ML031110335
| ML031110335 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/07/2002 |
| From: | Office of Nuclear Regulatory Research |
| To: | |
| References | |
| FOIA/PA-2003-0018 | |
| Download: ML031110335 (22) | |
Text
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002) kR(3PreDeision-ar Art Howell Ron Lloyd Ed Hackett Joe Donoghue Bob Haag Tom Koshy Pat Castleman Joelle Starefos Ronnie Bucci (Office of Inspector General)
Using modified IAEA approach: Fact Level; Conclusion Level; Root Cause. Conclusions are in bold and underlined; supporting facts are assigned beneath the conclusion. Other individual facts that require fact verification are shown as bold. Root Causes are designated by rc with associated conclusions mapped to each root cause.
WYlY: NRC and industrafailed to understandoperating experience relevant to nozzle cracking and boric acid corrosion rcl NRC and industry failed to assess operating experience relevant to nozzle cracking and boric acid corrosion b RCI NRC failed to follow-up on Generic Communications.
59 B RCI 62001 not used for DB (precursor events) 61 B RCl 62001 used 15 reactors (all RIV PWRs) 62 B RCI No insp followup of GL97-01 66 B RCI NRC followup for 88-05 audited 10 plants; DB acceptable 84 B RCI RI1I factored BU2001-01 commitments as part of Baseline prog.
129 B RC1 TI on BU2001-01 didn't address BA issues 132 B RC1 2515 IP do not look at BA/GC followup 133 B RC1 The old inspection program (9000 series) looked at OE issues 154 B RC1 # of Generic Comm (NRC) not corrected with # of events 156 B RC1 MD8.5 can't be followed because it hasn't been updated 160 B RC1 No NRC programmatic guidance for effectiveness review of generic comm.
November 14,2002 (11:31AM) I of 22
\D
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002) 161 B RC1 Sample/shotgun method for verification of generic comml implementation 164 B RC1 IP62001 deleted w/o considering why it existed 165 B RC1 NRC generated 17 boric acid generic communication 187 B RC1 11/93 SER recommended inspection (visual) or leak detection system 189 B RC1 11/93 SER recognized circumferential cracking, but didn't make recommendations 201 B RCl GL97-01 closeout for DB based on generic info 202 B RC1 DB was the only B&W licensee that didn't do inspections (ref GL97-0 1) NRC 232 B RC1 1972 requested enhanced ISI for BA corrosion 304 B RC1 1991 Action Plan - no evidence that it was done 310 B RC1 50.71e and Reg Guide changes to BA analysis not required in FSAR update ci RC1 NRC failed to implement procedures/programs failed to address implications of BA corrosion 14 CI RC1 Licensee stated that NRR knew about BA on head 15 CI RC1 SRI saw CR on BA on head 28 CI RC1 BA CRs not selected for PIR 29 CI RCl Abbreviated version (issue) of BA CRs not represented 33 CI RCl No apparent NRC followup of 96, 98 PCAQs 42 CI RCl Aware of BA on RPV head and didn't inspect 43 CI RC 1 SRI knew of flange leaks 49 CI RC1 DRP BC and former SRI (only) knew of flange leaks 50 CI RC1 Flange leaks not pursued 65 CI RCl1 1992 precursor insp no perf issues/no F/U of BA control prog November 14, 2002 (11:3 1AM) 2 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
-RYCsion-95 CI RC 1 RIII saw RC-2 as a material control problem -vs- boric acid prog prob 116 CI RC1 BC/SRI/RI didn't observe RPV head videos 128 CI RC1 RI reviewed CR/equivalent in some manner 130a CI RC1 BA buildup not a safety issue by NRC 169 CI RCI NRC 1993 SER addressed RVH nozzle cracks as not immed. safety issue 222 CI RCl NRC staff believed dry boric acid not corrosive 227 CI RC1 Industry and NRC were managing BA issue by leakage 229 CI RC1 NUMARC 1993 and NEI 1995 letters - GL88-05 will let the industry locate leaks before a real problem is identified 233 CI RCl 1993 2.206 Greenpeace response - cracking issues 295 CI RC1 Licensee asserted that NRC questioned how the licensee was able to do a