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| number = ML063250343 | | number = ML063250343 | ||
| issue date = 11/14/2006 | | issue date = 11/14/2006 | ||
| title = | | title = APS Response to NRC Inspection Report 05000528-06-011, 05000529-06-011, & 05000530-06-011 | ||
| author name = Levine J M | | author name = Levine J M | ||
| author affiliation = Arizona Public Service Co | | author affiliation = Arizona Public Service Co |
Revision as of 15:40, 10 February 2019
ML063250343 | |
Person / Time | |
---|---|
Site: | Palo Verde |
Issue date: | 11/14/2006 |
From: | Levine J M Arizona Public Service Co |
To: | Document Control Desk, NRC Region 4 |
References | |
102-05593-JML/SAB/JAP/DFH, EA-06-221, IR-06-011 | |
Download: ML063250343 (29) | |
See also: IR 05000528/2006011
Text
A-- A subsidiary
of Pinnacle West Capital Corporation
James M. Levine Mail Station 7602 Palo Verde Nuclear Executive
Vice President
Tel (623) 393-5300 PO Box 52034 Generating
Station Generation
Fax (623) 393-6077 Phoenix, Arizona 85072-2034
102-05593-J
ML/SAB/JAP/DFH
November 14, 2006 U.S. Nuclear Regulatory
Commission
ATTN: Document Control Desk Washington, DC 20555 Dear Sir: Subject: Palo Verde Nuclear Generating
Station (PVNGS)Units 1, 2 and 3 Docket Nos. STN 50-528, 50-529, and 50-530 APS Response to NRC Inspection
Report 05000528/2006011;
EA 06-221 In NRC Special Inspection
Report, dated September
28, 2006, the NRC indicated
that APS failed to recognize
that improper chemistry
controls for the spray pond systems in all three units caused degraded performance
over a period of years. The report discusses
a finding that may have a greater than very low safety significance.
APS has reviewed the NRC Inspection
Report and has no substantive
disagreement
with the facts as documented
in the report.In accordance
with the Inspection
Manual Chapter 0609, the NRC is currently evaluating
the safety significance
of the finding. At a November 20, 2006 Regulatory
Conference
in Arlington, Texas, APS will provide the NRC its perspective
on the facts and analytical
assumptions
relevant to determining
the safety significance
of the finding.Regardless
of the ultimate significance
of the finding, APS takes this matter seriously.
We have implemented
immediate
actions to assure the system remains within the design basis, have implemented
or planned additional
actions to prevent recurrence, and have considered
this issue in light of our ongoing improvement
plans.The purpose of this letter is to provide the results of APS' evaluation
of the spray pond issue in advance of the Regulatory
Conference
to assure the NRC that APS recognizes
the programmatic
and organizational
implications
of this matter. APS is providing
this information
to facilitate
a focused discussion
at the conference
on the safety significance
of the spray pond degraded performance.
U.S. Nuclear Regulatory
Commission
ATTN: Document Control Desk APS Response to NRC Inspection
Report 05000528/2006011;
EA 06-221 Page 2 Enclosure
1 to this letter contains a summary of APS' evaluation
and how APS considered
the results in the context of other ongoing corrective
actions. Enclosure
1 also includes an APS response to the five apparent violations
related to the potentially
greater than green finding.Finally, the non-cited
violations
described
in the Inspection
Report are not addressed
in this submittal
because APS agrees with the violations
which have been entered into, and will be resolved in the corrective
action program.APS noted some minor corrections
for the subject Inspection
Report and is submitting
Enclosure
2 for completeness.
The actions described
in Enclosure
1 represent
corrective
actions and are not regulatory
commitments.
There are no regulatory
commitments
in this letter.If you have any questions, please contact James A. Proctor at (623) 393-5730.Sincerely, JML/SAB/JAP/DFH/gt
Enclosures:
1. Summary of APS Investigation
and Corrective
Actions 2. Corrections
to NRC Inspection
Report cc: B. S. Mallett NRC Region IV Regional Administrator
M. B. Fields NRC NRR Project Manager G. G. Warnick NRC Senior Resident Inspector
for PVNGS
ENCLOSURE
1 Summary of APS Investigation
Into Loss of Thermal Performance
of the Essential
Cooling Water (EW)And Emergency
Diesel Generator (EDG) Intercooler
Heat Exchangers, And Corrective
Actions I. Introduction
On March 30, 2006 Arizona Public Service Company (APS) met with the NRC to discuss progress of the comprehensive
integrated
improvement
plan, which addresses performance
issues at the Palo Verde Nuclear Generating
Station (PVNGS). APS outlined the elements of its Performance
Improvement
Plan (PIP), and how, as part of that plan, APS management
is monitoring
performance
and adjusting
its improvement
initiatives, as appropriate.
APS has considered
and incorporated
in its PIP the organizational
issues resulting
from its review of the Recirculation
Actuation
Signal (RAS) Sump Event, the substantive
cross-cutting
issues in Problem Identification
and Resolution (PI&R) and Human Performance (HU), and other indicators
of performance.
A separate, stand-alone
95002 action plan was developed
to address the issues directly related to the YELLOW finding for the RAS.APS recognizes
that its corrective
actions for the 95002 action plan as well as the PIP have not yet resulted in the desired improved performance.
As a result, APS recently set forth to revise the 95002 action plan to include additional
corrective
actions to address the remaining
issues; particularly, improving
the adequacy of technical
rigor, reinforcement
of a questioning
attitude among personnel, and improving
metrics to better measure performance.
APS has similarly
set forth to revise the PIP to include further corrective
actions to address the two substantive
cross-cutting
issues (i.e., PI&R and HU).Recognizing
that the actions that have been taken have not been fully effective, a more rigorous approach has been adopted for developing
the revision to the 95002 action plan and PIP. The approach includes development
of problem statements
and comparing
these to the actions previously
taken. From an understanding
of the shortcomings
of those previous actions, additional
actions to be taken will be identified.
