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05000528/FIN-2014404-09Licensee-Identified Violation2015Q1
05000528/FIN-2014005-02Licensee-Identified Violation2014Q4Title 10 CFR 55.49, Integrity of Examinations and Tests, requires, in part, that facility licensees shall not engage in any activity that compromises the integrity of any application, test, or examination required by this part. Contrary to the above, during the week of November 12, 2013, the licensee caused a compromise to examination integrity by exceeding, 50 percent overlap on exam items during the same examination cycle. Specifically, the licensee repeated three of the required five job performance measures from one week to the next. The failure to meet 10 CFR 55.49 was evaluated through the traditional enforcement process because it impacted the ability of the NRC to perform its regulatory oversight function. This resulted in assignment of a Severity Level IV violation because it involved a nonwillful compromise of examination integrity and is consistent with Section 6.4.d of the NRC Enforcement Policy. The associated performance deficiency was screened as Green because there was not an actual effect on the equitable and consistent administration of any examination required by 10 CFR 55.59, Requalification. The licensee entered this issue into their corrective action program as Condition Report 4578169.
05000528/FIN-2014005-03Licensee-Identified Violation2014Q4Title 10 CFR 50.59(d)(1) requires, in part, that the licensee shall maintain records of changes in the facility, of changes in procedures, and of tests and experiments made pursuant to paragraph (c) of this section. These records must include a written evaluation which provides the bases for the determination that the change, test, or experiment does not require a license amendment pursuant to paragraph (c)(2) of this section. Contrary to the above, prior to August 28, 2014, the licensee failed to perform an evaluation against the criteria in 10 CFR 50.59(c)(2) for a change to the facility. Specifically, the licensee identified that Licensing Document Change Request 04-F020, performed on March 4, 2005, had changed the FSAR description of the auxiliary feedwater system. The new revision stated that portions of the auxiliary feedwater system, which are not contained within a Seismic Category I structure or installed underground, have been analyzed to show that the probability of being struck by a tornado missile is sufficiently low and do not require tornado missile protection. Previously, the FSAR described that all components of the auxiliary feedwater system were either enclosed by a Seismic Category I structure or are installed underground. This change had been inappropriately screened out of the 50.59 process in 2005. The licensees 50.59 screening did not recognize that this change to the FSAR description constituted a de facto change to the design of the facility. Consequently, the licensee failed to perform an evaluation against the criteria in 10 CFR 50.59(c)(2). On August 28, 2014, the licensee recognized the auxiliary feedwater recirculation lines do not meet the original FSAR criteria of being protected from tornado missiles. The licensee initiated PVAR 4568732 to document the lack of tornado missile protection for the auxiliary feedwater minimum flow recirculation lines. The licensee performed an immediate operability determination on August 29, 2014 and determined that there was a reasonable expectation that the auxiliary feedwater system would provide adequate decay heat removal following a tornado. The inspectors reviewed the licensees operability determination and verified that the licensee intends to submit a license amendment request for acceptance of the as-built configuration of the auxiliary feedwater system. Because the failure to implement the requirements of 10 CFR 50.59 had the potential to impact the NRCs ability to perform its regulatory function, the team evaluated the performance deficiency using traditional enforcement. In accordance with Section 2.1.3.E.6 of the NRC Enforcement Manual, the inspectors evaluated this finding using the significance determination process to assess its significance. The finding required a detailed risk evaluation because it involved the failure of two or more trains in a multi-train system. A Region IV senior reactor analyst performed a bounding detailed risk evaluation and determined that the bounding delta-CDF was less than 3.5E-8/year. In accordance with Section 6.1.d of the NRC Enforcement Policy, this violation is categorized as Severity Level IV violation because the resulting change was evaluated by the SDP as having very low safety significance (i.e., Green finding). This issue has been entered into the licensees corrective action program as CRDR 4570021.
05000528/FIN-2014005-01Failure to Verify the Adequacy of the Design of the Diesel Fuel Oil Cooler2014Q4The inspectors reviewed a self-revealing Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the licensees failure to adequately review the suitability of materials of the diesel fuel oil cooler. Specifically, the Unit 2 A diesel generator fuel oil cooler design allowed for the interface of two dissimilar metals which promoted galvanic corrosion. This corrosion ultimately affected the structural integrity of the cooler and rendered the A Essential Spray Pond inoperable. In response to this, the licensee has replaced all six of the fuel oil cooler covers and initiated a design change to remove the fuel oil cooler from service. The licensee has entered the issue into the corrective action program as Condition Report Disposition Request 4543394. The failure to verify the adequacy of the design of the diesel fuel oil cooler was a performance deficiency. The performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems cornerstone to ensure the availability, reliability, capability of systems that respond to initiating events to prevent undesirable consequences. Specifically the Unit 2 A diesel fuel oil cooler design allowed for the interface of two dissimilar metals which promoted galvanic corrosion. The corrosion ultimately affected the structural integrity of the cooler and rendered the Unit 2 A spray pond inoperable. In accordance with NRC Inspection Manual 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The finding screened to a detailed risk evaluation because it involved a potential loss of one train of safety related equipment for longer than the outage time allowed by technical specifications. By performing a detailed risk evaluation, a Region IV senior reactor analyst determined that the associated change to the core damage frequency was 1.5E- 7/year (Green). The dominant core damage sequences included loss of offsite power events that lead to station blackout conditions. The gas turbine generators and the auxiliary feedwater system helped to minimize the risk. This finding has no cross-cutting aspect because it is not indicative of current performance.
05000528/FIN-2014004-02Failure to Provide Adequate Technical Justification for Operability2014Q3The inspectors identified a Green non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to provide an adequate technical justification for continued operation of a degraded structure, system, or component. Specifically, after discovering that the turbine driven auxiliary feedwater pump exhaust line did not have any tornado missile protection, operators performed an immediate operability determination and declared the system operable. The inspectors determined that the licensee did not provide adequate technical justification for continued operation with this condition because: (1) the evaluation relied on a probabilistic risk assessment that assumed the turbine driven auxiliary feedwater pump fails due to impact from a tornado missile, and (2) the evaluation assumed that a future analysis would provide satisfactory results. In response to the inspectors concerns, plant personnel subsequently completed an analysis that provided a reasonable expectation that the turbine driven auxiliary feedwater pump would be able to perform its safety function if impacted by a tornado missile. The licensee entered this issue into the corrective action program as Palo Verde Action Request 4255816. The inspectors concluded that the failure of plant personnel to adequately evaluate the operability of a safety-related structure, system, or component was a performance deficiency. The inspectors concluded the performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors performed the initial significance determination for the performance deficiency using NRC Inspection Manual 0609, Appendix A, Exhibit 4, External Events Screening Questions, dated July 1, 2012. The finding required a detailed risk evaluation because the turbine driven auxiliary feedwater pump is one train of a system that supports a risk significant function. Therefore, a Region IV senior reactor analyst performed a bounding detailed risk evaluation. The change to the core damage frequency was determined to be 7E-10/year (Green). The dominant core damage sequences included a tornado induced loss of offsite power initiating event, failure of the turbine driven auxiliary feedwater pump, and random failures of the motor driven auxiliary feedwater pumps. The low frequency for the tornadoinduced loss of offsite power initiating event helped to minimize the risk significance. The inspectors determined this finding has a cross-cutting aspect in the area of human performance because the licensee failed to utilize a conservative bias in its evaluation of the missing tornado missile protection, considering the risk significance of the turbine driven auxiliary feedwater pump and lack of any technical evaluation.
05000528/FIN-2014004-03Inadequate Calculations to Support the Degraded Voltage Relay Setpoint2014Q3The team identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the licensees failure to assure the adequacy of degraded voltage relay (DVR) setpoints. Specifically, the team identified that the licensee failed to perform calculations to demonstrate the voltage setpoints for the installed degraded voltage relays would afford adequate voltage to safety-related loads during worst case accident loading. The failure to assure the adequacy of DVR setpoints for voltage and the time delay by performing adequate voltage drop calculations was a performance deficiency. This finding is more than minor because it was associated with the design control attribute of the Mitigating Systems cornerstone and it adversely impacted to the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events. Specifically, the failure to properly ensure that safety-related electrical devices had adequate voltage could impact their safety function. The basis for this conclusion was that despite the non-conservative voltage inputs to voltage calculations and, therefore, loss of design margin for available voltage, there was still adequate voltage for the circuits to perform their safety function based on worst case voltage as demonstrated in the updated calculations. The licensee developed design basis calculations for its DVR voltage setpoints and committed to develop a plant design change and an associated license amendment to shorten the existing time delay in Technical Specication 3.3.7.3(a). There is no cross-cutting aspect associated with this finding because it is a historical condition and not indicative of current performance.
