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05000298/FIN-2018003-02Cooper2018Q3Failure to Perform Process Applicability DeterminationThe inspectors identified a Green, non-cited violation of Technical Specification 5.4.1.a, Procedures, for the licensees failure to follow Administrative Procedure 0.9, Tagout, Revision 88, for performing a monthly audit and Process Applicability Determination. Specifically, the inspectors noted that a clearance order on the safety-related residual heat removal service water booster pump room fan coil unit was hanging for greater than 90 days with no Process Applicability Determination performed, which resulted in the power switch for the fan coil unit being unintentionally tagged out of its normal configuration for almost 2 years
05000341/FIN-2018003-03Fermi2018Q3Failure to Identify a Condition Adverse to Quality on Division 2 Residual Heat Removal Service Water Outlet Flow Control ValveA finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, and TS 3.7.1 Residual Heat Removal Service Water (RHRSW) System, were self-revealed for the licensees failure to identify a condition adverse to quality on the Division 2 RHRSW outlet flow control valve E1150F068B. Specifically, troubleshooting and the associated post maintenance testing failed to identify and correct a failed anti-rotation key which resulted in an inoperable Division 2 RHRSW system for longer than its TS 3.7.1 allowed outage time.
05000259/FIN-2018002-03Browns Ferry2018Q2Failure to analyze for a Water Hammer event due to Spurious Operation of Residual Heat Removal Service Water (RHRSW) Valves during a Fire EventAn Apparent Violation (AV) of 10 CFR 50.48(c)(3)(ii) was identified for the failure to perform a required analysis using the methodology in Chapter 2 of NFPA 805 for the RHRSW piping as a result of a postulated fire scenario.
05000373/FIN-2018002-01LaSalle2018Q2Failure to Implement a Preventative Maintenance Strategy for Residual Heat Removal Service Water Pump Shorting RelaysA self-revealed Green finding of very low safety significance was identified for the licensees failure to implement a preventative maintenance (PM) strategy for the residual heat removal service water (RHRSW) pump shorting relays in accordance with procedure MAAA716210, Performance Centered Maintenance (PCM) Process, Revision 11. Specifically, a PCM template was issued in 2002 that required periodic as-found testing and calibration for control and timing relays, but a maintenance strategy was never implemented. As a result, one of the normally closed contacts on the Unit 1 D RHRSW pump shorting relay developed a high contact resistance and prevented the Unit 1 D RHRSW pump from starting.
05000341/FIN-2018002-04Fermi2018Q2Failure to Identify a Condition Adverse to Quality on Division 2 Residual Heat Removal Service Water Outlet Flow Control ValveA self-revealed TBD finding and an associated apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, and Technical Specification 3.7.1 Residual Heat Removal Service Water (RHRSW) System, were identified for failure to identify a condition adverse to quality while performing corrective maintenance on Division 2 RHRSW outlet flow control valve E1150F068B prior to returning the Division 2 RHRSW system to service. Specifically, troubleshooting and associated post maintenance testing failed to identify and correct a failed anti-rotation key which resulted in an inoperable Division 2 RHRSW system for longer than its Technical Specification 3.7.1 allowed outage time.
05000341/FIN-2018002-02Fermi2018Q2Inadequate Preventative Maintenance in Residual Heat Removal Service Water System Outlet Flow Control Valves Results in Lower Bonnet (Backseat) Bushing FailureA self-revealed Green finding and associated non-cited violation (NCV) of 10 Code of Federal Regulations (CFR) Part 50, Appendix Criterion V, Instructions, Procedures, and Drawings were identified for failure to ensure activities affecting quality were prescribed in a manner consistent with the circumstances to the residual heat removal service water system(RHRSW). Specifically, preventative maintenance procedure M681 failed to establish an appropriate interval and guidance for periodic valve internals inspections on the Division 2 RHRSW system outlet flow control valve to prevent significant degradation from galvanic corrosion given known internal and external operating experience
05000265/FIN-2018001-02Quad Cities2018Q1Failure to Establish Design Standard for Unit 2 Residual Heat Removal Service Water PumpsThe inspectors identified a finding of very low safety significance (Green) and a Non-Cited Violation of 10 CFR 50, Appendix B, Criterion III, Design Control, for the licensees failure to ensure that the design bases standard and other requirements necessary to assure adequate quality were included in the design documents for the Unit 2 residual heat removal service water pumps. Consequently, the licensee failed to ensure the Unit 2 pumps were designed and constructed in accordance with the Standards of the Hydraulic Institute as identified in the Updated Final Safety Analysis Report.
