Text

NRC Integrated Inspection Report 05000346/2018002
	ML18222A345
Person / Time
Site:	Davis Besse
Issue date:	08/10/2018
From:	Jamnes Cameron; NRC/RGN-III
To:	Bezilla M; FirstEnergy Nuclear Operating Co
References
	IR 2018002
	Download: ML18222A345 (24)
	v • d • e

UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION III

2443 WARRENVILLE RD. SUITE 210

LISLE, ILLINOIS 60532-4352

August 10, 2018

Mark Bezilla

Site Vice President

FirstEnergy Nuclear Operating Co.

Davis-Besse Nuclear Power Station

5501 N. State Rte. 2, Mail Stop A-DB-3080

Oak Harbor, OH 43449-9760

SUBJECT: DAVIS-BESSE NUCLEAR POWER STATIONNRC INTEGRATED INSPECTION

REPORT 05000346/2018002

Dear Mr. Bezilla:

On June 30, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed an integrated

inspection at your Davis-Besse Nuclear Power Station. On July 31, 2018, the NRC inspectors

discussed the results of this inspection with you and other members of your staff. The results of

this inspection are documented in the enclosed report.

Based on the results of this inspection, the NRC has identified four issues that were evaluated

under the risk significance determination process as having very low safety significance

(Green). The NRC has also determined that three violations are associated with these issues.

Because the licensee initiated condition reports to address these issues, these violations are

being treated as Non-Cited Violations (NCVs), consistent with Section 2.3.2 of the Enforcement

Policy. These NCVs are described in the subject inspection report.

If you contest the violations or significance of these NCVs, you should provide a response within

30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear

Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with

copies to the Regional Administrator, Region III; the Director, Office of Enforcement; and the

NRC Resident Inspector at the Davis-Besse Nuclear Power Station.

M. Bezilla -2-

If you disagree with a cross-cutting aspect assignment or a finding not associated with a

regulatory requirement in this report, you should provide a response within 30 days of the date

of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory

Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the

Regional Administrator, Region III; and the NRC resident inspector at Davis-Besse Nuclear

Power Station.

This letter, its enclosure, and your response (if any) will be made available for public inspection

and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document

Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for

Withholding.

Sincerely,

/RA/

Jamnes L. Cameron, Chief

Branch 4

Division of Reactor Projects

Docket Nos. 50-346;72-014

License Nos. NPF-3

Enclosure:

Inspection Report 05000346/2018002

cc: Distribution via LISTSERV

M. Bezilla -3-

Letter to Mark Bezilla from Jamnes Cameron dated August 10, 2018

SUBJECT: DAVIS-BESSE NUCLEAR POWER STATIONNRC INTEGRATED INSPECTION

REPORT 05000346/2018002

DISTRIBUTION:

Jeremy Bowen

RidsNrrDorlLpl3

RidsNrrPMDavisBesse Resource

RidsNrrDirsIrib Resource

DRPIII

DRSIII

ROPreports.Resource@nrc.gov

ADAMS Accession Number: ML18222A345

OFFICE RIII

NAME JCameron:lg

DATE 8/10/2018

OFFICIAL RECORD COPY

U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Docket Numbers: 50-346;72-014

License Numbers: NPF-3

Report Numbers: 05000346/2018002

Enterprise Identifier: I-2018-002-0015

Licensee: FirstEnergy Nuclear Operating Company (FENOC)

Facility: Davis-Besse Nuclear Power Station

Location: Oak Harbor, OH

Dates: April 1 through June 30, 2018

Inspectors: D. Mills, Senior Resident Inspector

M. Garza, Acting Senior Resident Inspector

J. Harvey, Resident Inspector

J. Rutkowski, Project Engineer

J. Beavers, Resident Inspector, Duane Arnold Energy

Center

Approved by: J. Cameron, Chief

Branch 4

Division of Reactor Projects

Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring licensees performance

by conducting an integrated quarterly inspection at Davis-Besse Power Plant in accordance with

the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for

overseeing the safe operation of commercial nuclear power reactors. Refer to

https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and

violations being considered in the NRCs assessment are summarized in the table below.

List of Findings and Violations

Failure to Follow the Makeup and Purification Procedure

Cornerstone Significance Cross-cutting Report

Aspect Section

Initiating Events Green H.12 71152 -

NCV 05000346/2018002-01 Annual

Closed Follow-Up of

Selected

Issues

A self-revealed Green finding and associated Non-Cited Violation of Technical

Specification 5.4.1.a, Procedures, was identified when the licensee failed to follow station

procedure DB-OP-06006, Makeup and Purification System. Specifically, the licensee failed

to open MU177, the Make-Up Filter 1 Outlet Isolation valve, which resulted in the isolation of

letdown while swapping make-up filters.

