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	Quarter	Site	Title	Description
05000416/FIN-2018003-02	2018Q3	Grand Gulf	Minor Violation	Minor Violation: The licensee did not include any unplanned power changes as inputs for the Unplanned Power Changes per 7,000 Critical Hours performance indicator (PI) that was reported to the NRC for the second quarter 2016. Based on a plant event that took place on June 17, 2016, the inspectors noted that the PI data submitted by the licensee may not have been accurate. In response, the licensee submitted frequently asked question (FAQ) 17-01 to the reactor oversight process working group. This FAQ resulted in the determination that three unplanned power changes should have been reported associated with the event in question. Following resolution of the FAQ, the licensee reported the associated PI data. As required by 10 CFR 50.9, Completeness and accuracy of information, information provided to the NRC by a licensee shall be complete and accurate in all material respects. Contrary to the above, from July 2016 through May 2017, information provided to the NRC by the licensee was not complete and accurate in all material respects. Specifically, the data for the Unplanned Power Changes per 7,000 Critical Hours PI did not include any unplanned power changes for the second quarter 2016. Screening: The inspectors determined that this violation was of minor significance in accordance with the NRC Enforcement Policy, Section 6.9.d.11, since the PI data in question did not ultimately result in the PI changing from Green to White. Enforcement: The licensee entered this issue into their corrective action program as Condition Report CR-GGN-2016-06028. The licensee took action to restore compliance by submitting an appropriate correction to the PI data. This failure to comply with 10 CFR 50.9 constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy. The disposition of this violation closes URI 05000416/2017001-02, Grand Gulf Unplanned Power Changes per 7000 Critical Hours Performance Indicator.
05000416/FIN-2018003-01	2018Q3	Grand Gulf	Failure to Develop Adequate Work Instructions	A self-revealed, Green finding was identified when feedwater heater drain tank oscillations caused a feedwater perturbation which required a manual reactor scram. Specifically, the licensee failed to develop appropriate work instructions for filling and venting the feedwater heater 6A level transmitters.
05000298/FIN-2018002-02	2018Q2	Cooper	Failure to Maintain Adequate Work Instructions for Traversing In-Core Probe System Limit Switches	A self-revealed, Green non-cited violation of Technical Specification 5.4, Procedures, was identified when the licensee failed to maintain Procedure 14.2.14, TIP Chamber Shield Maintenance, with adequate instructions for reinstalling the traversing in-core probe system in-shield limit switches. As a result, the licensee experienced multiple failures of the shield limit switches resulting in inoperable primary containment isolation valves.
05000298/FIN-2018002-01	2018Q2	Cooper	Failure to Maintain Alarm Procedure for Service Water Booster Pump Ventilation Manual Actions	The inspectors identified a Green non-cited violation of Technical Specification 5.4, Procedures, when the licensee failed to maintain Procedure 2.3_R-1 with the bounding time restrictions for required manual ventilation actions identified in Engineering Evaluation NEDC 92-064, Transient Temperature Rise in SWBP Room After Loss of Cooling, Revision 3C2. As a result, the licensee relied on procedure guidance that contained an incorrect, less restrictive allowance of 13 hours for completion of manual actions rather than the bounding 5.8-hour allowance described in NEDC92-064.
05000458/FIN-2018012-04	2018Q2	River Bend	Failure to Submit a Licensee Event Report for a Manual Scram	The inspectors identified a Severity Level IV non-cited violation of 10 CFR 50.73, Licensee Event Report System, for the licensees failure to submit a required licensee event report (LER). Specifically, on February 1, 2018, after an unexpected trip of the recirculation pump B, the licensee initiated a manual scram of the reactor that was not part of a preplanned sequence and failed to submit an LER within 60 days.
05000458/FIN-2018012-01	2018Q2	River Bend	Failure to Conduct Adequate Transient Snap Shot Assessment Following Recirculation Pump Trip	The inspectors identified a finding for the licensees failure to adequately validate simulator response during a transient snap shot assessment following an unexpected trip of reactor recirculation pump A on December 19, 2012.
05000458/FIN-2018012-03	2018Q2	River Bend	Failure to Establish Procedural Guidance for Determining Core Flow During Unanticipated Single Loop Operations	The inspectors reviewed a self-revealed,non-cited violation of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to establish appropriate instructions in the abnormal operating procedure for thermal hydraulic instabilities. Specifically, the procedural step for determining core flow when in single loop operations at low power did not provide appropriate instructions to operators. As a result, station personnel could not conclusively determine core flow and inserted a manual reactor scram.
05000458/FIN-2018012-05	2018Q2	River Bend	Failure to Develop an Adequate Operational Decision-Making Issue for Compensatory Measures Related to a Degraded Condition of the Feedwater System Sparger Nozzles	The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure to develop an adequate Operational Decision-Making Issue (ODMI) document per Procedure EN-OP-111, Operational Decision-Making Issue Process. Specifically, the licensee failed to develop an ODMI that provided adequate guidance to the operators for safely operating the plant with degraded feedwater sparger nozzles.
05000458/FIN-2018012-06	2018Q2	River Bend	Failure to Provide Adequate Procedures for Post-Scram Recovery	The inspectors reviewed a self-revealed, non-cited violation of Technical Specification 5.4.1.a for the licensees failure to establish, implement and maintain a procedure required by Regulatory Guide 1.33, Revision 2, Appendix A, dated February 1978. Specifically, Procedure OSP-0053, Emergency and Transient Response Support Procedure, Revision 22, which is required by Regulatory Guide 1.33, inappropriately directed operations personnel to establish feedwater flow to the reactor pressure vessel using the main feedwater regulating valve as part of the post-scram actions. This resulted in the main feedwater regulating valves being operated outside their design limits. This resulted in catastrophic failure of the main feedwater regulating valve variseals and subsequent damage to multiple fuel assemblies.
05000458/FIN-2018012-02	2018Q2	River Bend	Failure to Identify and Correct a Broken Feedwater Chemistry Probe	Two examples of a self-revealed non-cited violation (NCV) of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, were identified for the licensees failure to identify that a broken chemistry probe in the feedwater system had the potential to cause an adverse impact on plant safety, and promptly implement appropriate measures to address that condition.
05000458/FIN-2018012-07	2018Q2	River Bend	Failure to Perform 10 CFR 50.59 Evaluation for Main Feedwater System Sparger Nozzle Damage	The inspectors identified a Severity Level IV non-cited violation of 10 CFR 50.59 , Changes, Tests, and Experiments, for the licensees failure to provide a written safety evaluation for the determination that operation with compensatory measures for damaged feedwater sparger nozzles did not require a license amendment pursuant to 10 CFR 50.90, Application for amendment of license, construction permit, or early site permit. Specifically, the licensee failed to recognize that compensatory measures prohibiting operation in single loop conditions required technical specification changes, and as such required prior NRC approval.
05000458/FIN-2018001-02	2018Q1	River Bend	Installation of an Incorrectly Specified Relay Causes Plant Transient and Reactor Scram	The inspectors reviewed two examples of a self-revealed finding for the licensees installation of an incorrectly specified relay in 1) the control circuitry for the feedwater level control systemand 2) the turbine generator voltage regulator circuitry. In each instance, the incorrectly specifiedrelay failed in service, causing a plant transient and automatic reactor scram
05000458/FIN-2018001-01	2018Q1	River Bend	Failure to Implement Procedure for Storage of Material in the Pools	The inspectors identified a non-cited violation of Technical Specification 5.4.1.a for the licensees failure to implement written procedures for activities referenced in Appendix A of Regulatory Guide 1.33, Revision 2, dated February 1978. Specifically, the licensee failed to implement radioactive material control Procedure ADM-0071, Fuel Pools Material Control, Revision 8, for the storage and movement of spent Tri-Nuke filters
05000298/FIN-2017012-02	2017Q4	Cooper	Inadequate Testing Activities for Emergency Transformer Bus	The inspectors identified a non- cited violation of Technical Specification 5.4.1.a for the licensees failure to maintain Maintenance Procedure 7.3.41, Examination and High Pot Testing of Non- Segregated Buses and Associated Equipment, Revision 10, to contain adequate instructions for testing of the emergency station service transformer 4160 V bus. Specifically, the inspectors identified a violation of Technical Specification 5.4.1.a for the licensees failure to maintain adequate instructions for performing high potential testing of the emergency transformer bus bars between March 23, 2015, and April 18, 2017. As a result, the licensee did not properly assess corona- related degradation on the emergency transformer bus, which resulted in an emergency transformer bus fault and a loss of the emergency transformer and the supplemental diesel generator on January 17, 2017. Immediate corrective actions to restore compliance included replacement of the faulted portions of the emergency transformer bus, and extent of condition inspection and cleaning of the remainder of the emergency transformer bus bars. Long term corrective actions include replacement of the emergency transformer bus insulation and revision of high potential testing procedure instructions. The licensee entered this issue into the corrective action program as Condition Report CR- CNS -2017- 02164. The licensees failure to maintain Maintenance Procedure 7.3.41 to properly assess degradation of the emergency station service transformer bus, in violation of Technical Specification 5.4.1.a, was a performance deficiency. The performance deficiency was determined to be more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Initiating Events Cornerstone, and affected the 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, the finding resulted in the licensees failure to identify and repair indications of corona -related degradation on the emergency station service transformer bus, which resulted in an emergency station service transformer bus fault, and a loss of the emergency station service transformer and the supplemental diesel generator on January 17, 2017. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At -Power, dated June 19, 2012, the inspectors determined that the finding required a detailed risk evaluation because it involved the partial loss of a support system that contributes to the likelihood of, or causes, an initiating event (loss -of-offsite power) and the finding affected mitigation equipment (supplemental diesel generator). A senior reactor analyst performed a detailed risk evaluation in accordance with Inspection Manual Chapter 0609, Appendix A, Section 6.0, Detailed Risk Evaluation. The analyst concluded that the finding is of very low safety significance (Green). 4 The performance deficiency had a cross-cutting aspect in the area of human performance, associated with change management , because the licensee failed to use a systematic process for evaluating and implementing a change so that nuclear safety remained the overriding priority. Specifically, on March 23, 2015, the licensee changed the Maintenance Procedure 7.3.41 bus testing method from performance of a megger test to performance of a high potential test, but failed to use a systematic process to evaluate the change to ensure that the new test had instructions that were adequate and consistent with industry Institute of Electrical and Electronics Engineers standards (H.3).