In order to monitor the effectiveness
of the actions, a more rigorous approach will be applied to establishing
the appropriate
metrics. First the intent of the metric will be defined. From this the criteria to be used for populating
the metric will be established
and the data sources will be identified.
The metrics will then be developed
and populated
with the appropriate
data.This enhanced approach has been applied to the 95002 action plan and is being applied to the PIP action plans for the substantive
cross-cutting
issues. These three revised action plans will be submitted
to the NRC by December 15, 2006. This revised approach is also being applied to the three other focus areas of the PIP, namely leadership, accountability
and standards.
1
In Section II of this enclosure, APS sets forth corrective
actions to address the SP root and contributing
causes. However, APS did not limit its considerations
of appropriate
corrective
actions to the SP; rather, APS considered
the broader implications
of the root cause investigation.
Specifically, many of the root and contributing
causes identified
in the spray pond event are substantially
the same as those identified
in the RAS sump event and other self-assessments
APS has conducted.
For example, root cause three and contributing
cause two (personnel
failed to effectively
identify problems, and missed numerous opportunities
to resolve the foulant problem);
contributing
cause six (personnel
did not always exhibit a sufficiently
questioning
attitude);
and contributing
cause seven (personnel
did not apply appropriate
technical
rigor in their evaluations)
reflect the very performance
deficiencies
that the aforementioned
action plans are designed to correct. For this reason, the investigation
relies, in part, on the established
corrective
actions in the revised 95002 and PIP action plans.The purpose of this enclosure
is to summarize
APS' investigation, to describe the corrective
actions, and to summarize
further corrective
actions, particularly
in response to the five apparent violations
related to the NRC's potentially
greater than green finding.This enclosure
does not address APS' position on the significance
of the NRC finding, as that will be the subject of a Regulatory
Conference
between APS and the NRC on November 20, 2006.I.A. Summary of Key Events Leading to Identification
of Possible Degraded Performance
The spray pond (SP) system is the ultimate safety-related
heat sink and is an open water, standby cooling system. The key safety functions
for the SP system are heat removal and maintenance
of vital auxiliaries.
The primary function of the SP system is to remove heat from all essential
components
required for normal and emergency shutdown of the plant. The SP system also provides cooling to the Emergency
Diesel Generators (EDG), which is an essential
function, necessary
for a reliable source of on-site AC electrical
power.The design bases for the SP system assume that the system will function for 26 days without makeup water, losing approximately
85% of its original volume of water to evaporation
and drift.During the mid-1 990s, APS initiated
monitoring
of performance
of the Essential
Cooling Water (EW) heat exchangers
in part due to NRC and industry initiatives, such as Generic Letter (GL) 89-13, "Service Water System Problems Affecting
Safety-Related
Equipment." EW thermal performance
is monitored
and reported as a percent of the design value, which includes the capability
to remove assumed design heat loads, with bounding coolant conditions
and with an industry standard for service fouling. As manufactured, the performance
capability
of the EW heat exchangers
for new conditions
is greater than the design value. A margin of 0% reflects performance
at the 2
design value, including
the service fouled condition.
Positive margin reflects heat exchanger
performance
above the design value. Negative margin does not necessarily
reflect an inability
to perform its safety function.
This is because actual heat removal conditions (e.g., coolant temperatures, environmental, actual heat loads) are typically less severe than the assumed bounding design conditions.
In 1994, zinc-phosphate
treatment
was introduced
into the SP system to mitigate internal piping corrosion
caused by small localized
failures of the internal coating, specifically
in underground
spray pond piping. Leaks detected in EW heat exchanger tubes and inspection
of spray pond piping internals
promoted greater attention
to corrosion
control.In the spring of 1995, there was a release of corrosion
nodules that caused limited blockage of EDG heat exchanger
tubes. APS performed
additional
inspections
to assess the extent of condition.
After the initial release of corrosion
nodules, the amount quickly subsided and has remained within the inspection
acceptance
criteria established
as a result of this event. This condition
was documented
in Licensee Event Report 05000528/1995-005-00.
In the late 1990s, APS first identified
fouling of EDG intercoolers
through trending of diesel intake temperatures.
There were losses of EDG intercooler
performance
and visual inspection
of all EDG heat exchangers
revealed a white film, generally
associated
with the zinc-phosphate
chemical treatment.
The Palo Verde maintenance
team addressed
this issue by mechanical
cleaning initially, and followed this with a chemical cleaning process in 2001. During the time period from 1995 to 2001, APS identified
no visual fouling in the EW heat exchangers.
In 2001, Palo Verde changed chemical vendors to GE-Betz from Calgon. Prior to 2001, the dispersant
used for the essential
spray ponds was Calgon PCL-401. In 2001, GE-Betz provided Palo Verde with a dispersant (HPS-1) that GE-Betz personnel
asserted to be equivalent
to the Calgon product.In the Spring 2002 Unit 2 refueling
outage, APS identified
the first negative thermal performance
margin of any EW heat exchanger.
Data collected
during the refueling outage on the EW B heat exchanger
was analyzed and determined
to be negative 9.5%.In September
2002, a low margin (positive
3.6%) was measured on Unit 1 EW B heat exchanger.
In April 2003 Unit 3 EW A thermal performance
was measured at a negative 22%margin.In September
2003, the Unit 2 EW A heat exchanger
exhibited
a 1% margin, before cleaning.3
In November 2003, APS initiated
corrective
action based on a loss of thermal margin in all 3 units' EW heat exchangers.
APS concluded
that the EW heat exchangers
were fouling due to a reaction between the new dispersant (HPS-1) and the non-oxidizing
biocide used to control algae growth. APS concluded, at that time, that these two chemicals
were reacting to form a polymer, thus fouling the heat exchangers.
During the course of APS' current investigation, the investigation
team determined
that this conclusion
was incorrect.