05000341/FIN-2017004-02Fermi2017Q4Division 2 Residual Heat Removal Service Water System Outlet Flow Control Valve Lower Bonnet (Backseat) Bushing FailureThe inspectors evaluated the licensee's handling of selected degraded performance issues involving the following risk-significant structures, systems, and components (SSCs):Residual heat removal service water system. 13 The inspectors assessed performance issues with respect to the reliability, availability, and condition monitoring of the SSCs. Specifically, the inspectors independently verified the licensee's handling of SSC performance or condition problems in terms of:appropriate work practices;identifying and addressing common cause failures;scoping of SSCs in accordance with 10 CFR 50.65(b);characterizing SSC reliability issues;tracking SSC unavailability;trending key parameters (condition monitoring);10 CFR 50.65(a)(1) or (a)(2) classification and reclassification; andappropriateness of performance criteria for SSC functions classified (a)(2) and/or appropriateness and adequacy of goals and corrective actions for SSC functions classified (a)(1).In addition, the inspectors verified problems associated with the effectiveness of plant maintenance for risk-significant SSCs were entered into the licensee's corrective action program with the appropriate characterization and significance. Selected CARDs were reviewed to verify corrective actions were appropriate and implemented as scheduled.This inspection constituted one quarterly maintenance effectiveness inspection samples as defined in IP 71111.12.FindingsDivision 2 Residual Heat Removal Service Water System Outlet Flow Control Valve Lower Bonnet (Backseat) Bushing FailureIntroduction. The inspectors identified an unresolved item (URI) to further evaluate the events and causes of a failure of the Division 2 RHRSW system outlet Flow Control Valve (FSC) lower bonnet (backseat) bushing. Specifically, additional information was needed to determine if one or more performance deficiencies exist.Description. On October 23, 2017, the Division 2 RHRSW system was started to support weekly addition of biocide to the Division 2 RHR reservoir (ultimate heat sink) as a preventative measure to minimize raw water system fouling, which typically entailed running both Division 2 RHRSW pumps for approximately 12 hours. Approximately 20 minutes after system startup, the control room received an overhead annunciator alarm for reactor building south west quad leakage to floor drain sump high along with indication that the reactor building south west quad sump pumps were running. A non-licensed operator was dispatched to the field to investigate the alarms and identified the Division 2 RHRSW outlet Flow Control Valve (FCV) (E1150F068B), located in the Division 2 RHR heat exchanger room in the reactor building, had a significant packing leak calculated to be approximately 16 gallons per minute. The leakage did not impact any other plant equipment in the local area and was captured by the Division 2 RHR heat exchanger room floor drains, which discharge into the reactor building south west quad room sump. Control room operators subsequently shutdown the Division 2 RHRSW pumps to stop the packing leakage and declared the Division 2 RHRSW system inoperable 14 The licensee formed an emergent issues team to further investigate the issue.Following valve disassembly and inspection, the licensee identified the valve lower bonnet (backseat) bushing no longer had sufficient thread engagement to remain in place and that the valve packing had been ejected from the valve stuffing box. A temporary modification was implemented to install a new backseat bushing welded directly to the valve bonnet. The system was subsequently returned to service on October 27, 2017.The Division 2 RHRSW outlet FCV is a safety-related, 24inch Powell globe valve with a motor operator. The primary safety function of the outlet FCV is to fully open to support heat transfer from the Division 2 RHR heat exchanger to the ultimate heat sink. The valve remains fully open during RHRSW pump operation (combined pump flow on the order of 10,000 gallons per minute) and generally is not throttled other than during initial startup of the pumps for a short period of time to help mitigate any potential water hammer events.The licensee completed a root cause analysis documented in CARD 1728611 at the end of the inspection period. The direct cause of the Division 2 RHRSW outlet FCVpacking leakage was determined to be the valve bonnet carbon steel threads corroded to the point of no longer functioning as an adequate mechanical connection. This resulted in the backseat bushing detaching from the valve bonnet allowing the packing to be ejected. The root cause was determined to be previous operating experience resolution for galvanic corrosion for valves in the safety-related service water systems was less than adequate resulting in a failure to recognize the vulnerability of galvanic corrosion on passive valve components. Contributing causes consisted of (1) RHRSW system operation produces significant valve vibration levels and periodic wetting and then drying conditions promoting a corrosive environment and (2) high levels of ionic impurities, as measured by chloride concentration, in RHRSW accelerate galvanic corrosion.The inspectors reviewed the root cause analysis report and several previous issues associated with the Division 2 RHRSW outlet FCV. Those events included, but were not limited to:On May 22, 2017, while placing Division 2 RHRSW in service for biocide treatment of the Division 2 RHR reservoir, the Division 2 RHRSW outlet FCVfailed to fully open. Troubleshooting discovered the direct cause was failure of the anti-rotation bushing stem key due to broken tack welds caused by high vibration during system operation. Previous troubleshooting on what was believed to be an indication issue on May 5, 2017 for the Division 2 RHRSW outlet FCV was inadequate and did not identify the failure of the anti-rotation key. As a result, the RHRSW FCV was returned to service on May 7, 2017, and subsequently failed on the next on-demand stroke on May 22, 2017. The licensee submitted Licensee Event Report 05000341/201700300 to report this event in accordance with 10 CFR 50.73(a)(2)(i)(B) as a condition prohibited by Technical Specification 3.7.1 and 10 CFR 50.73(a)(2)(v)(B) as a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat. The system was returned to service on May 24, 2017. On September 28, 2017, while Division 2 RHRSW was out of service for planned valve performance monitoring, a partial stem-to-disc separation was detected.This additional monitoring was put in place based on previous industry operating experience of potential stem-to-disc separation following anti-rotation key failures. Upon further investigation and valve-disassembly, the stem-to-disc jam nut tack welds were found broken and the stem had unthreaded approximately 0.225 inches from the disc. Repairs were performed to replace the broken tack welds on the disc jam nut. The disc guide pin was also identified to be damaged and the licensee performed an engineering evaluation to permanently remove the disc guide pin. A broken tack weld was also noted on the backseat bushing which was repaired. The system was returned to service on October 3, 2017.The inspectors questioned the potential relationships between the aforementioned events given the potential for each event to have influenced the eventual failure of the backseat bushing. The inspectors needed additional information to determine whether or not the valve, including the backseat bushing, was subject to an over thrust condition as a result of one or a combination of irregular limit switch settings, anti-rotation key failure, broken and subsequent removal of the disc guide pin, stem-to-disc unthreading, and various broken tack welds. Other additional information was needed in order to determine:if the Division 2 RHRSW outlet FCV was of appropriate design for the known conditions of high vibrations, periods of cavitation on startup and shutdown, and a highly susceptible corrosive environment due to periods of wet and dry conditions with known dissimilar metals highly susceptible to galvanic corrosion;the technical basis behind not including globe valves in the corrosion monitoring program following previously noted and evaluated concerns of RHRSW system susceptibility from years past; andthe technical basis and management of chemistry controls on the RHR reservoirs.Because the licensee completed their root cause evaluation at the end of the inspection period and additional information was required to determine if one or more performance deficiencies exists associated with the various Division 2 RHRSW outlet FCV problems, this issue is being treated as an unresolved item pending receipt of additional information and subsequent inspector review. (URI 05000341/201700402, Division 2 Residual Heat Removal Service Water System Outlet Flow Control Valve Lower Bonnet (Backseat) Bushing Failure)
05000259/FIN-2017003-02Browns Ferry2017Q3Failure to Maintain Intake Building Flood BarrierAn NRC- identified NCV of Technical Specification (TS) 5.4.1, Procedures, was identified for the failure to follow procedure MCI -0-023- PMP003, Emergency Equipment Cooling Water (EECW) and Residual Heat Removal Service Water Pump (RHRSW) Removal and Reinstallation, Revision 22. The performance deficiency is more than minor because it affected the Mitigating Systems cornerstone attribute of Equipment Performance and adversely affected the cornerstone objective. A detailed risk evaluation by a regional SRA determined the finding was Green . The licensee entered the violation into the CAP as CR 1338684. The finding had a cross cutting aspect in the Avoid Complacency component of the Human Performance area because the maintenance staff chose to not refer to a previously related condition report (CR) (PER 599190) or the maintenance procedure that were corrective actions for a previous NRC finding. (H.12).