05000528/FIN-2014004-01Failure to Translate Design Basis Requirements for Establishing Operability of Spray Pond System2014Q3The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the failure to correctly translate the mission time of the essential spray pond system into a procedure used to determine operability. In response to the inspectors concerns, the licensee re-evaluated essential spray pond operability determinations that had used the erroneous 26-day mission time and concluded that acceptable margin was available to ensure the system would remain operable for the 30-day mission time. The licensee entered this issue into the corrective action program as Palo Verde Action Request 4550539. The failure to ensure that design basis information associated with the mission time of the essential spray pond system was correctly translated into a procedure used to determine operability was a performance deficiency. This performance deficiency was more than minor because if left uncorrected, it had the potential to lead to a more significant safety concern. Specifically, the failure to use the correct mission time when determining operability could establish nonconservative results that could lead to the essential spray pond system not being able to meet its design safety function. The inspectors performed an initial screening of the finding in accordance with NRC Manual Chapter IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Using IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, dated July 1, 2012, this finding is of very low safety significance (Green) because it: (1) was not a deficiency affecting the design or qualification of a mitigating system; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of a single train for greater than its technical specification allowed outage time; and (4) does not represent an actual loss of function of one or more non-technical specification trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for greater than 24 hours. This finding has a cross-cutting aspect in the area of human performance because the licensee failed to create and maintain complete, accurate, and up-to-date documentation. Specifically, after initially recognizing the adverse condition, the licensee did not document a standing order or temporary procedure change to prevent operability evaluations from using the incorrect essential spray pond mission time.
05000528/FIN-2014003-02Licensee-Identified Violation2014Q2Palo Verde Nuclear Generating Station Unit 1 Operating License Condition 2.C(7), Unit 2 Operating License Condition 2.C(6), and Unit 3 Operating License Condition 2.F required, in part, that the licensee implement and maintain, in effect, all provisions of the approved fire protection program as described in the Final Safety Analysis Report for the facility, as supplemented and amended, and as approved in the Safety Evaluation Report (SER), through Supplement 11. Palo Verde Nuclear Generating Station Updated Final Safety Analysis Report, Section 9.5.1.3, stated, in part, that fire protection has been achieved consistent with 10 CFR Part 50, Appendix R, Part III, Sections G, J, and O. Appendix R, Section III.G.2, states, in part, that where cables or equipment, including associated non-safety circuits that could prevent operation or cause maloperation due to hot shorts, open circuits, or shorts to ground, of redundant trains of systems necessary to achieve and maintain hot shutdown conditions, are located within the same fire area outside of primary containment, one of three means of protecting cables to ensure that one of the redundant trains is free of fire damage shall be provided. Contrary to the above, on October 4, 2013, the licensee identified that non-safe shutdown cables that shared common electrical cable trays with safe shutdown cables were not electrically protected, and therefore, did not provide means of protecting the cables to ensure that the credited train of safe shutdown equipment would be free of fire damage. Specifically, the licensee identified that the battery ammeter circuits which provide control room current indication for the train B and D, class 1E batteries and battery chargers do not include overcurrent protection features to limit fault current. During a postulated fire event in the control room, fire-induced failures could have damaged the ammeter circuits, resulting in a secondary fire and damage to other safe shutdown cables that are in direct physical contact with these cables, which could affect the availability of equipment needed to place the plant in a safe shutdown condition. A senior reactor analyst performed a detailed risk evaluation and the bounding change to the core damage frequency was less than 3.6E-7/year. The dominant core damage sequences involved a control room fire initiating event in Panel B01, a secondary cable fire in a cable tray associated with one train of safety related equipment, and having the alternate train of safety related equipment out of service for maintenance. The low fire frequency and the normal train separation and protection, that are required by the fire protection program, helped to minimize the significance. The licensee entered this violation into its corrective action program as Condition Report/Disposition Request 4458522. The licensee established compensatory measures in the affected fire zones and initiated corrective actions to install fuses in the affected circuits. The licensee submitted Licensee Event Report 05000528;529;530/2013-003-00 to report this issue. Refer to Section 4OA3 of this inspection report for the review and closure of the licensee event report.
05000530/FIN-2014003-01Failure to Follow Operator Challenges Procedure2014Q2The inspectors identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations personnel to follow station procedures to ensure that appropriate contingency actions are entered in the operator challenge listing in the control room. Specifically, upon discovery that the pressurizer master level controller could not be placed into manual mode on February 20, 2014, the licensee did not prescribe appropriate contingency actions for operation of the pressurizer level control system. As a result, on March 15, 2014, Unit 3 exceeded the pressurizer maximum level mandated by Technical Specification 3.4.9. The licensee subsequently replaced the faulty controller and has entered this issue in their corrective action program as Palo Verde Action Request 4540981. The failure of operations personnel to follow station procedures for identifying, documenting, and tracking operator challenges was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it adversely affected the configuration control attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to document an operator work around in the pressurizer level control system allowed operators to place the system in a configuration that challenged the availability, reliability, and capability of the pressurizer to respond to reactor coolant system pressure transients. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance because the licensee did not challenge the uncertain condition of the pressurizer level controller. Specifically, after identifying the unexpected failure of the pressurizer level controller, operations personnel did not fully evaluate and manage the risks associated with the degraded condition before proceeding.
05000528/FIN-2014003-03Leakage on Reactor Vessel Bottom-Mounted Instrumentation Nozzle 32014Q2On October 6, 2013, during an examination of the bottom mounted instrument (BMI) nozzles on the reactor vessel of Unit 3, white residue was discovered at the annulus region of Nozzle 3. The residue was collected for testing and identified as boron, lithium and trace amounts of primary water radionuclides, which was indicative of pressure boundary leakage during the operating cycle. Pressure boundary leakage is prohibited by Technical Specification 3.4.14. Non-destructive examination of Nozzle 3 identified axial cracking in the nozzle tube and a near-surface weld flaw in the J-groove weld that connects the nozzle to the reactor vessel. This allowed for a reactor coolant leak path in the pressure boundary. Corrective actions included completion of an American Society of Mechanical Engineering (ASME) Code approved half-nozzle repair and increasing the frequency of bottom mounted instrument visual examinations to every refueling outage. An extent of condition evaluation found no indication of unacceptable flaws or leakage in the remaining 60 BMI nozzle assemblies in Unit 3. Additionally, review of past inspections did not identify any evidence of leakage from bottom mounted instrument nozzles in Units 1 or 2. Destructive testing determined the cause of the event was primary water stress corrosion cracking of the bottom mounted instrument nozzle due to a weld defect that went undetected during fabrication. Inspectors reviewed all available causal information to assess if there was an opportunity to correct this condition prior to failure of the pressure boundary. Inspectors determined that initial installation and examinations of the affected weld were completed within the specifications used at the time of fabrication. Only surface examinations of the root weld pass, and inspections at every 0.5 in of weld thickness were required, and there was an allowance for cold straightening of nozzles, if required. As such, the defect associated with the weld during fabrication was not reasonably within the licensees ability to foresee, prevent, and correct. Therefore, the inspectors determined that no performance deficiency occurred. The issue is considered within the traditional enforcement process because there was no performance deficiency associated with the violation of NRC requirements. Inspection Manual Chapter 0612, Power Reactor Inspection Reports, Section 0612-09 states, in part, that such violations are dispositioned using traditional enforcement and may warrant enforcement discretion. The NRC Enforcement Policy, Section 6.1 (Reactor Operations), was reviewed to evaluate the significance of this violation. This violation was more than minor and best characterized at Severity Level IV (very low safety significance) because it is similar to Enforcement Policy Section 6.1.d.1. Additionally, a qualitative assessment of the observed RCS leakage condition concluded the risk was of very low safety significance (Green). The basis for this qualitative risk determination was that the leakage rate was very small with little boron residue accumulation on the lower reactor vessel head and no appreciable accumulation on the structures beneath the vessel. Any leakage was within the capability of RCS makeup systems. Additionally, detailed inspections did not reveal any loss of vessel material. The NRC decided to exercise enforcement discretion in accordance with Section 3.5 of the NRC Enforcement Policy and refrain from issuing enforcement action for the violation of Technical Specification 3.4.14.a (EA-13-232) for the following reasons: this issue is of very low safety significance (Green); it was determined that this issue was not within the licensees ability to foresee and correct; the licensee's actions did not contribute to the degraded condition; and the actions taken were reasonable to identify and address this matter. Further, because the licensees actions did not contribute to this violation, it will not be considered in the assessment process or the NRCs Action Matrix. Specific documents reviewed during this inspection are listed in the attachment. This licensee event report and its supplement are closed.
05000528/FIN-2014405-01Security2014Q2
05000528/FIN-2014007-03Licensee-Identified Violation2014Q1On September 24, 2013, the licensees Nuclear Assurance Department identified in corrective action audit 2013-008 that the station had not established an effective schedule for completion of corrective actions for systems, structures, and components that had been determined to be degraded or nonconforming. These degraded or nonconforming conditions were conditions adverse to quality. Title 10 CFR 50, Appendix B, Criterion XVI requires that the licensee establish measures to ensure that conditions adverse to quality are promptly identified and corrected. Contrary to this requirement, the licensee failed to establish measures to ensure that these conditions adverse to quality were promptly corrected. This violation is of very low safety significance (Green) because the degraded structures, systems, and components remained operable. The licensee entered the condition into its corrective action program, performed an apparent cause evaluation under CRDR 4458511, and initiated corrective actions to restore compliance.