In March 2004, the Chemistry
department
began using a new dispersant (DN2317), which was acquired from the vendor, GE-Betz. The new dispersant
was used to address the increase in fouling rate that had been concluded
to be associated
with the interaction
of the HPS-1 dispersant
and biocide.Immediately
following
the change in dispersant
the thermal performance
of the EW heat exchangers
improved, further supporting
the incorrect
conclusion
regarding
the previous dispersant.
Because the new dispersant
was not directly measurable, a molybdenum
tracer had been added to the dispersant
to allow detection
and to provide an indirect correlation
to the amount of dispersant
available
in the ponds. However, there was a difference
in the consumption
rate of the dispersant, and the molybdenum.
Over time, the molybdenum
tracer provided a false indication
that sufficient
levels of dispersant
were present in the ponds. Consequently, no dispersant
was added for an extended period of time.As a result, in October of 2005, when Unit 1 was in a refueling
outage and Unit 2 and 3 were in forced shutdowns, a loss in thermal performance
margin was identified
indicating
that the fouling rate had increased.
Unit 1 and 3 EW heat exchangers
were cleaned during their refueling
outages (Fall 2005 for Unit 1 and Spring 2006 for Unit 3).When it was projected
that the rate of fouling would not support Unit 2 EW function during the summer of 2006, both Unit 2 EW heat exchangers
were cleaned during online equipment
maintenance
outages.I.B. APS Identification
of Possible Degraded Performance
and Initiation
of an Investigation
Team On May 17, 2006, APS identified
that the EDG 2B intake air temperature
was higher than the maximum limits specified
in the data collection
logs. APS declared the EDG inoperable
on May 19, 2006 and inspected
and cleaned the intercooler.
At that time, APS took immediate
corrective
actions to clean the intercoolers
on all six EDGs and inspect the EDG Jacket Water (JW) and Lube Oil (LO) heat exchangers
in Unit 1. Unit 1 EW heat exchangers
were also re-cleaned
prior to the summer.As a result of these issues, APS initiated
an investigation
team that consisted
of individuals
from the Chemistry
Department (Palo Verde and APS Corporate
Chemistry), Engineering
Department, Performance
Improvement
Team members with plant operations
experience, and industry consultants.
The scope of the investigation
included a review of all heat exchangers
that are cooled by spray pond water and 4
addressed
the lack of dispersant
control for the SP from approximately
March of 2004 until June of 2005. The investigation
team evaluated
both past and current plant documents
including
sampling results, reviewed industry information, obtained independent
analysis of foulant samples and conducted
limited inspections
of the system to support their investigation
and to draw their conclusions.
The next section summarizes
the results of the investigation
team, the causal analysis results and APS' corrective
actions. Subsequent
to this effort, APS has reviewed, along with EPRI and other experts, the safety significance
of these issues. As indicated
in the cover letter, APS will provide its perspective
on the safety significance
of this matter during the November 20, 2006 Regulatory
Conference.
II. Results, Causal Analysis and Corrective
Actions II.A. Direct Cause and Extent of Condition II.A.1 Direct Cause The direct cause of the loss of thermal performance
from the EDG intercooler
and EW heat exchangers
was the formation
of an insulating
precipitant
on the SP side of the heat exchanger
surfaces.This precipitant, calcium-zinc-phosphate, formed when the chemical constituents
were present in sufficient
concentrations
and the control factors (i.e., pH and dispersant)
were not adequately
controlled.
II.A.2 Extent of Condition APS took a broad perspective
in considering
the extent of condition
and assessed the plant heat transfer systems, beginning
with components
of the essential
spray system.Three types of foulant were identified
during the investigation:
zinc-hydroxide
film, scale (calcium-phosphate
or calcium carbonate)
and precipitant (calcium-zinc-phosphate).
Other Spray Pond Heat Exchangers
In addition to the EDG intercoolers
and the EW heat exchangers, three other heat exchangers
on the EDGs are cooled by the SP system.EDG Jacket Water and Lube Oil Coolers The EDG JW and LO heat exchangers
were less susceptible
to fouling than the EDG intercooler
or EW heat exchanger.
It was not possible to quantify the amount of thermal performance
loss in the EDG JW and LO coolers by calculational
methods; but, it was determined
there was ample margin to respond to a DBA and cope with minor degrees of fouling based on the following:
5
- Less precipitant
existed in the EDG JW and LO heat exchangers
than the EDG intercooler
and EW heat exchangers.
- Original tube plugging design margin remains intact.* Performance
monitoring
provides assurance
that the thermostatic
control valves, which regulate temperature, are functioning
within their setpoint band.* Assuming full load and peak Design Basis Accident (DBA) spray pond temperatures, should any thermostatic
valve reach its full open position, there is additional
margin beyond the limit of the thermostatic
valve to the manufacturer's
operating
limit." Loads will be less than the design values when peak SP temperature
occurs.EDG Fuel Oil Coolers The fuel oil heat exchanger
was supplied as original equipment
on the EDG. It is a carry-over
from earlier diesel models, with an original purpose to support extended idle, no-load, operation.
The fuel oil piping system recirculates
excess fuel oil to the suction of the fuel oil transfer pump, which heats the fuel oil by pump heat. The fuel oil cooler was intended to prevent fuel oil from overheating
during extended no-load operation.
The fuel consumption
of a KSV-20 at no-load is sufficient
to preclude the need for cooling; therefore, EDG safety functions
would not have been impacted by a loss of thermal performance
in the EDG Fuel Oil cooler.Potential
for SP Foulant to Manifest as Scale Another immediate
concern was that with the presence of the constituents
in sufficient
amounts to form a precipitant
there was a possibility
that the chemical constituents
may also form scale. Scale has a crystalline
structure, tenaciously
adheres to surfaces, and has an increased
likelihood
of forming with rising temperature, because scale forming constituents
become more insoluble.