05000298/FIN-2017012-01	2017Q4	Cooper	Inadequate Inspection Activities for Emergency Transformer Bus	The inspectors reviewed a self -revealed, non- cited violation of Technical Specification 5.4.1.a for the licensees failure to implement Maintenance Procedure 7.3.41, Examination and High Pot Testing of Non- Segregated Buses and Associated Equipment, Revision 10, during inspection of the emergency station service transformer 4160 V bus bars. Specifically, the inspectors identified a violation of Technical Specification 5.4.1.a for the licensees failure to implement inspection instructions to examine the emergency transformer bus insulation for discoloration and to repair the associated components on March 23, 2015. As a result, the licensee did not properly assess corona -related degradation on the emergency transformer bus, which resulted in an emergency transformer bus fault and a loss of the emergency transformer and the supplemental diesel generator on January 17, 2017. Immediate corrective actions to restore compliance included replacement of the faulted portions of the emergency transformer bus, and extent of condition inspection and cleaning of the remainder of the emergency transformer bus bars . The long term corrective action is replacement of the emergency transformer bus insulation. The licensee entered this issue into the corrective action program as Condition Report CR- CNS -2017- 00223. The licensees failure to implement Maintenance Procedure 7.3.41 to properly assess degradation of the emergency station service transformer bus, in violation of Technical Specification 5.4.1.a, was a performance deficiency. The performance deficiency was determined to be more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Initiating Events Cornerstone, and affected the 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, the finding resulted in the licensees failure to identify and repair indications of corona -related degradation on the emergency station service transformer bus, which resulted in an emergency station service transformer bus fault, and a loss of the emergency station service transformer and supplemental diesel generator on January 17, 2017. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At -Power, dated June 19, 2012, the inspectors determined that the finding required a detailed risk evaluation because it involved the partial loss of a support system that contributes to the likelihood of, or causes, an initiating event (loss -of-offsite power) and 3 the finding affected mitigation equipment (supplemental diesel generator). A senior reactor analyst performed a detailed risk evaluation in accordance with Inspection Manual Chapter 0609, Appendix A, Section 6.0, Detailed Risk Evaluation. The analyst concluded that the finding is of very low safety significance (Green). The performance deficiency had a cross -cutting aspect in the area of problem identification and resolution, associated with evaluation because the licensee failed to thoroughly evaluate emergency station service transformer bus discoloration and high potential test failures to ensure that resolutions addressed the causes and extent of conditions commensurate with their safety significance. Specifically, the licensee failed to thoroughly evaluate emergency station service transformer bus discoloration identified during the 2015 inspection, the hipot testing failures t hat followed the inspection, and the extent of condition of the 2015 testing and inspection deficiencies (P.2).
05000298/FIN-2017003-03	2017Q3	Cooper	Loss of Control Room Ventilation Due to Inadequate Post-Maintenance Testing Activities	The inspectors identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion XI, Test Control, for the licensees failure to assure that all testing required to demonstrate that the control room emergency filter system would perform satisfactorily in service was identified and performed in accordance with written test procedures. Specifically, on May 25, 2017, following corrective maintenance to replace bent positioning rods for the A and B discharge dampers for the control room supply fans, the licensee failed to ensure that all testing described in Maintenance Procedure 7.0.5, CNS Post-Maintenance Testing, Revision 53, was identified and performed, in order to assure that the control room filter system would be able to perform its safety function. As a result, on May 26, 2017, after the licensee restored the system back to service, the in-service B discharge damper was found partially closed, resulting in the supply fan failing to meet minimum flow requirements and the control room emergency filter system being declared inoperable. Corrective actions to restore compliance included replacement of the damper positioning arm, interim actions requiring post-maintenance testing after each repositioning of the dampers, and long term actions to modify the damper control arms to prevent bending and improve position verification methods. The licensee entered this deficiency into the corrective action program as Condition Report CR-CNS-2017-05794.The licensees failure to assure that adequate post-maintenance testing was identified and performed for work on the control room supply fan discharge dampers was a performance deficiency. Using Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, the inspectors determined the performance deficiency was more than minor, and therefore a finding, because it was associated with the structure, system, and component, and barrier performance attribute of the Barrier Integrity Cornerstone and adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers (control room envelope) protect the public from radionuclide releases caused by accidents or events. Specifically, the finding resulted in control room supply fan B failing to meet minimum flow requirements and the control room emergency filter system being declared inoperable. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings at Power, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it did not represent a degradation of the barrier function of the control room against smoke or a toxic atmosphere. The finding had a cross-cutting aspect in the area of problem identification and resolution associated with evaluation. Specifically, the licensee failed to ensure that the organization thoroughly evaluated indications of degraded supply fan flow that occurred during testing, and failed to properly assess bent discharge damper positioning rod deficiencies discovered during the maintenance activities, to ensure that resolutions addressed causes and extent of conditions were commensurate with their safety significance ( P. 2).
05000298/FIN-2017003-02	2017Q3	Cooper	Failure to Account for Instrument Uncertainty in Safety-Related Ventilation Surveillance Procedures	The inspectors identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion XI, Test Control, for multiple examples of the licensees failure to assure that required testing was performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. Specifically, on July 12, 2017, the inspectors identified that Surveillance Procedure 6.1SGT.501, Standby Gas Treatment A Carbon Sample, Carbon Adsorber and HEPA Filter In-place Leak Test, and Components Leak Test, Revision 16, failed to account for test instrument uncertainty in the surveillance acceptance criteria. In response to the inspectors question, the licensee discovered that instrument uncertainty was not accounted for in several standby gas treatment system surveillance procedures, as well as surveillance procedures for the control room emergency filter system; diesel generator ventilation system; control building essential ventilation system; emergency core cooling essential ventilation systems; and several emergency preparedness ventilation systems. Corrective actions to restore compliance included incorporation of instrument uncertainty into procedure changes for the affected surveillance procedures and verification that the new acceptance criteria did not challenge past operability for the affected systems. The licensee entered this issue into the corrective action program as Condition Report CR-CNS-2017-04229.The inspectors determined that the licensees failure to assure surveillance test procedures for safety-related ventilation systems incorporated test instrument uncertainty into acceptance criteria was a performance deficiency. Because the systems involved in this performance deficiency were systems that mitigate the consequences of accidents, the inspectors evaluated the finding under the Mitigating Systems Cornerstone. In accordance with Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, the inspectors determined that the performance deficiency was more than minor, and therefore a finding, because it was a programmatic deficiency which adversely impacted the procedure quality attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the acceptance criteria for the licensees safety-related ventilation systems did not assure the availability of these systems to respond to accident conditions, as required by the technical specifications. The inspectors assessed the significance of this finding in accordance with Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings at Power, dated June 19, 2012, and determined this finding was of very low safety significance (Green) because it: was not a design deficiency; 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 longer than its technical specification allowed outage time; and did not result in the loss of a high safety-significant, nontechnical specification train. The finding had a cross-cutting aspect in the area of human performance associated with documentation because the licensee failed to ensure that the organization created and maintained complete, accurate, and up-to-date documentation (H.7).