Failure to Apply Technical Specification for Safety Features Actuation System Instrumentation

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.14 71153 -

Systems NCV 05000346/2018002-02 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance and an associated Non-Cited Violation of

Technical Specification 3.3.5.b, Safety Features Actuation System (SFAS) Instrumentation,

for the licensees failure to place the reactor in Mode 3 within six hours of identifying that two

channels of Safety Features Actuation System Borated Water Storage Tank level

instrumentation were inoperable. Specifically, the licensee inappropriately exited Technical

Specification 3.3.5.b, and failed to place the reactor in Mode 3 while two Borated Water

Storage Tank level instruments were inoperable for more than six hours.

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Failure to Perform a Procedure Affecting Quality

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.8 71153 -

Systems NCV 05000346/2018002-03 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance and an associated non-cited violation of

10 Code of Federal Regulation (CFR) Part 50, Appendix B, Criterion V, Instructions,

Procedures, and Drawings, due to the licensees failure to implement DB-OP-03006,

Miscellaneous Instrument Shift Checks, Specifically, the licensee declared SFAS Channel 1

operable without performing the required channel check.

Misapplication of the Operability Determination Process

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.13 71153 -

Systems FIN 05000346/2018002-04 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance due to the licensees misapplication of

NOP-OP-1009, Operability Determinations and Functionality Assessments. Specifically,

the licensee failed to apply the Operability Determination process in accordance with

procedures.

Additional Tracking Items

Type Issue Number Title Report Status

Section

LER 05000346/2016008-01 Application of Technical 71153 Closed

Specification for the Safety

Features Actuation System

Instrumentation

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TABLE OF CONTENTS

PLANT STATUS ........................................................................................................................... 5

INSPECTION SCOPES ................................................................................................................ 5

REACTOR SAFETY ................................................................................................................. 5

OTHER ACTIVITIES - BASELINE ........................................................................................... 8

INSPECTION RESULTS .............................................................................................................. 9

EXIT MEETINGS AND DEBRIEFS ............................................................................................ 14

DOCUMENTS REVIEWED......................................................................................................... 18

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PLANT STATUS

The unit remained at or near rated thermal power for the entirety of the inspection period.

On March 28, 2018, FirstEnergy Solutions (FES) / FirstEnergy Nuclear Operating

Company (FENOC) verbally notified the Nuclear Regulatory Commission that they intended to

shut down all four of their operating nuclear power plants. Based on that notification, the first to

shut down will be Davis-Besse, by May 31, 2020. On March 31, 2018, FES, FirstEnergy

Nuclear Generation (FENGEN), and FENOC filed for bankruptcy. The Nuclear Regulatory

Commission continues to maintain focus on public health and safety and the protection of the

environment. This will include a continuous evaluation by inspectors to determine whether the

licensees financial condition is impacting safe operation of the plant.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in

effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with

their attached revision histories are located on the public website at http://www.nrc.gov/reading-

rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared

complete when the IP requirements most appropriate to the inspection activity were met

consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection

Program - Operations Phase. The inspectors performed plant status activities described in

IMC 2515 Appendix D, Plant Status and conducted routine reviews using IP 71152, Problem

Identification and Resolution. The inspectors reviewed selected procedures and records,

observed activities, and interviewed personnel to assess licensee performance and compliance

with Commission rules and regulations, license conditions, site procedures, and standards.

REACTOR SAFETY

71111.01Adverse Weather Protection

Summer Readiness (1 Sample)

The inspectors evaluated summer readiness of offsite and alternate alternating current

power systems.

71111.04Equipment Alignment

Partial Walkdown (4 Samples)

The inspectors evaluated system configurations during partial walkdowns of the following

systems/trains:

(1) Auxiliary feedwater train 1 during planned maintenance and testing on auxiliary

feedwater train 2 during the week ending April 14, 2018;

(2) Motor driven feedwater pump during auxiliary feedwater train 2 maintenance during the

week ending April 21, 2018;

(3) Containment spray system during the week ending April 28, 2018; and

(4) Decay heat/low pressure injection train 2 when train 1 was out of service during the

week ending June 2, 2018.

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Complete Walkdown (1 Sample)

The inspectors evaluated system configurations during a complete walkdown of the High

Pressure Injection system during the week ending April 28, 2018.