The corrective
actions to establish
correct chemistry
control in the spray ponds address the precipitant
and also resolve the propensity
to form scale. Additionally, an analysis was performed
by the Electric Power Research Institute (EPRI) on APS'behalf to assess the possibility
and extent of scale formation
in light of the concentration
of chemical constituents
during the period in question.
The results of this analysis predict a minor amount of scale formation
under DBA conditions.
The results of the aggregate
impacts of the precipitant
and scaling propensity
will be presented
at the November 20, 2006 Regulatory
Conference.
Applicability
to Other Open Cooling Water Systems The investigation
team also evaluated
the susceptibility
of other open cooling water systems to fouling problems.6
The SP fouling problem was viewed as being directly applicable
to the Circulating
Water (CW) System, which is also an open cooling water system. Unlike the SP system, the CW system is a continuously
operating
system and does not fulfill a safety function, but is relied upon for power operations.
It was concluded
there was no immediate
impact to CW but to ensure lessons learned from this event are considered
by the Water Reclamation
Facility (WRF) personnel
who maintain CW chemistry, the results of the evaluation
will be reviewed with WRF personnel
for lessons learned and technical
issues.Applicability
to Heat Exchangers
Addressed
by NRC Generic Letter 89-13 The EW and EDG heat exchangers
are within the scope of equipment
addressed
by GL 89-13. In view of the issues identified
with the spray pond it was concluded
an assessment
of GL 89-13 implementation
should be performed.
See corrective
actions to be taken in Section II.A.3 below.II.A.3. Corrective
Actions -Direct Cause and Extent of Condition Corrective
Actions Taken and Results Achieved The SP system chemistry
was corrected
as follows:* Dispersant
additions
were resumed in all spray ponds." Additional
acid was added to lower pH in all ponds." Feed and bleed was used to reduce calcium and phosphate
concentrations
in each spray pond.EW heat exchangers
were cleaned in all three units starting with the Unit 3 heat exchangers
in the spring 2006 refueling
outage.EDG intercoolers
were cleaned in all three units and a Standing Order was issued to increase the EDG test frequency
to assess intercooler
performance.
This standing order continued
through September
29, 2006. It was removed after APS gained confidence
that the immediate
corrective
actions were effective.
Procedure
40DP-9OP08, "Diesel Generator
Test Records," was revised to require a work order to be generated
to clean any EDG intercooler
if temperature
exceeds 120F, to ensure the system does not exceed its Design Basis Manual (DBM) limit of 130F.The SPs have been cleaned, facilitating
improved chemistry
control and accessibility
for inspections.
Additional
cleaning and inspection
activities
of the EDG and EW heat exchangers
have been scheduled
to ensure the effectiveness
of the completed
corrective
actions and to ensure there are no unintended
consequences
of the chemistry
changes.7
Corrective
Actions to Be Taken Modifications
will be installed
to add higher capacity acid and dispersant
pumps. (Due date: December 31, 2006).Systems Engineering
will conduct a self-assessment
of the SP systems to include NRC GL 89-13 and industry operating
experience
on service water systems. (Due date: February 28, 2007)II.B Five Root Causes Identified
The investigation
identified
the following
five Root Causes: " Root Cause #1: Inadequate
Chemistry
Control Program" Root Cause #2: Managed to Inadequate
Chemistry
Metrics" Root Cause #3: Inadequate
Resolution
of Performance
Problems* Root Cause #4: Management
Reliance on an Expert" Root Cause #5: Ineffective
Change Management
This section summarizes
each root cause and the associated
corrective
actions.II.B.1 Root Cause #1 and Corrective
Actions -Inadequate
Chemistry
Control Program The Palo Verde chemistry
control program for the SP system was ineffective.
The program used control ranges that were inadequate
for some parameters
and lacked other necessary
elements.Corrective
Actions and Results Achieved Procedure
74DP-9CY04, "System Chemistry
Specifications," was revised to establish control limits, sampling frequencies
and action levels that ensure the spray ponds are able to perform their specified
function in a DBA.The strategic
plan for SP Chemistry
Control was revised to include chemistry
control requirements
for fouling, corrosion
control, and biological
control.The dispersant
was changed to one that is directly measurable.
The Chemistry
Department
was trained in the direct, root and contributing
causes of the investigation.
Extent of Cause Corrective
Actions An assessment
of the chemistry
controls for closed cooling water systems is in progress. (Due date: November 30, 2006)8
A Chemistry
Design Basis Manual will be developed. (Due date: December 24, 2007)II.B.2 Root Cause #2 and Corrective
Actions -Managed to Inadequate
Chemistry Metrics A single metric, corrosion
rate, existed for the SP system, which had the unintended
affect of causing personnel
to make decisions
based on this metric and misunderstand
the health of the SP chemistry.
There was no metric for fouling.Corrective
Actions Taken and Results Achieved The Chemistry
Department
revised the performance
indicators
for the SP Chemistry Control Program to ensure measurable
targets are established
for corrosion, fouling, and biological
control.Corrective
Actions to Be Taken Training will be provided to the Chemistry
Technical
Advisors, their backups, and Chemistry
Supervision
on the indications
of fouling mechanisms
associated
with the chemicals
used in the SP system. The training will also include changes to the Chemistry
Management
Expectations
on Qualification, Validation
and Verification (QV&V) and technical
rigor. (Due date: November 21, 2006)The System Health Report for the SP system will be updated in the engineering
program database to reflect the metrics established
by Chemistry. (Due date: January 15, 2007)Extent of Cause Corrective
Actions The site's metric guideline
was revised to identify that a thorough review of a proposed metric is necessary
to identify and measure necessary
objectives
so that unintended
consequences
are minimized (e.g., single metric such as reliability
without a complementary
metric of availability).