05000528/FIN-2014002-05Licensee-Identified Violation2014Q1Technical Specification Limiting Condition for Operation (LCO) 3.2.1, Condition A, requires that if the Core Operating Limit Supervisory System (COLSS) calculated core power exceeds the Core Operating Limit Supervisory System calculated core power operating limit based on linear heat rate (LHR), actions must be taken to restore linear heat rate to within limits, within one hour. Technical Specification Limiting Condition for Operation 3.2.4, Condition A, requires that if Core Operating Limit Supervisory System calculated core power is not within limits, actions must be taken to restore the Departure from Nucleate Boiling Ratio to within limits, within one hour. If these actions are not completed, Technical Specifications Limiting Condition for Operation 3.2.1, Condition C, and Limiting Condition for Operation 3.2.4, Condition C, require that thermal power be reduced to less than 20 percent of rated thermal power within six hours. Contrary to the above, on December 3, 2013, Unit 3 operations personnel failed to reduce rated thermal power in accordance with the actions specified in Technical Specifications Limiting Condition for Operation 3.2.1, Condition C, and Limiting Condition for Operation 3.2.4, Condition C. Specifically, on December 3, 2013, while recovering from a dropped control element assembly, Unit 3 operators inappropriately exited Limiting Condition for Operation 3.2.1 and Limiting Condition for Operation 3.2.4, resulting in the licensee exceeding the allowed completion time of Condition C by 12 minutes. Licensee engineering personnel identified this condition during a post-event review of plant data on December 15, 2013. The licensees subsequent cause evaluation determined that the operating crew had inappropriately exited Limiting Condition for Operation 3.2.1 and Limiting Condition for Operation 3.2.4 prior to fully understanding and reconciling instrument and alarm discrepancies. Planned corrective actions will revise Procedure 40DP-9OP02, Conduct of Shift Operations, to add guidance and actions for operators prior to exiting a Limiting Condition for Operation. Procedure 40AO-9ZZ11, CEA Malfunctions, will also be revised to incorporate lessons learned from this event. The inspectors used the NRC Inspection Manual Chapter 0609, Attachment 0609.04, Initial Characterization of Findings, and concluded that the finding is of very low safety-significance (Green) because the finding did not affect a reactor protection system trip signal, did not involve control manipulations that unintentionally added positive reactivity, and did not result in a mismanagement of reactivity by operators. The issue has been entered into the licensees corrective action program as Action Request 4485144.
05000528/FIN-2014002-02Failure to Comply with Technical Specification 3.7.22014Q1The inspectors identified a non-cited violation of Technical Specification Limiting Condition for Operation 3.7.2, Condition G, for the failure of plant personnel to follow the actions specified in Technical Specification 3.7.2 for one main steam isolation valve inoperable in Mode 1. Specifically, following the failure of main steam isolation valve 170 on November 6, 2013, Unit 1 operators exceeded the Technical Specification time requirement to place the Unit in Mode 2 before restoring operability of the equipment. The licensee entered this issue into the corrective action program as Action Request 4521714. The failure of plant personnel to perform the actions specified in Technical Specification 3.7.2, Condition G, was a performance deficiency. The performance deficiency is more than minor and therefore is a finding, because it affected the human performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors performed the initial significance determination for the failed MSIV-170. For this evaluation, the valve was failed in the open position. The inspectors used NRC Inspection Manual Chapter 0609, Attachment 0609.04, Initial Characterization of Findings, and NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, to determine that the finding screened to a detailed risk evaluation because it involved a potential loss of one train of safety-related equipment for longer than the technical specification allowed outage time. A Region IV senior reactor analyst performed the detailed risk evaluation, which determined that the finding was of very low safety significance. This finding had a cross-cutting aspect in the area of human performance, associated with the aspect of consistent process, because the licensee did not use a consistent, systematic approach to make decisions regarding the operability of main steam isolation valve 170 (H.13).
05000528/FIN-2014002-06Licensee-Identified Violation2014Q1Title 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, requires, in part, that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, prior to November 15, 2013, the licensee failed to correct a condition adverse to quality. Specifically, on October 9, 2013, the licensee found foreign material in one of the Unit 3 steam generators. The licensee determined the material to be from an uncaptured Flexitallic gasket in the feedwater system. This material resulted in a wear scar on a steam generator tube, and as a result the affected tube was plugged. On December 12, 2006, the licensee discovered foreign material in a Unit 2 steam generator. That material required plugging of the tube, and was also from Flexitallic gaskets in the feedwater system. The licensees apparent cause evaluation for the 2006 event identified that the use of uncaptured Flexitallic gaskets was the source of the foreign materials. The cause evaluation assigned no corrective action to replace these gaskets with a captured design that minimizes the potential for foreign material generated from the gaskets. The licensee entered the issue into the corrective action program as Condition Report Disposition Request 4466275 and initiated corrective actions to replace the non-captured gaskets with captured caskets. The inspectors used the NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process for Findings At-Power, and concluded that the finding is of very low safety significance (Green) because the finding did not involve a degraded steam generator tube condition where one tube could not sustain 3 times the differential pressure across a tube during normal full power, steady state operation, and because the steam generators did not violate accident leakage performance criterion.
05000528/FIN-2014002-03Failure to Establish Adequate Procedures for Performing Nitrogen Pre-Charge Checks2014Q1The inspectors reviewed a self-revealing, non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to prescribe activities affecting quality by documented procedures of a type appropriate to the circumstances. Specifically, the licensee failed to establish appropriate procedures for performing nitrogen pre-charge checks of the main steam isolation valve (MSIV) accumulators. As a result of the licensees failure to establish appropriate procedures, the Unit 1, main steam isolation valve 170 hydraulic oil reservoir catastrophically failed on November 6, 2013, rendering the main steam isolation valve and both of its accumulators inoperable. The licensee entered this issue in the corrective action program as Condition Report Disposition Request 474316. The licensees failure to prescribe nitrogen precharge checks by documented procedures of a type appropriate to the circumstances was a performance deficiency. The performance deficiency is more than minor and therefore is a finding, because it affected the procedure quality attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors performed the initial significance determination for the failed main steam isolation valve 170. For this evaluation, the valve was failed in the open position. The inspectors used the NRC Inspection Manual Chapter 0609, Attachment 0609.04, Initial Characterization of Findings. The inspectors used the NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The finding screened to a detailed risk evaluation because it involved a potential loss of one train of safety related equipment for longer than the technical specification allowed outage time. A Region IV senior reactor analyst performed the detailed risk evaluation, which determined that the finding was of very low safety significance. The inspectors determined this finding has a cross-cutting aspect in the area of problem identification and resolution, associated with the operating experience aspect, because the licensee did not effectively evaluate internal operating experience when establishing procedures for the main steam system (P.5).
05000528/FIN-2014002-01Failure to Follow Protected Equipment Procedure2014Q1The inspectors reviewed a Green self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of Projects personnel to follow station procedures which required obtaining permission from either the work control or operations department prior to performing work in the vicinity of protected train equipment. As a result, Projects personnel inadvertently tripped a breaker to the emergency diesel generator A essential fan, rendering the emergency diesel generator inoperable and requiring entry into Condition B of Technical Specification 3.8.1, AC Sources Operating. Operations personnel subsequently reset the breaker, returned the emergency diesel generator to operable status and exited Condition B of Technical Specification 3.8.1. The licensee entered this issue in the corrective action program as Condition Report Disposition Request 4495126. The failure of plant personnel to follow station procedures for protected equipment was a performance deficiency. The performance deficiency is more than minor and therefore is a finding, because it was associated with the Mitigating Systems Cornerstone attribute of equipment performance and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609 Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors determined that the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined the finding had a cross-cutting aspect in the area of human performance associated with the training aspect, because the station did not provide adequate training to supplemental workers to ensure an understanding of standards and work requirements, in that the workers did not recognize either the safety significance of the equipment located in the vicinity of the work area or the potential impact of their actions (H.9).