71111.05QFire Protection Quarterly

Quarterly Inspection (4 Samples)

The inspectors evaluated fire protection program implementation in the following selected

areas:

(1) Emergency core cooling system pump room 1-2, (fire area A), during the week ending

April 28, 2018;

(2) Auxiliary building rooms 104, 106, 106A, and 109, (fire area A), during the week ending

April 28, 2018;

(3) Auxiliary feedwater train 2, (fire area F) during the week ending May 19; and

(4) Component cooling water room, (fire area T), during the week ending May 26, 2018.

71111.06Flood Protection Measures

Underground Cables (1 Sample)

The inspectors evaluated cable submergence protection in:

(1) Manholes mh3101, mh3108, mh3109, mh3010 during the week ending April 14, 2018.

71111.07Heat Sink Performance

Heat Sink (1 Sample)

The inspectors evaluated closed cooling water 3 performance following a pinhole leak repair

during the week ending May 19, 2018.

71111.11Licensed Operator Requalification Program and Licensed Operator Performance

Operator Requalification (1 Sample)

The inspectors observed and evaluated licensed operator requalification training during the

week ending May 26, 2018.

Operator Performance (1 Sample)

The inspectors observed and evaluated operators perform a reactor downpower and place

feedwater components in manual control to support planned maintenance on a feedwater

flow component during the week ending May 26, 2018.

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71111.12Maintenance Effectiveness

Routine Maintenance Effectiveness (2 Samples)

The inspectors evaluated the effectiveness of routine maintenance activities associated

with the following equipment and/or safety significant functions:

(1) Decay heat/low pressure injection train 1; and

(2) Component cooling water availability.

71111.13Maintenance Risk Assessments and Emergent Work Control (4 Samples)

The inspectors evaluated the risk assessments for the following planned and emergent

work activities:

(1) Auxiliary feedwater train 2 out of service for planned maintenance during the week

ending May 12;

(2) E-31A outage to relieve cable stress due to turbine building floor movement during the

week ending May 12;

(3) Control room emergency ventilation system train 1 out of service for planned

maintenance during the week ending May 26; and

(4) Decay heat/low pressure injection train 1 out of service for planned maintenance during

the week ending June 2.

71111.15Operability Determinations and Functionality Assessments (4 Samples)

The inspectors evaluated the following operability determinations and functionality

assessments:

(1) Forward flow / closure valve SW277CR 2018-03174 during the week ending April 6;

(2) Containment Isolation Valve Train 2 position indication lights not litCR 2018-04305

during the week ending May 12, 2018;

(3) Leading Edge Flow Monitor FailureCR 2018-04296 during the week ending

May 12, 2018; and

(4) Emergency Diesel Generator 2 silencer through-wall leakCR 2018-04599 during the

week ending May 26, 2018.

71111.18Plant Modifications (1 Sample)

The inspectors evaluated the following temporary or permanent modifications:

(1) Borated Water Storage Tank Loop Seal, ECP 16-0478, during the week ending

June 23, 2018.

71111.19Post Maintenance Testing (3 Samples)

The inspectors evaluated the following post maintenance tests:

(1) Auxiliary feedwater train 2 following planned maintenance, during the week ending

May 12, 2018;

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(2) Service water train 1 following planned maintenance, during the week ending

May 26, 2018; and

(3) Decay heat/low pressure injection train 1 following planned maintenance, during the

week ending June 9, 2018.

71111.22Surveillance Testing

The inspectors evaluated the following surveillance tests:

Routine (1 Sample)

(1) Emergency diesel generator 1 monthly surveillance during the week ending

April 7, 2018.

71114.06Drill Evaluation

Emergency Planning Drill (1 Sample)

The inspectors evaluated a tabletop drill at the Emergency Operating Facility on

June 4, 2018.

OTHER ACTIVITIES - BASELINE

71151Performance Indicator Verification (3 Samples)

The inspectors verified licensee performance indicators submittals listed below:

(1) MS05: Safety System Functional Failures (SSFFs) for the period from the second

quarter 2017 through the first quarter 2018;

(2) MS06: Emergency AC Power Systems for the period from the second quarter 2017

through the first quarter 2018; and

(3) MS07: High Pressure Injection Systems for the period from the second quarter 2017

through the first quarter 2018.

71152Problem Identification and Resolution

Annual Follow-Up of Selected Issues (1 Sample)

The inspectors reviewed the licensees implementation of its corrective action program

related to the following issues:

(1) CR 2018-03036; Misposition of Make Up Filter 1 Outlet Isolation (MU177)

One violation for this issue is documented in this report.

