IR 05000397/2017007

NRC Problem Identification and Resolution Inspection Report 05000397/2017007

ML17100A117
Person / Time
Site:	Columbia
Issue date:	04/06/2017
From:	Hipschman T R Division of Reactor Safety IV
To:	Reddemann M E Energy Northwest
Hipschman T R
References
IR 2017007
Download: ML17100A117 (29)

Text

April 6, 2017

Mr. Mark Chief Executive Officer Energy Northwest

MD 1023 P.O. Box 968

Richland, WA 99352

SUBJECT: COLUMBIA GENERATING STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000397/2017007

Dear Mr. Reddemann:

On March 2, 2017, the U.S. Nuclear Regulat ory Commission (NRC) completed a problem identification and resolution inspection at the Columbia Generating Station and discussed the results of this inspection with you and members of your staff. The results of this inspection are documented in the enclosed report.

The NRC inspection team reviewed the station's corrective action program and the station's 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 staff's performance in each of these areas adequately supported nuclear safety.

The team also evaluated the station's processes for use of industry and NRC operating experience information and the effectiveness of the station's audits and self-assessments. Based on the samples reviewed, the team determined that your staff's performance in each of these areas adequately supported nuclear safety.

Finally, the team reviewed the station's programs to establish and maintain a safety-conscious work environment, and interviewed station personnel to evaluate the effectiveness of these programs. Based on the team's observations and the results of these interviews, the team found evidence that a chilled work environment in which personnel had been hesitant to raise some issues for fear of retaliation, had existed within the electrical maintenance shop as recently as late 2016. However, the station's recent efforts to address these issues, including some organizational changes, appear to have restored a safety-conscious work environment. The team did not identify any significant ongoing challenges with the safety-conscious work environment at Columbia.

NRC inspectors documented one finding of very low safety significance (Green), which involved a violation of NRC requirements. The NRC is treat ing this violation as a non-cited violation (NCV), consistent with Section 2.3.2.a of the Enforcement Policy. If you contest this violation or its 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 Columbia Generating Station.

If you disagree with the cross-cutting aspect assignment for the non-cited violation, 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 Columbia 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/

Thomas R. Hipschman, Team Leader Inspection Programs and Assessment Team Division of Reactor Safety

Docket No: 50-397 License No: NPF-21

Enclosure:

Inspection Report 05000397/2017007

w/Attachment:

1. Supplemental Information 2. Information Request 3. Supplemental Information Request

cc w/ encl: Electronic Distribution

Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION IV Docket(s): 05000397 License: NPF-21

Report: 05000397/2017007 Licensee: Energy Northwest Facility: Columbia Generating Station Location: North Power Plant Loop Richland, WA 99354 Dates: February 13 through March 2, 2017

Inspectors:

E. Ruesch, J.D., Senior Reactor Inspector, Team Lead J. Braisted, Ph.D., Reactor Inspector N. Okonkwo, Reactor Inspector G. Kolcum, Senior Resident Inspector C. Stott, Reactor Inspector Approved By: Thomas R. Hipschman, Team Leader Inspection Programs and Assessment Team

Division of Reactor Safety 2

SUMMARY

IR 05000397/2017007; 02/13/2017 - 03/02/2017; COLUMBIA GENERATING STATION; Problem Identification and Resolution (Biennial)

The inspection activities described in this report were performed between February 13 and March 2, 2017, by four inspectors from the NRC's Region IV office and the senior resident inspector at Columbia Generating Station. The report documents one finding of very low safety significance (Green), which involved a violation of NRC requirements. The significance of inspection findings is indicated by their color (Green, White, Yellow, or Red), which is determined using Inspection Manual Chapter 0609, "Significance Determination Process." Their cross-cutting aspects are determined using Inspection Manual Chapter 0310, "Aspects Within the Cross-Cutting Areas." Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement Policy. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process."

Assessment of Problem Identification and Resolution Based on its inspection sample, the team concluded that the licensee maintained a corrective action program in which individuals generally identified issues at an appropriately low threshold. Once entered into the corrective action program, the licensee generally evaluated and addressed these issues appropriately and timely, commensurate with their safety significance.

The licensee's corrective actions were generally effective, addressing the causes and extents of condition of problems.

The licensee appropriately evaluated industry operating experience for relevance to the facility and entered applicable items in the corrective action program. The licensee incorporated industry and internal operating experience in its root cause and apparent cause evaluations.

The licensee performed effective and self-critical nuclear oversight audits and self-assessments. The licensee maintained an effective process to ensure significant findings from these audits and self-assessments were addressed.

At the time of the inspection, the licensee maintained a safety-conscious work environment in which personnel were willing to raise nuclear safety concerns without fear of retaliation. The team noted evidence that as recently as late 2016, a chilled work environment had existed within the electrical maintenance group. However, recent actions by the licensee appeared to have restored a safety-conscious work environment.

Cornerstone: Mitigating Systems

• Green/SL-IV. The team identified a Green, Severity Level IV non-cited violation of 10 CFR Part 50 Appendix B Criteria VII and XV, for the licensee's failure to ensure materials intended for installation in safety-related applications conformed to procurement requirements or, if they did not, were adequately controlled and evaluated.

The failure to establish a program to evaluate and control nonconforming materials in accordance with the procurement requirements of 10 CFR 21 was a performance deficiency.