05000528/FIN-2013009-03Failure to Establish Adequate Procedures for an Alternate Source of Spray Pond Inventory2014Q1The team identified a Green, non-cited violation of Technical Specification 5.4.1, which states, in part, Written procedures shall be established, implemented, and maintained covering the following activities: Part a. The applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Section 6 of Regulatory Guide 1.33, Appendix A, requires procedures for combating emergencies and other significant events. Specifically, prior to January 24, 2014, emergency procedures to provide make-up water to the essential spray pond beyond its 26-day water inventory did not provide sufficient details and contained inaccuracies for supplying the essential spray ponds with water from the regional aquifer via a well. In response to this issue, the licensee confirmed that there had never been an event at the site for which the procedure would have been utilized. This finding was entered into the licensees corrective action program as Palo Verde Action Requests (PVARs) 4496901, 4497291, 4498167, and 4499085. The team determined that the failure to establish adequate procedures for an alternate source of spray pond inventory was a performance deficiency. This performance deficiency was more than minor because it adversely affected the Mitigating Systems Cornerstone attribute of Procedure Quality and affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the continuous capability of the ultimate heat sink to perform its safety function beyond the 26-day inventory of the essential spray ponds was not ensured. In accordance with Inspection Manual Chapter 0609, Appendix A, Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 2, Mitigating Systems Screening Questions, the issue screened as having very low safety significance (Green) because it was a design or qualification deficiency that did not represent a loss of operability or functionality; did not represent an actual loss of safety function of the system or train; did not result in the loss of one or more trains of nontechnical specification equipment; and did not screen as potentially risk-significant due to seismic, flooding, or severe weather. The team determined that this finding did not have a cross-cutting aspect because the most significant contributor did not reflect current licensee performance
05000528/FIN-2013009-04Failure to Follow Surveillance Testing Procedure2014Q1The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, which states, in part, Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Specifically, between November 5, 2010 and September 17, 2012, the licensee failed to follow Procedure 73DP-9ZZ14, Surveillance Testing, Step 3.6.1, Failed Step or Out-of-Tolerance Data, which requires personnel to write a Palo Verde Action Request (PVAR) when a failed surveillance test is encountered. On three separate occasions, the licensee failed to initiate a Palo Verde action request when the containment air lock door seal surveillance test failed. In response to this issue, the licensee confirmed that minor maintenance had been performed on the containment air lock door seals immediately following the failure of the surveillances and the surveillances then met the procedure requirements. This finding was entered into the licensees corrective action program as Palo Verde Action Requests (PVARs) 4499119 and 4499123. The team determined that the failure to follow Procedure 73DP-9ZZ14, Surveillance Testing, which required maintenance personnel to write a Palo Verde action request upon the failure of a surveillance test, was a performance deficiency. This performance deficiency was more than minor because if left uncorrected, it would lead to a more significant safety concern. Specifically, by not initiating Palo Verde action requests for failed surveillances, the licensee missed the opportunity to enter the failures into their corrective action program, perform formal operability determinations, consider the conditions for identification of maintenance rule functional failures, identify performance trends, and ultimately, correct the adverse condition in a timely manner. In accordance with Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 3, Barrier Integrity Screening Questions, the issue screened as having very low safety significance (Green) because it did not represent an actual open pathway in the physical integrity of reactor containment and did not involve an actual reduction in function of hydrogen igniters in the reactor containment. This finding had a cross-cutting aspect in the area of human performance because licensee leaders failed to ensure that personnel, equipment, procedures, and other resources are available and adequate to support nuclear safety.
05000528/FIN-2014007-02Failure to Follow Station Process for Root Cause Evaluation2014Q1The inspectors identified a Green finding for the failure of station personnel to follow procedures to implement root cause evaluations. Specifically, approximately one third of the root cause evaluations reviewed by inspectors resulted in a probable cause with further information needed to validate the cause. Of this subset, eighty percent of the evaluations did not adhere to station processes. The failure of station personnel to follow station procedures to implement root cause evaluations was a performance deficiency. The performance deficiency was more than minor, therefore a finding, because if left uncorrected the performance deficiency could become a more significant safety concern in that significant conditions adverse to quality could reoccur prior to the implementation of appropriate corrective action. The finding is associated with multiple cornerstones, though it is most closely associated with the Mitigating Systems Cornerstone and the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent and systematic approach when making decisions (H.13).
05000528/FIN-2013009-05Improper Extension of Surveillance Interval for Surveillance Requirements Associated with the Engineered Safety Features Actuation Signal System Sequencer and Relays2014Q1The team identified a Green, non-cited violation of Technical Specification 5.5.18, Surveillance Frequency Control Program which states, in part, This program provides controls for Surveillance Frequencies. The program shall ensure that Surveillance Requirements specified in the Technical Specifications are performed at intervals sufficient to assure the associated Limiting Conditions for Operation are met. Part (b) states, Changes of the Frequencies listed in the Surveillance Frequency Control Program shall be made in accordance with NEI 04-10, Risk-Informed Method for Control of Surveillance Frequencies, Revision 1. Specifically, prior to February 3, 2014, previous regulatory commitments for the engineered safety features actuation signal system surveillance test frequencies were not properly addressed as required by Technical Specification 5.5.18.b and NEI 04-10. The licensee did not follow the guidance of NEI 04-10 when they revised the Surveillance Frequency Control Program to test each train of the engineered safety features actuation signal system from every 18 months to every 36 months. In response to this issue, the licensee confirmed that the engineered safety features actuation signal system remained operable because the system had been tested satisfactory and none of the technical specification surveillances were overdue. This finding was entered into the licensees corrective action program as Palo Verde Action Requests (PVARs) 4500910 and 4500874. The team determined that the failure to adequately address a regulatory commitment when extending the surveillance testing frequency associated with the engineered safety features actuation signal system was a performance deficiency. This performance deficiency was more than minor because it was associated with the Mitigating Systems Cornerstone attribute of Equipment Performance, and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of the engineered safety features actuation signal system to respond to initiating events to prevent undesirable consequences. Specifically, the NRC commitment identified in document RCTSAI 7673 committed the licensee to: the BOP ESFAS system will be fully tested at least every 18 months at the time of refueling. When making a change to the Surveillance Frequency Control Program associated with the surveillance test frequency of the engineered safety features actuation signal system, the licensee failed to collect and review all commitments made to the NRC as required by NEI 04-10, Risk-Informed Method for Control of Surveillance Frequencies, Revision 1, and failed to follow the requirements of NEI 99-04, Guidelines for Managing NRC Commitment Changes, Revision 0. In accordance with NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 2, Mitigating Systems Screening Questions, the issue screened as having very low safety significance (Green) because it was a design or qualification deficiency that did not represent a loss of operability or functionality; did not represent an actual loss of safety function of the system or train; did not result in the loss of one or more trains of non-technical specification equipment; and did not screen as potentially risk-significant due to seismic, flooding, or severe weather. This finding had a cross-cutting aspect in the area of human performance because the licensee leaders did not use a systematic process for evaluating and implementing change so that nuclear safety remains the overriding priority.
05000528/FIN-2014002-04Failure to Declare an Unusual Event2014Q1The inspectors identified a non-cited violation of 10 CFR 50.54(q) for the failure of operations personnel to implement the emergency plan in response to a certain emergent event. Specifically, on November 6, 2013, after the hydraulic reservoir for main steam isolation valve 170 exploded during a nitrogen pre-charge pressure check, plant operators did not declare an Unusual Event as required by the emergency plan. The licensee entered the issue into the corrective action program as Action Request 4522120 and initiated an apparent cause evaluation to identify the cause and corrective actions. The failure to implement the emergency plan and declare an Unusual Event is a performance deficiency. The performance deficiency is more than minor, and therefore is a finding, because not classifying an event potentially puts the public at risk and affected the Emergency Preparedness Cornerstone attribute of emergency response organization performance. The inspectors evaluated the finding using Manual Chapter 0609, Appendix B, Emergency Preparedness Significance Determination Process, and determined to be of very low safety significance (Green). This finding was entered into the licensees corrective action program as Action Request 4522120. This finding has a crosscutting aspect in the area of human performance associated with the aspect of consistent process, because the licensee did not use a consistent, systematic approach to make decisions (H.13).
05000528/FIN-2014007-01Failure To Provide Adequate Technical Justification For Operability of Containment Spray and Diesel Fuel Oil Systems2014Q1The inspectors identified multiple examples of a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations personnel to follow station procedures used to perform operability determinations. Specifically, operations personnel failed to provide sufficient technical justification for the reasonable assurance of operability of a degraded condition involving one train of containment spray system and nonconforming conditions associated with diesel fuel oil piping. The inspectors concluded the failure of operations personnel to follow station procedures to perform operability determinations was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a consistent process cross-cutting aspect in the area of human performance because the licensee did not use a consistent and systematic process to make decisions (H.13).
05000528/FIN-2013009-02Deficiencies in Emergency Diesel Generator Engine Room and Control Room Ventilation Air Flow Testing and Evaluation2014Q1The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XI, Test Control, which states, in part, A test program shall be established to assure that all testing required to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. Specifically, in June, 2013, the licensee failed to evaluate performance test results when high air flow measurements from the emergency diesel generator engine room and control room ventilation air flow performance tests contained values that were beyond the capability of the equipment. Consequently, the condition of the higher measured airflow had not been evaluated to determine if the test results were valid. In response to this issue, the licensee confirmed that the equipment had remained operable, based on the review of more accurate testing performed in 2006. This finding was entered into the licensees corrective action program as Palo Verde Action Request (PVAR) 4500070. The team determined that the failure to establish and incorporate adequate air flow acceptance criteria into the emergency diesel generator control room supply fan and engine room exhaust fan performance tests was a performance deficiency. This performance deficiency was more than minor because it adversely affected the Mitigating Systems Cornerstone attribute of Equipment Performance and affected the cornerstone objective to ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to incorporate adequate acceptance criteria into the safety-related equipment performance tests was a significant deficiency of test control which could cause unacceptable fan performance conditions to go undetected. In accordance with Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 2, Mitigating Systems Screening Questions, the issue screened as having very low safety significance (Green) because it was a design or qualification deficiency that did not represent a loss of operability or functionality; did not represent an actual loss of safety function of the system or train; did not result in the loss of one or more trains of nontechnical specification equipment; and did not screen as potentially risk-significant due to seismic, flooding, or severe weather. This finding had a cross-cutting aspect in the area of human performance because the licensee failed to use decision-making practices that emphasize prudent choices over those that are simply allowable.