05000298/FIN-2017003-01	2017Q3	Cooper	Failure to Ensure Suitability of Materials for the Reactor Building Northeast Fan Coil Unit	The inspectors reviewed a self-revealed, non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the licensees failure to assure that appropriate measures were established for the selection and review for suitability of application of materials, parts, equipment, and processes that were essential to the safety-related functions of a reactor building fan coil unit. Specifically, on March 9, 2016, the licensee installed a new coil for the reactor building northeast quad fan coil unit, but failed to assure the suitability of application of the materials, parts, and equipment associated with the new coil design in that the new component had measurably higher air resistance across the coil than the previous design. As a result, on August 1, 2017, the fan coil unit failed air flow surveillance testing during the next performance of the test, resulting in the fan coil unit being declared inoperable. Corrective actions to restore compliance included cooling coil cleaning activities, implementation of compensatory measures to restore operability, and generation of a work order to replace the degraded cooling coil. The licensee entered this deficiency into the corrective action program as Condition Report CR-CNS-2017-04701.The licensees failure to assure that the newly designed coil installed in the northeast quad fan coil unit was appropriately reviewed for suitability and adequacy was a performance deficiency. The performance deficiency was evaluated using Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, and was associated with the Mitigating Systems Cornerstone. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the performance deficiency resulted in the northeast quad fan coil unit being declared inoperable. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it: was not a design deficiency where the component maintained operability; 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 longer than its technical specification allowed outage time; and did not result in the loss of a high safety-significant, nontechnical specification train. The finding had a cross-cutting aspect in the area of human performance associated with design margins, because the licensee failed to ensure that the organization operated and maintained equipment within design margins, and failed to ensure that these margins were carefully guarded and changed only through a systematic and rigorous process with special attention placed on maintaining safety-related equipment. Specifically, although the new fan coil units air flow immediately degraded from 7950 scfm to 7360 scfm after coil installation in 2016, which significantly degraded the margin to the minimum flow requirements, the licensee did not take action to address the degraded performance until it failed subsequent air flow testing (H.6).
05000298/FIN-2017010-04	2017Q2	Cooper	Failure to Monitor No. 2 Diesel Generator under 50.65(a)(1) due to Inadequate Maintenance Rule Evaluation	Green. The team identified a non-cited violation of 10 CFR 50.65(a)(1)/(a)(2), for the licensees failure to perform an a(1) evaluation and establish a(1) goals when the No. 2 diesel generator a(2) preventive maintenance demonstration became invalid. Specifically, on April 28, 2017, the No. 2 diesel generator exceeded its performance criteria when it experienced a second maintenance rule functional failure, but the licensee failed to perform an associated a(1) evaluation. The licensee had failed to appropriately evaluate a February 4, 2017, failure associated with the No. 2 diesel generator jacket water heater failure in the Maintenance Rule Program and, as a result, the site failed to evaluate and monitor the equipment under 10 CFR 50.65(a)(1) as required. Corrective actions taken by the licensee to restore compliance included reevaluation of the February 4, 2017, functional failure and performance of an a(1) evaluation. The issue was entered into the licensees corrective action program as Condition Report CR-17-03930. The licensees failure to monitor the No. 2 diesel generator in accordance with the requirements of 10 CFR 50.65(a)(1), due to incorrectly evaluating one maintenance rule functional failure, in violation of 10 CFR 50.65(a)(1)/(a)(2), was a performance deficiency. The inspectors screened the performance deficiency using Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, and determined that the issue was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it: was not a design deficiency; did not represent a loss of system and/or function; did not represent an actual loss of function; did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time; and did not result in the loss of a high safety-significant nontechnical specification train. The finding had a cross-cutting aspect in the area of problem identification and resolution associated with evaluation, because the licensee failed to ensure that the organization thoroughly evaluated 5 the No. 2 diesel generator issues to ensure that resolutions addressed causes and extent of conditions commensurate with their safety significance (P.2)
05000298/FIN-2017010-03	2017Q2	Cooper	Programmatic Failure to Identify and Correct Adverse Trends	Green. The team identified a Green non-cited violation of 10 CFR 50, Appendix B, Criterion XVI, for the licensees programmatic failure to promptly identify adverse trends and enter them into the corrective action program. Often, when adverse trends were identified, they were addressed using informal processes. This was particularly the case for safety culture-related trends such as adverse trends in organizational behaviors. The licensee entered this violation into its corrective action program as Condition Report CR-CNS-2017-03938, and took action to formalize identification processes for potential adverse trends. The programmatic failure to promptly identify adverse trends as required by station procedures was a performance deficiency. This performance deficiency is more than minor because if left uncorrected, it has the potential to become a more significant safety concern. Specifically, failure to arrest an adverse trend, particularly in organizational behaviors, could lead to increased likelihood of a worker-induced initiating event or a failure to effectively mitigate an accident. Using Inspection Manual Chapter 0609, Appendix A, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train. This finding has a trending cross-cutting aspect in the problem identification and resolution cross- cutting area because the organization failed to use available information in the aggregate to identify programmatic and common cause issues (P.4).
05000298/FIN-2017010-02	2017Q2	Cooper	Failure to Perform Timely Operability Determinations	Green. The team identified a Green non-cited violation of Technical Specification 5.4.1.a, for the licensees multiple failures to immediately evaluate operability of degraded or nonconforming conditions. The team identified multiple examples of these operability determinations not being performed within one shift, as required by procedure. Further, aggregate data indicated routine noncompliance with procedural requirements to document operability immediately and without delay. The licensee entered this violation into its corrective action program as Condition Report CR-CNS-2017-03937, and began evaluating actions to restore compliance. Multiple failures to perform immediate operability determinations timely as required by station procedures is a performance deficiency. This performance deficiency is more than minor because it was associated with the equipment performance attribute of the mitigating systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of system s that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train. This finding has a consistent process cross-cutting aspect in the human performance cross-cutting area because operators failed to use a consistent, systematic approach to make decisions regarding operability using the organizations well-defined decision making process (H.13)
05000298/FIN-2017010-01	2017Q2	Cooper	Failure to Assign Corrective Actions to Prevent Recurrence of High Pressure Coolant Injection Failure	Green. The team identified a non-cited violation of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to assign corrective actions to preclude repetition of a significant condition adverse to quality associated with the loss of the high pressure coolant injection system. Specifically, between July 28, 2016, and June 29, 2017, the licensee failed to assign or complete corrective actions to prevent recurrence to address the failure of a relay coil that resulted in a loss of safety function for the single train high pressure coolant injection system. Corrective actions to restore compliance included reevaluation of the corrective 3 actions assigned to the root cause of the condition and the creation of corrective actions to prevent recurrence for the condition. The licensee entered this deficiency into the corrective action program as Condition Report CR 17 03544. The licensees failure to assign corrective actions to preclude repetition of a significant condition adverse to quality, in violation of 10 CFR 50, Appendix B, Criterion XVI, was a performance deficiency. The performance deficiency was evaluated using Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, and was associated with the Mitigating Systems cornerstone. The team determined that the performance deficiency was more than minor, and therefore a finding, because if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. Specifically, the licensees failure to assign corrective actions to preclude repetition of a significant condition adverse to quality could reasonably result in the condition recurring and creating more safety-significant equipment failures. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, the inspectors determined that the finding had very low safety significance (Green) because it: was not a design deficiency; did not represent a loss of system and/or function; did not represent an actual loss of function; did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time; and did not result in the loss of a high safety-significant non-technical specification train. The finding had a cross-cutting aspect in the area of problem identification and resolution associated with resolution, because the licensee failed to ensure that the organization took effective corrective actions to address issues in a timely manner commensurate with their safety significance (P.3).
05000298/FIN-2017010-05	2017Q2	Cooper	Failure to adopt appropriate procedures in accordance with 10 CFR Part 21	Severity Level IV. The team identified a violation of 10 CFR 21.21(a), for the licensees failure to adopt appropriate procedures to evaluate deviations and failures to comply to identify those associated with substantial safety hazards. Specifically, Procedure EN-LI-108, 10 CFR 21 Evaluations and Reporting, Revision 5C0, was inadequate to ensure that the correct reportability call was made for a manufacturing flaw discovered in a relay that had resulted in a loss of safety function for the high pressure coolant injection system on April 25, 2016. In particular, the procedure (1) led the licensee to incorrectly conclude that a substantial safety hazard could not be created, (2) allowed a limited extent of condition in performing the substantial safety hazard evaluation such that similarly dedicated parts were not included in the scope, and (3) included incorrect guidance in Attachment 9.3. Corrective actions to restore compliance included re-evaluation of the defect under Part 21 requirements and a procedure adequacy review of the EN-LI-108-01 procedure. The licensee entered this issue into the corrective action program as Condition Reports CR-17-03936 and CR-17-04143. The failure to adopt appropriate procedures to evaluate deviations and failures to comply to identify those associated with substantial safety hazards, in violation of 10 CFR 21.21(a), was a performance deficiency. The NRCs reactor oversight process considers the safety significance of findings by evaluating their potential safety consequences. Using Inspection Manual Chapter 0612, Appendix B, Issue Screening, dated September 7, 2012, the team determined that the performance deficiency was of minor safety significance under the reactor oversight process because it involved a failure to make a report; however the underlying equipment failure was previously evaluated as having very low safety significance. The traditional enforcement process separately considers the significance of willful violations, violations that impact the regulatory process, and violations that result in actual safety consequences. Traditional enforcement applied to this finding because it involved a violation that impacted the regulatory process. The team used the NRC Enforcement Policy, dated November 1, 2016, to determine the significance of the violation. The inspectors determined that the violation was similar to Examples 6.9.d.10 and 6.9.d.13 of the Enforcement Policy, because although the procedure resulted in an inadequate reportability review and the issue was not reported as a manufacturing flaw, the licensee had reported some aspects of the event under the requirements of 10 CFR 50.73. As a result, the team determined that the violation should be classified as a Severity Level IV violation. Cross-cutting aspects are not assigned to traditional enforcement violations.
