Text

Integrated Inspection Report 05000341/2018002
	ML18227A091
Person / Time
Site:	Fermi
Issue date:	08/14/2018
From:	Billy Dickson; NRC/RGN-III/DRP/B5
To:	Polson K; DTE Energy
References
	IR 2018002
	Download: ML18227A091 (33)
	v • d • e

UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION III

2443 WARRENVILLE RD. SUITE 210

LISLE, ILLINOIS 60532-4352

August 14, 2018

Mr. Keith Polson, Senior VP

and Chief Nuclear Officer

DTE Energy Company

Fermi 2 - 260 TAC

6400 North Dixie Highway

Newport, MI 48166

SUBJECT: FERMI POWER PLANT, UNIT 2NRC INTEGRATED INSPECTION REPORT

05000341/2018002

Dear Mr. Polson:

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

inspection at your Fermi Power Plant, Unit 2. On July 10, 2018 and August 3, 2018, the NRC

inspectors discussed the results of this inspection with Mr. Caragher, 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 three issues that were evaluated

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

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

Because you have 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.

Additionally, Section 71153 of the enclosed report discusses a finding with an apparent violation

for which the NRC has not reached a preliminary significance determination. This finding

involved the apparent failure of the licensee to identify a condition adverse to quality while

performing corrective maintenance on Division 2 Residual Heat Removal Service Water outlet

flow control valve prior to returning the system to service. Because of this, the system was

inoperable longer than allowed by Technical Specification 3.7.1. Since the NRC has not made

a final determination in this matter, a Notice of Violation is not being issued for this inspection

finding at this time. In addition, please be advised that the characterization of the apparent

violation described in the enclosed inspection report may change as a result of further NRC

review.

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 Inspectors at the Fermi Power Plant.

K. Polson -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 inspectors at Fermi Power Plant.

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/

Billy Dickson, Chief

Branch 5

Division of Reactor Projects

Docket Nos. 50-341

License Nos. NPF-43

Enclosure:

Inspection Report 05000341/2018002

cc: Distribution via LISTSERV

K. Polson -3-

Letter to Keith Polson from Billy Dickson dated August 14, 2018

SUBJECT: FERMI POWER PLANT, UNIT 2NRC INTEGRATED INSPECTION REPORT

05000341/2018002

DISTRIBUTION:

Jeremy Bowen

RidsNrrDorlLpl3

RidsNrrPMFermi2 Resource

RidsNrrDirsIrib Resource

DRPIII

DRSIII

ROPreports.Resource@nrc.gov

ADAMS Accession Number: ML18227A091

Publicly Available Non-Publicly Available Sensitive Non-Sensitive

OFFICE RIII

NAME BDickson:lg

DATE 8/14/2018

OFFICIAL RECORD COPY

U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Docket Numbers: 50-341

License Numbers: NPF-43

Report Numbers: 05000341/2018002

Enterprise Identifier: I-2018-002-0020

Licensee: DTE Energy Company

Facility: Fermi Power Plant, Unit 2

Location: Newport, MI

Dates: April 1 through June 30, 2018

Inspectors: T. Briley, Senior Resident Inspector

P. Smagacz, Resident Inspector

V. Myers, Senior Health Physicist

J. Nance, Resident Inspector

R. Ng, Project Engineer

K. Pusateri, Acting Resident Inspector

J. Steffes, Senior Resident Inspector, Perry

Approved by: B. Dickson, Chief

Branch 5

Division of Reactor Projects

Enclosure

SUMMARY

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

by conducting an integrated quarterly inspection at Fermi Power Plant, Unit 2 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.

Licensee-identified non-cited violations are documented in report sections: 71111.12

and 71153.

List of Findings and Violations

Failure to Document a Condition Assessment Resolution Document for Reactor Recirculation

Motor-Generator Set A Brush Gear Sparking

Cornerstone Significance Cross-Cutting Report

Aspect Section

Initiating Events Green [H.14] - Human 71111.11 -

FIN 05000341 /2018002-01 Performance - Licensed

Closed Conservative Operator

Bias Performance

A self-revealed Green finding was identified for failure to document a Condition Assessment

Resolution Document (CARD) for 5-inch rooster tail sparking on reactor recirculation motor-

generator set A brush gear, which ultimately resulted in a manual recirculation pump A trip

and plant transient.

Inadequate Preventative Maintenance in Residual Heat Removal Service Water System

Outlet Flow Control Valves Results in Lower Bonnet (Backseat) Bushing Failure

Cornerstone Significance Cross-Cutting Report Section

Aspect

Mitigating Green [P.2] - Problem 71111.12 -

Systems NCV 05000341/2018002-02 Identification and Maintenance

Closed Resolution - Effectiveness

Evaluation

A self-revealed Green finding and associated non-cited violation (NCV) of 10 Code of Federal

Regulations (CFR) Part 50, Appendix Criterion V, Instructions, Procedures, and Drawings

were identified for failure to ensure activities affecting quality were prescribed in a manner

consistent with the circumstances to the residual heat removal service water system

(RHRSW). Specifically, preventative maintenance procedure M-681 failed to establish an

appropriate interval and guidance for periodic valve internals inspections on the Division 2

RHRSW system outlet flow control valve to prevent significant degradation from galvanic

corrosion given known internal and external operating experience.