05000528/FIN-2013009-01Failure to Translate Design Basis Requirements for Establishing Operability of the Spray Pond System2014Q1The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, which states, in part, Measures shall be established to assure that applicable regulatory requirements and the design basis, are correctly translated into specifications, drawings, procedures, and instructions. These measures shall include provisions to assure that appropriate quality standards are specified and included in design documents and that deviations from such standards are controlled. Specifically, prior to February 7, 2014, the licensee used Engineering Calculation 13-NS-C088, Mission Times for EW, SP, SI, AF, and DG systems, for establishing a 26-day mission time of the spray pond system instead of a 30-day availability time as required by Regulatory Guide 1.27, Ultimate Heat Sink For Nuclear Power Plants, and approved in their safety evaluation report. Consequently, spray pond system operability determinations performed per Procedure 40DP-9OP26, Operations PVAR Processing and Operability Determination/ Functional Assessment, used the incorrect mission time. In response to this issue, the licensee performed a review of the operability determinations in question using 30 days for the mission time and confirmed that the spray pond system remained operable and maintained an adequate safety margin. This finding was entered into the licensees corrective action program as Palo Verde Action Request (PVAR) 4500910. The team determined that the failure to ensure that design basis information associated with the mission time of the spray pond system was correctly translated into a procedure used to determine operability was a performance deficiency. This performance deficiency was more than minor because it adversely affected the Mitigating Systems Cornerstone attribute of Equipment Performance and affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to use the correct mission time when determining operability was a significant deficiency of design control in that operability determination evaluations could establish nonconservative results that could lead to the spray pond system not being able to meet its design safety function. In accordance with Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 2, Mitigating Systems Screening Questions, the issue screened as having very low safety significance (Green) because it was a design or qualification deficiency that did not represent a loss of operability or functionality; did not represent an actual loss of safety function of the system or train; did not result in the loss of one or more trains of non-technical specification equipment; and did not screen as potentially risk-significant due to seismic, flooding, or severe weather. This finding had a cross-cutting aspect in the area of human performance because the licensee implemented an engineering study with inaccurate information establishing the incorrect mission time used in operability d.eterminations for the spray pond system.
05000528/FIN-2013005-04Licensee-Identified Violation2013Q4Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, on August 29, 2013, operations personnel failed to accomplish an activity affecting quality in accordance with procedures. Specifically, the operations personnel did not have a technical basis for declaring the essential spray pond system operable when it was not in a seismic configuration analyzed in the current licensing basis. Removal of a spray pond piping spool piece during planned maintenance on Unit 3 emergency diesel generator A resulted in the inoperable spray pond train. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609 Appendix A, The Significance Determination Process (SDP) for Findings at-Power. Inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered no. The licensee entered the issue into the corrective action program as PVAR 4450413.
05000528/FIN-2013005-01Inadequate Modification of Safety Related Accumulators2013Q4The inspectors identified a Green non-cited violation of 10 CFR 50, Appendix B, Criterion III, Design Control, for the failure to assure that a modification to the main steam and main feedwater isolation valve accumulators was suitable for the reliable operation of these components. Specifically, on September 4, 2009, the licensee failed to assess the suitability of a small dead band for a thermal relief valve in the accumulator valve manifold assembly and the impact on reliable operation of the associated valves. The licensee entered this issue into the corrective action program as Palo Verde Action Request 4429273. The licensee isolated the thermal relief valve from the actuators. The failure to assure that the modification of the main steam and main feedwater isolation valve accumulators was suitable for the reliable operation of these components was a performance deficiency. The performance deficiency is more than minor, and therefore is a finding, because it was associated with the Mitigating Systems Cornerstone attribute of equipment performance and adversely affects the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609 Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The inspectors concluded the finding was of very low safety significance (Green) because all questions in Exhibit 2 could be answered in the negative. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance associated with resources component because the licensee did not maintain design margins by minimizing long standing equipment issues.
05000528/FIN-2013005-03Licensee-Identified Violation2013Q4Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, prior to October 26, 2012, the licensee failed to have an adequate test procedure to perform safety injection check valve testing. Specifically, the licensee identified that latent test procedure deficiencies allowed a cold leg safety injection header manual drain valve common to both emergency core cooling system (ECCS) trains to be open without an evaluation that ECCS flow requirements would be satisfied. The licensee identified that deficiencies in previous revisions of surveillance test (ST) procedure 73ST-9SI05, Leak Test of HPSI/LPSI Containment Isolation Check Valves, existed since 1983 and that failure to have adequate test procedures to prevent a flow diversion of the ECCS could result in a degraded condition and prevent a safety related system from performing as design. To prevent recurrence, the licensee revised the procedure to ensure the minimum required ECCS flow is available during safety injection check valve testing. The inspectors determined that the finding represented a loss of system function and needed a detailed risk evaluation. The significance of this error was bound by using an exposure period composed of the accumulated time that this activity was performed when procedures would have allowed for this configuration. This exposure period was approximately 7 hours. The inspectors used the Palo Verde Standardized Plant Analysis Risk (SPAR) model, Revision 8.20, dated May 31, 2012, with a truncation limit of E-11, to perform simplified calculations. Inspectors considered one train unavailable for high pressure safety injection and only two pathways available for injection on the redundant train, as bounding assumptions for the analysis. The incremental conditional core damage probability, assuming one year of exposure, for these sequences was 3.0E-6. The change to the core damage frequency (delta-CDF) considering the 7 hour exposure period was therefore: delta-CDF = 3.0E-6 * 7hour/8760 hours per year = 2.4E-9/year Since the change to the core damage frequency was less than 1.0E-7/year, the inspectors were not required to consider the contribution from external events or calculate the change to the large early release frequency. Since the calculated delta CDF was less than 1E-6, and the large early release frequency was not a significant contributor, the finding was of very low safety significance (Green). A Region IV senior reactor analyst reviewed the results and agreed with the conclusion. The licensee entered the issue into the corrective action program as PVAR 4430283.
05000529/FIN-2013005-02Failure to Replace Oil Soaked Insulation Results in a Fire2013Q4The inspectors reviewed a Green self-revealing finding for the licensees failure to promptly identify and correct an adverse condition. Specifically, the licensee failed to identify that operating limits for main feedwater pump (MFP) vapor extractors did not prevent lube oil leakage, and insulation surrounding the Unit 2 train A MFP became soaked with oil. As a result, the oil soaked insulation, exposed to hot surface temperatures over time, became degraded and initiated a fire in the turbine building, resulting in declaration of an unusual event. No violation of regulatory requirements occurred because the finding occurred on non-safety secondary plant equipment. The licensee entered the finding into the licensees corrective action program as Condition Report Disposition Request 4458504 and 4452395. The failure to promptly identify and correct an adverse condition was a performance deficiency. The performance deficiency is more than minor, and therefore is a finding, because it was associated with the Initiating Events Cornerstone and was a precursor to a more significant event which resulted in a fire and an emergency declaration. The inspectors assessed the significance of the finding in accordance with NRC Inspection Manual Chapter (IMC) 0609, appendix A, Significance Determination Process for Findings At-Power, using Exhibit 1, Initiating Events Screening Questions. The finding required a detailed risk evaluation because it resulted in increasing the fire frequency. A Region IV senior reactor analyst performed the detailed risk evaluation. The bounding change to the core damage frequency was 1.0E-7/year (Green). The most prominent core damage sequences included a transient coupled with various failures of the auxiliary feedwater and main feedwater pumps. The automatic runback function of the feedwater control system helped to minimize the change to the core damage frequency. The inspectors determined the finding has a cross-cutting aspect in the area of problem identification and resolution associated with the operating experience (OE) component because the licensee failed to implement and institutionalize OE through changes to station processes, procedures, equipment, and training programs to ensure MFP turbine vapor extractors are operated appropriately and that fire hazards associated with oil soaked insulation are promptly identified and corrected.