05000458/FIN-2017001-01	2017Q1	River Bend	Failure to Follow Station Guidance on Control of Scaffolding	Green . The inspectors identified a non-cited violation of Technical Specification 5.4, Procedures, for the licensees failure to follow station maintenance procedures related to the control of scaffolding in the reactor building. Specifically, the licensee installed scaffolding less than two inches from safety -related containment unit cooler HVR -UC1 B without completing an engineering evaluation. The licensee entered this issue into their corrective action program as Condition Report CR- RBS -2016- 07963 . Corrective actions included removing the scaffolding. The licensees installation of scaffolding within two inches of a safety -related containment unit cooler , without completing an engineering evaluation, was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, containment unit cooler HVR- UC1B was rendered inoperable by the incorrectly installed scaffolding and remained inoperable until the scaffolding was removed. The inspectors screened the finding in accordance with NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At -Power. Using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding to be of very low safety significance ( Green) because the finding did not represent an actual loss of function of one or more trains of safety-related equipment for greater than its technical specification allowed outage time. This finding has a cross -cutting aspect in the area of human performance, avoid complacency , because the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risks, even while expecting successful outcomes . Specifically, the station failed to implement appropriate error reduction tools when it did not perform and document Procedure EN -MA -133, Control of Scaffolding, Attachments 9.5 and 9.6 , which could have prevented the scaffolding construction error (H. 12).
05000458/FIN-2017001-02	2017Q1	River Bend	Failure to Properly Pre - Plan and Perform Maintenance on the Control Building Chilled Water System	Green . The inspectors identified a non- cited violation of Technical Specification 5.4, Procedures, for the licensees failure to properly pre-plan and perform maintenance on safety -related components in accordance with documented instructions appropriate to the circumstances. Specifically, the licensee used work order instructions that did not contain sufficient detail for the reassembly of SWP -PVY32C, a safety -related valve in the control building ventilation system . As a result, SWP -PVY32C developed a refrigerant leak, and on November 17, 2015 , the valve failed. This in turn caused the control building ventilation system to fail , and the high pressure core spray system was consequently declared inoperable. The licensee entered this condition into their corrective action program as Condition Report CR- RBS -2017- 02364. Corrective actions included incorporating the torque values into the model work order instructions for future maintenance and reassembly . The failure to properly pre-plan and perform maintenance on safety -related components in accordance with documented instructions was a performance deficiency. The performance deficiency was more than minor , and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, when the control building ventilation system failed, it impact ed the operability of the high pressure core spray system. The inspectors screened the finding in accordance with NRC Inspection Manual Chapter 0609, Significance Determination Process. Using NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At -Power, Exhibit 2 Mitigating Systems Screening Questions, the inspectors determined that the finding was of very low safety significance (Green) because it did not affect the design or qualification of a mitigating structure, system, or component (and the structure, system, or component maintained its operability), it did not represent a loss of safety function, it did not represent an actual loss of function of at least a single train for greater than its technical specification outage time, and it did not represent an actual loss of function of one or more non-technical specification trains of equipment designated as high safety significant in accordance with the licensees Maintenance Rule program for greater than 24 hours. This finding has a cross- cutting aspect in the area of human performance, challenge the unknown, because individuals did not stop when faced with uncertain conditions. Specifically, workers proceeded with assembling the valve when the torque values or torqueing sequence were not specified (H.11)
05000458/FIN-2017001-03	2017Q1	River Bend	Failure to Enter Applicable Technical Specification Action Statements When Control Building Chillers Were O ut of Service	Green . The inspectors identified a non- cited violation of Technical Specifications 3.8.4, DC Sources - Operating, 3.8.7, Inverters Operating, and 3.8.9, Distribution Systems Operating, for the licensees failure to either restore inoperable electrical power subsystems, inverters, and distribution subsystems to operable status within the applicable completion times, or be in Mode 3 in 12 hours and Mode 4 in 36 hours. Specifically, electrical power systems required by the above limiting condition s for operation were inoperable due to the associated division of the control building chilled water system chillers being out of service and therefore unavailable to provide the technical specification support function of attendant cooling that is needed for the associated electrical systems to perform their specified safet y functions. As a result of this deficiency, the station reduced the reliability and availability of systems cooled by control building chilled water system chillers by allowing configurations that did not conform to the single failure criterion. The lic ensee entered this issue into their corrective action program as Condition Report CR- RBS -2015 -02525 . Corrective actions included entering the appropriate limiting conditions for operation of affected safety -related systems when the non -safety related support system were non -functional. 4 The failure to either restore inoperable electrical power subsystems, inverters, and distribution subsystems to operable status within the applicable completion times, or be in Mode 3 in 12 hours and Mode 4 in 36 hours wa s a performance deficiency . Specifically, electrical power systems required by the above limiting condition s for operation were inoperable due to the associated division of the control building chilled water system chillers being out of service and therefore unavailable to provide the technical specification support function of attendant cooling that is needed for the associated electrical systems to perform their specified safety functions. The performance deficiency was more than minor, and therefore a finding, because it wa s associated with the configuration control attribute of the Mitigating Systems Cornerstone, and adversely affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that res pond to initiating events to prevent undesirable consequences. As a result of this deficiency, the station reduced the reliability and availability of systems cooled by control building chilled water system chillers by allowing configurations that did not conform to the single failure criterion. The inspectors performed an initial screening of the finding in accordance with NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At -Power. Using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, the finding was determined to require a detailed risk evaluation because it represented a loss of system and/or function. A senior reactor analyst performed a det ailed risk evaluation for a previously identified performance deficiency associated with the licensees failure to account for a loss of all control building chilled water system cooling scenario, either quantitatively or qualitatively, which resulted in uncompensated impairment to all systems associated with the main control room (Agencywide Documents Access and Management System (ADAMS) Accession N o. ML16132A144). This previously performed detailed risk evaluation bounds the risk associated with the finding dispositioned in this write- up: the failure to either restore inoperable electrical power subsystems, inverters, and distribution subsystems to operable status within the applicable completion times, or be in Mode 3 in 12 hours and Mode 4 in 36 hours. Therefore, the finding was determined to be of very low safety significance (Green). No cross -cutting aspect was assigned as the performance deficiency is not indicative of current licensee performance
05000416/FIN-2016004-02	2016Q4	Grand Gulf	Failure to Use Procedures and Engineering Controls to Maintain Occupational Doses ALARA	Green. The inspectors identified a non-cited violation of 10 CFR 20.1101(b) for the licensees failure to implement radiation exposure reduction procedures and engineering controls to minimize unplanned and unintended radiation dose to workers and to maintain occupational doses as low as is reasonably achievable (ALARA). Several radiological work permits exceeded initial dose estimates with minimal or no actions taken to evaluate the basis for the dose overrides and to develop mitigating strategies. The primary contributor to the unplanned exposures was elevated dose rates from increased cobalt-60 activity associated with a failure to properly plan and execute spent fuel pool and reactor cavity cleanup operations. In addition, the licensee failed to observe radiological work permit hold points, to initiate ALARA Management Committee meetings, and to perform radiological assessments of radiological work permit dose estimates as procedurally required. As immediate corrective actions, the licensee reviewed the work activity, documented lessons learned, and generated Condition Reports CR-GGN-2016-03151 and CR-GGN-2016-08543 to address these programmatic weaknesses for future outages. The failure to implement procedures and engineering controls to minimize unplanned and unintended radiation dose and to maintain occupational doses as low as is reasonably achievable was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the Occupational Radiation Safety Cornerstone attribute of program and process (ALARA planning) and adversely affected the cornerstone objective to ensure the adequate protection of worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. Specifically, inadequate ALARA planning and radiological controls resulted in unplanned, unintended dose for a number of work activities in which the actual collective dose exceeded 5 person-rem and exceeded the planned, intended dose by more than 50 percent. Using Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, the inspectors determined this finding to be of very low safety significance (Green) because the finding involved ALARA planning and controls, and because the licensees latest 3-year rolling average did not exceed 240 person-rem per unit for boiling water reactors. The finding had a cross-cutting aspect in the area of problem identification and resolution, associated with operating experience, in that, the licensees organization failed to systematically and effectively collect, evaluate, and implement relevant internal and external operating experience in a timely manner. Specifically, the licensee failed to implement and incorporate relevant internal operating experience from Refueling Outage 18, which was of similar radiological circumstances, to mitigate the effects of cobalt-60 activity in the reactor cavity and unplanned spent fuel pool cleanup outages (P.5).