This performance was more than minor because if left uncorrected it had the potential to become a more significant safety concern. Using Inspection Manual Chapter 0609 Appendix A, dated June 19, 2012, the team determined that this finding was of very low safety significance (Green) because it was a deficiency affecting the design or qualification of a structure, system, or component, and operability was maintained. The finding has a conservative bias cross-cutting aspect in the human performance cross-cutting area because licensee personnel improperly rationalized the adequacy of the nonconforming components to perform their safety-related functions (H.14).

Because this performance deficiency was also a violation that impacted the regulatory process, in that the licensee accepted a change to plant design without appropriate evaluation and notification, it was also evaluated for traditional enforcement. The team determined that the violation was Severity Level IV because it was similar to several examples in Section 6.5.d of the NRC Enforcement Policy.

4

REPORT DETAILS

4OA2 Problem Identification and Resolution

The team based the following conclusions on a sample of corrective action documents that were open during the assessment period, which ranged from March 20, 2015, to the end of the on-site portion of this inspection on March 2, 2017.

.1 Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The team reviewed approximately 200 condition reports (CRs), including associated root cause analyses and apparent cause evaluations, from approximately 22,000 that the licensee had initiated or closed between March 20, 2015, and March 2, 2017. The majority of these (all but about 200) were lower-level condition reports that did not require cause evaluations. The inspection sample focused primarily on higher-significance condition reports for which the licensee evaluated and took actions to address the cause of the condition. In performing its review, the team evaluated whether the licensee had properly identified, characterized, and entered issues into the corrective action program, and whether the licensee had appropriately evaluated and resolved the issues in accordance with established programs, processes, and procedures. The team also reviewed these programs, processes, and procedures to determine if any issues existed that may impair their effectiveness.

The team reviewed a sample of performance metrics, system health reports, operability determinations, self-assessments, trending reports and metrics, and various other documents related to the licensee's corrective action program. The team evaluated the licensee's efforts in determining the scope of problems by reviewing selected logs, work orders, self-assessment results, audits, system health reports, action plans, and results from surveillance tests and preventive maintenance tasks. The team reviewed daily CRs and attended the licensee's Condition Review Group, Operations Focus, Management Review Team, and Operability Determination Quality Review Board meetings to assess the reporting threshold and prioritization efforts, and to observe the corrective action program's interfaces with the operability assessment and work control processes. The team's review included an evaluation of whether the licensee considered the full extent of cause and extent of condition for problems, as well as a review of how the licensee assessed generic implications and previous occurrences of issues. The team assessed the timeliness and effectiveness of corrective actions, completed or planned, and looked for additional examples of problem s similar to those the licensee had previously addressed. The team conducted interviews with plant personnel to identify other processes that may exist where problems may be identified and addressed outside the corrective action program.

The team reviewed corrective action doc uments that addressed past NRC-identified violations to evaluate whether corrective actions addressed the issues described in the inspection reports. The team reviewed a sample of corrective actions closed to other corrective action documents to ensure that the ultimate corrective actions remained appropriate and timely.

The team considered risk insights from both the NRC's and Columbia Generating Station's risk models to focus the sample selection and plant tours on risk-significant systems and components. The team focused a portion of its sample on the safety-related 4160vac and 480vac systems, which the team selected for a five-year in-depth review. The team conducted walk-downs of this system and other plant areas to assess whether licensee personnel identified problems at a low threshold and entered them into the corrective action program.

b. Assessments

1. Effectiveness of Problem Identification

During the 24-month inspection period, licensee staff generated approximately 22,000 condition reports. The team determined that most conditions that required generation of a condition report by SWP-CAP-01, "Corrective Action Program," and its progeny procedures had been appropriately entered into the corrective action program.

However, the team noted several examples where the licensee had failed to properly identify conditions in accordance with procedures. On February 13 and 15, NRC inspectors spent approximately 4-5 hours touring areas of the plant containing safety-related equipment. During this time, the inspectors identified several conditions-all in areas routinely toured by operations personnel or where maintenance was ongoing-in which the licensee failed to follow procedural requirements to prevent potential seismically induced damage to safety-related

equipment:

• An improperly secured ladder in the vicinity of safety-related switchgear, which the licensee had determined had been in place for approximately four months. This was in an area that was toured at least shiftly by operators. (CR 361352)

• Scaffolding erected less than two inches away from safety-related equipment, in violation of procedures, without attached documentation indicating an engineering evaluation had determined the configuration acceptable. The licensee later determined that an appropriate evaluation had been performed, but the scaffolding had not been appropriately tagged. (CR 361441)

• Seismic clips for air filters on emergency diesel generator 2 were improperly installed. Maintenance had recently been done in the area, but this deficiency had not been identified and corrected. (CR 361452)

The team determined that this number of issues identified by inspectors in a short time, in areas regularly toured by licensee personnel, indicated a potential failure of licensee personnel to understand what constituted a degraded or nonconforming condition, or a failure of licensee personnel to understand seismic housekeeping requirements. However, the team determined this was a minor performance deficiency not subject to enforcement action.