71153Follow-Up of Events and Notices of Enforcement Discretion

Licensee Event Reports (1 Sample)

The inspectors evaluated the following licensee event reports which can be accessed at

https://lersearch.inl.gov/LERSearchCriteria.aspx:

8

(1) Licensee Event Report (LER) 05000346/2016-008-01, Application of Technical

Specifications for the Safety Features Actuation System Instrumentation. Two violations

and a finding for this issue are documented in this report. This LER is closed.

Evaluation of Davis-Besse Safety Condition in Light of Financial Conditions

The licensees parent company, FirstEnergy Solutions, was under bankruptcy

protection/reorganization during the inspection period. As such, NRC Region III conducted

special reviews of processes at Davis-Besse. Using the flexibilities in the baseline inspection

program, the inspectors evaluated several aspects of the licensees operations to assess

whether any identified plant performance issues could be related to the stations financial

condition. The factors reviewed included: (1) impact on regulatory-required plant staffing,

(2) corrective maintenance backlog, (3) changes to the planned maintenance schedule,

(4) corrective action program implementation, and (5) reduction in outage scope, including

risk-significant modifications. In particular, the inspectors verified that licensee personnel

continued to identify problems at an appropriate threshold and enter these problems into the

corrective action program for resolution. The inspectors also verified that the licensee continued

to develop and implement corrective actions commensurate with the safety significance of the

problems identified.

The review of processes at Davis-Besse included continuous reviews by the Resident

Inspectors, as well as the specialist-led baseline inspections completed during the inspection

period which are documented previously in this report.

INSPECTION RESULTS

71152Problem Identification and Resolution

Observation - Selected Issue Follow-Up for 71152 - Annual Sample Review

CR-2018-03036: Misposition of Make Up Filter 1

Outlet Isolation (MU 177)

On March 31, 2018, while placing makeup system filter 1 in service using DB-OP-06006,

Makeup and Purification System, Revision 42, the licensee received two unexpected alarms:

Letdown or MU [make-up] Filter dP [differential pressure] Hi followed by Letdown Pressure

Hi. The licensee immediately opened MU12B, the Makeup Filter 2 Inlet Isolation, to establish

letdown flow. During this time the letdown relief valve lifted and reseated, diverting

approximately six gallons of water to the reactor coolant drain tank.

Through the investigation of the issue, the licensee found MU177, the Make-Up Filter 1 Outlet

Isolation valve, had not been opened on March 30, 2018, as required by Step 4.9.16.j of

DB-OP-06006. The licensees corrective actions included operator remediation, a

requirement to have shiftly engagement calls with Operations Management, and

reinforcement of the value of reverse briefs by operators as a human performance tool. This

issue was documented in CR-2018-03036, Disposition of Make-Up Filter 1 Outlet

Isolation (MU177).

9

As appropriate, the inspectors verified the following attributes during their review of the

licensee's corrective actions for the above condition reports and other related condition

reports:

complete and accurate identification of the problem in a timely manner commensurate

with its safety significance and ease of discovery;

consideration of the extent of condition, generic implications, common cause, and

previous occurrences;

evaluation and disposition of operability/functionality/reportability issues;

classification and prioritization of the resolution of the problem commensurate with

safety significance;

identification of corrective actions, which were appropriately focused to correct the

problem; and

completion of corrective actions in a timely manner commensurate with the safety

significance of the issue.

The inspectors verified the licensee assessed and corrected the issue in a timely manner. A

violation associated with this issue is documented in this report.

Failure to Follow the Makeup and Purification Procedure

Cornerstone Significance Cross-cutting Report

Aspect Section

Initiating Events Green H.12 71152 -

NCV 05000346/2018002-01 Annual

Closed Follow-Up of

Selected

Issues

A self-revealed Green finding and associated Non-Cited Violation (NCV) of Technical Specification 5.4.1.a, Procedures, was identified when the licensee failed to follow station

procedure DB-OP-06006, Makeup and Purification System. Specifically, the licensee failed

to open MU177, the Make-Up Filter 1 Outlet Isolation valve, which resulted in the isolation of

letdown while swapping make-up filters.

Description:

On March 31, 2018, while placing make-up system filter 1 in service using DB-OP-06006,

Makeup and Purification System, Revision 42, the licensee received two unexpected

alarms: Letdown or MU [make-up] Filter dP [differential pressure] Hi followed by Letdown

Pressure Hi. The licensee immediately opened MU12B, the Makeup Filter 2 Inlet Isolation,

to establish letdown flow.