05000416/FIN-2016004-01	2016Q4	Grand Gulf	Failure to Incorporate Design Requirements for Switchgear Room Cooling	Green. The inspector identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, involving the failure to implement appropriate design control measures associated with a safety-related service water flow calculation. Specifically, several unverified and potentially nonconservative inputs were identified associated with Calculation MC-QIP41-97020, Revision 11, Determination of Minimum Allowable SSW Flows (LOCA Lineup) to Safety Related Heat Exchangers, used to analyze minimum service water flow to the vital switchgear room coolers. The licensee entered this issue into their corrective action program as Condition Report CR-GGN-2016-07597, initiated action to update Calculation MC-QIP41-97020, and initiated actions to analyze the ability of vital switchgear room cooling to meet its specified safety function. This performance deficiency was more than minor, and therefore a finding, because it was associated with the design control attribute of the Mitigating Systems Cornerstone, and it adversely affected the cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the licensee did not assure that the vital switchgear ventilation system was capable of maintaining the rooms temperature below design requirements under all conditions. The NRC performed an initial screening of the finding in accordance with NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Using Inspection Manual Chapter 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, dated July 1, 2012, this finding had very low safety significance (Green) because it: (1) was not a deficiency affecting the design or qualification of a mitigating system; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of a single train for greater than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for greater than 24 hours. This finding had a cross-cutting aspect in the documentation aspect of the human performance cross-cutting area because the licensee failed to maintain complete, accurate, and up-to-date documentation of the design temperature limits for safety-related equipment. Specifically, the licensee failed to document and evaluate a change to temperature limits related to switchgear cooling to ensure that its use as a design parameter was consistent with original design specifications of the equipment (H.7).
05000391/FIN-2016002-04	2016Q2	Watts Bar	Failure to Follow Operability Procedure Results in Potential Inoperability of the 2A-A Auxiliary Feedwater Pump	The NRC identified a SL IV NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, at Watts Bar Unit 2 for the licensees failure to follow procedure OPDP-8, Operability Determination Process and Limiting Condition for Operation Tracking, Revision 22. Specifically, the 2A-A motor-driven auxiliary feedwater pump (MDAFW) was potentially inoperable in mode 3 due to inadequate compensatory measures that were being controlled outside of the operability process. The issue was corrected and the pump returned to operable status on April 19, 2016. The issue was entered into the licensees corrective action program as CR 1163431. The performance deficiency was more than minor because it represented an improper or uncontrolled work practice that could impact quality or safety, involving safety-related SSCs. Specifically, failure to appropriately use the operability process when measures must be established to compensate for degraded or nonconforming conditions can lead to SSC inoperability. As described in IMC 2517, the significance of this issue was determined using traditional enforcement, because the cornerstone associated with this finding was not being assessed by the reactor oversight process (ROP). The inspectors determined this finding to be of very low safety significance, SL IV because it represented a failure to meet a regulatory requirement, specifically a quality assurance (QA) criteria to follow quality-related procedures, which had more than minor safety significance. The finding was assigned a cross-cutting aspect of Work Management in the Human Performance area because the minor maintenance work order created to compensate for the oil loss from the 2A-A MDAFW pump was never reviewed by operations, which could have identified the out of process error. (H.5).
05000298/FIN-2016002-01	2016Q2	Cooper	Failure to Meet Technical Specification Requirements for Traversing In-Core Probe B Ball Valve (	The inspectors identified a non-cited violation of Technical Specification 3.6.1.3, Primary Containment Isolation Valves, for the licensees failure to maintain traversing incore probe B ball valve, a primary containment isolation valve, operable for its containment isolation function. Specifically, on May 5, 2016, from 5:20 a.m. until 1:08 p.m., the licensee failed to maintain the traversing in-core probe B ball valve operable or isolate its flow path within 4 hours of indications that the mechanical in-shield limit switch had failed. This failure prevented the ball valve from performing its containment isolation function. The licensee took immediate corrective actions upon discovery to restore compliance with Technical Specification 3.6.1.3 by de-energizing the ball valves solenoid operating valve, causing it to close. The licensee entered this deficiency into their corrective action program for resolution as Condition Report CR-CNS-2016-03665. The licensees failure to maintain the traversing in-core probe B ball valve, a primary containment isolation valve, operable for its containment isolation function, in violation of Technical Specification 3.6.1.3, was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the human performance attribute of the Barrier Integrity Cornerstone and adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases and that the radiological barrier functionality of containment is maintained. Specifically, the traversing in-core probe B ball valve was unable to perform its primary containment isolation function with a failed mechanical inshield limit switch. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, the inspectors determined that the finding was of very low safety significance (Green) because it did not represent an actual open pathway in the physical integrity of reactor containment (valves, airlocks, etc.), containment isolation system (logic and instrumentation), and heat removal components; and did not involve an actual reduction in function of hydrogen igniters in the reactor containment. The finding had a cross-cutting aspect in the area of human performance associated with conservative bias because the licensee failed to use decision making practices that emphasized prudent choices over those that were simply allowable and failed to ensure proposed actions were determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically, the licensee failed to validate the assumption that the traversing in-core probe B ball valve would fulfill its containment isolation function with a failed mechanical in-shield limit switch, and failed to validate the degraded condition prior to exceeding the 4-hour completion time of Technical Specification 3.6.1.3 (Section 1R12). (H.14)
05000298/FIN-2016002-02	2016Q2	Cooper	Failure to Follow Work Instructions for Post-Maintenance Testing of Safety-Related Ventilation Systems	The inspectors identified two examples of a non-cited violation of Technical Specification 5.4.1.a, associated with the licensees failure to perform required postmaintenance testing for safety-related ventilation systems in accordance with documented instructions, prior to system restoration. Specifically, the licensee failed to follow work order instructions contained in Work Orders 5062878 and 5065112 for (1) performing surveillance testing to measure the airflow of emergency diesel generator supply fan coil unit HV-DG-1C following maintenance, and (2) performing leak testing of a newly created control room ventilation boundary penetration. Corrective actions included performing the required surveillance test for the diesel generator ventilation unit, retesting the control room penetration in accordance with the procedure, and initiating site-wide communications discussing the errors and reemphasizing procedural adherence. The licensee entered these deficiencies into their corrective action program for resolution as Condition Reports CR-CNS-2016-02207 and CR-CNS-2016-02232. The licensees failure to perform required post-maintenance testing for safety-related ventilation systems, in accordance with documented instructions, was a performance deficiency. This performance deficiency was associated with multiple cornerstones. The first example of the performance deficiency was more than minor, and therefore a finding, because it was associated with the human performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to measure supply fan coil unit HV-DG-1C airflow resulted in delayed identification that the maintenance had resulted in degraded flow through the ventilation unit. The second example of the performance deficiency was more than minor, and therefore a finding, because it was associated with the human performance attribute of the Barrier Integrity Cornerstone and affected the cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases and that the radiological barrier functionality of the control room is maintained. Specifically, the licensees failure to follow post-maintenance testing instructions resulted in a challenge to the operability of the newly created control room boundary penetration seal. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, the inspectors determined that the finding was of very low safety significance (Green) because it did not represent a design or qualification deficiency; did not represent a loss of safety function; did not represent a loss of a single train for greater than its technical specification allowed outage time; did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating events; did not represent an actual open containment pathway; and did not involve a reduction in function of hydrogen igniters. The finding had a crosscutting aspect in the area of human performance associated with work management, because the licensee failed to implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority, including the need for coordination with different work groups or job activities. Specifically, the licensee failed to control, execute, and coordinate safety-related ventilation work activities to ensure all required post-maintenance testing was completed satisfactorily prior to declaring the associated equipment operable (Section 1R19). (H.5)
05000298/FIN-2016002-03	2016Q2	Cooper	Failure to Maintain Design Control for High Pressure Coolant Injection System Electrical Circuit	The inspectors reviewed a self-revealed, non-cited violation of 10 CFR Part 50, Appendix B, Criterion III, Design Control, for the licensees failure to verify the adequacy of design of the high pressure coolant injection auxiliary lube oil pump 125 Vdc starter circuit. Specifically, in 1984, the licensee modified the design of the starter circuit and eliminated a resistor that served to protect the circuit from shorting due to indication light bulb failures. As a result, on April 26, 2016, a shorted light bulb resulted in the loss of power to the auxiliary lube oil pump, rendering the high pressure coolant injection system inoperable and unavailable. Immediate corrective actions included replacing the light socket and blown fuse and changing out the nonessential light bulb with an essential bulb. This event was entered into the licensees corrective action program as Condition Report CR-CNS-2016-02318, and the licensee initiated a root cause evaluation to investigate the failure. The licensees failure to verify the adequacy of design of the high pressure coolant injection auxiliary lube oil pump starter circuit in accordance with 10 CFR Part 50, Appendix B, Criterion III, was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, at the time the modification was installed, the licensee had not taken sufficient actions to ensure that the electrical circuit was protected from light bulb shorting failures, resulting in the high pressure coolant injection system ultimately being rendered inoperable. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings AtPower, dated June 19, 2012, inspectors determined that the finding required a detailed risk evaluation because it represented a loss of the system and function of high pressure coolant injection. The inspectors determined that the finding was of very low safety significance (Green) through performing a detailed risk evaluation. A cross-cutting aspect was not assigned to this finding because the performance deficiency occurred in 1984, and therefore, is not indicative of current licensee performance (Section 4OA3).