05000321/FIN-2017002-01Hatch2017Q2Hardened grease prevents 1RHRSW pump breaker operationGreen. A self-revealing, Green, non-cited violation (NCV) of Hatch Unit 1 Technical Specification 5.4 Procedures, was identified when procedures to rejuvenate grease in the 1C' residual heat removal service water (RHRSW) Pump breaker were not implemented resulting in failure of the pump to start. The violation was entered into the licensees corrective action program as condition report (CR) 10263236 and the breaker was replaced to restore compliance. Failure to rejuvenate the lubricating grease on 4kv DHPVR breakers in accordance with vendor guidance was a performance deficiency. Specifically, the hardened grease prevented the 1C RHRSW pump breaker from closing resulting in the inoperability of the 1C RHRSW pump. The performance deficiency was associated with the Mitigating Systems cornerstone and was more than minor because it adversely affected the cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors screened this finding using IMC 0609, Appendix A, The Significant Determination Process (SDP) For Findings At-Power, dated June 19, 2012. Because all four questions in Section A of Exhibit 2, Mitigating Systems Screening Questions, were answered no, the finding screened as Green. The inspectors determined that this finding did not have an associated cross cutting aspect because this finding is not reflective of current licensee performance.
05000263/FIN-2017002-02Monticello2017Q2Licensee-Identified ViolationThe licensee identified a finding of very low safety significance (Green) and associated NCV of TS 3.7.1, Residual Heat Removal Service Water (RHRSW) System; which requires, in part, that two RHRSW subsystems shall be operable in Modes 1, 2, and 3 or per Condition A, One RHRSW subsystem inoperable; the RHRSW subsystem must be restored to OPERABLE status within 7 days or the applicable conditions and required actions of Limiting Condition forOperations 3.4.7, Residual Heat Removal Shutdown Cooling System Hot Shutdown, for RHR shutdown cooling made inoperable by RHRSW System must be entered. Contrary to the above, on March 27, 2017, the licensee exited the requirements in TS 3.7.1, with a Tag Section still hanging, rendering B RHRSW subsystem inoperable, while in Mode 1. This was identified by the licensee when the maintenance organization notified operations that work was complete, and the Tag Section was released. The licensee reentered TS 3.7.1, Condition A, entered the issue as CAP 1554105 and assigned a Human Performance Event Investigation. A crew clock reset was also taken as well as communicating lessons learned to the entire plant organization.This finding was more-than minor because the performance deficiency wasassociated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected its objective to ensure the availability and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, RHRSW System is designed to provide cooling water for the RHR System heat exchangers, required for a safe reactor shutdown following a Design Basis Accident or transient. Two RHRSW subsystems are required to be OPERABLE to provide the required redundancy to ensure that the system functions to remove post-accident heat loads, assuming the worst case single active failure occurs coincident with the loos of offsite power. The finding was of very low safety significance (Green) because it was not a design or qualification deficiency, did not involve an actual loss of safety system, did not represent actual loss of a safety function of a single train for greater than its TS allowed outage time, and did not represent an actual loss of function of one or more non-Tech Spec Trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for >24 hours.
05000298/FIN-2017001-03Cooper2017Q1Failure to Identify a Condition Adverse to QualityThe inspectors identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to identify a condition adverse to quality for Division 1 residual heat removal service water booster pump A, in accordance with Station Procedure 0-CNS-LI-102, Corrective Action Process, Revision 6. Specifically, on January 5, 2017, the inspectors identified an oil level lower than normally expected, oil on the pump skid, and an oil droplet formed on the Division 1 residual heat removal service water booster pump A inboard bearing sight glass. The inspectors informed the control room of this condition, and the licensee determined the oil leakage from the pumps sight glass would have prevented the pump from operating for the required 30 days during a design basis accident. The immediate corrective action was to repair the Division 1 residual heat removal service water booster pump A inboard bearing sight glass, restoring operability of the pump. The licensee entered this deficiency into the corrective action program as Condition Report CR-CNS-2017-00054. The licensees failure to identify a condition adverse to quality for Division 1 residual heat removal service water booster pump A, in violation of Station Procedure 0-CNS-LI-102, 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 Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events. Specifically, the oil leakage from the service water booster pump A inboard bearing sight glass would have prevented the pump from operating for its required 30-day mission time during a design basis accident and resulted in the pump 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; 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 human performance associated with challenge the unknown because the licensee failed to stop when faced with uncertain conditions and failed to ensure that risks are evaluated and managed before proceeding. Specifically, the licensee did not maintain a questioning attitude during job-site reviews to identify and resolve unexpected conditions, including lower than the expected oil level in the service water booster pump A inboard bearing sight glass, oil on the pump skid, and an oil droplet formed on the bottom of the sight glass (H.11).