05000528/FIN-2013407-01Security2013Q4
05000528/FIN-2013004-02Failure to Include Inspection Requirements in Preventative Maintenance Basis2013Q3The inspectors identified a Green finding for the failure of licensee personnel to follow Procedure 30DP-9MP08, Preventive Maintenance Program. Specifically, plant personnel did not ensure that requirements for performing inspection and replacement of degraded tie-wraps in electrical cubicles were contained in preventative maintenance basis documents. Consequently, degraded cable tie-wraps in Unit 1 load center L02, were not inspected prior to, and resulted in a catastrophic electrical fault on July 2, 2013. The licensee rebuilt the load center cubicle and has entered this issue into their corrective action program as Palo Verde Action Request 4454845. The failure to follow established procedures for updating preventive maintenance basis documents with requirements and recommendations from previous component failures was a performance deficiency. This performance deficiency is more than minor, and therefore is a finding, because it was associated with the procedure quality attribute of the Initiating Events Cornerstone and adversely affects the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, by not including the requirements and recommendations from the history of previous failures in the preventive maintenance basis, the licensee did not consider pertinent operating experience when evaluating changes to the preventive maintenance program. Consequently, the licensee did not inspect degraded cable tie-wraps in Unit 1 load center L02, prior to experiencing a catastrophic electrical fault on July 2, 2013, that upset plant stability. The inspectors used the NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, to determine the significance. The finding was of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. The issue had a cross-cutting aspect in the area of problem identification and resolution associated with the operating experience component because the licensee did not implement and institutionalize operating experience through changes to the stations preventive maintenance program.
05000528/FIN-2013004-01Failure to Maintain an Effective Emergency Plan for a Seismic Event2013Q3The inspectors identified a non-cited violation of 10 CFR 50.54 (q)(2) for the failure to maintain an effective emergency plan action level scheme in accordance with 50.47(b)(4). Specifically, the Alert threshold for HA1.1, Natural or Destructive Phenomena Affecting VITAL AREAS, requires a declaration of an Alert for a seismic event greater than operating basis earthquake as indicated by any force balance accelerometer reading greater than 0.10g. Operators rely on alarms to verify ground acceleration beyond the operating basis earthquake and the inspectors determined the seismic monitor alarm set point was 0.13g. This could result with the inability of operations personnel to classify an event at the Alert level. A design change modified the seismic monitoring set point to 0.1g and restored compliance. The licensee entered the issue into their corrective action program as Palo Verde Action Request 3624077. The failure to maintain an effective emergency action level scheme was a performance deficiency. The performance deficiency was more than minor, and therefore is a finding, because it adversely affected the Emergency Response Organization Performance attribute of the Emergency Preparedness Cornerstone and its objective to ensure that the licensee is capable of implementing adequate measures to protect the health and safety of the public in the event of a radiological emergency. Specifically, the licensees ability to declare an Alert based on Natural Phenomenon at the correct threshold was degraded. The inspectors assessed the significance of the finding in accordance with the NRC Inspection Manual Chapter 0609, Appendix B, Emergency Preparedness Significance Determination Process, Figure 5.4-1, and determined the finding to be of very low safety significance because compensatory measures were available for emergency response organization personnel to perform the classification duties. The inspectors determined the cause of this finding is not indicative of current performance and therefore no cross-cutting aspect is assigned.
05000528/FIN-2013003-03Failure to Implement Corrective Action for Embedded Operator Work Around2013Q2Title 10 CFR 50.59(c)(1) requires, in part, that a licensee may make changes in the facility as described in the final safety analysis report without obtaining a license amendment pursuant to Section 50.90 only if a change to the technical specifications incorporated in the license is not required. Contrary to the above, between 2003 and March 8, 2013, the licensee made changes to the reactivity of fuel discharged to the spent fuel pool without obtaining a license amendment. Specifically, the licensee received license amendments for power uprates in 2003 and 2005, but did not recognize the impact of the power uprates relative to spent fuel pool criticality. Consequently, the licensee did not update the spent fuel pool criticality analysis of record and did not request a license amendment to revise the affected Technical Specifications 3.7.17 and 4.3.1.1. On March 8, 2013, the licensees engineering staff discovered that the spent fuel pool analysis of record had not been updated to account for the replacement steam generator power uprate. The power uprate required higher moderator and fuel temperatures within the core, thereby increasing plutonium production, which in turn increases the reactivity of the spent fuel. This condition resulted in Technical Specifications 3.7.17 and 4.3.1.1 being non-conservative. The licensee initiated PVAR 4363316 to document the condition and issued an Event Notification to the NRC to report an unanalyzed condition. The licensee also performed a prompt operability determination to show that despite the non-conservative technical specifications, the fuel in the spent fuel pool remains in a safe configuration. The licensee planned corrective actions to revise the spent fuel pool analysis of record using updated methodology and input parameters. Traditional enforcement applied to this finding because it involved a violation that impacted the regulatory process. Assessing the violation in accordance with Enforcement Policy, the team determined it to be of Severity Level IV because it resulted in a condition evaluated by the SDP as having very low safety significance.
05000528/FIN-2013003-04Licensee-Identified Violation2013Q2Title 10 CFR 50.59(c)(1) requires, in part, that a licensee may make changes in the facility as described in the final safety analysis report without obtaining a license amendment pursuant to Section 50.90 only if a change to the technical specifications incorporated in the license is not required. Contrary to the above, between 2003 and March 8, 2013, the licensee made changes to the reactivity of fuel discharged to the spent fuel pool without obtaining a license amendment. Specifically, the licensee received license amendments for power uprates in 2003 and 2005, but did not recognize the impact of the power uprates relative to spent fuel pool criticality. Consequently, the licensee did not update the spent fuel pool criticality analysis of record and did not request a license amendment to revise the affected Technical Specifications 3.7.17 and 4.3.1.1. On March 8, 2013, the licensees engineering staff discovered that the spent fuel pool analysis of record had not been updated to account for the replacement steam generator power uprate. The power uprate required higher moderator and fuel temperatures within the core, thereby increasing plutonium production, which in turn increases the reactivity of the spent fuel. This condition resulted in Technical Specifications 3.7.17 and 4.3.1.1 being non-conservative. The licensee initiated PVAR 4363316 to document the condition and issued an Event Notification to the NRC to report an unanalyzed condition. The licensee also performed a prompt operability determination to show that despite the non-conservative technical specifications, the fuel in the spent fuel pool remains in a safe configuration. The licensee planned corrective actions to revise the spent fuel pool analysis of record using updated methodology and input parameters. Traditional enforcement applied to this finding because it involved a violation that impacted the regulatory process. Assessing the violation in accordance with Enforcement Policy, the team determined it to be of Severity Level IV because it resulted in a condition evaluated by the SDP as having very low safety significance.
05000528/FIN-2013003-02Failure to Prevent Recurrence of a Significant Condition Adverse to Quality2013Q2A self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, occurred because the licensee failed to correct and prevent recurrence of a significant condition adverse to quality associated with the emergency diesel generator automatic voltage regulator circuitry. Specifically, from February 2011 to January 2013, the licensee failed to correct the cause of an induced voltage transient in the automatic voltage regulator circuitry, resulting in the Unit 2 train B diesel generator not reaching rated voltage during a surveillance test. The licensee entered the issue into their corrective action program as CRDR 4329997 and replaced and retested electrical components that could allow a voltage transient on the instantaneous pre-positioning circuit board. The performance deficiency associated with this finding is the failure of the licensee to correct and prevent recurrence of a significant condition adverse to quality. The performance deficiency is more than minor, and therefore a finding, because it is associated with the equipment performance attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The senior resident inspector performed the initial significance determination for the train B emergency diesel generator (EDG) failure. The inspector evaluated the significance of the issue under the SDP, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings at-Power. The finding screened to a detailed risk evaluation because it involved a potential loss of one train of safety related equipment for longer than the technical specification allowed outage time. A Region IV senior reactor analyst performed the detailed risk evaluation. The exposure period was 43 days. The change to the CDF was 7.2E-7/year (Green). The finding was not significant to the large early release frequency. The dominant core damage sequences included loss of offsite power events that lead to station blackout conditions. The gas turbine generators, train A emergency diesel generator, and the DC battery life extension to six hours helped to limit the risk. The finding has a cross-cutting aspect in the area of Problem Identification and Resolution associated with the corrective action program component because the licensee failed to thoroughly evaluate problems such that the resolutions address causes and extent of condition, as necessary.