2

Failure to Adequately Evaluate the Operability of Emergency Diesel Generator 11

Cornerstone Significance Cross-Cutting Report

Aspect Section

Mitigating Green [P.2] - 71111.15

Systems NCV 05000341/2018002-03 [Evaluation]

Closed

A finding of very low safety significance was self-revealed for the licensees failure to

adequately evaluate the operability of a condition adverse to quality identified on Emergency

Diesel Generator (EDG) 11. Specifically, a lube oil leak was evaluated as having no impact to

the operation of the emergency diesel generator. However, during the next surveillance run

of EDG 11, the engine had to be shut down and declared inoperable due to the lube oil leak

degrading during operation.

Failure to Identify a Condition Adverse to Quality on Division 2 Residual Heat Removal

Service Water Outlet Flow Control Valve

Cornerstone Significance Cross-Cutting Report Section

Aspect

Mitigating TBD [H.11] - Human 71153 -

Systems Apparent Violation Performance - Followup of

05000341/2018002-04 Challenge the Events and

Unknown Notices of

Open Enforcement

Discretion

A self-revealed TBD finding and an associated apparent violation of 10 CFR Part 50,

Appendix B, Criterion XVI, Corrective Action, and Technical Specification 3.7.1 Residual

Heat Removal Service Water (RHRSW) System, were identified for failure to identify a

condition adverse to quality while performing corrective maintenance on Division 2 RHRSW

outlet flow control valve E1150F068B prior to returning the Division 2 RHRSW system to

service. Specifically, troubleshooting and associated post maintenance testing failed to

identify and correct a failed anti-rotation key which resulted in an inoperable Division 2

RHRSW system for longer than its Technical Specification 3.7.1 allowed outage time.

Additional Tracking Items

Type Issue Number Title Report Status

Section

URI 05000341/2017004-01 Reactor Recirculation Motor- 71111.11 Closed

Generator Set A Brush Gear

Failure

URI 05000341/2017004-02 Division 2 Residual Heat 71111.12 Closed

Removal Service Water

System Outlet Flow Control

Valve Lower Bonnet

(Backseat) Bushing Failure

LER 05000341/2017-003-00 Division 2 Residual Heat 71153 Closed

Removal Service Water

System Inoperable due to

Inoperable RHRSW Outlet

Flow Control Valve

3

Type Issue Number Title Report Status

Section

LER 05000341/2018-001-00 Secondary Containment 71153 Closed

Pressure Exceeded Technical

Specification Due to Reactor

Building HVAC

4

TABLE OF CONTENTS

PLANT STATUS ........................................................................................................................... 6

INSPECTION SCOPES ................................................................................................................ 6

REACTOR SAFETY .................................................................................................................. 6

RADIATION SAFETY ................................................................................................................ 9

OTHER ACTIVITIES - BASELINE .......................................................................................... 10

INSPECTION RESULTS ............................................................................................................ 11

EXIT MEETINGS AND DEBRIEFS ............................................................................................ 22

DOCUMENTS REVIEWED......................................................................................................... 23

5

PLANT STATUS

Unit 2 began the inspection period at approximately 100 percent rated thermal power. On

April 14, 2018, the unit automatically scrammed due to the loss of station service transformer 64

and the associated plant transient described in NRC Event Notification No. 53336. The unit was

restarted on May 5, 2018 and synchronized to the grid on May 6. 2018. On May 8, 2018, the

unit reached 91.5 percent rated thermal power when vibrations on the north reactor feedwater

pump (NRFP) limited power ascension. The unit remained between approximately 87 percent

and 92 percent rated thermal power for troubleshooting of the vibration issues on the NRFP until

May 16, 2018, when power was reduced to approximately 55 percent rated thermal power to

remove the NRFP from service for maintenance. The unit remained at approximately 55

percent rated power until May 24, 2018, when the NRFP was restored to service. The unit

returned to approximately 100 percent rated thermal power on May 25, 2018. On

June 23, 2018, the unit was reduced to approximately 60 percent rated thermal power for

planned main steam line isolation channel functional testing and a rod pattern adjustment. The

unit returned to approximately 100 percent rated thermal power on June 24, 2018, for the

remainder of the inspection period.

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

Impending Severe Weather (1 Sample)

The inspectors evaluated readiness for impending adverse weather conditions for severe

thunderstorms forecasted from May 2, 2018 through May 3, 2018.

Seasonal Extreme Weather (1 Sample)

The inspectors evaluated readiness for seasonal extreme weather conditions prior to the

onset of hot weather forecasted May 26, 2018 through June 2, 2018.