During investigation of the issue the licensee found MU177, the Make-up Filter 1 Outlet

Isolation Valve, unexpectedly closed. This was because on March 30, 2018, when preparing

to swap filters, the licensee failed to follow Step 4.9.16.j of DB-OP-06006, which required

opening of MU177. Additionally, the licensee determined that while letdown flow was

isolated, the letdown relief valve lifted and reseated. Approximately six gallons of water were

diverted to the reactor coolant drain tank.

10

Corrective Actions: The licensees corrective actions included operator remediation, a

requirement to have shiftly engagement calls with operations management, and

reinforcement of the value of reverse briefs by operators as a human performance tool.

Corrective Action Reference: This issue was documented in CR-2018-03036, Misposition

of Make-Up Filter 1 Outlet Isolation (MU177).

Performance Assessment:

Performance Deficiency: The inspectors determined the licensees failure to follow

DB-OP-06006, Makeup and Purification System, Revision 42, was a performance deficiency.

Specifically, the licensee failed to open MU177, Make-Up Filter 1 Outlet Isolation, as required

by Step 4.9.16.j.

Screening: The performance deficiency was more than minor because it was associated with

Initiating Events cornerstone attribute of equipment performance, and adversely affected the

cornerstone objective of limiting the likelihood of events that upset plant stability and

challenge critical safety functions during shutdown as well as power operations. Specifically,

the licensees failure to open MU177 resulted in the letdown relief valve lifting, diverting

reactor coolant to the reactor coolant drain tank.

Significance: Using Inspection Manual Chapter (IMC) 0609, Attachment 4, Initial

Characterization of Findings, and IMC 0609 Appendix A, The Significance Determination

Process for Findings at Power, issued June 19, 2012, the finding was screened against the

Initiating Events cornerstone. The inspectors determined this issue was of very low safety

significance (Green) because the inspectors answered No to all the screening questions.

Cross Cutting Aspect: This finding has a cross-cutting aspect of Avoid Complacency in the

area of the Human Performance because the licensee failed to recognize and plan for the

possibility of mistakes, latent issues, and inherent risk, even while expecting successful

outcomes. Individuals implement appropriate error reduction tools. Specifically, the licensee

did not appropriately implement error reduction tools. [H.12]

Enforcement:

Violation: Technical Specification 5.4.1.a, Procedures, states, in part, written procedures

shall be established, implemented, and maintained covering the following activities: the

applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A,

February 1978. Section 3.n of Regulatory Guide 1.33, Revision 2, Appendix A,

February 1978, states, in part, instructions for energizing, filling, venting, draining, startup,

shutdown, and changing modes of operation should be prepared, as appropriate, for the

following systems: chemical and volume control system (including letdown/purification

system). Step 4.9.16.j of DB-OP-06006, Makeup and Purification System, Revision 42,

stated, open MU177, Make-up Filter 1 Outlet Isolation.

Contrary to the above, on March 30, 2018, the licensee failed to implement a written

procedure required by Technical Specification 5.4.1.a. Specifically, the licensee failed to

implement procedure DB-OP-06006, Makeup and Purification System, Revision 42, which

resulted in the isolation of letdown while swapping make-up filters.

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Disposition: Because it was of very low safety significance and was entered into the

licensees corrective action program as CR-2018-03036, this violation is being treated as an

NCV consistent with Section 2.3.2 of the Enforcement Policy. (NCV 05000346/2018002-01:

Failure to follow Makeup and Purification Procedure)

71153Follow-Up of Events and Notices of Enforcement Discretion

Failure to Apply Technical Specification for Safety Features Actuation System Instrumentation

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.14 71153 -

Systems NCV 05000346/2018002-02 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance and an associated NCV of Technical

Specification 3.3.5, Safety Features Actuation System (SFAS) Instrumentation for the

licensees failure to place the reactor in Mode 3 within six hours of identifying that two

channels of SFAS Borated Water Storage Tank level instrumentation were inoperable.

Specifically, the licensee exited Technical Specification (TS) 3.3.5.b, the six hour shutdown

technical specification, while two BWST level instruments were still inoperable.

Description:

Licensee Event Report (LER) 05000346/2016-008-01, Application of Technical

Specifications for the Safety Features Actuation System Instrumentation.

On June 30, 2016 at 0829 EDT, Channel 1 of the Borated Water Storage Tank (BWST) level

instrumentation for the Safety Features Actuation System (SFAS) was declared inoperable

and removed from service for scheduled maintenance. The Limiting Condition for

Operation (LCO) for Technical Specification 3.3.5 stated in part, four channels of SFAS

instrumentation for each Parameter [BWST level] shall be operable. At this time, Reactor

Operators entered TS 3.3.5.a, which required the inoperable channel be tripped. Later that

day at 2344, Channel 2 became inoperable due to a loss of power from a failed power supply.