05000298/FIN-2017001-04Cooper2017Q1Failure to Address Nonconforming Pipe Thinning in Accordance with the ASME CodeThe inspectors identified a non-cited violation of 10 CFR 50.55a(g)(4) for the licensees failure to use an approved method to disposition an American Society of Mechanical Engineers Code nonconforming condition in the residual heat removal service water system. Specifically, the licensee identified multiple locations with localized pipe thinning below the American Society of Mechanical Engineers Code B31.1 design minimum pipe-wall thickness during an ultrasonic examination but failed to use an approved method to calculate a new acceptable pipe-wall thickness. As a corrective action to restore compliance, the licensee replaced this section of piping on November 1, 2016, during Refueling Outage 29. The licensee entered this issue into the corrective action program as Condition Reports CR-CNS-2016-05558 and CR-CNS-2016-05963. The licensees failure to use an approved method to calculate a new minimum allowable pipe-wall thickness, in violation of 10 CFR 50.55a(g)(4), was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the design control attribute of the Mitigating System Cornerstone and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, calculating an allowable minimum pipe-wall thickness value that is below the American Society of Mechanical Engineers code design minimum value reduces the pipings structural integrity, potentially leading to the failure of the piping. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings AtPower, dated June 19, 2012, inspectors determined the finding screened as having 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. This finding had a cross-cutting aspect in the area of human performance associated with design margins because the licensee failed to operate and maintain the residual heat removal service water system within the American Society of Mechanical Engineers code minimum pipe-wall thickness. Specifically, having identified that the affected pipe location was below the allowable pipe-wall thickness, the licensee opted to calculate and accept a new minimum pipe-wall thickness value that was not consistent with code requirements instead of repairing the affected piping at the time of discovery (H.6).
05000254/FIN-2017001-01Quad Cities2017Q1Failure to Ensure Hardware Secure for Breaker MOC Switch LinkageGreen . A finding of very low safety significance and an associated NCV of 10 CFR 50, Appendix B, Criterion V was self -revealed on January 27, 2017, when the Unit 1C residual heat removal service water (RHRSW ) pump was started for a routine surveillance evolution and all expected annunciators and equipment failed to operate properly, which led to the licensee declaring the Unit 1C RHRSW pump inoperable. Specifically, t he licensee failed to establish a procedure for the mechanism operated contact (MOC) switch linkage arm that was appropriate to the circumstances to ensure the component would c ontinue to perform its function. Immediate corrective actions included reconnecting the MOC switch linkage arm assembly and test ing it by starting the 1C RHRSW pump prior to declaring the pump operable. In addition, the licensee planned procedure revisions to QCEPM 0200 11 that would specify a torque value to ensure the MOC switch linkage arm was adequately secured and could perform its function. Th is issue was entered into the licensees corrective action program as Issue Report 3967424 . The finding was determined to be more than minor because the finding was associated with the Mitigating Systems cornerstone attribute of equipment performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to ensure the MOC switch linkage arm was adequately fastened led to the failure of the component and its associated Unit 1C RHRSW pump d uring breaker operation on January 27, 2017. T he finding was determined to be of very low safety significance (Green), because the inspectors answered No to all of the questions in IMC 0609, Appendix A, The Significance Determination Process for Findings at Power , Exhibit 2, Mitigating Systems Screening Questions, Section A, Mitigating SSCs and Functionality. The inspectors determined this finding affected the cross- cutting area of human performance, in the aspect of avoid complacency, which state s, Individuals recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, the licensee failed to recognize a potential risk and inherent latent issue for a condition identified in 2015 at Quad Cities, when a MOC switch failed to perform its function due to a missing nut in a different breakers linkage assembly. The licensee identified and corrected the 3 condition but failed to evaluate the cause of the missing nut because it did not impact the operability of the component . I n the 2015 instance, the MOC switch issue only affected indications for the component and had no adverse impact on the ability of the component to perform its function (H.12 ).
05000324/FIN-2016003-01Brunswick2016Q3Failure to Implement Risk Management Actions during Elevated RiskAn NRC-identified Green non-cited violation (NCV) of 10 CFR 50.65(a)(4) was identified for the failure of the licensee to implement all necessary prescribed risk management actions (RMAs) during a 2A residual heat removal (RHR) and residual heat removal service water (RHRSW) outage. Specifically, between August 31, 2016, and September 1, 2016, the licensee failed to post protective equipment signs on the 2B RHR/RHRSW motor control centers (MCCs) whose unavailability would have taken Unit 2 into a Yellow risk condition. The licensee took immediate corrective actions to protect the 2B RHR/RHRSW MCCs in the field. The licensee entered this issue into the corrective action program (CAP) as nuclear condition report (NCR) 2059064. The inspectors determined the failure of the licensee to adequately post protected equipment signs for the 2B RHR/RHRSW system, whose unavailability would have taken the unit into a Yellow risk condition, was a performance deficiency. The finding was more than minor because if left uncorrected, the failure to perform RMAs could result in a loss of a safety-related mitigating function, specifically the RHR low pressure coolant injection (LPCI). Using IMC 0609, Appendix K, issued May19, 2005, Maintenance Risk Assessment and Risk Management Significance Determination Process, Flowchart 2, Assessment of RMAs, the inspectors determined the finding screened as very low safety significance (Green) since the incremental core damage probability was less than 1E-6. The finding has a crosscutting aspect in the area of human performance associated with the procedure adherence attribute because the licensee failed to follow plant procedures to fully protect the 2B RHR/RHRSW loop during the 2A RHR/RHRSW loop outage.