6

71111.04Equipment Alignment

Partial Walkdown (3 Samples)

The inspectors evaluated system configurations during partial walkdowns of the following

systems/trains:

(1) Division 1 emergency equipment cooling water system (EECW) during planned Division

2 maintenance during the week ending May 26, 2018;

(2) Division 1 core spray system during Division 2 maintenance during the week ending

June 23, 2018; and

(3) Reactor core isolation cooling system (single train risk significant system) during the

week ending June 30, 2018.

71111.05AQFire Protection Annual/Quarterly

Quarterly Inspection (6 Samples)

The inspectors evaluated fire protection program implementation in the following selected

areas:

(1) Reactor Building Second Floor Division 1 EECW area during the week ending

May 26, 2018;

(2) Auxiliary Building Fourth Floor control room during the week ending June 9, 2018;

(3) Auxiliary Building Fourth Floor computer room and area above control room during

the week ending June 9, 2018;

(4) Turbine Building Second Floor main turbine lube oil reservoir on June 9, 2018;

(5) Reactor Building Sub-Basement & Basement Division 2 core spray pump room during

the week ending June 9, 2018; and

(6) Auxiliary Building Sub Basement high pressure coolant injection pump room during

the week ending June 9, 2018.

71111.07Heat Sink Performance

Heat Sink (1 Sample)

The inspectors evaluated Division 2 EECW backup heat exchanger performance during the

week ending June 30, 2018.

71111.11Licensed Operator Requalification Program and Licensed Operator Performance

Operator Requalification (1 Sample)

The inspectors observed and assessed an operations crew evaluated scenario in the plant

training simulator on May 29, 2018.

Operator Performance (1 Sample)

The inspectors observed and evaluated operations crew response to an automatic reactor scram on April 14, 2018; reactor start up activities May 4-6, 2018; and north reactor

feedwater pump restoration following corrective maintenance on May 25, 2018.

7

The inspectors also reviewed the status of URI 05000341/2017004-01, Reactor

Recirculation Motor-Generator Set A Brush Gear Failure. This did not constitute an

inspection sample.

71111.12Maintenance Effectiveness

Routine Maintenance Effectiveness (3 Samples)

The inspectors evaluated the effectiveness of routine maintenance activities associated

with the following equipment and/or safety significant functions:

(1) Reactor feedwater pumps;

(2) Control center heating, ventilation, and air conditioning (CCHVAC); and

(3) Division 1 EECW system.

The inspectors also reviewed the status of URI 05000341/2017004-02, Division 2 Residual

Heat Removal Service Water System Outlet Flow Control Valve Lower Bonnet (Backseat)

Bushing Failure. This did not constitute an inspection sample.

Quality Control (1 Sample)

The inspectors evaluated maintenance and quality control activities associated with the

following equipment performance issues:

(1) Division 1 CCHVAC motor vibrations in February and March 2018.

71111.13Maintenance Risk Assessments and Emergent Work Control (2 Samples)

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

work activities:

(1) Emergent work on reactor recirculation pump A discharge valve B3015F031B stem

during the weeks ending April 28, 2018 and May 5, 2018; and

(2) Maintenance during the week ending May 26, 2018, including emergent work on the

north reactor feedwater pump and planned work on the Division 1 EECW room cooler.

71111.15Operability Determinations and Functionality Assessments (2 Samples)

The inspectors evaluated the following operability determinations and functionality

assessments:

(1) Operability and functionality of reactor recirculation pump A discharge valve

B3015F031B following identification of valve stem indications documented in

CARD 18-23497, during the week ending May 3, 2018; and

(2) Operability and functionality of emergency diesel generator 11 following identification of

a lube oil leak as documented in CARD 18-24354, during the week ending

June 9, 2018.

8

71111.19Post Maintenance Testing (3 Samples)

The inspectors evaluated the following post maintenance tests:

(1) Reactor recirculation pump A discharge valve following stem repairs during the week

ending May 5, 2018;

(2) Identification and removal of a fuel bundle with a small fuel element defect during the

week ending April 28, 2018; and

(3) North reactor feedwater pump following disassembly and repairs of elevated vibrations

during the week ending May 26, 2018.

71111.20Refueling and Other Outage Activities (1 Sample)

The inspectors evaluated forced outage activities due to the loss of station service

transformer 64 from April 14, 2018 to May 6, 2018.

71111.22Surveillance Testing

The inspectors evaluated the following surveillance tests:

Routine (1 Sample)

(1) Reactor protection system manual scram weekly during the week ending May 19, 2018.

In-service (1 Sample)

(1) High pressure coolant injection pump and valve operability test at 1025 psi during the

week ending June 9, 2018.

71114.06Drill Evaluation

Emergency Planning Drill (1 Sample)

The inspectors evaluated a graded emergency planning drill on May 15, 2018.