05000390/FIN-2016002-06	2016Q2	Watts Bar	Failure to Satisfy TS LCO 3.6.3	The NRC identified a Green NCV of TS for the failure to recognize and take the required actions in TS 3.6.3 for inoperable containment penetration flow paths. Specifically, the required actions of TS 3.6.3 applied on November 21, 2015, and were not taken until January 30, 2016. Upon discovery, on January 30, 2016, the affected containment penetrations were isolated by placement of a clearance, thereby satisfying the TS required actions. The licensee entered the violation into the CAP as CR 1172114. The performance deficiency was more than minor because the ERCW supply and discharge containment penetrations for the 1D upper containment cooler were inoperable for longer than the TS allowed outage time. Because the 1D upper containment cooler ERCW containment penetrations were inoperable and resulted in the failure to satisfy TS LCO 3.6.3, reasonable assurance of the integrity of the containment design barrier was adversely affected. The inspectors determined the finding was of low safety significance (Green) because the upper containment cooler ERCW penetrations are small lines (<1-2 inches in diameter) and IMC 0609, Appendix H Containment Integrity Significance Determination Process dated May 6, 2004, Table 4.1 states that small lines (<1-2 inches in diameter) would not generally contribute to LERF. This finding had a cross-cutting aspect in the area of Human Performance, Conservative Bias, because the licensee failed to make the prudent choice to fully evaluate the unsuccessful surveillance test on November 15, 2015, and instead simply documented the issue in the corrective action program and deferred the solution, resulting in the TS violation six days later.
05000390/FIN-2016002-02	2016Q2	Watts Bar	Failure to Translate Design Requirements into a Maintenance Procedure for the 1B-B Charging Pump Room Cooler	The NRC identified a Green NCV of 10 Code of Federal Regulations (CFR) 50, Appendix B, Criterion III, Design Control for the licensees failure to specify nominal shaft size along with specific acceptance criteria for shaft tolerance measurements for the 1B-B centrifugal charging pump (CCP) room cooler fan shaft. The licensee repaired the room cooler by replacing the fan shaft and the finding was entered into the licensees corrective action program as CR 1146474. The performance deficiency was more than minor because it affected the equipment performance attribute of the mitigating system cornerstone to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The inspectors determined that this finding required a detailed risk analysis since it represented an actual loss of function of a single train for greater than its TS-allowed outage time. The finding does not present an immediate safety concern because the licensee has verified current operability. A Senior Reactor Analyst evaluated the increase in core damage frequency due to the pump being non-functional over the exposure period and determined it was 3.6E-7/year (Green). The dominant scenario was a loss of component cooling water, which combined with a loss of RCP seal injection causes a loss of coolant accident and leads to core damage. The risk increase was very low because of the limited exposure time, the availability of the opposite train pump, and the time dependent nature of the pump failing due to lack of room cooling. The inspectors determined that the finding had a cross-cutting aspect of design margin in the area of Human Performance because the licensee failed to carefully guard margins through a systematic and rigorous process. Specifically, the translation of shaft diameter from design documents into 0-MI-0.16 lacked rigor and allowed an undersized shaft to go undetected, leading to cooler failure.
05000390/FIN-2016002-01	2016Q2	Watts Bar	Failure to Ensure that a Train of Source Range Detection was Available to Monitor Neutron Population During a Fire Event	The NRC identified a Green NCV of Operating License Condition 2.F for the licensees failure to ensure that a train of source range detection was available to monitor neutron population during the initial stages of a fire event on Unit 1. This issue was entered into the licensees corrective action program as CR 1098240. The licensees failure to ensure a train of source range detection was free from fire damage was a performance deficiency. The performance deficiency was more than minor because it was associated with the protection against external events (fire) attribute of the Mitigating Systems Cornerstone and it adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the licensee failed to maintain the capability to monitor neutron population during the early stage of a fire event. In accordance with IMC 0609, Appendix F, Fire Protection Significance Determination Process, the finding was determined to be of very low safety significance (Green) because the reactor would have been able to reach and maintain a stable plant condition. No cross-cutting aspect was identified for this issue.
05000390/FIN-2016002-03	2016Q2	Watts Bar	Untimely 10 CFR 50.73 Notification of an Inoperable Charging Pump	The NRC identified a Severity Level (SL) IV non-cited violation (NCV) of 10 Code of Federal Regulations (CFR) 50.73(a)(2)(i)(B) for the licensee's failure to notify the NRC that the technical specification (TS) limiting condition for operation (LCO) 3.5.2 required action and completion time were not met when the 1B-B centrifugal charging pump (CCP) was inoperable due to an inoperable room cooler. Subsequently, the licensee submitted LER 2016-006-00 for this event on June 30, 2016. This issue was placed in the licensees corrective action program (CAP) as CR 1165380. Since the failure to submit an event report within the time requirements may impact the ability of the NRC to perform its regulatory oversight function, this performance deficiency was dispositioned under traditional enforcement and the violation was assessed using Section 2.2.4 of the NRCs Enforcement Policy. Using the example listed in Section 6.9.d.9, A licensee fails to make report required by 10 CFR 50.73, the issue was determined to be a SL IV violation. In accordance with IMC 0612, Power Reactor Inspection Reports, dated May 6, 2016, traditional enforcement violations are not assessed for cross-cutting aspects.
05000391/FIN-2016002-05	2016Q2	Watts Bar	Failure to Perform A TDAFW Surveillance In Accordance With Procedures	The NRC identified a SL IV NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, at Watts Bar Unit 2 for the licensees failure to follow the surveillance test program procedure by making adjustments to the turbine-driven auxiliary feedwater (TDAFW) pump control system during the performance of a surveillance instruction. The licensee reperformed the surveillance instruction with satisfactory results. The issue was entered into the licensees corrective action program as CR 1167102. The performance deficiency was more than minor because making adjustments to the TDAFW pump control system during the performance of a surveillance instruction could invalidate the test and result in the TDAFW pump being inappropriately declared operable. As described in IMC 2517, the significance of this issue was determined using traditional enforcement, because the cornerstone associated with this finding was not being assessed by the reactor oversight process (ROP). The inspectors determined this finding to be of very low safety significance, SL IV, because it represented a failure to meet a regulatory requirement, specifically a QA criteria to follow quality-related procedures, which had more than minor safety significance. The finding was assigned a cross-cutting aspect of Conservative Bias in the Human Performance area because numerous individuals were aware the speed adjustment had been made while completing the surveillance instruction but did not question the appropriateness of that adjustment until prompted by NRC inspectors.
05000390/FIN-2016002-07	2016Q2	Watts Bar	Untimely 10 CFR 50.73 Notification of Inoperable Containment Penetrations	The NRC identified a SL IV NCV of 10 CFR 50.73(a)(2)(i)(B) for the licensee's failure notify the NRC that the TS LCO 3.6.3 required action and completion time were not met for an inoperable emergency raw cooling water (ERCW) containment isolation valve. Subsequently, the licensee submitted LER 2016-009-00 for this issue on July 15, 2016. This issue was placed in the licensees corrective action program as CR 1174000. Since the failure to submit an event report within the time requirements may impact the ability of the NRC to perform its regulatory oversight function, this performance deficiency was dispositioned under traditional enforcement and the violation was assessed using Section 2.2.4 of the NRCs Enforcement Policy. Using the example listed in Section 6.9.d.9, A licensee fails to make report required by 10 CFR 50.73, the issue was determined to be a SL IV violation. In accordance with IMC 0612, Power Reactor Inspection Reports, dated May 6, 2016, traditional enforcement violations are not assessed for cross-cutting aspects.
05000391/FIN-2016002-08	2016Q2	Watts Bar	Failure to Follow Maintenance Procedure Results in overspeed trip of the 2C-S Turbine Driven Auxiliary Feedwater Pump	A self-revealed Severity Level (SL) IV non-cited violation (NCV) of 10 Code of Federal Regulations (CFR) 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified at Watts Bar Unit 2 for the licensees failure to follow procedure 0-MI-1.003, Disassembly, Inspection, and Reassembly of Auxiliary Feedwater Pump Turbine. Specifically, the valve stem spring coil gap was not set in accordance with procedure, causing the turbine-driven auxiliary feedwater (TDAFW) pump to trip on electrical overspeed when the level control valves (LCVs) were closed. This issue was corrected on May 30, 2016, when the proper spring coil gap was set and verified and the post maintenance test was performed satisfactorily. The issue was entered into the licensees corrective action program as CR 1175968. The performance deficiency was more than minor because it represented an improper or uncontrolled work practice that could impact quality or safety involving safety-related structures, systems, and components (SSCs). The finding was a SL IV violation because it represented a failure to meet a regulatory requirement, specifically a quality assurance (QA) criteria to follow quality-related procedures, which had more than minor safety significance. The finding was assigned a crosscutting aspect of resources in the Human Performance area because the licensee failed to ensure that personnel, equipment, procedures, and other resources are available and adequate to support nuclear safety. Specifically, the procedure that set the coil spring gap lacked sufficient detail and rigor to ensure that the coil gap would be set appropriately by the technicians.