05000333/FIN-2016007-02FitzPatrick2016Q2Failure to adequately evaluate a procedure change impacting a PRA-credited time critical operator actionThe team identified a Green finding involving Entergys inability to complete a time critical operator action within the assumed probabilistic risk assessment (PRA) credited accident mitigation time limit to prevent undesirable consequences (i.e., core damage) under a postulated scenario (i.e., using the residual heat removal service water (RHRSW) system as an alternate injection source into the reactor pressure vessel (RPV) via the residual heat removal (RHR) system during a loss of coolant accident (LOCA)). Specifically, in response to a known degraded condition impacting an RHRSW valve, Entergy did not adequately evaluate an associated temporary procedure change to EP-8, Alternate Injection Systems, to ensure operator actions could be accomplished to initiate RHRSW injection to the RPV within the PRA-credited time. Entergy entered the issue into their CAP as CR 2016-1396 and CR 2016-1429 and completed corrective actions to pre-stage a ladder for operator use and provide additional guidance to plant operators. The finding was more than minor because it was associated with the design control (plant modifications) attribute of the Mitigating Systems cornerstone and adversely affected the cornerstones objective of ensuring reliability, availability, and capability of systems and operators that respond to initiating events to prevent undesirable consequences (i.e., core damage). The team evaluated the finding in accordance with IMC 0609, Appendix A, The Significance Determination Process for Findings at Power, Exhibit 2 Mitigating Systems Screening Questions, and concluded it required a detailed risk evaluation (DRE). A Region I Senior Reactor Analyst performed the DRE and concluded that the failure of an operator action to align RHRSW for RPV alternate injection within the assumed PRA accident mitigation time limit results in an estimated increase in core damage frequency in the mid E-8/year range, or very low safety significance (Green). The finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation, because Entergy did not thoroughly evaluate issues to ensure that resolutions address causes and extent-of-conditions commensurate with their safety significance. Specifically, Entergy did not thoroughly evaluate the effect of an alternate injection procedure change on PRA-credited time critical operator actions. (PI.2)
05000259/FIN-2016007-01Browns Ferry2016Q1Failure to Promptly Identify Conditions Adverse to Quality Associated with RHRSW Room Flood BarriersAn NRC identified non-cited violation (NCV) of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, was identified for the licensee's failure to promptly identify conditions adverse to quality associated with deficient flood barrier penetrations in the B Residual Heat Removal Service Water (RHRSW) compartment. As an immediate corrective action, the licensee evaluated the deficiencies and determined that the equipment in the room would remain operable during a design basis flood. The violation was entered into the licensee's corrective action program as CR 1119892. The performance deficiency was more-than-minor because it was associated with the protection against external factors attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective of ensuring the capability of systems that respond to initiating events to prevent undesirable consequences (i.e. core damage). Specifically, the capability of the flood protection function of the B RHRSW compartment was adversely affected due to the presence of degraded penetrations. The finding was screened using IMC 0609 Appendix A, Exhibit 4, External Events Screening Questions, dated June 19, 2012. The finding screened as very low safety significance (Green) because the finding would not cause a plant trip, initiating event, degrade two or more trains of a multi-train system or function, and it would not degrade one or more trains of a system that supports a risk significant system or function. Additionally, the finding did not involve the total loss of any safety function. The inspectors determined that the finding had a cross-cutting aspect in the Human Performance area of Conservative Bias (H.14) because personnel characterized the potential deficiencies as not unacceptable rather than establishing that final acceptability was still in question which required timely resolution.
05000324/FIN-2015004-01Brunswick2015Q4Inadequate Procedure for the 2C RHRSW Booster Pump Motor BearingsA self-revealing Green non-cited violation (NCV) of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified for the failure of the licensee to have an adequate procedure for the 2C residual heat removal service water (RHRSW) pump motor bearing maintenance. Specifically, licensee procedure 0CM-M503, Maintenance Instructions for the RHRSW Booster Pump Motors, did not contain information to ensure proper sealing of the 2C RHRSW motor bearings. This finding resulted in a violation of technical specification (TS) 3.0.4, Limiting Condition for Operation (LCO) Applicability, and TS 3.7.1, RHRSW System. As immediate corrective actions, the licensee applied sealant to the motor bearings. Additionally, the licensee revised procedure 0CM-M503 and added a detailed location for applying the sealant to the RHRSW pump motors. The licensee entered this issue into the Corrective Action Program (CAP) as nuclear condition report (NCR) 742643. The inspectors determined the licensees failure to have an adequate procedure for the 2C RHRSW pump motor bearing maintenance was a performance deficiency. The finding was more than minor because it was associated with the procedural 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 inadequate procedure resulted in the inoperability of the Loop A RHRSW subsystem, and the loss of safety function while the Loop B RHRSW subsystem was out for maintenance. Using IMC 0609, Appendix A, issued June 19, 2012, the SDP for Findings At-Power, Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding screened to a more detailed risk evaluation, since the finding represented a loss of system and/or function. The regional Senior Reactor Analyst performed a detail risk review of the finding. The at-power model was conservatively used to bound the risk that would happen at the proposed time of failure, which was many days after shutdown due to the time it takes for the oil leak to cause potential bearing failure. Since the licensee had procedures for running the service water (SW) system without the RHRSW pumps energized, and the decay heat loads at the time of failure would be low, a failure rate of only 0.1 for the loss of function was assumed. This was also conservative, since the adverse conditions that would have prevented refill of the oil were LOCA assumptions, and LOCA sequences did not contribute greatly to the risk in the model. The at-power models solution was more than an order of magnitude below the Green/White threshold for the SDP. Therefore, the finding was determined to be of very low safety significance (Green). The finding has a cross-cutting aspect in the area of human performance associated with the challenge the unknown attribute because the licensee did not stop when faced with uncertain conditions, and risks were not evaluated and managed before proceeding. Specifically, the licensee continued through the 2010 and 2013 2C RHRSW pump maintenance outages, even when the bearings were found without sealant. Additionally, the licensee did not question the procedurally required location for the sealant.