RADIATION SAFETY

71124.02Occupational As Low As Reasonably Achievable Planning and Controls

Radiological Work Planning (1 Sample)

The inspectors evaluated the licensees radiological work planning by reviewing the

following activities:

(1) RWP 17-4004, Reactor Reassembly and Support Activities;

(2) RWP 17-4002, Reactor Core Alteration, Bridge Maintenance, LPRM [Local Power

Range Monitor] Replacement and Support Activities;

(3) RWP 17-4003, RB - 5 ISI/IVVI [Inservice inspection/In-Vessel Visual Inspection] and

Support Activities;

(4) RWP 17-3017, SRVs [Safety/Relief Valves] Maintenance and Inspection, Including

Replacement and Support Tasks Drywell and RB Bullpen; and

9

(5) RWP 17-3015, CRDM [Control Rod Drive Mechanism] Exchange/Support Tasks -

Drywell and RB Bullpen.

Verification of Dose Estimates and Exposure Tracking Systems (1 Sample)

The inspectors evaluated dose estimates and exposure tracking.

OTHER ACTIVITIES - BASELINE

71151Performance Indicator Verification (3 Samples)

The inspectors verified licensee performance indicators submittals listed below:

(1) MS06: Emergency alternate current power system - 1 Sample (April 1, 2017 -

March 30, 2018);

(2) MS07: High pressure injection system - 1 Sample (April 1, 2017 - March 30, 2018); and

(3) BI02: Reactor coolant system leak rate sample - 1 Sample (April 1, 2017 -

March 30, 2018).

71152Problem Identification and Resolution

Annual Follow-Up of Selected Issues (2 Samples)

The inspectors reviewed the licensees implementation of its corrective action program

related to the following issues:

(1) Root cause evaluation and associated corrective actions associated with reactor

recirculation motor-generator set A brush gear failure as documented in

CARD 17-29439; and

(2) Root cause evaluation and associated corrective actions associated with Division 2

RHRSW outlet flow control valve lower bonnet (backseat) bushing failure as

documented in CARD 17-28611.

71153Follow-Up of Events and Notices of Enforcement Discretion

Events (1 Sample)

The inspectors evaluated Event Notification No. 53336, Reactor Scram due to Loss of

Station Service Transformer 64, and licensees response on April 14, 2018.

Licensee Event Reports (2 Samples)

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

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

(1) Licensee Event Report (LER) 05000341/2017-003-00, Division 2 RHRSW Inoperable

due to Inoperable RHRSW Outlet Flow Control Valve; and

(2) Licensee Event Report (LER) 05000341/2018-001-00, Secondary Containment

Pressure Exceeded Technical Specification Due to Rector Building HVAC System

Manipulation.

10

INSPECTION RESULTS

71111.11Licensed Operator Requalification Program and Licensed Operator Performance

Failure to Document a Condition Assessment Resolution Document for Reactor Recirculation

Motor-Generator Set A Brush Gear Sparking

Cornerstone Significance Cross-Cutting Report

Aspect Section

Initiating Events Green [H.14] - Human 71111.11 -

FIN 05000341/2018002-01 Performance - Licensed

Closed Conservative Operator

Bias Performance

A self-revealed Green finding was identified for failure to document a Condition Assessment

Resolution Document (CARD) for 5-inch rooster tail sparking on reactor recirculation motor-

generator set A brush gear, which ultimately resulted in a manual recirculation pump A trip

and plant transient.

Description:

On November 25, 2017, while performing a routine reactor building rounds tour, a non-

licensed operator identified 5-inch rooster tail sparks on the generator end of reactor

recirculation motor-generator set A brush gear. The non-licensed operator immediately

contacted the control room to report the observed conditions and marked the routine brush

gear inspection unsatisfactory for the shiftly reactor building rounds tour. The licensed reactor

operators in the control room discussed the information and determined the sparking to not be

of significance given previous experience and not having a clear understanding of what is or

is not acceptable sparking for brush gear assemblies. As a result, no condition assessment

resolution document was generated.

As discussed in Section 1R11.1 of Inspection Report 05000341/2017004 (ADAMS Accession

Number ML18036A012), at approximately 2:38 p.m., on November 26, 2017, while the plant

was operating at 100 percent reactor thermal power, the control room unexpectedly received

a recirculation system A generator field ground alarm with no other abnormal indications

noted in the control room. A non-licensed operator was dispatched to the reactor recirculation

motor-generator room in the reactor building and immediately noted an acrid odor along with

significant arcing and sparking on the generator end of reactor recirculation motor-generator

set A. Subsequently, at 2:56 p.m., control room operators manually tripped reactor

recirculation motor-generator set A and entered abnormal operating procedure 20.138.01,

Reactor Recirculation Pump Trip. In accordance with the abnormal operating procedure, the

control room operators promptly inserted control rods and stabilized the plant at

approximately 35 percent reactor thermal power in single loop operation. The abnormal

operating procedure was exited at 4:37 p.m. following completion of associated operator

actions and plant stabilization.