Despite this failure to document some adverse plant conditions in the corrective action program, the team concluded that the licensee generally maintained a low threshold for the formal identification of problems and entry into the corrective action program for evaluation. Toward the end of the inspection period, licensee personnel were routinely initiating approximately 700 CRs per month. All of the personnel interviewed by the team understood the requirements for condition report initiation; almost all expressed a willingness to enter newly identified issues into the corrective action program at a very low threshold.

2. Effectiveness of Prioritization and Evaluation of Issues The sample of CRs reviewed by the team focused primarily on issues screened by the licensee as having higher-level significance, including those that received cause evaluations, those classified as significant conditions adverse to quality, and those that required engineering evaluations. The team also reviewed a number of condition reports that included or should have included immediate operability determinations to assess the quality, timeliness, and prioritization of these

determinations.

The team noted that the licensee's process for determining operability of a potentially degraded structure, system, or component, was not straightforward. Specifically, the operability screening process requires operators to answer yes or no first to whether a degraded or nonconforming condition (DNC) exists, then to whether an operable but degraded condition exists. Usually, the formal determination of operability is contained within the notes for the DNC screen, but there is no explicit documentation of operability in the condition reporting system. This resulted in some inconsistency in the application of operability screening questions by licensed operators in the control room. The licensee's operability determination quality review board has mitigated much of this inconsistency, but the team noted that long-term tracking of operable-but-degraded conditions remains challenging under this process.

The team also identified several examples where the licensee's evaluation of a condition was either inconsistent with program procedures or was not fully supported by documentation:

• The team reviewed the root cause evaluation (RCE), "Phase 2 Residual Heat Removal Fuel Pool Cooling Assist Window Exceeded Technical Specification Completion Time," associated with CR 00321583. The purpose of the RCE was to determine why the licensee required an emergency license amendment to extend the completion time of multiple technical specification actions in order to support the restoration of a train of the residual heat removal system when a planned modification to the system exceeded its work window and original seven-day completion time. The licensee initially screened the CR as a Category "A" with a "SCAQ" Priority. A Category A is one that involves an event or condition that is deemed high risk based on actual or potential consequences and probability of recurrence that adversely affect the safe operation of the facility, the health and safety of personnel or the public, or the environment and includes significant condition adverse to quality (SCAQ). A SCAQ is a failure, malfunction, deficiency, deviation, defective or damaged material and equipment, or nonconformance that adversely affects the safety-related function(s) of a structure, system or component, or part deemed significant based on actual or potential consequences that adversely affects the safe operation of the facility, the health and safety of personnel or the public, or the environment. These conditions are subject to the requirement of 10 CFR Part 50, Appendix B, Criterion XV, "Nonconforming Materials, Parts, or Components," and Criterion XVI, "Corrective Action," to determine the root cause and take corrective action to preclude repetition. The licensee later downgraded the Priority to CAQ, Condition Adverse to Quality, from SCAQ. A SCAQ would require corrective action to preclude repetition, whereas a CAQ would require corrective action but not necessarily any to preclude repetition. When the team requested clarifying information as to why they downgraded the Priority, the licensee responded with "Not SCAQ because emergency license amendment was granted prior to the expiration of original TECH SPEC". Therefore, the decision to downgrade the Priority was based upon an action taken by the NRC and not the licensee's performance of their modification.

• The team reviewed apparent cause evaluation (ACE), "CEP-V-3A found out of normal position" associated with CR 00344031 during the inspection.

The licensee performed the ACE to determine why containment exhaust purge valve 3A (CEP-V-3A) was unexpectedly found in the open position (CEP-V-3A is normally closed) during shift turnover on January 26, 2016. The licensee concluded that "no direct cause, apparent cause, or contributing cause can be determined". On February 13, 2017, the licensee again discovered CEP-V-3A in the open position and documented finding CEP-V-3A in the incorrect position in CR 00361359. The CRG assigned the CR as a Category "A" and as a Priority "CAQ". Category A refers to an event or condition that is deemed high risk based on actual or potential consequences and probability of recurrence that adversely affect the safe operation of the facility, the health and safety of personnel or the public, or the environment. Priority CAQ refers to conditions adverse to quality, which is an all-inclusive term used in reference to any of the following: failures, malfunctions, deficiencies, defective items, and nonconformances. Furthermore, the CRG determined that "causes known" and "corrective actions known" was "partial". According to Attachment 8.2, "CAQ Risk and Evaluation Level Guidance," to station procedure, SWP-CAP-06, "Condition Report Review," an ACE would be the appropriate cause evaluation. The team requested additional clarification on why the CRG responded "partial" for causes and corrective actions known when a previous ACE did not determine a direct, apparent, or contributing cause the first time the licensee discovered CEP-V-3A in the incorrect position. The licensee responded with, "Partial cause was agitation of the wire by craft during work partial corrective actions known was keeping individuals away from this location until a trouble shooting plan is completed." According to Attachment 8.2, a "partial" answer is acceptable for "Are the causes known?" if the "direct causes are known and verified". However, as the licensee had not yet begun troubleshooting the issue, they could not verify that agitating the wires was the direct cause of CEP-V-3A opening. Therefore, CRG should have answered "no" to "causes known", which would have led the CRG to an "Uncertainty Assessment" of "High" and ultimately a Root Cause Evaluation rather than an Apparent Cause Evaluation.