05000324/FIN-2015002-04Brunswick2015Q22C Residual Heat Removal Service Water (RHRSW) Pump Oil LeakThe inspectors opened a URI to review the licensees evaluation of the motor oil leak on the 2C RHRSW pump and determine if there is a performance deficiency. On April 8, 2015, the licensee identified an oil leak on the motor for the 2C RHRSW pump in excess of the amount that would be acceptable for the pump to meet the 30-day mission time, and the pump was declared inoperable. The licensees immediate corrective actions were to apply sealant to the mechanical joints of the bearing housings. The licensee entered this issue in the CAP as NCR 742643. This issue is being tracked as a URI: URI 05000324/2015002-04, 2C Residual Heat Removal Service Water Pump Oil Leak.
05000387/FIN-2014009-01Susquehanna2014Q2Inadequate Corrective Actions for Degraded ESW and RHRSW PipingThe inspectors identified a Green non-cited violation (NCV) of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for PPLs failure to take adequate corrective actions for a condition adverse to quality involving the emergency service water (ESW) and residual heat removal service water (RHRSW) systems. Specifically, PPL did not take timely and appropriate corrective actions to address carbon steel pipe wall thinning on the B ESW and B RHRSW discharge piping on the lower level of the ESW pump house. PPL completed immediate corrective actions including cleaning the affected piping, conducting ultrasonic testing (UT) thickness testing of the affected piping, calculating acceptance criteria for the UT tests (minimum wall thickness), and calculating a degradation rate of the piping given worst case historical corrosion and water in the environment. Additional actions included initiation of multiple condition reports (CR) to enter the issues into the corrective action program (CR-2014-18803, CR-2014-18945, CR-2014-18932), and plans to add the piping to the PPL Pipe Corrosion Program (PCP) for trending and future examination consideration. The finding is more than minor because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, the wetting and associated external corrosion of the piping without appropriate monitoring could adversely impact the structural integrity of the B RHRSW and ESW headers. In addition, the finding is similar to the example 3.i in Inspection Manual Chapter (IMC) 0612 Appendix E, Examples of Minor Issues, because PPL had to perform calculations to assess whether the actual wall thickness met minimum structural integrity requirements. In accordance with IMC 0609, Significance Determination Process, Attachment 4, Initial Characterization of Findings, Table 2, Cornerstones Affected by Degraded Condition or Programmatic Weakness, inspectors determined this performance deficiency affected the Mitigating Systems Cornerstone. Using IMC 0609, Appendix A, The SDP for Findings At-Power, Exhibit 2, Mitigating Systems Screening Questions, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because the finding does not represent an actual loss of function of one or more non-Tech Spec Trains of equipment designated as high safety-significant in accordance with PPLs maintenance rule program for greater than 24 hours. The inspectors determined that this finding had a human performance cross-cutting aspect related to Consistent Process because PPL did not use their decision making process consistently to re-evaluate decisions to ensure they remained appropriate when previous decisions were called into question. Specifically, despite repeated identification of pipe wetting conditions and observations of worsening corrosion, plant personnel did not reevaluate structural integrity. Additionally, plant personnel used an inconsistent approach in dealing with the issue, as was demonstrated by the difference in treatment to prevent corrosion on the A train of the RHRSW and ESW systems. (H.13)
05000271/FIN-2014007-01Vermont Yankee2014Q2Inadequate Design Control of SBO Loading CalculationThe team identified a finding of very low safety significance (Green), in that Entergy did not ensure correct implementation of their design control process when establishing the capacity requirement for the new Station Blackout (SBO) alternate alternating current (AAC) power source. Specifically, Entergy did not use the latest revision of the SBO load capacity analysis as a design input to the load capacity requirement when verifying the adequacy of the sizing of the new SBO diesel generator (DG). Entergy entered the issue into their corrective action system to evaluate the capability of the SBO DG to support the expected SBO loads and initiated actions to ensure the design analysis assumptions for loading are consistent with the established operational procedures for SBO response. The finding is more than minor because it is associated with the design control attribute of the Mitigating Systems cornerstone and affected the cornerstone objective of ensuring the capability of systems that respond to initiating events to prevent undesirable consequences. In addition, inspectors reviewed IMC 0612, Appendix E, Examples of Minor Issues, and found that example 3.j was similar, in that, the team had reasonable doubt of the capability of the SBO DG to operate within its analyzed load rating. Specifically, the most limiting condition with residual heat removal service water (RHRSW) pumps in service had not been accounted for in the SBO DG load rating evaluation. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 2 of IMC 0609, Mitigating Systems Screening Questions, Section A, Mitigating SSCs and Functionality, the team concluded that this finding was a design deficiency that did not result in the SBO DG losing its functionality. Specifically, the team evaluated decay heat level requirements and determined there was reasonable assurance the SBO DG load would have remained within its design rating. The team determined that this finding had a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because the design control engineering change process procedure was not adequately followed, in that, the increased SBO load associated with a second RHRSW pump was not evaluated and resolved through the design review process.