At this time, operators should have entered TS 3.3.5.b, which required restoring at least one

channel immediately or placing the reactor into Mode 3 (hot shutdown), within six hours. At

0140 on July 1, 2016, operators realized that they should apply TS 3.3.5.b, but did not enter

the Technical Specification until 0245. At 0330, operators exited TS 3.3.5.b with Channel 1

declared operable with compensatory measures, including proceduralized operator actions to

be performed for a manual suction swap. At that time, the Channel 1 instrument was

electrically and physically disconnected and incapable of performing its function or passing

the Technical Specification required surveillance, which is required to be met in all modes of

applicability of the LCO.

The inspectors questioned the licensees basis for operability. From discussions with the

licensee on July 1, 2016, the inspectors determined the defined compensatory measures

were not sufficient for the licensee to declare Channel 1 operable. At 1325 on July 1, 2016,

the licensee declared Channel 1 inoperable and reentered TS 3.3.5.b. At 1351, the licensee

exited TS 3.3.5.b after maintenance was completed and Channel 1 was restored to service.

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The inspectors determined the reactor had been in a Mode other than Mode 3 (or lower) for a

total of 14 hours1.62037e-4 days 0.00389 hours 2.314815e-5 weeks 5.327e-6 months and 7 minutes.

Corrective Actions: The corrective actions included reentering TS 3.3.5.b and performing

corrective maintenance on the Channel 1 instrumentation to restore it to operable. The

Licensee performed a root cause analysis and developed a case study from lessons learned.

Additionally, the licensee issued an operations standing order; revised multiple procedures;

and performed additional training regarding lessons learned from this event, Technical

Specification compliance, and correct application of the operability determination process.

Corrective Action Reference: The licensee documented this issue in CR 2016-08419

Performance review of LCO 3.3.5 application during LT1525A maintenance.

Performance Assessment:

Performance Deficiency: The inspectors determined the licensees failure to place the reactor

in Mode 3 within six hours, as required by TS 3.3.5.b, was a performance deficiency.

Specifically, with two channels of the BWST level instrumentation inoperable, the licensee

failed to enter Mode 3 within six hours.

Screening: The finding was determined to be more than minor because it was associated

with the Mitigating Systems function of Long Term Heat Removal, and affected the

cornerstones objective of ensuring the availability, reliability, and capability of systems to

respond to initiating events to prevent undesirable consequences. Specifically, the finding

resulted in the loss of the emergency core cooling system (ECCS) suction swap permissive

function, which could have resulted in the loss of system safety function (i.e., ECCS due to a

premature suction source transfer).

Significance: The inspectors determined the finding could be evaluated using the SDP in

accordance with IMC 0609, Significance Determination Process, Attachment 0609.04,

Phase 1-Initial Screening and Characterization of Findings, for the Mitigating Systems

cornerstone. The inspectors evaluated the finding using Appendix A, The Significance

Determination Process for Findings At-Power. The inspectors answered Yes to Question

A.2 in Exhibit 2 because the finding represented the inoperability of the ECCS suction swap

permissive for fourteen hours, which was greater than the TS 3.3.5 allowed outage time of

6 hours6.944444e-5 days 0.00167 hours 9.920635e-6 weeks 2.283e-6 months for this function. Therefore, a detailed risk evaluation was performed using

IMC 0609, Appendix A. The risk evaluation was performed by Region III SRAs and the

bounding core damage frequency (CDF) was determined to be 7.0E-7/yr. Since the total

estimated change in core damage frequency was less than 1.0E-6/year, the finding/violation

was initially determined to be Green. Additionally since the CDF was greater than

1.0E-7/year, the finding was reviewed for potential Large Early Release Frequency (LERF)

contribution. Davis Besse is a 2-loop Babcock and Wilcox Pressurized Water Reactor with a

large dry containment. The core damage sequences important to LERF were steam

generator tube rupture events and inter-system LOCA events. These events were not the

dominant core damage sequences for this finding. Therefore, based on the detailed risk

evaluation, the SRAs confirmed that the finding was of very-low safety significance (Green).

Cross Cutting Aspect: This finding had a cross-cutting aspect of Conservative Bias in the

area of Human Performance, which states individuals use decision making practices that

emphasize prudent choices over those that are simply allowable. A proposed action is

determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,

13

the licensee failed to use decision making practices that emphasized prudent choices, over

those that they believed were simply allowable. [H.14]

Enforcement:

Violation: Technical Specification 3.3.5.b, SFAS Instrumentation, states in part, with one of

more Parameters with two or more channels inoperable, be in Mode 3 within six hours.