Procedure MOP01, Conduct of Operations, Revision 27, step 3.29.10 instructs rounds

operators to report all concerns to the control room. Generate CARDs as necessary to

correct identified deficiencies. The rounds were marked as unsatisfactory for the brush gear

inspection on November 25, 2017 and reported to the control room. A CARD was not

generated to evaluate the condition. Procedure MQA11, Condition Assessment Resolution

Document, step 5.1.1 for initiating a CARD states when a condition (see definition in step

4.4.7) is identified, complete the initiator section of the E-CARD [computer software program

11

for writing CARDs]. A condition is defined as a potential or real situation that may require

further review, evaluation, or action for resolution. The situation may be adverse to quality,

may not meet Fermi expectations, or may provide opportunities for improvement. The

five-inch rooster tail sparks and unsatisfactory rounds reading fall under the framework of

that definition.

Corrective Actions: The reactor recirculation motor-generator set A brush gear was repaired,

conduct of operations and operator rounds procedures were revised to clearly establish

acceptance criteria for arcing and/or sparking and expectations for generating CARDs, and

training was provided to operations personnel on expectations for CARD generation.

Corrective Action Reference: CARD 17-29439

Performance Assessment:

Performance Deficiency: The inspector determined that the licensees failure to document a

CARD for 5-inch rooster tail sparking on reactor recirculation motor-generator Set A brush

gear was a performance deficiency. This ultimately resulted in a manual recirculation

pump A trip and plant transient.

Screening: The inspectors determined the performance deficiency was more than minor

because it adversely affected the Equipment Performance attribute of the Initiating Events

cornerstone objective to limit the likelihood of events that upset plant stability and challenge

critical safety functions during shutdown as well as power operations. Specifically, by not

documenting an adverse sparking condition in a CARD, appropriate action to resolve the

issue was not taken and resulted in a manual recirculation pump A trip and plant transient.

Significance: The inspectors assessed the significance of the finding using IMC 0609,

Appendix A, The Significance Determination Process (SDP) For Findings At-Power. The

inspectors answered no to the transient initiator screening question in Exhibit 1 since the

finding did not cause a reactor trip and a loss of mitigation equipment relied upon to transition

the plant from the onset of the trip to a stable shutdown condition. Therefore, this finding

screened as of very low safety significance (Green).

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

component of the Human Performance cross-cutting area, which states that the licensee will

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, control room operators independently rationalized away the

identified motor-generator set sparking as a non-issue prior to informing the shift manager or

maintenance personnel and no action was taken to address the issue. [H.14]

Enforcement: The inspectors did not identify a violation of regulatory requirements

associated with this finding since the reactor recirculation motor-generator is not a safety

related system. Therefore, 10 CFR 50, Appendix B does not apply to this system.

The disposition of this finding along with the observation in Section 71152 below closes

URI 05000341/2017004-01.

12

71111.12Maintenance Effectiveness

Inadequate Preventative Maintenance in Residual Heat Removal Service Water System

Outlet Flow Control Valves Results in Lower Bonnet (Backseat) Bushing Failure

Cornerstone Significance Cross-Cutting Report Section

Aspect

Mitigating Green [P.2] - Problem 71111.12 -

Systems NCV 05000341/2018002-02 Identification and Maintenance

Closed Resolution - Effectiveness

Evaluation

A self-revealed Green finding and associated NCV of 10 CFR Part 50, Appendix B,

Criterion V, Instructions, Procedures, and Drawings were identified for the licensees failure

to ensure activities affecting quality were prescribed in a manner consistent with the

circumstances to the RHRSW. Specifically, preventative maintenance procedure M-681

failed to establish an appropriate interval and guidance for periodic valve internals inspections

on the Division 2 RHRSW system outlet flow control valve to prevent significant degradation

from galvanic corrosion given known internal and external operating experience.

Description:

As discussed in Section 1R12.1 of Inspection Report 05000341/2017004 (ADAMS Accession

Number ML18036A012), the Division 2 RHRSW system was started on October 23, 2017 to

support routine addition of biocide to the Division 2 RHR reservoir (ultimate heat sink) as a

preventative measure to minimize raw water system fouling, which typically entailed running

both Division 2 RHRSW pumps for approximately 12 hours1.388889e-4 days 0.00333 hours 1.984127e-5 weeks 4.566e-6 months . Approximately 20 minutes after

system startup, the control room received an overhead annunciator alarm for reactor building

south west quad leakage to floor drain sump high along with indication that the reactor

building south west quad sump pumps were running. A non-licensed operator was

dispatched to the field to investigate the alarms and identified that the Division 2 RHRSW

outlet flow control valve (E1150F068B), located in the Division 2 RHR heat exchanger room in

the reactor building, had a significant packing leak calculated to be approximately 16 gallons

per minute. The leakage did not impact any other plant equipment in the local area and was

captured by the Division 2 RHR heat exchanger room floor drains, which discharged into the

reactor building south west quad room sump. Control room operators subsequently shutdown

the Division 2 RHRSW pumps to stop the packing leak and declared the Division 2 RHRSW

system inoperable.