05000352/FIN-2014002-01Limerick2014Q1Failure to Adhere to Technical Specifications When Making Change to ODCMThe NRC identified a non-cited violation of Technical Specification (TS) 6.14, Offsite Dose Calculation Manual (ODCM), for failure to evaluate and provide sufficient information to support a change to the ODCM. Specifically, LGS revised the ODCM to allow the residual heat removal service water (RHRSW) monitors to be non-functional due to loss of flow for a period of up to 4 hours before they were required to be declared inoperable and did not provide sufficient information to support the change including a determination that the change would maintain the level of radioactive effluent release control. LGS entered the issue into their corrective action program (CAP) as Issue Report (IR) 1639697 and revised the applicable alarm response card (ARC-MRC-010 E4) to declare the monitor inoperable under similar conditions. A dose calculation was also completed that indicated no significant public dose consequences associated with the monitors inoperable status. The failure to evaluate and provide sufficient information to support a change to the ODCM, in accordance with the requirements of TS 6.14 is a performance deficiency. This performance deficiency is more than minor because it affected the Public Radiation Safety Cornerstone attribute of Plant Facilities/Equipment and Instrumentation. Using Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety Significance Determination Process, dated February 12, 2008, the inspectors determined this to be a finding of very low safety significance (Green) because: the finding was in the effluent release program; was not a substantial failure to implement the effluent program; and the dose to the public did not exceed the 10 Code of Federal Regulations (CFR) Part 50 Appendix I criterion or 10 CFR 20.1301(e) limits. This finding was associated with a cross cutting aspect of Human Performance, Design Margins. Specifically, LGS did not conduct a sufficiently rigorous review of a change in the operability status of a safety-related radiation monitor (RHRSW radiation monitors) to ensure that the change would not adversely impact the level of radioactive effluent release control.
05000259/FIN-2013005-01Browns Ferry2013Q4Failure to Document Service Water Freeze Protection DeficienciesThe NRC identified a non-cited violation (NCV) of 10 CFR 50, Appendix B, Criterion V, Procedures, for the licensees failure to implement 0-GOI-200-1, Freeze Protection Inspection. Specifically, the licensee failed to enter freeze protection discrepancies into the corrective action program as part of the Freeze Protection Discrepancy List per 0-GOI-200-1 for the residual heat removal service water (RHRSW) and emergency equipment cooling water (EECW) systems. As a corrective action, the licensee entered the required deficiencies onto the Freeze Protection Discrepancy List. The licensee has entered this issue into their corrective action program as problem evaluation reports 800190 and 821426. The finding was more than minor because, if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern, in that the intake room piping would continue to be exposed to freezing temperatures without adequate freeze protection which could affect RHRSW and EECW systems ability to perform their safety functions. The inspectors performed a Phase 1 screening in accordance with IMC 0609, Significance Determination Process, Appendix A, Exhibit 1, Initiating Event screening question E, and determined the finding was of very low safety significance (Green) because it did not impact the frequency of an internal flooding event. The cause of this finding has a cross-cutting aspect in the Work Practice component of the Human Performance area, because the licensee failed to define an effectively communicate expectations regarding procedural compliance and tha personnel follow procedures. (H.4(b))
05000259/FIN-2013004-01Browns Ferry2013Q3Failure to enter Technical Specification for Residual Heat Removal Service Water MaintenanceThe NRC identified a non-cited violation (NCV) of Technical Specifications (TS) 5.4.1.a, Procedures, for the licensees failure to follow OPDP-8, Operability Determination Process and Limiting Conditions for Operation Tracking. Specifically, the licensee failed to enter a seven day action statement C.1 of Technical Specification 3.7.1, Residual Heat Removal Service Water (RHRSW) system and Ultimate Heat Sink when planned maintenance rendered two RHRSW pumps inoperable. The licensee entered this issue into their corrective action program as Problem Event Report (PER) 751300. This finding was determined to be more than minor because if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. The finding affected the Mitigating Systems cornerstone and using IMC 0609.04, Initial Characterization of Findings and IMC 0609 Appendix A, Exhibit 2 Mitigating Systems screening questions, the finding screened as very low safety significance (Green). The finding did not represent an actual loss of function of a single train for greater than its technical specification allowed outage time and did not represent an actual loss of function of one or more non-technical specification equipment for greater than 24 hours because the licensee restored the C1 and C2 RHRSW pumps on July 5, 2013. The inspectors determined that this finding had a cross-cutting aspect in the area of human performance associated with the work practices component because the licensee failed to ensure that expectations for procedural compliance were properly communicated and that personnel followed procedures.
05000331/FIN-2013004-01Duane Arnold2013Q3Extent of Condition Not Properly EvaluatedA finding of very low safety significance and associated non-citied violation (NCV) of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified by the inspectors for the licensees failure to accomplish safety-related procedure EN-AA-203-1001, Operability Determinations/Functionality Assessments. Specifically, during the Fall 2012 refueling outage, the licensee failed to evaluate the extent of condition under a prompt operability determination (POD) for the A residual heat removal service water (RHRSW) subsystem after identifying several locations of the B RHRSW supply piping that was less than the minimum acceptable wall thickness. By not performing a POD, the operations shift manager (OSM) was not able to perform his or her responsibility to review, assess, and approve the operability call regarding the potential for wall thinning of the A RHRSW piping. The licensee entered the inspectors concerns into the CAP as Condition Report (CR) 01892263. The licensee completed a POD to evaluate the extent of wall thinning condition for the A RHRSW subsystem and determined that the A RHRSW subsystem was operable but with reduced margin to design specifications. This was reviewed and approved by the OSM. The inspectors determined that the issue of concern represented a performance deficiency because it was the result of the licensees failure to meet a procedural requirement, and the cause was reasonably within the licensees ability to foresee and correct and should have been prevented. The performance deficiency was determined to be more than minor and a finding because if left uncorrected, failing to properly assess the impact of extent of condition for operability on similar structures, systems, or components (SSCs) would have the potential to lead to a more significant safety concern. The inspectors applied IMC 0609, Attachment 4, Initial Characterization of Findings, to this finding. Because the finding pertained to operations while the plant was both shutdown and operating, the inspectors referenced both IMC 0609, Appendix G, Shutdown Operations Significance Determination Process, and IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power. Per IMC 0609, Appendix G, the inspectors determined that the finding did not require a quantitative assessment and therefore screened as very low safety significance (Green). Additionally, per IMC 0609, Appendix A, the inspectors determined that although the finding was a deficiency affecting the design and qualification of the SSC, the SSC maintained its operability and therefore also screened as very low safety significance (Green). The inspectors determined that the performance characteristic of the finding that was the most significant causal factor of the performance deficiency was associated with the cross-cutting aspect of Human Performance, having Decision Making components, and involving the licensee making safety or risk-significant decisions using a systematic process, especially when faced with uncertain or unexpected plant conditions, to ensure safety is maintained. Further, this includes formally defining the authority and roles for decisions affecting nuclear safety, and implementing these roles and authorities as designed. Specifically, the evaluation of extent of condition for the identified pipe wall thinning of the B RHRSW subsystem was not performed under the systematic operability determination process which resulted in bypassing the OSMs role in assessing and approving operability following the identification of a degraded or non-conforming condition.