An effectiveness
review of site and department
metrics will be conducted
to determine
if appropriate
metrics have been established
and are being used by leaders to guide actions. (Due date: March 30, 2007)Other Chemistry
Department
metrics will be reviewed to ensure complementary
metrics exist where appropriate. (Due date: April 30, 2007)9
ll.B.3 Root Cause #3 and Corrective
Actions -Inadequate
Resolution
of Performance
Problems Palo Verde personnel (leaders and frontline)
failed to effectively
resolve previously
identified
problems with a zinc-related
foulant despite numerous opportunities
to do so.One specific example of inadequate
resolution
of performance
problems was cited as an apparent violation
of 10 CFR 50 Appendix B, Criterion
XVI, "Corrective
Actions", for the failure to correct the degraded performance
of EW 2B, when identified
in March 2002.Corrective
Actions Taken and Results Achieved Procedure
74DP-OCY01, "Specifications
for Bulk Chemicals," was revised to require a chemical compatibility
test when changing chemicals.
Tools have been developed
to improve engineering
work product quality, including
the Engineering
Department
Guides (EDG) 01 and 02 to minimize human performance
errors.The Condition
Reporting
procedure
was revised to include checklists
for processing
CRDRs to improve resolution
of conditions
that are adverse to quality.Management
Expectations
for questioning
attitude and technical
rigor have been incorporated
into Chemistry
Department
Policy (CDP-01).Corrective
Actions to Be Taken Procedure
70TI-9EW01, "Thermal Performance
Testing of Essential
Cooling Water Heat Exchangers", will be revised to improve heat exchanger
performance
management. (Due date: January 31, 2007)The Systems Engineering
Department
performance
monitoring
database will be revised to include a parameter
for the differential
temperature
between the EDG intake air manifold and the SP cooling water to detect degradation
of the intercoolers. (Due date: February 28, 2007)Extent of Cause Corrective
Action This cause is illustrative
of the issues being addressed
by the revised PIP action plan for PI&R. The investigation
compared the issues for the SP event to the action being taken in the revised PI&R action plan and concluded
that plan will appropriately
address the extent of cause. As noted in Section I. Introduction, the revised PIP action plan for the PI&R cross-cutting
issue will be submitted
to the NRC by December 15, 2006.10
ll.B.4 Root Cause #4 and Corrective
Actions -Management
Reliance on an Expert There were instances
where the chemistry
advisor's
working assumptions
were flawed and the lack of technical
support from other technical
specialists
resulted in missed opportunities
to preclude the precipitant
from occurring.
Corrective
Actions Taken and Results Achieved Chemistry
Standards
and Expectations
have been revised to require independent
review of calculations
that relate to changes to chemistry
design controls or the Chemistry
Design Basis Manual.Corrective
Actions to Be Taken Procedure
74DP-9CY04, "System Chemistry
Specifications" will be revised to require a technically
independent
review when making changes to chemistry
control regimes.(Due date: November 17, 2006)The Chemistry
Department
will designate
backups to selected advisors in the chemistry department, will develop training plans and identify critical attributes
for these backups.(Due date: November 30, 2006).A training program specific to chemistry
will be developed
and implemented, using the Engineering
Training Program Description (TPD) as a reference.
Critical job skills and functions
of Chemistry
Technical
Support staff and Instrument
Maintenance
staff will be identified
and a structure
for additional
development
of current staff and for development
of replacement
personnel
will be included. (Due date: April 30, 2007)Extent of Cause Corrective
Actions Each department
will evaluate susceptibility
to reliance on experts and take appropriate
corrective
actions. (Due date: December 15, 2006)ll.B.5 Root Cause #5 and Corrective
Actions -Ineffective
Change Management
APS did not adequately
assess the significance
or impacts of changes made to the Chemistry
Control Program or activities
that impact the program.Corrective
Actions Taken and Results Achieved Procedure
93DP-OLC17, "10 CFR 50.59 and 72.48 Guidance Manual," was revised to require a 50.59 screening
when changing chemicals
and corresponding
changes were made to Chemistry
procedure
74DP-OCY01, "Specifications
for Bulk Chemicals." The commitments
for Generic Letter 89-13 were verified to be accurately
reflected
in the Regulatory
Commitment
Tracking System.11
Ineffective
Change Management
has been captured in the Performance
Improvement
Plan and led to the development
of the "RAPID" (Recognize, Assess, Plan, Implement, and Drive) program to help manage the change process at Palo Verde.Corrective
Actions to Be Taken Systems Engineering
will conduct a self-assessment
of the SP systems to include NRC GL 89-13 and industry operating
experience
on service water systems. (Due date: February 28, 2007)Recognizing
similarities
to the issues identified
in the Davis Besse SOER 02-4, a review of the SOER and Palo Verde's evaluation
will be performed
to ensure outstanding
issues are appropriately
identified, prioritized
and are being properly addressed. (Due date: March 1, 2007)II.C Contributing
Causes The investigation
identified
the following
nine contributing
causes: " Contributing
Cause #1: Palo Verde did not solicit outside assistance
- Contributing
Cause #2: Inadequate
Prioritization
of the SP System* Contributing
Cause #3: Narrow Focus* Contributing
Cause #4: Emphasis on Cost Control* Contributing
Cause #5: Erosion of Design Margin" Contributing
Cause #6: Questioning
Attitude of Workers" Contributing
Cause #7: Lack of Rigor in Evaluations" Contributing
Cause #8: Living with Problems* Contributing
Cause #9: Removing UFSAR Requirements
This section summarizes
each contributing
cause and the associated
corrective
actions.I1.C.1 Palo Verde Did Not Solicit Outside Assistance
Palo Verde personnel
did not effectively
compare their chemical control program for the SP system with other plants because personnel
considered
the ultimate heat sink for Palo Verde to be unique.Corrective
Actions Taken and Results Achieved Chemistry
Department
Policy (CDP-01) was revised to incorporate
a requirement
for Corporate
Chemistry
or an outside individual
to conduct a review of the SP system Chemical Control Program on a semi-annual
basis.12
Palo Verde's Nuclear Assurance
Department
revised the master assessment
plan to require procedures
selected for reviews during audits to include a full basis review of the entire procedure
against the applicable
licensing
and design basis.II.C.2 Inadequate
Prioritization
of the SP System Palo Verde management
did not effectively
prioritize
the SP system problems to ensure they were resolved in a timely manner.Corrective
Actions to Be Taken Modifications
will be installed
to add higher capacity acid and dispersant
pumps. (Due date: December 31, 2006).The Tower Blowdown (TB) makeup line will be restored to Unit 1 spray ponds. (Due date: March 30, 2007)The temporary
modification
for zinc and biocide chemical addition will be replaced by a modification
in all three units. (Due date: September
30, 2008)The feasibility
of installing
a SP filter system will be performed. (Due date: June 30, 2007)II.C.3 Narrow Focus Palo Verde personnel
occasionally
displayed
a narrow focus to problem solving, which resulted in missed opportunities
to address the cause, rather than the symptoms.