05000528/FIN-2013003-01Failure to Follow Operability Determination Procedure for Maintaining Administrative Limits2013Q2The inspectors identified a Green non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations and engineering personnel to follow station procedures to perform operability determinations and functional assessments. Specifically, plant personnel did not maintain appropriate controls to ensure that the temperature limit established in the operability determination for the spent fuel pool criticality analysis was maintained. The licensee entered the issue into their corrective action program as PVAR 4380424, began taking more frequent readings of spent fuel pool temperature indicators, and lowered the spent fuel pool temperature alarm setpoint. The failure to follow Procedure 40DP-9OP26 for performing operability determinations is a performance deficiency. This performance deficiency is more than minor, and therefore a finding, because it is associated with the Barrier Integrity Cornerstone attribute of procedure quality and it adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases caused by accident or events. The inspectors evaluated the significance of the finding using Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. The inspectors reviewed all Barrier Integrity screening questions in IMC 0609, Appendix A, Exhibit 3 Section D, and all questions were answered No. Therefore, the finding was determined to be of very low safety significance. The inspectors determined that the finding has a cross-cutting aspect in the area of human performance associated with decision making. Specifically, the licensee did not communicate the administrative limits established in the spent fuel pool criticality operability determination to appropriate operations personnel
05000528/FIN-2013404-01Security2013Q1
05000528/FIN-2013404-02Licensee-Identified Violation2013Q1
05000528/FIN-2013008-01Licensee-Identified Violation2013Q1The following violation of very low safety significance (Green) was identified by the licensee and is a violation of NRC requirements which meets the criteria of the NRC Enforcement Policy for being dispositioned as a non-cited violation. License Condition 2.C.(6), Fire Protection, requires the licensee to maintain in effect all provisions of the approved fire protection program described in listed regulatory documents. Supplemental Safety Evaluation Report 5 states the alternative shutdown capability for PVNGS 1-3 complies with the requirements of Section III.L of Appendix R and, therefore, is acceptable. Title 10 CFR Part 50, Appendix R, Section III.L.3 requires that the alternative shutdown capability shall be independent of the specific fire area. Contrary to the above, the design of three circuits in the remote shutdown system was not independent from the effects of fire damage in the case of a fire in the control room. The licensee entered this deficiency in their corrective action program as Palo Verde Action Request 4311694 and Palo Verde Action Request 4329210 and issued Licensee Event Report 05000528; 529; 530/2012-005-00. The licensee has revised Procedure 40AO-9ZZ19, Control Room Fire, to address this finding. The finding was evaluated for safety significance using Inspection Manual Chapter 0609, Appendix F, Fire Protection Significance Determination Process, Attachment 1. The finding was assigned a low degradation rating due to the performance and reliability of the remote shutdown following a control room evacuation being minimally impacted by the finding. Based on the low degradation rating, the finding screened as having a very low safety significance (Green) in Phase 1, Task 1.3.1, Qualitative Screening for All Finding Categories, Question 1.
05000528/FIN-2013002-07Licensee-Identified Violation2013Q1Title 10 CFR Part 50, Appendix B, Criteria V, Procedures, requires, in part, that activities affecting quality shall be prescribed by documented procedures of a type appropriate to the circumstances. Contrary to the above, prior to April 15, 2012, the licensee failed to prescribe documented procedures for activities affecting quality of a type appropriate to the circumstances. Specifically, during low power physics testing in Unit 3, one control element assembly (CEA) stopped moving while its associated group was being inserted, concurrent with a boron dilution of the reactor coolant system. Operators stopped the control element assembly movement, but were forced to manually trip the reactor because reactor power increased above the test band limits. The licensees investigation determined that the low power physics testing procedure, 72PY-9RX04, did not effectively communicate or provide contingencies for stabilizing power during additions of positive or negative reactivity when selected CEAs are not available to stabilize power. The licensee implemented corrective actions to revise the procedure to include appropriate contingencies and to determine acceptable power limits requiring a manual reactor trip during low power physics testing. The inspectors concluded that the finding is of very low safety-significance (Green) because it did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition, and has been entered into the licensees corrective action program as CRDR 4173029.
05000528/FIN-2013002-06Licensee-Identified Violation2013Q1Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, prior to November 8, 2012, the licensee failed to prescribe heat exchanger visual inspection procedures of a type appropriate to the circumstances. Specifically, on November 8, 2012, during a scheduled occupational safety area walkdown, the licensee identified through-wall leakage on the outside of a Unit 3 spray pond system drain line on the train A essential cooling water heat exchanger. The licensee declared the Unit 3 train A spray pond system inoperable and began actions to make immediate repairs. The licensees subsequent apparent cause investigation determined that pre-existing coating defects were likely present and the corrosion process had begun prior to the most recent visual inspection. The investigation also concluded that procedures for visual inspection of heat exchangers were inadequate in that they did not explicitly mentioned the need to inspect nozzles as potential areas subject to localized corrosion. Therefore, the pre-existing flaw in the Unit 3 drain nozzle had gone undetected during previous visual inspections. The licensee revised their heat exchanger visual inspection procedure to identify small heat exchanger nozzles as an area requiring additional emphasis and requiring documentation of nozzle inspection results. The inspectors concluded that the finding is of very low safety-significance (Green) because the as-found nozzle wall flaw would not have prevented the spray pond system from performing its safety function and the issue has been entered into the licensees corrective action program as PVAR 4285944.
05000528/FIN-2013002-04Failure to Comply with Technical Specifications2013Q1A self-revealing, Green NCV of Technical Specification (TS) Limiting Condition for Operation (LCO) 3.0.4 was identified after Unit 2 operators entered a mode with a limiting condition for operation not met. Specifically, following maintenance on auxiliary feedwater pump steam supply valve, SGA-UV-138, plant personnel did not ensure the requirements of TS 3.7.5, Auxiliary Feedwater System, were met prior to entering Mode 3. During subsequent testing, a bonnet steam leak was discovered on the valve, resulting in the valve being declared inoperable and the plant returned to Mode 5 for repairs. The licensee restored the valve to operable status before re-entering Mode 3. The licensee entered the issue into the corrective action program (CAP) as CRDR 4284491 and is evaluating further corrective actions. The inspectors concluded that the failure of plant personnel to comply with technical specifications was a performance deficiency. The inspectors concluded the performance deficiency is more than minor because it affected the equipment performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the SDP, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and 0609 Appendix A, The SDP for Findings at-Power. Inspectors concluded that the finding was of very low safety significance (Green) because the finding is not a design or qualification issue, did not represent an actual loss of safety function of the system or train, did not result in the loss of one or more trains of non-technical specification equipment, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors determined this finding has a cross-cutting aspect in the area of human performance associated with the component of resources because the licensee failed to provide an adequate work package to ensure the valve was operable prior to entering.
05000528/FIN-2013002-05Shutdown Cooling Piping Failure2013Q1A self-revealing, Green NCV of 10 CFR Part 50, Appendix B, Criterion III Design Control, was identified for the failure of the licensee to assure that applicable regulatory requirements and the design basis are correctly translated into specifications, drawings, procedures, and instructions. Specifically, operations personnel altered the piping configuration with an added fitting to a low pressure safety injection drain line. As a result the pipe failed during shutdown cooling operations, rendering that train inoperable. The licensee repaired the weld in accordance with ASME Code, entered the issue into the licensees CAP as CRDR 4263357,and revised procedural guidance to return components to their design configuration. The inspectors concluded that the failure of the licensee to correctly translate the design basis into specifications, drawings, procedures and instructions was a performance deficiency. The performance deficiency was more than minor, therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and its objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the SDP, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix G, Shut Down Operations Significance Determination Process. The inspectors determined that because there was an injection path available, the leak could be isolated prior to depletion of the reactor water tank, and the steam generators were available for heat removal. As a result, the issue was found to be of very low safety significance (Green). The inspectors determined the finding had no cross-cutting issues because it is not indicative of current performance.
05000528/FIN-2013002-08Licensee-Identified Violation2013Q1Title 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires in part, that measures shall be established to assure that applicable regulatory requirements and the design basis, for those structures, systems, and components to which this appendix applies, are correctly translated into specifications, drawings, procedures, and instructions. Contrary to the above, prior to June 29, 2011, the licensee failed to establish measures to assure that applicable regulatory requirements and the design basis, for those structures, systems, and components to which this appendix applies, were correctly translated into specifications, drawings, procedures, and instructions. Specifically, the licensee identified that the Unit 1 Qualified Safety Parameter Display System (QSPDS) did not meet the cable separation criteria of Regulatory Guide 1.75, Physical Independence of Electrical Systems. Both trains of power supply cables were found wrapped around each other. The licensees investigation concluded that PVNGS Specification 13-EN-306, Installation Specification for Cable Splicing and Terminations, had not been adequately implemented into modification and maintenance instructions. The licensee implemented corrective actions to restore the required cable separation and revise Procedure 30DP-0AP01, Maintenance Work Order Writers Guide, to require that cable separation criterion be incorporated into main control board work instructions. The inspectors concluded that the finding is of very low safety-significance (Green) because the inadequate power supply cable separation would only result in the loss of power to the modems that feed the QSPDS plasma displays on the main control board, and the train A Post Accident Monitoring recorders, fed directly from the QSPDS chassis rack, would still be available to plant operators. Additionally, the licensee entered the issue into the corrective action program as CRDR 3802732.