05000390/FIN-2016002-10	2016Q2	Watts Bar	Untimely 10 CFR 50.73 Notification of an Inoperable Rod Position Indication	The NRC identified a SL IV NCV of 10 CFR 50.73(a)(2)(i)(B) for the licensee's failure notify the NRC that the TS LCO 3.1.8 required action and completion time were not met when the analog rod position indication (ARPI) and the demand position indication system were not operable. Subsequently, the licensee submitted LER 2016-007-00 for this issue on June 20, 2016. This violation was placed in the licensees corrective action program as CR 1163150. Since the failure to submit an event report within the time requirements may impact the ability of the NRC to perform its regulatory oversight function, this performance deficiency was dispositioned under traditional enforcement and the violation was assessed using Section 2.2.4 of the NRCs Enforcement Policy. Using the example listed in Section 6.9.d.9, A licensee fails to make report required by 10 CFR 50.73, the issue was determined to be a SL IV violation. In accordance with IMC 0612, Power Reactor Inspection Reports, dated May 6, 2016, traditional enforcement violations are not assessed for cross-cutting aspects.
05000390/FIN-2016002-09	2016Q2	Watts Bar	Untimely 10 CFR 50.73 Notification of Failure to Meet Technical Specification Surveillance Requirement 3.5.2.3 for the Emergency Core Cooling System	The NRC identified a SL IV NCV of 10 CFR 50.73(a)(2)(i)(B) for the licensee's failure to report, within 60 days of discovery, a condition which was prohibited by the plants TS associated with recent performances of TS surveillance requirement (SR) 3.5.2.3 for verification that emergency core cooling system (ECCS) piping is full of water. Subsequently, the licensee submitted LER 2016-003-00 for this issue on May 10, 2016. This violation was placed in the licensees corrective action program as CR 1166564. Since the failure to submit an event report within the time requirements may impact the ability of the NRC to perform its regulatory oversight function, this performance deficiency was dispositioned under traditional enforcement and the violation was assessed using Section 2.2.4 of the NRCs Enforcement Policy. Using the example listed in Section 6.9.d.9, A licensee fails to make report required by 10 CFR 50.73, the issue was determined to be a SL IV violation. In accordance with IMC 0612, Power Reactor Inspection Reports, dated May 6, 2016, traditional enforcement violations are not assessed for cross-cutting aspects.
05000458/FIN-2015010-01	2016Q1	River Bend	Technical Specification Allowed Outage Time During Loss of Non-Technical Specification Supported Systems	The team identified an unresolved item related to the licensees treatment of the control building chilled water system (HVK) chillers as a non-technical specification support system for other technical specification systems. The team noted that when an entire division of HVK chillers is out of service, such as chillers 1A and 1C for division I, the licensee would only enter the Technical Specification (TS) 3.7.3, Control Room Air Conditioning (AC) System, action statement for the condition of one control room AC subsystem being inoperable (condition A). The licensee did not enter TS action statements associated with inoperability of other components cooled by HVK chillers, such as the AC switchgear, DC switchgear, and vital inverters. The licensee, instead, has incorporated a safety evaluation for the Perry Plant (ML020950074), dated April 5, 2002, into the bases for TS 3.0.6 and applied that document as guidance: ...no TS limits the duration of the non-TS support subsystem outage, even though the single-failure design requirement of the supported TS systems is not met. However, by assessing and managing risk in accordance with 10 CFR 50.65(a)(4), an appropriate duration for the maintenance activity can be determined. The NRC team questioned whether the Perry Plants safety evaluation could be applied generically, if the licensee improperly incorporated the safety evaluation via the 10 CFR 50.59 process, if the guidance conflicted with section 9.2.10.3 of the Updated Safety Analysis Report (USAR) for River Bend Station, and if the safety evaluation for the Perry Plant conflicted with guidance found in Generic Letter 80-30, Clarification of the Term Operable As It Applies to Single Failure Criterion For Safety Systems Required by TS. The aggregate impact of these decisions resulted in the River Bend Station placing TS systems cooled by HVK, such as the AC switchgear, DC switchgear, and vital inverters, in a single-failure vulnerable configuration for durations exceeding the allowed outage time specified in the TS. Pending further evaluation of the above issue by NRC Headquarters staff via a Technical Specification interpretation request (ML15231A111) and subsequent review by NRC inspectors, this issue will be tracked as URI 05000458/2015010-01, Technical Specification Allowed Outage Time During Loss of Non-Technical Specification Supported Systems. Further discussion of performance deficiencies associated with the HVK chiller system is included in Section 2.6.a of this report.
05000390/FIN-2016001-08	2016Q1	Watts Bar	Charging Pump 1B-B Room Cooler Fan Bearing Failure	Inspectors identified an unresolved item (URI) associated with the failure of the 1B-B charging pump room cooler. This item is unresolved pending review of an equipment apparent cause evaluation that was performed after deficiencies were identified by inspectors in the past operability evaluation. On September 27, 2015, the licensee installed a new bearings on the 1B-B CCP room cooler fan shaft as part of planned maintenance (PM) under WO 115790759. The WO noted the room cooler had a broken lubrication line close to the point where it is attached to the outboard fan shaft bearing, but the new bearing on the fan shaft, including the outboard shaft bearing, were installed without an immediate repair of the lubrication line. The bearing replacements for WO 115790759 were accomplished in accordance with maintenance procedure 0-MI-0.16, Maintenance Guidelines for Belt Driven Equipment, Rev. 7. Appendix D, Bearing Installation, Step 14 requires, All remote lubrication lines, remote vibration attachments, etc. shall be verified as attached prior to return to service. The work order noted at this step that the lubrication line to the outboard fan shaft bearing was broken in half and will need to be replaced prior to return to service and the step was left blank. The licensee did not initiate a CR for this degraded condition. Due to the broken lubrication line, the outboard fan shaft bearing was the only fan shaft bearing that was not greased during installation. October 15, 2015, the licensee completed the PMT for the room cooler and noted it to be satisfactory. The broken lubrication line documented in the PM WO was identified and CR 1093983 was initiated to document the condition. This CR stated that the broken lubrication line did not affect the functionality of the fan and could be repaired at the next scheduled PM. This assessment was not questioned during the review of the CR for operability. The fan was returned to service and declared operable. On December 4, 2015, the room cooler failed in service. The licensee declared the 1BB charging pump inoperable and entered the applicable TS LCO. Investigation revealed that the outboard fan shaft bearing had failed. At this point, the inappropriate treatment of the degraded lubrication line under 0-MI-0.16 and the associated PMT was identified. This issue was documented in the licensees CAP in CR 1111791. The licensee performed a past operability evaluation (POE) for CR 1111791 which concluded the fan was operable until several hours before the time of the failure. The POE was based largely on statements from the bearing vendor indicating that the new bearing was pre-lubricated at the factory and should have performed under load for a long period of time without needing to be pre-greased at installation. The POE was hampered by the fact that the licensee did not retain the damaged bearing for failure analysis. The inspectors reviewed the POE and determined that it failed to adequately document sufficient information to either discount the broken lubrication line as a cause of the bearing failure or to identify another cause. In response, the licensee opened an investigation of the cause of the bearing failure under an equipment apparent cause evaluation. Because more information is necessary to evaluate the cause of the 1B-B CCP room cooler fan shaft bearing failure, future inspection is required to determine if a more than minor performance deficiency or violation exists associated with this issue. Specifically, the inspectors need to review the equipment apparent cause evaluation, which was not completed by the end of the inspection period. This is identified as URI 05000390/2016001-08, Charging Pump 1B-B Room Cooler Fan Bearing Failure.
05000390/FIN-2016001-10	2016Q1	Watts Bar	Failure to Maintain an Adequate Surveillance Procedure for Emergency Core Cooling System Venting	The inspectors identified an apparent violation of TS 5.7.1.1.a, Procedures, for the licensees failure to maintain procedure 1-SI-63-10.1-A, ECCS Discharge Pipes Venting Train A Inside Containment, Revisions 11-16, in accordance with the requirements of Regulatory Guide 1.33. Specifically, the procedure did not have provisions for quantifying accumulated gases during venting which allowed emergency core cooling system (ECCS) piping to be vented without being evaluated for potential adverse impacts on system operability. The licensee implemented manual ultrasonic testing (UT) of gas accumulation and entered this issue into their corrective action program as CR 1136359. The performance deficiency was more than minor because, if left uncorrected, it had the potential to lead to a more significant safety concern. Specifically, if left uncorrected, the potential existed for an unacceptable void affecting ECCS operability to develop prior to the next scheduled surveillance. The inspectors determined the finding could not be screened to GREEN and may require a detailed risk evaluation following a determination of whether the finding represents a loss of system and/or function. Because the safety characterization of this finding is not yet finalized, it is being documented with a significance of To Be Determined (TBD). The inspectors determined that the finding had a cross-cutting aspect of Change Management in the area of Human Performance because the licensee failed to use a systematic process to implement changes to the ECCS venting procedure to ensure that Generic Letter 2008-01 commitments would continue to be met.