• In two instances in 2016, the licensee identified failures of purchased parts or material to conform to quality standards. In both cases, the licensee generated condition reports to evaluate the condition, but in neither of these cases was the suitability of the parts formally evaluated in accordance with quality assurance requirements, and then accepted or rejected for safety-related use. This failure of the licensee's programs to ensure conformance with quality requirements is discussed as a non-cited violation in

Section 4OA2.5, below.

Overall, the team determined that the licensee's process for screening and prioritizing issues that had been entered into the corrective action program supported nuclear safety. The licensee's operability determinations were consistent, accurately documented, and completed in accordance with procedures.

3. Effectiveness of Corrective Actions

In general, the corrective actions identified by the licensee to address adverse conditions were effective. However, the team noted a number of instances in which corrective actions had been untimely or incompletely accomplished:

• During the 2015 NRC Problem Identification and Resolution inspection, the team identified an instance where the licensee had not generated a condition report when a degraded/nonconforming condition was identified and, consequently, issued a green, non-cited violation for the failure to adhere to station procedures. Specifically, the licensee performed an inspection of a motor-operated valve, but did not initiate a condition report when the amount of grease in the limit switch gearbox was found to be out-of-specification.

(When the team brought the issue up with the licensee, the licensee evaluated the condition and confirmed that the valve was in a degraded/nonconforming condition and should have written a condition report.) The licensee documented that the as-found component condition was a "Code 5" according to procedure MI-3.6.4, "Work Package Closure".

Code 5 means that reliability of the component has degraded, although not to the point of failure, and recommends replacement or repairs due to normal wear or aging to ensure reliable operation until the next inspection and to consider performing the preventive maintenance task more frequently. The corrective actions for the violation involved additional training on when to initiate a condition report and a few procedural enhancements. Specifically, the licensee revised the motor-operated valve maintenance procedure with additional guidance on when to initiate a condition report that would encompass another grease-related concern. Additionally, the licensee revised procedure MI-3.6.4, which defines as-found component condition codes, to state that any Code 1 through 4 as-found component conditions require a condition report. However, this procedure applies to many types of components, not just motor-operated valves, and, therefore, a potential gap remains where the licensee could assign another component an as-found condition of Code 5 and not initiate a condition report when a degraded/nonconforming condition exists. Therefore, while the licensee fixed the specific issue that the original viol ation involved, it did not universally fix the condition across the plant for similar issues. (CR 00361460)

• During the 2015 NRC Problem Identification and Resolution (PI&R) inspection, the team identified an issue involving the failure to translate the design basis into Component Classification Evaluation Records (CCERs). Specifically, some CCERs were found to contain inaccurate information. The significance of this issue is that information from the CCERs could be used to make incorrect decisions related to equipment design or qualification or when determining current licensing bases requirements. An initial recommendation was made in AR-SA 00333088 to place CCERs into "History" status rather than maintaining them as active design basis documents in September 2015.

However, the licensee did not take any action on the recommendation until February 2017 when the licensee ultimately decided to keep all safety-related and augmented-quality CCERs active just not any nonsafety-related CCERs.

However, in the interim, the licensee initiated several condition reports for inaccurate CCERs, but closed them without action by stating that "Design Engineering management has concluded that CCER documents are to be made historical and, therefore, will not be updated. No further action is required." The licensee did not recognize that this situation could have occurred and, therefore, did not pursue a review of CCERs with known inaccuracies to have them corrected. The team reviewed condition reports related to CCERs issued since the previous NRC PI&R inspection and a sampling of safety-related CCERs during this inspection and did not identify any inaccuracies of significance. (CRs 00362101, 00362104, and 00362106)

Overall, the team concluded that the licensee generally identified effective corrective actions for the problems evaluated in the corrective action program. The licensee generally implemented these corrective acti ons in a timely manner, commensurate with their safety significance, and reviewed the effectiveness of the corrective actions appropriately.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The team examined the licensee's program for reviewing industry operating experience, including reviewing the governing procedures. The team reviewed a sample of industry operating experience communications and the associated site evaluations to assess whether the licensee had appropriately assessed the communications for relevance to the facility. The team also reviewed assigned actions to determine whether they were appropriate.

b. Assessment Overall, 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 noted one instance in which the licensee did not incorporate operating experience information into station processes, which contributed to the failure to prevent a significant event. In the section for operating experience (OE) in the Root Cause Evaluation (RCE) for CR 340546, "Traversing In-core Probe Detector Containing Special Nuclear Material Not Located in Designated Storage Area," two events that occurred at different sites were found to have simila r events previously happen. One event was reviewed by the licensee and had a one-time action associated with it. The other event noted was not specifically evaluated for impact by the licensee. The licensee noted in the RCE, "Both of these instances could have raised awareness of SNM [special nuclear material] material [sic] and were missed opportunities to evaluate our SNM process/program." The licensee also said, "The proposed corrective actions will address the OE identified items." While the corrective actions for this RCE for CR 340546 did address the particular issues discussed in these two OE examples, the licensee failed to question why their OE program missed these two opportunities to evaluate their SNM program.