05000528/FIN-2013002-02Failure to identify weak performance during an exercise2013Q1The inspectors identified a Green NCV of 10 CFR 50.47(b)(14) for the licensees failure to identify and correct a performance deficiency during an evaluated exercise. Specifically, the licensee failed to identify that the Emergency Director in the Simulator Control Room did not evaluate emergency action level RS-1 when information was available indicating a need to upgrade the emergency classification because of offsite radiation dose. The failure to identify a deficiency occurring during a drill and ensure correction is a performance deficiency within the licensees control. The finding is more than minor because the failure to identify a deficiency and ensure correction impacts the Emergency Preparedness cornerstone objective associated with the emergency response organization performance cornerstone attribute. The finding is a non-cited violation of 10 CFR 50.47(b)(14). The finding was evaluated using the Emergency Preparedness SDP and identified as having very low safety significance because it was a failure to comply with NRC requirements and was not a loss of the planning standard function because the classification deficiency was associated with a successful performance indicator opportunity. The Emergency Director declared the correct emergency classification within fifteen minutes of performing the dose assessment report using an emergency action level for which conditions currently existed, although this was not the first emergency action level that applied. This issue was entered into the CAP as PVAR 4365021. The finding was assigned a cross-cutting aspect of Low Threshold, because the licensee failed to completely and accurately recognize a performance deficiency.
05000528/FIN-2013002-01Multiple Failures to Identify Conditions Adverse to Quality2013Q1The inspectors identified two examples of a Green NCV of 10 CFR Part 50, Appendix B, Criterion XVI Corrective Action, for the failure of the licensee to promptly identify and correct conditions adverse to quality. Specifically, on July 19, 2012, personnel failed to follow Procedure 01DP-0AP12, Palo Verde Action Request Processing, and enter into the corrective action process a failure to comply with technical specifications to enter limiting condition for operation 3.0.3 when maintenance activities rendered safety related inverters inoperable. In addition, on May 2, 2011, the licensee also failed to enter an unanalyzed diversion of emergency core cooling system flow into the corrective action process, despite procedural guidance to the contrary. The licensee entered the issues into the corrective action program as Palo Verde Action Request (PVAR) 4347283 and PVAR 4389514 and is assessing corrective actions. The inspectors concluded that the failure to promptly identify and correct conditions adverse to quality was a performance deficiency. The inspectors determined the performance deficiency is more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and its objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors determined the two issues had similar causal factors and should be documented as one NCV in accordance with NRC enforcement guidance. The inspectors evaluated the significance of each issue under the SDP, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, Significance Determination of Reactor Inspection Findings for At-Power Situations. For the issue associated with inoperable safety related inverters, the inspectors determined the finding to be of very low safety significance (Green) because all questions in Exhibit 2.A could be answered no. For the issue associated with an unanalyzed condition of the high pressure safety injection system, the inspectors determined that the finding represented a loss of system function and needed a detailed evaluation. The inspectors used the Palo Verde Standardized Plant Analysis Risk model, Revision 8.20, with a truncation limit of E-11 and performed a bounding significance determination and found the finding to be of very low safety significance (Green). The bounding change to the core damage frequency was 2.4E-9/year. The dominant core damage sequences included: medium break loss of coolant accident, system transient, and steam generator tube rupture. The very short exposure period minimized the significance. A Region IV senior reactor analyst reviewed the results and agreed with the conclustions. This finding has a cross-cutting aspect in the area of human performance associated with the decision making component because the licensee failed to use a systematic process for dealing uncertain conditions adverse to quality.
05000528/FIN-2013002-03Failure to Maintain the Updated Final Safety Analysis Report for Radwaste Systems and Processes2013Q1The inspectors identified a Severity Level IV violation of 10 CFR 50.71(e), Maintenance of Records, Making of Reports, with two examples for the failure to restore compliance within a reasonable time after a previous Severity Level IV non-cited violation of 10 CFR 50.71(e) was identified. The violation was identified because the licensee failed to periodically update the Updated Final Safety Analysis Report (UFSAR) with all changes made in the facility or procedures. Specifically, Example 1: From 1988 to 2013, the licensee did not update Chapter 11.2.2.3, Liquid Radwaste System, with a description of the temporary adsorption tanks and their use. The licensee has entered this violation into their corrective action program as PVAR 3075089. Example 2: From December 2003 to January 2013, the licensee made changes to the facility and procedures as described in the UFSAR, and performed safety analyses and evaluations in support of these changes, but failed to update the UFSAR to include these changes. Specifically, the licensee built the old steam generator storage facility used for long-term storage of radioactive waste (six replaced steam generators and three reactor vessel heads) on the owner controlled site until decommissioning. The licensee has entered this violation into their corrective action program as Condition Report (CR) 3398042 and PVAR 4330483. This violation is more than minor because the NRC relies on licensees to identify and report conditions or events meeting the criteria specified in the regulations in order to perform its regulatory function. Because this issue affected the NRCs ability to perform its regulatory function, it was evaluated using the traditional enforcement process. The issue was characterized as a Severity Level IV violation in accordance with Section 6.1.d.3 of the NRC Enforcement Policy because the erroneous information in the UFSAR was not used to make an unacceptable change to the facility or procedures. A cross-cutting aspect was not assigned because the violation was handled through traditional enforcement.
05000528/FIN-2012005-04Inadequate Tracking of Functional Assessment for Spent Fuel Pool Heat Load2012Q4The inspectors identified a Green non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure of operations and engineering personnel to follow station procedures to perform operability determinations and functional assessments. Specifically, plant personnel did not maintain appropriate controls to ensure that the heat load and temperature limits established in the functional assessment for the spent fuel pools were monitored. This issue is captured in Palo Verde Action Request 4251108. To restore compliance, the licensee issued a technical specification component condition record to prohibit entry into Mode 4 following a refueling outage, until decay heat load in the spent fuel pool is verified to be less than the more restrictive limit established in the functional assessment. The failure to follow Procedure 40DP-9OP26 for performing functional assessments is a performance deficiency. This performance deficiency was more than minor because it is associated with the Barrier Integrity Cornerstone attribute of design control and it adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases caused by accident or events. Using Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and Manual Chapter 0609 Appendix A, The Significance Determination Process (SDP) for Findings At-Power, the inspectors determined that the finding had very low safety significance (Green) because the finding was confirmed not to adversely affect decay heat removal capabilities from the spent fuel pool causing the pool temperature to exceed the maximum analyzed temperature limit specified in the site-specific licensing basis. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance associated with decision making. Specifically, Palo Verde did not communicate the procedural limits established in the spent fuel pool functional assessment to appropriate operations personnel.
05000528/FIN-2012005-05Failure to Classify and Evaluate a Condition Adverse to Quality2012Q4The inspectors identified a Green non-cited violation of Palo Verde Unit 1 License Condition 2.C.7 for the failure of plant personnel to follow station procedures to classify and evaluate a condition adverse to quality. Specifically, after identifying movement of the corridor building as a result of ground saturation from a domestic service water line break, the licensee failed to classify the issue as a condition adverse to quality and perform a functional assessment of the corridor building. The licensee entered the issue into the corrective action program as Condition Report Disposition Request 4301801. To restore compliance, the licensee classified the Unit 1 corridor building movement as a Condition Adverse to Quality and performed a functional assessment, concluding the building was functional. The licensee is evaluating further corrective actions associated with this issue. The inspectors concluded that the failure of plant personnel to classify the Unit 1 corridor building movement as a condition adverse to quality and perform a functional assessment was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it affected the protection against external factors attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609, Appendix F, Fire Protection Significance Determination Process, and concluded the finding was of very low safety significance (Green) because it is assigned a low degradation rating because no significant degradation of the fire protection features of the corridor building occurred. The inspectors determined this finding has a crosscutting aspect in the area of human performance associated with the work practices component because the licensee failed to ensure supervisory and management oversight of work activities, such that nuclear safety is supported.
05000528/FIN-2012005-06Technical Support Center Diesel Generator Not Restored Following Maintenance2012Q4A self revealing Green non-cited violation of 10 CFR 50.47(b)(8) was identified for the failure to maintain adequate facilities to support emergency response. Specifically, the licensee found the technical support center battery disconnect switch had not been restored following maintenance activities. This configuration would have rendered the diesel generator unable to start automatically as designed in the event of a loss of off-site power. The licensee initiated immediate corrective actions to restore the technical support center diesel generator to a functional configuration and has begun implementation of a more formal process for component configuration verification of critical technical support center equipment. The licensee has entered this issue into their corrective action program as Palo Verde Action Request 4165625. The failure to follow Procedure 40OP-9NG01 for performing a functional test of 480V switchgear following maintenance activities is a performance deficiency. This performance deficiency was more than minor because it is associated with the Emergency Preparedness Cornerstone attribute of facilities and equipment and it adversely affected the cornerstone objective to ensure that the licensee is capable of implementing adequate measures to protect the health and safety of the public in the event of a radiological emergency. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and Manual Chapter 0609, Appendix B, Emergency Preparedness Significance Determination Process. The finding was determined to be of very low safety significance (Green) because the degraded planning standard function did not result in the loss of technical support center functionality for longer than 7 days. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance associated with resources. Specifically, the licensees work control procedures did not include critical technical support center systems to ensure that technical support center configuration control was maintained commensurate with its significance.
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