visual insp. given that boron was left on the head, but never followed up cp RC1 NRC procedures/programs failed to address implications of BA corrosion 45 CP RC1 Neither of Residents received training on BA 105 CP RC1 NRC doesn't review owner's group input 155 CP RC1 NUREG 6245 (CRDM crack) NRC not aware of B&W content 226 CP RC1 Postulated breech of RPV not considered 228 CP RC1 NRC doesn't review all of the industry guidance on BA 167 F RC1 AEOD had 80+ FTE; now 2.5 FTE for OE (RES) h RC1 NRC failed to adequately assess relevant operating experience 157 H RC1 OE review in NRC not performed by independent or long review 163 H RC1 NRR is reactive for short-term/current event November 14,2002 (11:31AM) 3 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NNtOf4Dedsionab 166 H RCI NRC generic issue program takes too long/too hard ...use bulletins instead 170 H RC1 Foreign OE was reviewed by NRC 171 H RCl 70 LERs about Boric Acid leaks 172 H RC1 Axial cracks known from early 1970s, Circumferential from 1980s 173 H RC1 LIC-503 references some wrong procedures in RES 183 H RC1 No clear process for using foreign experience 184 H RC 1 French corrective actions were documented but never used 185 H RC1 Mind set that French CA was an over reaction from NRC perspective;
. aggressive inspection was reponse 186 H RC1 NRC never asked the French why they were replacing their RPV heads 188 H RC1 Swedish, Spanish, Japanese, French have replaced heads 193 H RCI NRR staff not aware BA leakage OE 196 H RC1 Conclusion in the EPRI guidebook not supported 209 H RC1 RES procedure 2i not used/not known by staff 210 H RC1 Cracking/BA corrosion not considered by either NRR or RES to be a GI (MD 6.4) 221 H RC1 License Renewal report (GALL) addresses acceptability of GL88-05 for aging management to be updated to reflect lessons learned 230 H RC1 GI program relies on user needs before taking action 231 H RC1 Preferred process flow for OE: nothing; IN; BU; GL; GI (all else fails) 242a H RC1 MNSA and roll expansion- repair ofjoints, boric acid issues NRC 303 H RC1 NRR did not review the French experience 312 H RC1 NUREG 5576 events RE: TP4 & Salem 2 not known within NRC 313 H RC1 Circumferential cracks not picked up by GIP screening program November 14,2002 (11:31AM) 4 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NVWC&PreDevisionfl 314 H RCI All B&W plants experienced circ cracks (except 1) 315 H RC1 Tracking of foreign experience cost 316 H RC1 NUREG 6245 CRDM experience not known within NRC/Industry i RC1 Licensee failed to understand implications of BA corrosion.
32 J RC1 BA on head was a "routine" CR 36 J RC1 1996 CR on BA stayed open for -2 years 130 J RC1 BA buildup not a safety issue by DB 155a J RC1 NUREG 6245 (CRDM crack) Industry not aware of B&W content 178 J RC1 BACC person also had many other duties as a system engineer 194 J RCI BWOG rep didn't know the significance of Brown/red tinted BA buildup 197 J RC1 Risk significance of BA on RPV head is low LIC 217 J RC1 BA procedure not "QA" until 5/02 234 J RC1 Mod on service structure delays 239 J RC1 Ombudsman & cleaning statements 274 J RC1 PRG staff didn't viewed head tapes 275 J RC1 Former VP viewed as-found, not after tape until Fall2001 282 J RC1 Only staff involved in head cleaning 296 J RC1 PCAQ 96-0551 was one of ten oldest CRs before it was resolved 298 J RC1 Multiple people involved in head cleaning w/o raising issues 302 J RC1 ISI summary only included outside CRDMs 325 J RC1 1993 topical report is same issue as Davis-Besse 339 J RC1 DB banking on another 5-years beyond Oconee cracking experience 342 J RC1 DB and ANO late in implementing service structure port mod November 14, 2002 (11:31AM) 5 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NRCPreDecisiii-n-al 347 J RC1 Former VP didn't see BA on head as important m RC1 Licensee failed to learned from internal/external OE.