Enforcement Actions: Contrary to the above, on July 1, 2016, the licensee failed to place the

reactor into Mode 3 within six hours of identifying one Parameter of SFAS instrumentation

with two channels inoperable. Specifically, licensee operators entered TS 3.3.5.b. at 0245

hours on July 1, 2016, following the determination that Channels 1 and 2 of SFAS

Instrumentation were inoperable. At 0330, licensee operators used inappropriate actions to

declare Channel 1 of SFAS Instrumentation operable, and subsequently failed to place the

reactor in Mode 3 before 0845 hours0.00978 days 0.235 hours 0.0014 weeks 3.215225e-4 months on July 1, 2016. Licensee operators appropriately

exited TS 3.3.5.b. at 1351 hours0.0156 days 0.375 hours 0.00223 weeks 5.140555e-4 months on July 1, 2016.

Disposition: Because it was of very low safety significance and was entered into the

licensees corrective action program as CR-2016-08419, this violation is being treated as an

NCV consistent with Section 2.3.2 of the Enforcement Policy. (NCV 05000346/2018002-02:

Failure to Apply Technical Specification for SFAS Instrumentation)

Failure to Perform a Procedure Affecting Quality

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.8 71153 -

Systems NCV 05000346/2018002-03 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance and an associated non-cited violation of

10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, due to

the licensees failure to implement DB-OP-03006, Miscellaneous Instrument Shift Checks,

Specifically, the licensee declared SFAS Channel 1 operable without performing the required

channel check.

Description:

Licensee Event Report (LER) 05000346/2016-008-01, Application of Technical

Specifications for the Safety Features Actuation System Instrumentation.

On June 30, 2016, at 0829 EDT, Channel 1 of the Borated Water Storage Tank (BWST) level

instrumentation for the Safety Features Actuation System (SFAS) was declared inoperable

and removed from service for scheduled maintenance. On July 1, 2016, at 0330, the channel

was declared operable with reference to compensatory measures. At that time, the

Channel 1 instrument was electrically and physically disconnected, and incapable of

performing its function.

On July 1, 2016, at 0700, the licensee performed DB-OP-03006, Miscellaneous Instrument

Shift Checks. Step 2.1.1 states, in part, a channel check shall be the qualitative assessment,

14

by observation, of channel behavior during operation. Section 4.2 requires a channel check

comparison for all four channels of the BWST level instrumentation. At that time, the level

instrumentation string for Channel 1 was de-energized, with the level instrument

disassembled. The licensee declared the channel check results satisfactory for Channel 1 by

referring to compensatory measures, including proceduralized operator actions that were not

applicable to the DB-OP-03006 acceptance criteria.

The inspectors questioned the licensees basis for operability and noted that the Channel 1

level instrument was not energized and was not physically attached to the system. The

inspectors subsequently determined the licensee failed to complete section 4.2 of

DB-OP-03006 for Channel 1 in accordance with Step 2.1.1 because the instrument string

was not in operation at the time the surveillance was completed. Additionally, the inspectors

determined the compensatory measures were not sufficient for the licensee to credit them

toward satisfactory test results.

Corrective Actions: The corrective actions included declaring Channel 1 inoperable and

performing corrective maintenance on the Channel 1 instrumentation to restore it to operable.

The Licensee performed a root cause analysis and developed a case study from lessons

learned. Additionally, the licensee issued an operations standing order; revised multiple

procedures; and performed additional training regarding lessons learned from this event,

Technical Specification compliance, and correct application of the operability determination

process.

Corrective Action Reference: The licensee documented this issue in CR 2016-08419,

Performance review of LCO 3.3.5 application during LT1525A maintenance.

Performance Assessment:

Performance Deficiency: The inspectors determined the licensees failure to implement

DB-OP-03006 was a performance deficiency. Specifically, step 2.1.1 requires a channel

check be performed by observation during operation. However, the licensee could not

perform the BWST level channel check comparison for Channel 1, as required by Step 4.2,

because the Channel 1 instrument string was de-energized and disconnected from its

associated system.

Screening: The performance deficiency was determined to be more than minor because it

was associated with the Mitigating Systems cornerstone attribute of Equipment Performance

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 follow procedures to establish the operability of SFAS Channel 1 negatively

affected the ability of the system to perform its accident mitigating function. Additionally, this

failure led to a violation of Technical Specifications as detailed elsewhere in this report.