However, the team concluded that in most cases 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.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The team reviewed a sample of licensee self-assessments and audits to assess whether the licensee was regularly identifying performance trends and effectively addressing them. The team also reviewed audit reports to assess the effectiveness of assessments in specific areas. The specific self-assessment documents and audits reviewed are listed in Attachment 1.

b. Assessment Overall, the team concluded that the licensee had an effective self-assessment and audit process. The team determined that self-assessments were self-critical and thorough enough to identify deficiencies. However, the team identified one potential vulnerability in the licensee's self-assessment program.

Station procedure SWP-ASU-02, "Self-Assessment and Benchmark Process," defines various types of peer, self-assessment, and benchmark activities and expectations related to the scheduling, performance, and documentation of those activities. These activities may be "focused" or "snapshot". Focused activities require pre-planning and receive oversight of the plan and report from both the responsible department manager and the Performance Assessment Review Board (PARB). Snapshot activities do not require planning and receive only responsible department manager oversight.

SWP-ASU-02, Step 4.3.1, directs department managers to identify periodic, baseline self-assessment activities for the next upcoming two or three years, but that other assessment activities may be identified as needed. Furthermore, the step includes the instruction that activities should be categorized commensurate with the organizational risk, identified resources, and oversight needed and that additional guidance may be found in attachments to the procedure. Additionally, SWP-ASU-02 directs the user to SWP-LIC-08 for NRC pre-inspection assessment requirements. However, whereas SWP-LIC-08 directs which NRC pre-inspection require a focused assessment rather than a snapshot assessment, the guidance in SWP-ASU-02 does not provide equivalent guidance for other periodic baseline assessment activities, such as reviews of specific engineering programs. Attachment 8.2, Self-Assessment and Benchmark Category Selection Guide, to SWP-ASU-02 identifies attributes that best match the self-assessment or benchmark activity and determine the best category assignment (i.e., focused or snapshot). One attribute, for example, is that a program or activity that represents the greatest organizational risk would result in a focused activity, whereas a program or activity that is associated with low organizational risk may result in a focused or snapshot activity. However, the license does not document in any procedure which programs or activities represent high or low organizational risk, so the decision to perform a focused or snapshot activity is effectively up to the department manager. The PARB, however, does review which activities are proposed by the manager, but again, program assessment activities, for example, do not have a "default" setting for focused or snapshot unlike NRC pre-inspection assessments. (CR 00362034)

.4 Assessment of Safety-Conscious Work Environment

a. Inspection Scope

The team interviewed 55 individuals in nine focus groups. The purpose of these

interviews was

(1) to evaluate the willingness of licensee staff to raise nuclear safety issues, either by initiating a condition report or by another method,

(2) to evaluate the perceived effectiveness of the corrective action program at resolving identified problems, and

(3) to evaluate the licensee's safety-conscious work environment (SCWE). The focus group participants included personnel from Engineering, Maintenance, Operations

and Operations Support, Security, Radiation Protection, and Chemistry. At the team's request, the licensee's regulatory affairs staff selected the participants blindly from these work groups, based partially on availability. To supplement these focus group discussions, the team interviewed the Employee Concerns Program manager to assess his perception of the site employees' willingness to raise nuclear safety concerns. The team reviewed the Employee Concerns Program case log and select case files. The team also reviewed the minutes from the licensee's most recent safety culture monitoring panel meetings.

b. Assessment 1. Willingness to Raise Nuclear Safety Issues All individuals interviewed indicated that they would raise nuclear safety concerns. All felt that their management was receptive to nuclear safety concerns and was willing to address them promptly. All of the interviewees further stated that if they were not satisfied with the response from their immediate supervisor, they had the ability to escalate the concern to a higher organizational level. Most expressed positive experiences after raising issues to their supervisors. All expressed positive experiences documenting most issues in condition reports.

The team expanded the scope of the SCWE portion of the inspection after initial identification of potential SCWE challenges within the maintenance department. As a result, the team interviewed 22 of approximately 103 in-field craft personnel in the maintenance department (these 22 were among the 55 total interviewed), along with the electrical maintenance manager and acting maintenance manager. Through these interviews, the team identified evidence that a chilled environment existed in the electrical maintenance group as recently as late 2016. However, after having noted indications of this chilled environment in surveys and external peer reviews, the licensee had taken actions that appeared to have corrected the issue and restored a safety-conscious work environment by the time of the on-site inspection. The team identified no current, significant challenges to the licensee's maintenance of an environment where all personnel felt free to raise concerns without fear of

retaliation.

2. Employee Concerns Program All interviewees were aware of the Employee Concerns Program. Most explained that they had heard about the program through various means, such as posters, training, presentations, and discussion by s upervisors or management at meetings. Most interviewees stated that they would use Employee Concerns if they felt it was necessary. Nearly all expressed confidence that their confidentiality would be maintained if they brought issues to Employee Concerns.

3. Preventing or Mitigating Perceptions of Retaliation When asked if there have been any instances where individuals experienced retaliation or other negative reaction for raising issues, all personnel interviewed-with the exception of the maintenance group-stated that they had neither experienced nor heard of retaliation, harassment, intimidation, or discrimination.

As noted above, the team determined that there was evidence that some personnel within the electrical maintenance group may have experienced or perceived retaliation for raising concerns as recently as late 2016. Since then, measures implemented by the licensee to eliminate these negative reactions had been preliminarily effective. In other groups, the team concluded that processes in place to mitigate these issues had been successfully implemented.