68 M RC1 DB's BACC didn't include Rx head/instr until 5/02 151 M RC1 Oconee OE not evaluated at DB until 5/2002 152 M RC1 OE in US ...Boric acid leaks. #1 area was CRDM, DB considered not significant 153 M RC1 100% B&W units had RCS PB leakage 162 M RC1 DB OE procedure doesn't require NRC LER review 168 M RC1 100% CE had RCS pressure boundary leakage 174 M RC1 45% of Oconee cracking (CRDM) appears in the same quadrant as DB leakage problems 175 M RC1 CE plants dominated RCS instrumentation nozzle leakage (10 of 13 leaks) 176 M RC1 Average # of operating years prior to CRDM leakage -22 years 179 M RC 1 Foreign experience would indicate that the "crack" model is flawed 191 M RC1 NUREG/CR 6245 recommended enhanced online leakage detection systems (NRC?)
192 M RC I Calvert Cliffs LER indicated wet boron vs dry 198 M RC 1 Annealing nozzle temps were different than required 200 M RC1 3 LERS involved pzr material wastage 242 M RC1 MNSA and roll expansion- repair ofjoints, boric acid issues LIC 276 M RC1 Two precursor BA events ...RC2, SG line 308 M RC1 1998 DB had a resin intrusion 314 M RC1 All B&W plants experienced circ cracks (except 1) 316 M RC1 NUREG 6245 CRDM experience not known within NRC/Industry 327 M RCI D-B should have been industry leader following the RC-2 event November 14,2002 (11:31 AM) 6 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002) 1345 lM RC1 ManyCRsonBACbutnoevidenceoftracking 346 M RC1 RCS system engineer not aware of 1996 PCAQ I November 14,2002 (11:31AM) 7 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NR'G=IreDetsioirdl rc2 Industry failed ensure that previouslX identified BA leakage issues were resolved and corrective actions were effectively implemented i RC2 Licensee failed to implement owners group guidance.
202a I RC2 DB was the only B&W licensee that didn't do inspections (ref GL97-
- 01) LIC 236 I RC2 No BWOG verification for implementation of GL97-01 237 I RC2 No BWOG verification for implementation of GL88-05 247 I RC2 No tracking system to ensure that industry guidance was included in site guidance/ processes.
261 I RC2 93 B&W report flange leaks need to be eval first 289 I RC2 BA corr handbook shows CAC/RM as evidence of RCS leak 322 I RC2 Former RCS system engineer not aware of 1993 B&W guidance 329 I RC2 Licensee did not view enhanced visual inspection to be commitment 341 I RC2 B&W topical assumed that BA leakage was found and repaired k RC2 Licensee failed to resolve chronic RCS leakage.
24 K RC2 Routine CAC cleaning 108 K RC2 CAC/RM fouling may have been the impetus for TS change in #107 109 K RC2 HEPA filter for RM may defeat the purpose of the RM workarounds -
vs- fix the problem 119 K RC2 Licensee not rigorous in finding RCS leaks 120 K RC2 Licensee deleted Mode 3 walkdown for BA 235 K RC2 CAC fouling and ALARA 244 K RC2 DB entered a 6-hour shutdown TS situation because of RM Problems with BA 248 K RC2 Ability to differentiate between flange leakage/ head penetration leakage 255 K RC2 Until RFO13 lic had flange leaks November 14,2002 (11:31 AM) 8 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002) 4 IB:reDecisional, 262 K RC2 Heavy boron buildup on CACs 268 K RC2 No systematic leak search for 12RFO 269 K RC2 Deleted mode 3 walkdown 273 K RC2 Long history of thermowell leaks 280 K RC2 Triage plan for flange leak / didn't fix all flange leaks 287 K RC2 100% NDE 5.7Rem estimate <past head cleaning 300 K RC2 Relief valve mod masking other leaks in 1998-99 time frame 330 K RC2 Containment >1 20F on several occasions 331 K RC2 CAC cleanings occurred as early as 1997 332 K RC2 Lic root cause didn't identify CAC cleaning in 1997 334 K RC2 CAC cleaning being tracked as a high dose job 335 K RC2 CACIRM not identified as a workaround 338 K RC2 SV temp mod failed to assess leakage 343 K RC2 Ops lack of ownership of plant material problems 344 K RC2 BACC program manager couldn't find all components in BACC program I RC2 Licensee failed to properly implement an adequate BACC program.