Significance: The inspectors assessed the significance of the finding using IMC 0609.04,

Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 2, Mitigating

Systems Screening Questions. The inspectors determined that this performance deficiency

did not result in a loss of a single train of a safety system for greater than its Technical

Specification allowed outage time. Therefore, the inspectors determined the finding to be of

very low safety significance (Green).

15

Cross Cutting Aspect: This finding had a cross-cutting aspect of Procedure Adherence in the

area of Human Performance, which states individuals follow processes, procedures, and work

instructions. Specifically, the licensee declared the SFAS Channel 1 operable without

meeting the acceptance criteria of the required procedures. [H.8]

Enforcement:

Violation: Title 10 CFR 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 shall be

accomplished in accordance with these instructions, procedures, or drawings. Instructions,

procedures, or drawings shall include appropriate quantitative or qualitative acceptance

criteria for determining that important activities have been satisfactorily accomplished.

Step 2.1.1 of DB-OP-03006, Revision 55, an Appendix B procedure affecting Technical

Specification-required equipment, states, in part, a channel check shall be the qualitative

assessment, by observation, of channel behavior during operation.

Contrary to the above, on July 1, 2016, the licensee failed to accomplish activities affecting

quality in accordance with procedures of a type appropriate to the circumstances.

Specifically, the licensee attempted to perform the Channel 1 BWST level instrument channel

check while the instrument was de-energized and physically disconnected from its associated

system, and thus not operating.

Disposition: Because it was of very low safety significance and was entered into the

licensees corrective action program as CR-2016-08419, this violation is being treated as an

NCV consistent with Section 2.3.2 of the Enforcement Policy. (NCV 05000346/2018002-03:

Failure to Perform a Procedure Affecting Quality)

Misapplication of the Operability Determination Process

Cornerstone Significance Cross-cutting Report

Aspect Section

Mitigating Green H.13 71153 -

Systems FIN 05000346/2018002-04 Follow-Up of

Closed Events and

Notices of

Enforcement

Direction

The NRC identified a finding of Green significance due to the licensees misapplication of

NOP-OP-1009, Operability Determinations and Functionality Assessments. Specifically,

the licensee failed to apply the Operability Determination process in accordance with

procedures.

Description:

Licensee Event Report (LER) 05000346/2016-008-01, Application of Technical

Specifications for the Safety Features Actuation System Instrumentation.

On June 30, 2016, at 0829 EDT, Channel 1 of the Borated Water Storage Tank (BWST) level

instrumentation for the Safety Features Actuation System (SFAS) was declared inoperable

16

and removed from service for scheduled maintenance. At this time, Reactor Operators

entered TS 3.3.5.a, which required the inoperable channel be tripped. On July 1, 2016,

at 0330, the channel was declared operable with reference to compensatory measures. At

this time, the Channel 1 instrument was electrically and physically disconnected, and

incapable of performing its function. A Prompt Operability Determination (POD) was initiated

in an attempt to evaluate operability based on the compensatory measures. NOP-OP-1009,

Operability Determinations and Functionality Assessments step 4.3.11 required that in the

case of PODs which have compensatory measures, the engineering director or designee

must grant concurrence. However, the duty engineering manager (directors designee)

indicated that operability could not be supported because the instrument could not meet its

surveillance requirements, and therefore, he did not provide his concurrence.

The inspectors questioned the licensees basis for operability. From discussions with the

licensee on July 1, 2016, the inspectors determined the defined compensatory measures

were not sufficient for the licensee to declare Channel 1 operable. At 1325 on July 1, 2016,

the licensee agreed with the inspectors assessment and declared Channel 1 inoperable.

At 1351 maintenance was completed on Channel 1 and the channel was restored to service.

Corrective Actions: The corrective actions included declaring channel 1 inoperable and

performing corrective maintenance on the Channel 1 instrumentation to restore it to operable.

The Licensee performed a root cause analysis and developed a case study from lessons

learned. Additionally, the licensee issued an operations standing order, performed additional

training regarding lessons learned from this event, Technical Specification compliance, and

correct application of the operability determination process.

Corrective Action Reference: The licensee documented this issue in CR 2016-08416,

Performance review of LCO 3.3.5 application during LT1525A maintenance.

Performance Assessment:

Performance Deficiency: The inspectors determined the licensees failure to implement

NOP-OP-1009 was a performance deficiency. Specifically, step 4.3.11 required that in the

case of a POD relying on compensatory measures, the engineering director or designee must

grant concurrence. However, the engineering duty manager (directors designee) stated that

operability could not be supported and that a POD could not be performed because the

instrument could not meet its surveillance requirements, and therefore did not provide his

concurrence.