.5 Finding

Failure to Evaluate and Control Nonconforming SSCs

Introduction.

The team identified a Green, Severity Level IV non-cited violation of 10 CFR Part 50 Appendix B Criteria VII and XV, for the licensee's failure to ensure materials intended for installation in safety-related applications conformed to procurement requirements or, if they did not, were adequately controlled and evaluated.

Description.

In May 2016, the licensee documented in CR 350038 that the grease used in mechanical snubbers had not been qualified for safety-related use in accordance with appropriate quality standards. The licensee performed an evaluation of the impact of this nonconformance, resulting in a determination that the grease was acceptable for use as-is. However, the licensee failed to document a formal commercial grade dedication and acceptance of the grease as quality-related. The licensee documented this failure in CR 361519.

In August 2016, the licensee documented in CR 353564 that multiple safety-related relays that had been accepted into warehouse stores had terminal blocks installed upside-down on their mounting plates. Maintenance personnel took actions to ensure nonconforming parts were segregated until the condition was corrected. However, the licensee failed to enter procurement processes to ensure that the parts were reviewed and accepted, rejected, repaired, or reworked in accordance with documented procedures. The licensee documented this failure in CR 362507.

Analysis.

The failure to establish a program to evaluate and control nonconforming materials in accordance with the procurement requirements of 10 CFR 21 was a performance deficiency. This performance was more than minor because if left uncorrected it had the potential to become a more significant safety concern. Using Inspection Manual Chapter 0609 Appendix A, dated June 19, 2012, the team determined that this finding was of very low safety significance (Green) because it was a deficiency affecting the design or qualification of a structure, system, or component, and operability was maintained. The finding has a conservative bias cross-cutting aspect in the human performance cross-cutting area because licensee personnel improperly rationalized the adequacy of the nonconforming components to perform their safety-related functions (H.14).

This performance deficiency was also a violation that impacted the regulatory process in that the licensee accepted a change to quality-related plant design without appropriate evaluation and notification, resulting in inaccurate information being contained in the final safety analysis report. Therefore, the violation was also evaluated for traditional enforcement. The team determined that the violation was Severity Level IV because it was similar to several examples in Section 6.5.d of the NRC Enforcement Policy.

Enforcement.

Title 10, Code of Federal Regulations Part 50 Appendix B Criterion VII requires that measures be established to assure that purchased material, equipment, and services conform to the procurement documents. Criterion XV requires that nonconforming items shall be reviewed and accepted, rejected, repaired, or reworked in accordance with documented procedures. Contrary to these requirements, in May and August 2016 the licensee failed to ensure purchased material conformed to procurement documents and failed to review and accept, reject, repair, or rework nonconforming items in accordance with documented procedures. Specifically, after receipt of information from a vendor in May 2016 that snubber grease did not conform to quality requirements, licensee engineers accepted the grease as-is and failed to dedicate the commercial-grade grease as described in 10 CFR Part 21. Additionally, in August 2016 after identifying that some safety-related relays had been accepted into stores with terminal blocks mounted upside-down, the licensee failed to control these nonconforming parts. In both cases, the licensee's measures failed to ensure conformance of parts or to control the parts if they failed to conform. Because this violation is of very low safety significance and Severity Level IV, and was entered into the licensee's corrective action program (CR 362507), it is being treated as a non-cited violation in accordance with section 2.3.2.a of the NRC Enforcement Manual: NCV 05000397/2017007-01, "Failure to Evaluate and Control Nonconforming SSCs."

4OA6 Meetings, Including Exit

Exit Meeting Summary

On March 2, 2017, the inspectors presented the inspection results to Mr. M. Reddeman, Chief Executive Officer, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

D. Brandon, Design Engineering Manager

D. Brown, Systems Engineering Manager

S. Dallas, Engineer Principal

A. Elsey, EQ Program Manager

D. Gregoire, Regulatory Affairs and Performance Improvement Manager

J. Hauger, Supervisor, Electrical I&C Systems

J. Hedgecock, Assistant Operations Manager, Support

M. Holle, Supervisor, BOP Engineering

M. Huber, Continuous Improvement Coordinator, Maintenance

M. Hummer, Engineer Principal, Licensing

T. Mclaen, Engineer Principal

C. Olivier, Assistant Operations Manager, Training

T. Parmelee, Principal Engineer, Compliance

D. Senner, Supervisor, Supplier Quality

M. Shymanski, Supervisor, Quality Services

M. Sjoren, Engineer, Minor Modifications

K. Stauffer, Engineer Principal

D. Stephens, Assistant Operations Manager, Crew

G. Strong, Supervisor, I&C Design

J. Trautvetter, Maintenance Services Manager

R. Wainwright, Component Group Manager, Electrical

L. Walker, Trending and Self-Assessment Program Manager

D. Weber, Design Leader

D. Wolfgramm, Compliance Supervisor

NRC Personnel

D. Bradley, Resident Inspector

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

05000397/2017007-01 NCV Failure to Evaluate and Control Nonconforming SSCs (Section 4OA2.5)