34 L RC2 1996 CR explicit on the BA concern 35 L RC2 -50% of RPV head cleaned in 1996 70 L RC2 BAC checklists not kept/tracked/trended 123 L RC2 None of the RPV head cleanings were 100%
124 L RC2 Lost control of video tapes 144 L RC2 BAC procedure wasn't followed 251 L RC2 Appropriate cleaning methods for RPV head (water-vs-vacuum)
November 14,2002 (11:31AM) 9 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
WC-PreeDeisional 254 L RC2 #4, 5 nozzles still had boron on them following cleaning 260 L RC2 Couldn't complete head cleaning due to schedule pressure 263 L RC2 Potential CRDM G9 leak was crack, not dispositioned 266 L RC2 RCS sys engr: scaffold was removed without permission 267 L RC2 RP considered head cleaning as decon, so no procedure 279 L RC2 No deviations from RFO12 WO to clean RPV head 281 L RC2 RCS sys engineer upset that they head wouldn't be totally cleaned 283 L RC2 Index of head tapes incomplete 284 L RC2 4/17/00 head mislabeled as as-left 285 L RC2 Head inspection tape not documented as to what was actually inspected - QA zip 301 L RC2 Molpus slides show that licensee understood BAC in 1999 [RC-2 event]
n RC2 Licensee staff resources & experience 159 N RC2 40-50% DB staff decrease over 10 years 238 N RC2 O&Mlcapital budget and actuals have decreased over last 10-years 246 N RC2 Multiple job assignments depending on cycle (outage, ops, EP) 256 N RC2 VP - No NDE tools by 12/31 277 N RC2 Lack of system engineer continuity 317 N RC2 Region I few resources/staff with materials backgrounds (NRC/DB) 333 N RC2 Inflation adjusted O&M decreased over period 1991-2001 q RC2 Licensing program guidance and implementation failed 31 Q RC2 We rely on lic to give NRC correct info 115 Q RC2 NRR PM limited visits to DB 182 Q RC2 After the RPV head videos were shown to the NRC, a vote was taken:
3 for shutdown; remaining (10-13) voted to allow continued operation November 14,2002 (11:31AM) 10 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002) v . .
AW2PWeDecisional-204 Q RC2 No process for verifying licensee info for continued operation 207 Q RC2 Some PM haven't visited plants 208 Q RC2 PM didn't review commitment change reports 211 Q RC2 NRR not implementing procedures 212 Q RC2 LA/SE for RM for RCS leakage didn't consider DB OE 213 Q RC2 NRR perception was that DB was a good performer 297 Q RC2 No NRC review of submittals/reports (ISI) I November 14,2002 (11:31AM) 11 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
AXRC-PreDecisionalh rc3 NRC failed to accurately assess DB safety performance a RC3 NRC failed to adequately assess symptoms of RCS leakage.
12 A RC3 CAC/Rad Monitor cleaning known by NRC through BC level 13 A RC3 BA on head known by SRI during RFO12 16 A RC3 RIII (Grant) knowledge of Rad Monitor 18 A RC3 BCs logs on CAC/RMs & discussed in morning meetings 19 A RC3 CAC cleaning observed by inspectors (DRS) 20 A RC3 PM knew about CACs 22 A RC3 DRP BC listed CAC cleaning (2001) 23 A RC3 RIII didn't see CAC/RM cleaning as important 37 A RC3 Long time to close out CRs 38 A RC3 No one suggested NRC look at RCS leakage in containment during PIR 41 A RC3 3 inspection reports discussing RMs without conclusions 52 A RC3 RIII didn't view leakage as a problem 58 A RC3 Multiple cleaning of CACs 76 A RC3 No documentation of CAC evaluation inspection 77 A RC3 No NRC doc of RM leak detection reliability insp.
83 A RC3 No open items for CACIRM or BA on head 87 A RC3 Pzr safety valve mod increased leakage; NRC accepted without question 88 A RC3 Assumed Pzr safety valve leakage was reason for CAC fouling 97 A RC3 CR for CAC/RM not seen as safety-sig would be screened out 98 A RC3 NRC Briefing package for Merrified didn't include BA problems 107 A RC3 TS requirements for CAC/RM were relaxed November 14,2002 (11:31AM) 12 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
N1-PreDecisionaI 118 A RC3 BC didn't tell RI to pursue BA issues 125 A RC3 RA knew of CAC issues eia RC3 NRC failure to adequately integrate Davis-Besse safely performance data 1 EIA RC3 Region viewed Davis-Besse as good performer.