The licensee formed an emergent issues team to further investigate the issue. Following

valve disassembly and inspection, the licensee identified the valve lower bonnet (backseat)

bushing no longer had sufficient thread engagement to remain in place and that the valve

packing had been ejected from the valve stuffing box. A temporary modification was

implemented to install a new backseat bushing welded directly to the valve bonnet. The

system was subsequently returned to service on October 27, 2017.

The licensee completed a root cause analysis in CARD 17-28611. The direct cause of the

Division 2 RHRSW outlet flow control valve packing leak was determined to be the valve

bonnet carbon steel threads corroded to the point of no longer functioning as an adequate

mechanical connection. This resulted in the backseat bushing detaching from the valve

bonnet allowing the packing to be ejected. The root cause was determined to be previous

operating experience resolution for galvanic corrosion for valves in the safety-related service

water systems was less than adequate. This resulted in a failure to recognize the

13

vulnerability of galvanic corrosion on passive valve components and a missed opportunity to

prevent future corrosion degradation on these valves. Contributing causes identified by the

licensee consisted of (1) RHRSW system operation produces significant valve vibration and

periodic wetting and then drying conditions promoting a corrosive environment and (2) high

levels of ionic impurities, as measured by chloride concentration, in RHRSW accelerate

galvanic corrosion.

In 2010, the Division 2 RHRSW outlet flow control valve did not indicate fully open after

routine startup of the system for biocide treatment despite normal flow rates. The Division 2

RHRSW flow control valve was identified to have internal mechanical degradation including a

partially unthreaded backseat bushing which was attributed to routine startup vibration and

cavitation (CARDs 10-23821 and 10-29933). As a corrective action, in March 2011 the

licensee developed preventative maintenance procedure M-680 and M-681 were developed

by March 17, 2011 to inspect and repair the internals of both Division 1 and Division 2

RHRSW outlet flow control valves on a ten year periodicity, respectively.

In 2012, a component design basis inspection self-assessment recommended a review of

material composition of components exposed to safety related service water based on

internal and external operating experience regarding William Powell check valve and

gate valve failures. The licensee developed recommendations and analysis under

CARD 12-24869 on the internal material composition for all valves exposed to the

corrosive/electrolytic water from the ultimate heat sink within the safety related service water

systems to determine the susceptibility to galvanic corrosion. All globe valves, including the

RHRSW outlet flow control valves, were excluded based on valve design due to low likelihood

of failure. Residual Heat Removal Service Water (RHRSW) was reviewed again in 2015

under CARD 15-28194 due to various issues with safety related service water equipment.

Globe valves were, again, excluded from this review.

On September 28, 2017, the licensee performed internal repairs on a partial stem-to-disc

separation on the Division 2 RHRSW outlet flow control valve detected during performance

monitoring following the anti-rotation key failure discussed in Section 71152 of this report.

The licensee noted and repaired a broken backseat bushing tack weld was noted during the

maintenance activity and subsequently repaired. The cause of the broken tack welds was not

thoroughly evaluated until the backseat bushing failed on October 23, 2017.

The inspectors concluded that the preventative maintenance procedures established in 2011

failed to establish an appropriate internal and guidance for periodic valve internals inspections

on the RHRSW system outlet flow control valves to prevent significant degradation from

galvanic corrosion given known internal and external operating experience. The

circumstances are such that the RHRSW outlet flow control valves are routinely wetted and

dried with water from the ultimate heat sink and that water consists of dissimilar metals

provided an environment for galvanic corrosion widely known and discussed by both the

industry and NRC through operating experience.

Corrective Actions: The Division 2 RHRSW outlet flow control valve backseat bushing was

repaired. Additionally, preventative maintenance procedures were revised to specifically

inspect the backseat bushing for degradation.

Corrective Action Reference: CARD 17-28611

14

Performance Assessment:

Performance Deficiency: The inspectors determined that the licensees failure to ensure that

activities affecting quality were prescribed in a manner consistent with the circumstances to

the RHRSW system was a performance deficiency. Specifically, the licensee failed to

establish an appropriate interval and guidance for periodic valve internals inspections on the

Division 2 RHRSW system outlet flow control valve per preventative maintenance procedure

M-681 to prevent significant degradation from galvanic corrosion given known internal and

external operating experience.

Screening: The inspectors determined the performance deficiency was more than minor

because it adversely impacted 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 (i.e. core damage).

Specifically, the Division 2 RHRSW was declared inoperable and unavailable to perform

repairs to a lower bonnet bushing failure.