LIST OF DOCUMENTS REVIEWED

Condition Reports

253882

290799

2758

2760

299909

2516

315069

315070

316380

316942

318360

321172

321368

21583

2256

23180

323281

323283

23284

23285

23286

23287

323288

323296

23313

323317

323337

23368

23401

23459

23666

323670

323677

23705

23713

23729

324023

324062

24071

24106

24110

324135

324146

24159

24160

24184

24254

324274

324302

24303

324304

324306

24374

24738

24739

24970

325146

325147

25189

25190

25191

325608

326248

26282

26573

26721

326996

327028

27143

27505

29272

29274

330654

330967

2054

332078

332565

2688

2700

333088

333128

333527

334133

334259

334459

336639

337295

337996

338097

338387

338392

338402

338429

339549

340134

340546

340834

340940

341324

341491

341507

342105

343062

343182

343760

343771

343786

344031

344160

345041

345577

346194

346261

346306

346679

346737

348194

348494

348583

349494

349585

349650

349912

350038

350393

350647

350866

351260

351571

2018

2219

352720

352938

2957

353037

353564

353697

354565

354588

354980

355027

355175

355469

355805

356418

356586

357370

357739

357985

358259

358665

358825

358841

359059

359064

359066

359072

359078

359157

359162

359175

359195

359206

359286

359316

359317

359318

359319

359320

359340

360005

360097

360343

360504

360819

360958

361029

361352

361359

361360

361441

361460

361461

361530

361777

361785

361940

361950

2034

2094

2101

362104

362106

Work Order

23010

1141855

1144408

1145663

1190859

2008233

2037502

2039187

2040823

2043605

2043801

2043817

2050318

2057031

2066173

2067045

2067241

2067243

2067253

2067254

2068839

2069005

2069006

2074914

2076992

2085135

2085983

2086044

2088230

2092224

2092689

2093228

2094683

EJ62

Work Request

29126776

Engineering Changes

EC13917 EC13992 EC13995 EC14698

EC14699

EC14861 EC15085 EC15407 EC15474 EC15576

EC15517

EC16976 EC16135 EC16170 EC16192 EC16223

EC16285

Classification Evaluation Records

C92-0272 C92-0308

C92-0432 C92-0650 C92-0828

C93-0279 C93-0432 C93-0574 Procedures Number Title Revision 1.3.66 Operability and Functionality Evaluation 33 1.3.68 Work Management Process 35

1.3.9 Temporary Modifications 53

1.5.13 Preventive Maintenance Optimization Living Program 36

10.25.231 DG1/DG2 Electronic Speed Control (Woodward 2301A) Setup and Test

10.25.4 Lubrication and Inspection of Limitorque MOV(s) 28 10.25.53 Inspection of Lighting Panel and Power Panels 9-11

10.25.53A Trouble Shooting Square D Model QMB DC Disconnect Switches 0 10.25.62 Transformer Inspection 27 26320 Pre-Job Brief Checklist 16 4.800.C5 800.C5 Annunciator Panel Alarms 31

CDM-01 Cause Determination Manual 16

DES-2-1 Plant Design Changes 57

DES-2-15 Engineering Change Revision 9

DES-2-18 Replacement Item Equivalency 7 ECP-DG3/INSP-

B101

HPCS-GEN-DG3 Electrical Inspection 12

ESP-SM8UV-M401 4.16KV Emergency Bus Degraded Voltage (SM8)-CFT 13

Procedures

Number Title Revision

EWD-47E-006 Electrical Wiring Diagram, Standby AC Power System Diesel Generator 2 Breaker E-CB-8/DG2

EWD-47E-007 Electrical Wiring Diagram, Standby AC Power System Diesel Generator 2 Breaker E-CB-DG2/8

GBP-AM-11 Long Range Planning on Current Year Funding 0

GBP-ERM-03 Enterprise Risk Management Program 7

MI-3.6.4 Work Package Closure 21

MUGM-01 MEL User's Guide Manual 11

OI-14 Columbia Generating Station Operational Challenges and Risk Program

OI-41 Operations Work Control Expectations 59

OI-69 Time Critical Operator Actions 9

OI-75 Operability Determination Quality Review Board 1

OPEX-01 Operating Experience Program Implementation Manual 8

OQAPD-01 Operational Quality Assurance Program Description (EN-QA-004)

OSP-ELEC-M701 Diesel Generator 1 - Monthly Operability Test 56

PJM-2-2 Project Plan Development 19 PPM 1.3.66 Operability and Functionality Evaluation 33

PPM 1.3.67 Operational Decision Making Process 16

PPM 1.5.11 Maintenance Rule Program 15

PPM 15.1.22 Plant Fire Extinguisher and Foam Cart Inspection 41 PPM 5.6.1 Station Blackout 28 PPM 6.2.1 New Fuel Handling Delivery Truck to Railroad Bay 26

PPM 6.2.2 New Fuel Handling Railroad Bay to Refuel Floor 30

PPM 6.2.3 New Fuel Handling on the Refueling Floor 37

PPM 6.2.4 New Fuel Inspection 32

QAP-ASU-01 Audit Performance 9

QAP-ASU-02 Quality Assurance Reports 3

QAP-ASU-03 Quality Assurance Records 2

SA-01 Self-Assessment/Benchmarking Manual 5

Procedures

Number Title Revision

SQI-10-3 Receiving Inspection 30 Standard-01 Worker Error Prevention Tools 10 Standard-03 Technical Human Performance Tools 2