21 EIA RC3 One PPR summary listed CAC cleaning 46 EIA RC3 Inspection on RM didn't provide any performance issues 54 EIA RC3 CCW event (10/98) resulted in Spec Insp 55 EIA RC3 NRC prompted Lic regarding RCS leak on MUIA described as positive in IR 56 EIA RC3 DB PIR viewed as the best by RIII 121 EIA RC3 NRC thought that the licensee was rigorous in their leak hunt 138 EIA, RC3 Range of opinions on whether an AIT/IlT/SI eii RC3 NRC failure to adequately inspect Davis-Besse safety performance 25 EIl RC3 PI&R/40500 did not review area 27 Ell RC3 Gap of 2 1/2 years between CA inspections (missed events) 39 EU RC3 Inspection reports don't list all docs reviewed (6 years of reports) 44 EU RC3 RC-2 escalated enforcement didn't require closeout inspection 51 EU RC3 Former SRI did not perform any followup on leak hunt plan RFO12 72 EU RC3 Verbatim comp. W/insp procedures (not there/can't do) 78 EU - RC3 1997 NOP/NOT walkdown by NRC found no leaks 96 EII RC3 RIII had differing views for RC-2 violation followup 122 ElI RC3 RI thought the RPV head was 100% cleaned 127 ElI RC3 ALARA insp didn't show that CAC cleaning was largest dose November 14,2002 (11:31AM) 13 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NR-PreDecisiondJ 181 EIl RC3 (Other than SRI ) NRC not told about red/brown BA buildup until after the DB event 223 EII RC3 Extending the inspection for DB was largely based on the belief that a "strong" VT-2 inspection was done at DB 270 EII RC3 Kerosene burner not eval'd for ctmt 271 EII RC3 No oper eval for the clogging of CACs 272 EIl RC3 Non-conservative assumption of LOCA steam clean CACs 278 EIl RC3 Lie didn't complete all RC2 CAs 290 EII RC3 No doc'd eval of CAC clogging 294 EU RC3 Inadequate temp mod safety eval on code safety seat leakage 309 EII RC3 Region III 1998 ISI inspection reviewed flange bolts, housing but didn't indicate BA ...corresponded with timing for BA on head and cleaning 340 ElI RC3 96, 98, 00 CRs indicate brown colored boron ...no record of NRC review of two f RC3 NRC staff resources & experience 2 F RC3 NRC staffing level not filled for all positions 3 F RC3 One year period (1999), only one Resident on site.
4 F RC3 Project Engineer - two 8-month gaps.
5 F RC3 Resident inspectors not certified.
6 F RC3 SRI position delayed in filling.
7 F RC3 High Project Manager turnover rate (9 PMs in 10-years) 9 F RC3 Limited commercial nuclear experience RI 10 F RC3 Resident inspector had a materials background 11 F RC3 SRI experience with only DB containment 40 F RC3 Low number of inspection hours compared to other RIII sites (12 in
_1999)
November 14,2002 (11:31 AM) 14 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
AWRGPreDecisional 53 F RC3 1998 events diverted inspection efforts re:BA issues 57 F RC3 Resident not aware of OOS logs 63 F RC3 PE little time at DB (1997& 1999) 92 F RC3 Between PE coverage gaps, 8 months/3months coverage/8 months 93 F RC3 BC had Clinton 0350 plant coincident w/DB 110 F RC3 RIII resources decreasing 111 F RC3 RHII insp contractor support poor 112 F RC3 RiII too many competing priorities which detract from insp.