05000390/FIN-2015010-01	2015Q3	Watts Bar	420 Minute Operator Manual Action to Provide Source Range Monitoring Capability	The inspectors identified an unresolved item associated with a fire protection safe shutdown OMA that established a time requirement of 420 minutes to provide a functional source range monitor. The inspection team noted that procedure 1-AOI-30.2 C36, Fire Safe Shutdown Room 737-A1A, Rev. 0005 included a 420 minute operator manual action (OMA) to establish a functional source range monitor. The OMA was listed as OMA 649 in Calculation EDQ00099920090016, Appendix R Unit 1 & 2 Manual Action, Rev. 4. The inspectors also noted the following: - Westinghouse Owners Group letter, WOG-05-36 (dated 01/28/2005), Section 6.2, Long Term Cold Shutdown Capability, stated that typical instrumentation to achieve a shutdown condition during Appendix R event included the source range monitors. - Technical Specification 3.3.1.L required an operable source range neutron flux channel in Modes 3, 4, and 5; and stipulated that positive reactivity additions (such as plant cooldown) be suspended when the instrument was inoperable. - Procedure 1-AOI-30.2, Fire Safe Shutdown, Rev. 0005, Step 5.3.15, stated that at least one channel of nuclear instrumentation indication must be available to monitor shutdown neutron population. - Procedure 1-AOI-30.2 C36 included a note that stated that RCS cooldown should not be initiated until source range monitoring capability can be assured. - Procedure 1-AOI-30.2 C36 directed operators to depressurize and cooldown an action that was typically required at 60 75 minutes. The 420 minute OMA would allow shutdown and subsequent cooldown of the reactor plant without operators having the ability to monitor neutron population. The licensee contended that OMA 649 was part of the sites licensing bases and thus the capability to monitor source range was not required until 420 minutes. The inspection team determined that this issue required additional inspection because the licensee did not provide an alternative method to monitor neuron population and did not provide adequate restrictions to prevent cooldown activities until monitoring capability was restored. Additionally, the OMA conflicted with the technical specification requirements for source range availability. The issue is unresolved pending additional review to determine if a performance deficiency exists. Required actions to resolve this issue include a detailed review of applicable docketed licensing bases correspondence; consultation with NRRs fire protection and technical specification branches; and an assessment to determine the applicable fire areas if the issue is to be determined to be a more-than-minor performance deficiency. This issue will be tracked as URI 05000290/2015010-01, 420 Minute Operator Manual Action to Provide Source Range Monitoring Capability.
05000368/FIN-2015008-01	2015Q2	Arkansas Nuclear	Failure to Properly Implement Procedures for Writing Procedures Important to Safety	The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, involving the licensees failure to perform activities affecting quality as prescribed by documented procedures of a type appropriate to the circumstances and accomplished in accordance with these procedures. Specifically, the team identified the licensee failed to ensure procedures important to safety were written in accordance with Procedure EN-AD-101-01, Nuclear Management Manual Procedure Writer Manual, Revision 14. The licensees failure to write procedures important to safety in accordance with Procedure EN-AD-101-01 was a performance deficiency. This finding was more than minor because it was associated with the procedure quality attribute of the Initiating Systems cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions. Specifically, the licensee did not adequately implement Procedure EN-AD-101-01 to ensure activities directing reactivity manipulations were accomplished in accordance with procedures of a type appropriate to the circumstances to prevent end-of-life axial-shape-index reactor trips. Using Inspection Manual Chapter 0609, Appendix A, the team determined that the finding was of very low safety significance (Green) because it did not cause the loss of mitigation equipment relied upon to transition the plant to a stable shutdown condition. This finding had a crosscutting aspect in the area of human performance associated with resources because leaders failed to ensure personnel, equipment, procedures, and other resources are available and adequate to support nuclear safety (H.1).
05000382/FIN-2015002-01	2015Q2	Waterford	Failure to Identify and Secure Potential Tornado-Borne Missile Hazards	The inspectors identified a non-cited violation of Technical Specification 6.8.1.a and Regulatory Guide 1.33, Revision 2, Appendix A, for the licensees failure to follow procedure OP-901-521, Severe Weather and Flooding, Revision 313. Specifically, on April 24, 2015, the licensee failed to assess and control potential tornado-borne missile hazards on-site as required by the procedure. The licensee entered this condition into their corrective action program as condition report CR-WF3-2015-02556. The licensee restored compliance by securing the identified hazards. This finding was more than minor because it was associated with the protection against external factors attribute of the Initiating Events cornerstone 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, in the event of a tornado at the site, the loose items could have become missiles with the potential to initiate a loss of off-site power adversely impacting safety-related equipment and personnel. The inspectors performed the initial significance determination for the finding using NRC Inspection Manual Chapter 0609, Appendix A, Exhibit 4, External Event Screening Questions, dated June 12, 2012. The finding required a detailed evaluation because it had the potential to degrade at least one train of a system that supports a risk significant system or function. Therefore, a senior reactor analyst performed a bounding detailed risk evaluation. The analyst determined that the finding was of very low safety significance (Green). The bounding change to the core damage frequency was less than 1.1E-7/year. The finding was not significant with respect to the large early release frequency. The dominant core damage sequences included tornado induced losses of off-site power, and random and common cause diesel generator failures. The ability to recover the diesel generators helped to minimize the significance of the event. The finding has a Resolution cross-cutting aspect in the area of Problem Identification and Resolution, because the licensee did not take effective corrective actions to address issues in a timely manner commensurate with their safety significance. Specifically, the licensee did not take effective corrective actions to address the issue after the inspectors identified it during previous tornado watches in 2013 and 2014.
05000368/FIN-2015008-02	2015Q2	Arkansas Nuclear	Failure to Correct containment Spray Pump Interlock to Shutdown Cooling Heat Exchanger Room Coolers	The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to correct a condition adverse to quality. Specifically, the licensee failed to correct the containment spray pump interlock to automatically start the shutdown cooling heat exchanger room coolers. The licensees failure to promptly correct a condition adverse to quality as required by 10 CFR Part 50, Appendix B, Criterion XVI, was a performance deficiency. The licensee has identified in multiple instances since 1989 a degraded or nonconforming condition with shutdown cooling heat exchanger room cooler interlocks, but has failed to correct the condition. This finding was more than minor because it was associated with the design control and equipment performance attributes of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to events to prevent undesirable consequences. Specifically, the licensee failed to correct the interlock feature that automatically starts the room coolers when the pump starts. Using Inspection Manual Chapter 0609, Appendix A, the team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train and did not screen as risk-significant in response to external events. This finding had a cross-cutting aspect in the area of problem identification and resolution associated with evaluation because the licensee failed to thoroughly evaluate the issue to ensure that the resolution addressed the cause (P.2).
05000368/FIN-2015008-03	2015Q2	Arkansas Nuclear	Inadequate Extent of Condition Review for Risk-Significant Condition	The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, that occurred because the licensees extent of condition performed in the root cause evaluation for the Yellow flooding finding failed to identify all potential water ingress paths into watertight rooms in the auxiliary building. The licensee identified additional examples of failures to construct the Unit 2 auxiliary building in accordance with the updated final safety analysis reports' description of internal and external flood barriers so that they could protect safety-related equipment from flooding. The team identified that the licensee had an opportunity to identify the unsealed conduit during a series of flooding reviews and walk-downs between 2012 and 2014, including an extent of condition review for unsealed conduits. Failure to identify and correct a condition adverse to quality as required by 10 CFR Part 50, Appendix B, Criterion XVI, and Procedure EN-LI-102 was a performance deficiency. This performance deficiency was more than minor because if left uncorrected, it could become a more significant safety concern. Specifically, the continued failure to identify all unsealed flooding penetrations could result in continued exposure of risk-significant equipment in the auxiliary building to flooding. This finding was associated with the Mitigating Systems cornerstone. Using Inspection Manual Chapter 0609, Appendix A, the team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train and did not screen as risk-significant in response to external events. This finding has a human performance cross-cutting aspect associated with teamwork, in that the licensee failed to communicate and coordinate their activities within and across organization boundaries to ensure that nuclear safety was maintained (H.4).
05000368/FIN-2015008-04	2015Q2	Arkansas Nuclear	Failure to Promptly Correct Breaker Auxiliary Switch Binding	The team identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the failure to promptly identify and correct a condition adverse to quality. Specifically, the licensee failed to promptly correct a design deficiency with breaker auxiliary contact switches that resulted in binding and could result in incorrect interlock signals to other equipment. The licensees failure to promptly identify a condition adverse to quality as required by 10 CFR Part 50, Appendix B, Criterion XVI, was a performance deficiency. The licensee failed to promptly correct a design deficiency with breaker auxiliary contact switches that resulted in binding and failed breaker interlocks. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events. Specifically, the untimely corrective actions have reduced the reliability of breaker interlocks, which may cause bus lockouts or safety equipment that could fail to automatically start. Using Inspection Manual Chapter 0609, Appendix A, the team determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train and did not screen as risk-significant in response to external events. The licensee has taken corrective actions to lessen the probability of bound switches by aligning shafts and lubricating bearing surfaces. This finding has a human performance cross-cutting aspect associated with consistent process in that the licensee failed to use risk insights in a systematic approach to make decisions (H.13).

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