In some cases, the corrective
actions that were put in place to solve one symptom resulted in the manifestation
of new problems.Corrective
Actions Taken and Results Achieved Procedure
74DP-9CY04, "System Chemistry
Specifications," was revised to establish control limits, sampling frequencies
and action levels that ensure the spray ponds are able to perform their specified
function in a DBA.Implemented
a program to walk down safety-significant
systems weekly on a 12 week schedule.
This walk down is performed
by Operations
and Engineering
personnel.
Corrective
Actions to Be Taken This cause is illustrative
of the issues being addressed
by the revised 95002 and PIP action plans. The investigation
compared the issues for the SP event to the action being taken in those action plans and concluded
they will appropriately
address this contributing
cause.13
An engineering
project, referred to as the Component
Design Basis Review (CDBR)began in October of 2006. The purpose of the review is to verify the design bases have been correctly
implemented
for high risk-significant
components
and operator actions.The review is estimated
to take 24-48 months to complete for approximately
250 components
and operator actions.II.C.4 Emphasis on Cost Control Palo Verde personnel, management
and frontline, have occasionally
made inappropriate
cost basis decisions
that result in inaction or delay for equipment
with perceived
lower safety significance.
Corrective
Actions Taken and Results Achieved The closed cooling water chemical addition systems were evaluated
and it was verified they are adequate to control chemistry.
Corrective
Actions to Be Taken Recognizing
similarities
to the issues identified
in the Davis Besse SOER 02-4, a review of the SOER and Palo Verde's evaluation
will be performed
to ensure outstanding
issues are appropriately
identified, prioritized
and are being properly addressed. (Due date: March 1, 2007)II.C.5 Erosion of Design Margin Personnel
used various corrective
action programs and processes
to accept progressively
greater amounts of degradation, eventually
changing the organization's
perception
of normal.Corrective
Actions to Be Taken Modifications
will be installed
to add higher capacity acid and dispersant
pumps. (Due date: December 31, 2006).The TB makeup line will be restored to Unit 1 spray ponds. (Due date: March 30, 2007)A Chemistry
Design Basis Manual will be developed. (Due date: December 24, 2007)Recognizing
similarities
to the issues identified
in the Davis Besse SOER 02-4, a review of the SOER and Palo Verde's evaluation
will be performed
to ensure outstanding
issues are appropriately
identified, prioritized
and are being properly addressed. (Due date: March 1, 2007)14
I1.C.6 Questioning
Attitude of Workers Palo Verde personnel
did not always question what they saw, which contributed
to the misunderstanding
that ultimately
impacted the SP heat exchanger
performance.
Corrective
Actions to Be Taken Develop and implement
site-wide
training on a case study, based on the SP investigation, emphasizing
lessons learned from this event. (Due date: October 1, 2007)This cause is illustrative
of the issues being addressed
by the revised 95002 action plan. The investigation
compared the issues for the SP event to the actions, being taken in this action plan and concluded
it will appropriately
address this contributing
cause.I1.C.7 Lack of Rigor in Evaluations
Palo Verde personnel
did not always apply an appropriate
amount of technical
rigor in evaluations
related to the thermal performance
of the SP heat exchangers.
Corrective
Actions to Be Taken This cause is illustrative
of the issues being addressed
by the revised 95002 action plan. The investigation
compared the issues for the SP event to the actions being taken in this action plan and concluded
it will appropriately
address this contributing
cause.II.C.8 Living with Problems Palo Verde personnel
have, in some cases, accepted and worked around problems.Corrective
Actions to Be Taken Recognizing
similarities
to the issues identified
in the Davis Besse SOER 02-4, a review of the SOER and Palo Verde's evaluation
will be performed
to ensure outstanding
issues are appropriately
identified, prioritized
and are being properly addressed. (Due date: March 1, 2007)This cause is illustrative
of the issues being addressed
by the revised 95002 and PIP action plans. The investigation
compared the issues for the SP event to the action being taken in those action plans and concluded
they will appropriately
address this contributing
cause.II.C.9 Removing UFSAR Requirements
Personnel
removed information
from the UFSAR that may have helped preclude this event.15
Corrective
Actions to Be Taken Revise the UFSAR to include spray pond chemical addition equipment
necessary
to maintain the design basis. (Due date: March 30, 2007)Revise the UFSAR to incorporate
the TB make up line modification
to Unit 1. (Due date: March 30, 2007)III. Review of Latent Design Issues APS recognizes
both the RAS event as well as the SP event revealed significant, latent design basis issues. As a result, APS will address the possibility
of other latent design issues that remain unidentified.
The cornerstone
of the effort to identify these issues is the component
design basis review (CDBR) which APS committed
to perform in a letter to the NRC dated June 2, 2006. The purpose of the review will be to verify the design bases have been correctly
implemented
for highly risk-significant
components
and operator actions as defined in the June 2, 2006 letter. The review will verify the capability
of these components
to perform their intended safety functions
and will use the inspection
methodologies
detailed in NRC Inspection
Procedure (IP) 71111.21, dated December 2, 2005.APS will implement
this component
design basis review in two phases. The first phase will include the highly risk-significant
components
and operator actions that are in the Mitigating
Systems Performance
Indicator
systems. It is expected that at least 20 of these components
and operator actions will be complete by the end of the first quarter 2007. The second phase will include the remaining
highly risk-significant
components
and operator actions.In addition to the CDBR, APS will initiate a Plant Health Committee (PHC) with the distinct purpose of providing
a high level management
overview of current and latent issues with the potential
to impact plant operations.