SWP-ASU-01 Evaluations of Programs, Processes, and Suppliers 27

SWP-ASU-02 Self-Assessment and Benchmark Process 18

SWP-CAP-01 Corrective Action Program 36

SWP-CAP-05 Corrective Action Review Board (CARB) 20

SWP-CAP-06 Condition Report Review 23

SWP-CAP-07 Trending Program 10

SWP-LIC-02 Licensing Basis Impact Determinations 13

SWP-LIC-08 Preparation and Conduct of NRC Inspections 5

SWP-OPS-02 Safety Function Determination Program 6

SWP-OPX-01 Operating Experience Program 0

SWP-PRG-03 Snubber Program 0.002

SWP-PRO-01 Procedure and Work Instruction Use and Adherence 30

SWP-PRO-02 Preparation, Review, Approval, and Distribution of

Procedures

045

SWP-TST-01 Post-Maintenance Testing Program 16

Drawings

Number Title Revision 807E580AA Schematic Diagram, Wide Range Monitor,

Mean Square Voltage 7 E501G Motor Control Center Starter Details 9 E502-2 Main One Line Diagram 63

E503-1 Motor Control Center, General Notes MCC, and Starter Index 87 E503-1A Motor Control Center Starter Details 5 E503-1E Motor Control Center Starter Details 4 E543-2VA-3 Connection Wiring Diagram, Diesel Generator 1 & 2

E-CP-DG/RP1 & E-CP-DG/RP2

Drawings

Number Title Revision

EWD-47E-046 Electrical Wiring Diagram, Standby AC Power System Diesel Generator 1 Governor Speed Control

EWD-47E-047 Electrical Wiring Diagram, Standby AC Power System Diesel Generator 1 Governor Speed Control 11

EWD-50E-014 Electrical Wiring Diagram DC Distribution System, Distribution Panel E-DP-S1/2D

EWD-50E-033 Electrical Wiring Diagram DC Electrical Distribution System, Distribution panel E-DP-SO/B

EWD-50E-033A Electrical Wiring Diagram DC Electrical Distribution System, Distribution panel E-DP-SO/B, Power supply Arrangement and Instrumentation

EWD-50E-033C Electrical Wiring Diagram DC Electrical Distribution System, Distribution panel E-DP-SD/B, Circuit Details

S622 PCB Transformer Reservoir, MISC, Plans, Sections and Details 1

Quality Audits Number Title Date

AU-AD-16 Document Control and Records Management May 19, 2016

AU-CSQ-15 Cyber Security and Software Quality Assurance Programs December 16, 2015

AU-EN-16 Engineering Program February 18, 2016

AU-FP-16 Fire Protection Program January 28, 2016

AU-MM-16 Procurement, Storage, and Issue of Parts, Materials, and Services Programs November 22, 2016

AU-OP/TS-15 Operations, Technical Specifications, and Applicable License Conditions Programs August 20, 2015

AU-PC-16,

AU-EM-16, AU-OD-

16,

AU-RE-16,

AU-NR-16 Chemistry/REMP/Non-Rad & Rad Effluents/ODCM Program October 18, 2016

AU-QP/QA-15 Nuclear Industry Evaluation Program NIEP Audit of Columbia Generating Station October 26, 2015

AU-RP-RW-15 Radiation Protection and Process Controls Programs November 5, 2015

Quality Audits Number Title Date

AU-SP-15 Control of Special Processes Program July 27, 2015

AU-TQ-16 Training, Qualification, and Performance of Unit Staff June 30, 2016

Other Number Title Revision Date

Desktop Guide - operations condition report review September 29, 2014

Quality Aggregate Performance Indicator January 2017

Quality Combined Summary Report February 27, 2017

48-00,71 Westinghouse Vendor Manual Instruction manual for Power substation Transformer and Load Interrupter Switchgear January 3-9, 1999

Burns and Roe

WO 3900-4000 Flooding Analysis of the Pipe Break And Missile Study October 15, 1982

DCP 85-0383-0A Diesel Engine Electronic Governor Speed Control 0 E/1-02-15-02 Short Circuit and Coordination Study for E-PP-7AA when powered by inverter E-IN-3A or E-IN-3B

E/1-02-16-01 Calculation for 1E to Non-1E Interfaces 0

EC-0000013917 Close

HPCS-V-11, Deactivate

HPCS-MO-11, & Unplug

HPCS-RLY-80/V11 from its base

LBD-IST-SNUBBER-4 Snubber Program Plan 0 Manual 82301 Woodward MPU High Signal Selector 8272-132/-164/-310/-311 Installation and Operation Manual

C

ML17100A117

SUNSI Review:

ADAMS:

Non-Publicly Available

Non-Sensitive

Keyword:

NRC-002 By:

EAR

Yes

No

Publicly Available

Sensitive

OFFICE DRP/PBA DRS/EB1 DRS/EB1 DRS/EB2 DRP/PBA DRS/IPAT DRS/IPAT NAME GKolcum JBraisted CStott NOkonkwo JGroom ERuesch THipschman

SIGNATURE /RA-e/ /RA/-e /RA-e/ /RA-e/ /RA/-e /RA/-e /RA/ DATE 03/27/2017 03/28/2017 03/27/2017 03/28/2017 04/03/2017 04/03/2017 04/06/2017

E=EMAIL