131 F RC3 No 1245 cert requirements for BA corrosion 158 F RC3 Contract support after '98 report dried up (staff decreased/# reports decreased) 215 F RC3 No guidance for background training for PM 317 F RC3 Region I few resources/staff with materials backgrounds (NRC/DB) 318 F RC3 ASME Code knowledge/representation g RC3 NRC failed to communicate critical information regarding Davis-Besse safety performance 17 G RC3 Other than DD-DRP; limited recollection of CAC/RM issues by RIII SES managers 94 G RC3 NRR inspection branch has no feedback form on Plant status time as addressed by RI interview 101 G RC3 Procedure for RIII morning meeting isn't followed 102 G RC3 RIII not conducive to info exchange 103 G RC3 Senior RIII Managers not the audience for the morning meeting 117 G RC3 RI not aware of FeO on CAC 126 G RC3 RA didn't know about BA on head 136 G RC3 IRO didn't participate to follow MD8.3 for AIT determination November 14, 2002 (11:31AM) 15 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
JVR&PreDecisional 137 G RC3 NRRLRIII didn't follow MD8.3 180 G RC3 Story differences between what DB told NRC -vs- what NRC thought they were told about BA by DB 203 G RC3 Deferral of DB shutdown not well documented 216 G RC3 Interviews indicate that NRR and RIII communications poor/nonexistent 291 G RC3 Late arrival of calcs for crack propagation o RC3 Licensee failed to communicate critical information 150 0 RC3 Lie Response to BU2001-01 contained many inaccurate info /response 177 0 RC3 Many licensee (DB) staff thought that a whole head inspection/cleaning was done 180 0 RC3 Story differences between what DB told NRC -vs- what NRC thought they were told about BA by DB 181 0 RC3 (Other than SRI ) NRC not told about red/brown BA buildup until after the DB event 240 0 RC3 BU2001-01 documentation responses by DB not accurate 241 0 RC3 12-16 people at DB reviewed DB response to BU2001-01 257 0 RC3 VP -Ops last know 264 0 RC3 Lic Managers / staff knew of head cleaning %, lower staff thought that head was 100% cleaned 265 0 RC3 Lic managers said they showed NRC the as-found video tapes of the head 321 0 RC3 Current VP said that engineering would know before Ops 326 0 RC3 E-mail makes D-B look bad for RPV head cleaning 328 0 RC3 Unclear as to who viewed the post cleaning video tape (DB) 336 0 RC3 12RFO QA audit of head cleaning was positive 337 0 RC3 Discrepancies with internal documents on whether head cleaned or not November 14,2002 (11:31AM) 16 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
CPar-eDecisionaL
- 348 0 l RC3 I Ops didn't view video tapes l November 14, 2002 (1 1:31AM) 17 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NRCPreDecisional.
rc4 NRC and industry failed to establish adequate requirements and guidance d RC4 NRC failed to establish adequate requirements.
139 D RC4 Enforcement history doesn't equate with OE 140 D RC4 Lack of enforcement for RCS leakage 141 D RC4 Enforcement/NRR trying to figure out what should be done for RCS leakage 142 D RC4 1997 SONGS nozzle cracking cited Maintenance Rule 143 D RC4 NRC response (policy) not consistent - SONGS/Oconee 145 D RC4 No ASME Code requirement (of inspections/RCS leakage) 146 D RC4 Code didn't require insulation to be removed for inspections 147 D RC4 VC Summer had RCS leakage and didn't report it 149 D RC4 Enf discretion issued for VCSummer and Oconee; no enf discretion or enforcement on ANO 205 D RC4 12/31/2001 was an arbitrary date for shutdown; basis question 219 D RC4 Code did not require insulation removal (VT-2) 243 D RC4 Enhanced visual meant for circ, not axial cracking (vol NDE) 245 D RC4 ANO a through wall CRDM crack is a statistical certainty 253 D RC4 Several CRDM nozzles cracked, some through wall NRC 305 D RC4 Nov 2001, NRC indicated that they did not like ASME code (VT-2) 307 D RC4 ASME code allows plant to start up from outage with known code class 1 flange leaks 319 D RC4 Age related risk from passive components not captured in PRA ep RC4 NRC failed to provide adequate Reactor Oversight Process (ROP) guidance.