The PHC will focus senior management
representatives
from Operations, Engineering, and Maintenance
on issues that need management
attention
and resolution, including:
weekly system health reviews, corrective
actions status, single point vulnerabilities
and resolutions, prioritization
of plant modifications, and station program health and implementation
reviews.The Plant Health Committee
represents
a function that is much more comprehensive
in management
oversight
and intrusiveness
into plant performance
than previous System Team Steering Committee
efforts. The details of the PHC will be discussed
further at the November 20, 2006 regulatory
conference.
16
IV. Response to Apparent Violations
This section sets forth APS' position on the five apparent violations
and summarizes
corrective
actions taken or planned that are directly related to the apparent violations.
IV.A. Apparent Violation
of Technical
Specification
3.7.7 Restatement
of Apparent Violation An apparent violation
of Technical
Specification
3.7.7 was identified
because Train B of the Essential
Cooling Water System in Unit 2 was not capable of performing
its safety function for approximately
6.8 months ending on September
27, 2003.Admission APS' significance
determination
has concluded
there was no violation
of TS 3.7.7. The details leading to this conclusion
will be presented
by APS during the November 20, 2006, Regulatory
Conference.
Specifically, our significance
determination
demonstrates
that the system would have been able to perform its safety function due to the large margin in the EW heat exchanger
design in spite of the degraded conditions.
Corrective
Actions The corrective
actions delineated
above in Section II of this Enclosure
address the degraded conditions
of the spray pond and have returned it to conformance
with its design basis.IV.B. Apparent Violation
of Criterion
Xl, Test Control Restatement
of Apparent Violation An apparent violation
of 10 CFR Part 50, Appendix B, Criterion
X1, "Test Control," was identified
because the two procedures
that were performed
to measure essential cooling water heat exchanger
performance
were implemented
in a way that was inadequate
to ensure the timely determination
that the requirements
and acceptance
limits contained
in applicable
design documents
were met.Admission APS admits this apparent violation.
Cause The potential
violation
has been entered into the Palo Verde Corrective
Action Program and the apparent cause evaluation
is currently
in progress.17
Corrective
Actions Taken and Results Achieved Since September
2002, an evaluation
of the EW heat exchanger
thermal performance
test data has occurred during the outage in which the data was collected.
Corrective
Actions to Be Taken Procedure
70TI-9EW01, "Thermal Performance
Testing of the Essential
Cooling Water Heat Exchangers," will be revised to require heat exchanger
performance
data analysis to be completed
prior to entry into Mode 4. (Due date: November 15, 2006)VI.C. Apparent Violation
of 10 CFR 50.59 Restatement
of Apparent Violation An apparent violation
of 10 CFR 50.59 was identified
for making nine revisions
to Procedure
74DP-9CY04, "System Chemistry
Specification," a procedure
described
in the Updated Final Safety Analysis Report, between 1998 and 2004 without performing
evaluations
of the potential
impact of the changes on the safety-related
components
in the spray pond system; the changes revised spray pond chemistry
parameter
limits which were subsequently
determined
to have contributed
to heat exchanger
fouling.Admission APS admits this apparent violation.
Cause APS determined
that the causes of the apparent violation
of 10 CFR 50.59 were as follows:* Changes to chemistry
limits were viewed as administrative
and related to maintenance." There was a failure to rigorously
evaluate the changes to the spray pond chemistry
control program Corrective
Actions Taken and Results Achieved Chemistry
procedure
was restored to the correct condition
and 10 CFR 50.59 was applied to these changes to implement
the current chemistry
regime of the SP System.The 10 CFR 50.59 guidance manual (93DP-OLC17)
was revised to provide specific requirements
for chemistry
related changes.18
Corrective
Actions to Be Taken In order to determine
if other chemistry
procedures
were changed without the proper 10 CFR 50.59 evaluations, a random sample of 58 chemistry
procedure
changes are being reviewed. (Due date: November 17, 2006)Chemistry
personnel
will be trained on the changes to the 10 CFR 50.59 guidance manual. (Due date: November 17, 2006)In addition to a' review of chemistry
related procedure
changes, a review of the performance
monitoring
results of the 10 CFR 50.59 performance
review team from the past year will be performed
to determine
if there are any adverse trends or areas needing additional
review. (Due date: December 30, 2006)IV.D. Apparent Violation
of Criterion
XVI, Corrective
Actions Restatement
of Apparent Violation An apparent violation
of 10 CFR Part 50, Appendix B, Criterion
XVI, "Corrective
Actions," was identified.
On March 19, 2002, performance
testing for Essential
Cooling Water Heat Exchanger
2B indicated
that the system would not be capable of performing
its design function, but this significant
condition
adverse to quality was not promptly identified, the cause determined, or corrective
actions taken to restore the required heat exchanger
performance.
The failure to correct this degraded performance
contributed
to the continued
degradation
and eventual loss of function for an estimated
period of 6.8 months.Admission APS admits this apparent violation
with the following
clarification.
As stated in Section IV.A, APS concluded
that the EW B heat exchanger
in Unit 2 would have been able to perform its function during the period in question.
APS admits that actions were not taken to promptly identify, accurately
determine
the cause and to establish
effective corrective
actions to prevent thermal performance
degradation.
Cause The evaluation
of the EW 2B condition
by engineering
personnel
lacked technical
rigor.Correction
Actions The corrective
actions for this violation
are provided in Section ll.B.3 of this enclosure.
