) Program

40OP-9AF02

Non-Essential Auxiliary Feedwater Pump Operation

40OP-9CH03

RCP Seal Injection System

60DP-0QQ02

Trend Analysis and Coding

65DP-0QQ01

Industry Operating Experience Review

73TD-0ZZ03

System Engineering Handbook

75RP-9RP20

Use and Control of HEPA Filtration and Vacuum

Equipment

81DP-0EE10

Design Change Process

Procedures

Number

Title

Revision

93DP-0LC18

Part 21 Reporting Process

Miscellaneous

Documents

Number

Title

Revision

or Date

2018 PVNGS Condition Reports CRG Refuse Back to

SC Rate / Through Rate Performance

August 27, 2018

Active Night Orders

August 10, 2017

Active Standing Orders

August 10, 2017

Control Room Discrepancies

August 10, 2017

Open Operator Burdens

August 10, 2017

Operations Challenges List

August 10, 2017

Operator Work Arounds

August 10, 2017

Organizational Effectiveness Monthly Performance

Summary: 2018 1st Quarter

March 2018

Organizational Effectiveness Quarterly Performance

Summary

2nd Quarter

2018

PRB Meeting Minutes: Monthly PRB (October 2017)

and U1R20 Refueling Outage Restart

Oct 31, 2017

PRB Monthly and U2R20 Startup Meeting Minutes

April 28, 2017

PVNGS Operations Quality Assurance Program

Description (QAPD)

0, 0a

Simulator to Unit Differences

August 22, 2018

Training Slides: Introduction to Cause Analysis

November 16,

2016

13-NS-C088

Mission Time Study

Design Equivalent

Change 00462

Containment Construction Vent Concrete Cover Rework

and Design Drawing Detail Revision

Drawing 12-E-

2YU-009

Diesel Storage Tank Conduit Plan & Section

NLR17C030201

Licensed Operator Continuing Training

April 5, 2017

INFORMATION REQUESTS

ML18291A562

SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002

By: EAR Yes No

Publicly Available Sensitive

OFFICE

RI/IPAT

SRI/PBA

RI/PBD

C/PBD

SRI/IPAT

TL/IPAT

NAME

PJayroe

GKolcum

DReinert

NOKeefe

ERuesch

GMiller

SIGNATURE

/RA-e/

/RA-e/

/RA-e/

/RA/

/RA/

/RA GAG for/

DATE

9/21/2018

9/21/2018

9/21/2018

10/16/2018

10/16/2018

10/16/2018