26 EP RC4 PI&R samples began 1999 for 3/01 (gap issue) 60 EP RC4 62001 cancelled in 10/01 November 14,2002 (11:31AM) 18 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NR&-PreDecisiowql 64 EP RC4 Limited entries into containment by NRC 67 EP RC4 NRC audit (GL88-05) of BAC didn't include Rx headlinstr 71 EP RC4 Two people felt that there were not enough hours in ROP for (BA) inspections didn't allow some inspection 73 EP RC4 Can't go outside of the baseline unless you have a >green finding 74 EP RC4 Baseline inspection doesn't include structures or passive components 75 EP RC4 Some good practices ceased following ROP implementation (ex.
containment closeout insp) 82 EP RC4 ISI didn't have inspection guidance to look at A600 nozzles 85 EP RC4 RIII issued SL3 for RC-2; would be a green finding today 89 EP RC4 RIII invoked MC0350 w/o DB having met criteria 90 EP RC4 DB event risk not completed yet 91 EP RC4 SDP has taken 5 months 106 EP RC4 MC2515 AppD doesn't provide thorough guidance for review of CR 113 EP RC4 Only 1 SES manager inside containment since 1996 114 EP RC4 Limited senior manager visits to DB 134 EP RC4 No NRC requirement to review employee concerns 225 EP RC4 Over-reliance on a risk information -vs- deterministic 252 EP RC4 62001 intended for 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> every other outage 293 EP RC4 All PI's green prior to event 311 EP RC4 Lessons learned weren't learned from previous lessons learned reviews (South Texas, Millstone, IP2) p RC4 Industry failed to provide adequate guidance and oversight relevant to nozzle cracking and boric acid leakage control.
196 P RC4 Conclusion in the EPRI guidebook not supported 199 P RC4 "Boric acid on the head is good."
November 14,2002 (11:31AM) 19 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
-NRwPreDecisionar 214 P RC4 INPO ratings declined from I to 2 within the last few years 218 P RC4 B&W didn't recommend the service structure mod 220 P RC4 DB experienced no insulation deflections caused by BA buildup on the head 259 P RC4 Lic did not eval use of power washer on head 306 P RC4 BWOG/Framatome indicated that they made no recommendations for service structure mods 323 P RC4 INPO noted chronic RCS leaks, but not BA on head 324 P RC4 INPO noted ALARA positive for CAC cleaning by power washer 350 P RC4 Vendor testing not representative of actual installation November 14,2002 (11:31AM) 20 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
NRrreDe monv1 w RC6 Awaiting additional review 345 W RC6 Many CRs on BAC but no evidence of tracking x RC6 Deleted 8 X RC6 PM inspection approach changing.
30 X RC6 CRs reviewed for PI&R -7000 47 X RC6 Neither the old/new insp programs found/discussed RM issues 48 X RC6 SSDI insp in 2000 indicated performance was worse than expected 69 X RC6 40500 insp in '98 indicated that commitment tracking NG 79 X RC6 SRI 97-98 no recollection of flange leaks 80 X RC6 Former SRI works for FENOC 81 X RC6 1992 uptake event insp closeout, then 1998 uptake occurred 86 X RC6 RC-2 event would have not gone beyond baseline 99 X RC6 PI&R doesn't allow independent look by inspectors 100 X RC6 Some interviews indicated RI/SRI not as visible in ctmt and CR post ROP 104 X RC6 PI&R team leader thought that the short form description of CR was adequate 135 X RC6 RIII inspector was told that DB was SALP 1 didn't take findings seriously (arrogant) 138 X RC6 Range of opinions on whether an AIT/HT/SI 148 X RC6 Nothing in allegation area was relevant to BA/cracking issues 190 X RC6 Staff action plan GL97-01 can't be found 195 X RC6 BACC person indicated that the next major nuclear accident will be caused by BAC 197a X RC6 Risk significance of BA on RPV head is low NRC 206 X RC6 PMs don't conduct site visits November 14,2002 (11:31AM) 21 of 22
Davis-Besse Lessons Learned Task Force Meeting (8/5-7/2002)
WRG-PreDecisiowalF 224 X RC6 Risk informed process didn't alert the NRC to a potential risk 249 X RC6 Bonus correlation with operations 250 X RC6 Basis for dose estimates for RPV head inspections 258 X RC6 Eng received closed door talking to for CR initiation 286 X RC6 Lic is doing an assessment of BU2001-01 submittal 288 X RC6 No VT-2 insp during RF012 per RCS sys eng 292 X RC6 QA group didn't have a problem with BAC RFO12 report shows positive finding 299 X RC6 Same job done by Framatome at other plants?
320 X RC6 Too much focus on PRA vs deterministic 349 X RC6 High turnover on BWOG positions from DB staff November 14, 2002 (11:31AM) 22 of 22