19
IV.E. Apparent Violation
of Criterion
III, Design Control Restatement
of Apparent Violation An apparent violation
of 10 CFR Part 50, Appendix B, Criterion
Ill, "Design Control," was identified
for failure to correctly
evaluate the scaling potential
of the safety-related
heat exchangers
cooled by the emergency
spray pond during a design basis accident.An error in the EPRI SEQUIL calculation
caused the licensee to incorrectly
conclude that scaling would not occur under the conditions
established
in the chemistry
control program.Admission APS admits this apparent violation.
Cause Incorrect
use of a computer model, erroneously
predicted
that calcium phosphate
scale would not form under the input conditions.
Chemistry
personnel
selected input parameters
to simulate conditions
for evaluation.
The individual
performing
the modeling was unfamiliar
with the software and while inputting
data into the model and selecting
the parameters
for the calculation, failed to set the super-saturation
parameter correctly.
This process relied on a single individual
to perform the computer modeling predictions
with no independent
reviews or peer checks.Corrective
Actions Taken and Results Achieved Utilizing
the correct input parameters
and settings Chemistry
reran the EPRI SEQUIL calculation.
The revised data indicated
that there was a high potential
for calcium phosphate
scaling.Chemistry
Standards
and Expectations
have been revised to require independent
review of calculations
that relate to changes to chemistry
design controls.
This requirement
will also apply to the Chemistry
Design Basis Manual, once developed.
Management
expectations
for questioning
attitude and technical
rigor have been incorporated
into Chemistry
Department
Policy (CDP-01).Corrective
Actions to Be Taken Procedure
74DP-9CY04, "System Chemistry
Specifications" will be revised to require a technically
independent
review when making changes to chemistry
control regimes.(Due date: November 17, 2006)20
Chemistry
Department
will designate
backups to the selected advisors in the chemistry department, will develop training plans and identify critical attributes
for these backups.(Due date: November 30, 2006).A training program specific to chemistry
will be developed
and implemented, using the Engineering
Training Program Description (TPD) as a reference.
Critical job skills and functions
of Chemistry
Technical
Support staff and Instrument
Maintenance
staff will be identified
and a structure
for additional
development
of current staff and for development
of replacement
personnel
will be included. (Due date: April 30, 2007)Each department
will evaluate susceptibility
to reliance on experts and take appropriate
corrective
actions. (Due date: December 15, 2006)Chemistry
will develop a plan that will provide for the proper use and independent
review of software generated
evaluations, calculations
and predictions. (Due date: January 22, 2007)V. Conclusion
APS takes the matter of the spray pond chemistry
controls seriously, and has considered
this issue in light of its ongoing improvement
plans. Immediate
actions have been taken to assure the spray pond systems remain within the design basis.Additional
actions have been taken and others planned to provide greater confidence
that similar events will not occur.21
Enclosure
2 Corrections
to NRC Inspection
Report 05000528/2006011;
Page 2, first subparagraph, second sentence: Change from: Train A Change to: Train B Page 14, Enforcement.
(1), third sentence: Change from: Train A Change to: Train B Page 29, third paraaraph, third column: Change from: 2/04 1 B -17%Change to: 2/04 1 B -18%Page A3-1, third row, first column: Change from: 4/95, 1 R4 perf test 56%and 33.8%margin at outage beginning and end Change to: 5/95, 1 R5 33.8% margin Page A3-1, third row, second column: Change from: 4/95, 1R4 perf test 39.8%margin Change to: 4/95, 1 R5 39.8%margin 1
Page A3-1, fourth row, first column: Change from: 10/96, 1R6;end of outage perf test 34.3%margin Change to: 10/96, 1 R6;end of outage perf test 55.7%margin Page A3-1, fourth row, second column: Change from: 9/96, 1 R6;early outage perf test 55.7%margin Change to: 9/96, 1 R6;early outage perf test 34.3%margin Page A3-2, fourth row, fith column: Change from: 4/03, 3R10;early outage perf test-22.0%margin before cleaning, 26.8% after.All tubes inspected with boroscope.
2
Change to: 4/03, 3R10;early outage perf test-22.0%margin before ECT Inspection
of all tubes, 26.8% after.17 tubes inspected with boroscope.
Page A3-3. first row, second column: Change from: 2/04, midcycle outage perf test -17.1%margin.Change to: 2/04, midcycle outage perf test -18%margin.Page A3-3, first row, third column: Change from: 3/04, midcycle outage perf test 28.6%before cleaning Change to: 3/04, midcycle outage perf test 28.6%no cleaning 3
Page A3-3. first row, fourth column: Change from: 3/04, midcycle outage, cleaning performed but no test.Change to: 3/04, midcycle outage, no cleaning no test.Page A3-3, first row, sixth column: Change from: 3/04, midcycle outage;cleaning performed but no test.Change to: 2/04, midcycle outage;cleaning performed but no test.Page A3-3. second row, fith column: Change from: 10/04, 3R11 EWHX 3A cleaned but not tested.Change to: 11/04, 3R11 EW HX 3A tested at 26.8%after cleaning.4
Page A3-3, second row, sixth column: Change from: 10/04, 3R1 1 34.6%margin before cleaning, 26.8% after.Change to: 10/04, 3R1 1 34.6%margin before cleaning.Page A3-3, sixth row, first column: Change from: 6/06, midcycle outage; perf test 28.6%before cleaning, 36.3% after.Change to: 6/06, midcycle outage; perf test 28.6%after cleaning.Page A3-3, sixth row, second column: Change from: 3/06, midcycle outage; perf test 32.9%margin before cleaning.Change to: 3/06, midcycle outage; perf test 32.9%margin no cleaning.5
Page A4-2, sixth paragraph, second column: Change from: Essential
Cooling Water 2B performance
measured at -17.1 percent.Change to: Essential
Cooling Water 1 B performance
measured at -18 percent.Paae A4-2, tenth paragraph, first column: Change from: 4/04 Change to: 5/04 6