Significance: The inspectors assessed the significance of the finding using IMC 0609

Appendix A, The Significance Determination Process (SDP) For Findings At-Power and

answered No to all four mitigating structures, systems, components and functionality

screening questions in Exhibit 2. The inspectors determined this finding was of very low

safety significance (Green) because: the finding did not affect the design or qualification

of a mitigating structure, system or component; did not represent a loss of system and/or

function; did not represent an actual loss of function of at least a single train for greater than

its Technical Specification (TS) allowed outage time, or two separate safety systems out-of-

service for greater than its TS allowed outage time; and did not represent an actual loss of

function of one or more non-TS trains of equipment designed as high safety-significant in

accordance with the licensees maintenance rule program for greater than 24 hours2.777778e-4 days 0.00667 hours 3.968254e-5 weeks 9.132e-6 months .

Cross-Cutting Aspect: The finding had a cross-cutting aspect in the Evaluation component of

the Problem Identification and Resolution cross-cutting area, which states that the licensee

will thoroughly evaluate issues to ensure that resolutions address causes and extent of

conditions commensurate with their safety significance. Specifically, a broken backseat

bushing tack weld was found damaged during corrective maintenance one month prior to the

backseat bushing failure in 2017 and the cause of the failure was not fully evaluated. [P.2]

Enforcement:

Violation: Title 10 CFR Part 50, Criterion V, Instructions, Procedures, Drawings states:

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. Instructions, procedures, or

drawings shall include appropriate quantitative or qualitative acceptance criteria for

determining that important activities have been satisfactorily accomplished.

Contrary to the above, from March 17, 2011 to October 23, 2017, the licensee failed to ensure

activities affecting quality were prescribed in a manner consistent with the circumstances to

the RHRSW system. Specifically, the licensee failed to establish an appropriate interval and

guidance for periodic valve internals inspections on the RHRSW system flow-control valves

preventative maintenance procedure M-681, to prevent significant degradation from galvanic

corrosion given known internal and external operating experience.

15

Disposition: This violation is being treated as a Non-Cited Violation, consistent with

Section 2.3.2 of the Enforcement Policy.

The disposition of this finding and the associated NCV, along with observation discussed in

Section 71152 and the disposition of a finding and the associated NCVs documented in

Section 71153 of this report close URI 05000341/2017004-02.

71111.15Operability Determinations and Functionality Assessments

Failure to Adequately Evaluate the Operability of EDG 11

Cornerstone Significance Cross-Cutting Report

Aspect Section

Mitigating Green [P.2] - 71111.15

Systems NCV 05000341/2018002-03 [Evaluation]

Closed

A finding of very low safety significance was self-revealed for the licensees failure to

adequately evaluate the operability of a condition adverse to quality identified on EDG 11.

Specifically, a lube oil leak was evaluated as having no impact to the operation of the

emergency diesel generator. However, during the next surveillance run of EDG 11, the

engine had to be shut down and declared inoperable due to the lube oil leak degrading during

operation.

Description:

On June 1, 2018, operators identified an approximately 0.5 gallon pool of oil under the lube oil

filter of EDG 11. The source of the oil was identified as a leak from the lube oil filter supply

piping flange clamp and quantified as approximately 1 drop every 2 minutes. Condition

Assessment Resolution Document (CARD) 18-24354 was written to document the condition.

The initial operability evaluation considered only the volume of oil that was leaking

comparatively to the total amount of oil available in the lube oil tank and sump. The

conclusion was that the leak rate was small enough not to challenge the available quantity of

oil for the EDG. No other action was required nor assigned.

On June 4, 2018, operators performed the monthly surveillance run for EDG 11. During the

run, the lube oil leak degraded into a pencil sized stream of oil. The EDG was immediately

shut down and declared inoperable until repairs could be affected. The previous operability

evaluation only took into consideration lube oil quantities, and did not evaluate for a potential

degradation at the flange clamp due to operating system temperature and pressure changes

while the system would be performing its specified safety function. Procedure MQA11-100,

Operability Determination Process, required that for any structure, systems, or component

(SSC) to be considered operable, the SSC must be capable of performing the specified safety

functions of its design, within the required range of physical conditions, initiation times, and

mission times in the current licensing basis.

Corrective Actions: The licensee entered this issue into their corrective action program. The

flange clamp was repaired; the EDG was successfully tested on June 6, 2018 and returned to

an operable condition. An extent of condition was performed on the other three EDGs to

ensure the integrity of the flange clamps on the lube oil system.

Corrective Action Reference: CARD 18-24437

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Performance Assessment:

Performance Deficiency: The licensees failure to adequately evaluate the operability of

EDG 11 in accordance with licensee procedure MQA11-100 that required the SSC to be

assessed while it performed the specified safety functions of its design, within the required

range of physical conditions, in order to be considered operable was a performance

deficiency. Specifically, the licensee evaluated an oil leak in the static, stand-by condition for

EDG 11, and not in its operating condition. During the next surveillance run, the oil leak

degraded under operating temperature and pressure, and the EDG was shut down and

declared inoperable.

Screening: The inspectors determined the performance deficiency was more than minor

because it adversely 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 (i.e., core damage).

Specifically, the failure to properly assess the operability of the EDG led to the EDG being

declared inoperable during the next surveillance run.

Significance: The inspectors assessed the significance of the finding using IMC 0609,

Appendix A, The Significance Determination Process (SDP) For Findings At-Power, and

answered No to all the Section A questions of Exhibit 2. Therefore, this performance

deficiency screened as Green.

Cross-Cutting Aspect: The finding had a cross-cutting aspect in the Evaluation component of

the Problem Identification and Resolution cross-cutting area, which states that the licensee

will thoroughly evaluate issues to ensure that resolutions address causes and extent of

conditions commensurate with their safety significance. Specifically, a condition adverse to

quality was not fully evaluated for potential degradation that may have called into question the

operability of the EDG when called upon to fulfill the EDGs safety function. [P.2]

Enforcement:

Violation: Title 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and

Drawings, requires, in part, that 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.

Procedure MQA11-100, Operability Determination Process, is a quality assurance conduct

manual implementing procedure that the licensee uses to assess operability of SSC and

support functions for compliance with Technical Specifications (TS) when a degraded,

nonconforming, or unanalyzed condition is identified. Step 3.2.1 of this procedure requires, in

part, that in order to be considered operable, a structure, systems, or component must be

capable of performing the specified safety functions of its design, within the required range of

physical conditions in the current licensing basis.

Contrary to the above, from June 1 to June 4, 2018, the licensee did not accomplish a

prescribed procedure for an activity affecting quality. Specifically, the licensee did not

evaluate the operability of EDG 11 in accordance with licensee procedure MQA11-100 that

required the SSC to be assessed while it performed the specified safety functions of its

design, within the required range of physical condition. The licensee only took into

consideration lube oil quantities, and did not evaluate for a potential degradation at the flange

17

clamp due to operating system temperature and pressure changes while the system would be

performing its specified safety function.

Disposition: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

71152Problem Identification and Resolution

Observation 71152 Annual Sample Review

Root Cause Evaluation and Corrective Actions Associated with Division 2 RHRSW Outlet

Flow Control Valve Lower Bonnet (Backseat) Bushing Failure as Documented in

CARD 17-28611.

As discussed in Section 71111.12 of this report and Section 1R12.1 of Inspection Report 05000341/2017004 (ADAMS Accession Number ML18036A012), a root cause evaluation was

performed for the bushing failure. The direct cause of the Division 2 RHRSW outlet flow

control valve packing leakage was determined to be the valve bonnet carbon steel threads

corroded to the point of no longer functioning as an adequate mechanical connection. This

resulted in the backseat bushing detaching from the valve bonnet allowing the packing to be

ejected. The root cause was determined to be previous operating experience resolution for

galvanic corrosion for valves in the safety-related service water systems was less than

adequate, resulting in a failure to recognize the vulnerability of galvanic corrosion on passive

valve components. Contributing causes consisted of (1) RHRSW system operation produces

significant valve vibration levels and periodic wetting and then drying conditions promoting a

corrosive environment and (2) high levels of ionic impurities, as measured by chloride

concentration, in RHRSW accelerate galvanic corrosion.

The root cause report identified weaknesses in the area of chemistry controls such that

chloride levels were very high compared to the established goals and that residual heat

removal reservoir coupon monitoring was not representative of actual corrosion rates.

Specifically, the coupon used for monitoring the residual heat removal reservoir was under

continuously submerged conditions verse periodic wetting and drying conditions for the valve.

The high levels of chloride were a result of biocide treatment and insufficient decanting of the

reservoir.

The inspectors reviewed the root cause evaluation and agreed with its conclusions.

Corrective actions planned or taken include, but are not limited to: Division 2 RHRSW outlet

flow control valve repairs, adding requirements to perform opportunistic inspections of service

water valves that are opened for other maintenance or inspections, development of a service

water valve internal inspection template with enhanced guidance, extent of condition reviews

for galvanic corrosion impacts on other susceptible valves, and changes to residual heat

removal reservoir chemical controls to main chlorides as low as possible.

The inspectors also reviewed the relationships between the various Division 2 RHRSW outlet

flow control valve issues discussed in Section 1R12.1 of Inspection Report 05000341/2017004 (ADAMS Accession Number ML18036A012). The inspectors determined

that the valve was not subject to an over thrust condition as a result of one or a combination of

irregular limit switch settings, anti-rotation key failure, broken and subsequent removal of the

disc guide pin, stem-to-disc unthreading, and various broken tack welds. Additionally, the

18

inspectors determined the valve design was appropriate given the circumstances and

consistent with industry standards.

Two findings and their associated non-cited violations were identified by the inspectors and

are discussed in Section 71111.12 and 71153 of this report.

This observation, along with the disposition of the two findings and the associated NCVs in

Section 71111.12 and Section 71153 of this report, close URI 05000341/2017004-02.

Observation 71152Annual Sample Review

Root Cause Evaluation and Corrective Actions Associated with Reactor Recirculation Motor-

Generator Set A Brush Gear Failure as Documented in CARD 17-29439