05000259/FIN-2013004-02Browns Ferry2013Q3Failure to Clean the Safety Related Pump Pit Once per Two CyclesAn NRC identified finding (FIN) was identified for the licensees exceeding the maximum allowed periodicity for inspecting and cleaning the Residual Heat Removal Service Water (RHRSW) pump pit per Raw Water Corrosion Program procedure (NPG-SPP 9.7.3). This finding was determined to be more than minor because, if left uncorrected, the failure to maintain the intake pump pit cleaning would have had the potential to lead to a more significant safety concern in that, it could lead to fouling of safety related coolers. challenging the heat exchanger heat removal function. The finding is associated with the Mitigating Systems cornerstone. Using IMC 0609 Appendix A, Exhibit 2, the finding screened as green because the finding did not represent an actual loss of function of a single train for greater than its technical specification allowed outage time and did not represent an actual loss of function of one or more non-technical specification equipment for greater than 24 hours. The cause of this finding was associated with the human performance area, resources component, cross cutting aspect of maintaining long term plant safety by maintenance of design margins and minimizing preventative maintenance deferrals due to the licensee not allocating resources to clean the intake pump pits.
05000352/FIN-2013007-01Limerick2013Q2Inadequate Fire Brigade TransportationThe NRC identified a Green, Non-Cited Violation (NCV) of License Condition 2.C.(3) of the Limerick Generating Station operating license, in that Exelon did not provide adequate procedural guidance for transporting the fire brigade and equipment to the spray pond pump house. Specifically, the existing fire procedure had incorrect guidance which would have needlessly delayed the fire brigade response. In response to this issue, Exelon initiated IR 1511763 and took prompt action to revise the affected procedures. The finding was more than minor because it negatively affected the protection against external factors (fire) attribute of the mitigating systems cornerstone as related to the objective of ensuring the reliability and availability of the Essential Service Water pumps and Residual Heat Removal Service Water pumps. The finding was determined to be of very low safety significance (Green) in accordance with Section D of Exhibit 2 in Appendix A of IMC 0609, The Significance Determination Process for Findings at Power, because the fire brigades response time was mitigated by other defense-in-depth elements such as: area combustible loading limits were not exceeded, installed fire detection systems were functional, and alternate means of safe shutdown were not impacted. The finding did not have a cross-cutting aspect because it was not indicative of current performance.
05000259/FIN-2013011-04Browns Ferry2013Q2Two BFN Assistant Unit Operators Closed and Danger Tagged the A1 RHRSW Pump Manual Discharge Valve Instead of the Required A2 RHRSW Pump Discharge ValveThe team identified a Green, self-revealing non-cited violation (NCV) of Technical Specification (TS) 5.4.1, Procedures. The team determined that BFNs clearance and tagging application related to the planned A2 residual heat removal service water (RHRSW) pump maintenance was not properly applied and verified as required by TVA Corporate Procedures NPG-SPP-10.2, Rev. 5, Clearance Procedure to Safely Control Energy, and NPG-SPP-10.3, Rev.1, Verification Program. Two BFN assistant unit operators (AUOs) closed and danger tagged the A1 RHRSW pump manual discharge valve instead of the required A2 RHRSW pump discharge valve on May, 6, 2013. Upon starting the A1 RHRSW pump, control room alarms provided the operators indication of a system problem, and in the course of responding to the alarm, the operators noted the danger tag. The tags were removed and the pump was declared inoperable to fill and vent the system prior to returning it to an operable status. This issue was entered in to the corrective action program as PER 722859. The performance deficiencies were reasonably within BFNs ability to foresee and correct. This Finding was more than minor because it was associated with the human performance attribute which occurred when the AUOs closed and tagged the wrong RHRSW pump discharge valve. The AUOs errors adversely affected the Mitigating System cornerstone objective of ensuring the availability, reliability, and capability of the RHRSW and RHR systems that respond to initiating events to prevent undesirable consequences. The team determined that this Finding was of very low safety significance (Green) because it did not represent an actual loss of safety function or safety systems out of service for greater than the TS allowed outage time. The team determined that this Finding had a cross-cutting aspect in the area of Human Performance, Work Practices, because BFN AUOs did not use self-checking and peer checking human error prevention techniques to prevent the inadvertent closure and danger tagging of the A1 RHRSW pump manual discharge valve instead of the required A2 RHRSW pump valve during the application of a tagging clearance.
05000259/FIN-2013011-08Browns Ferry2013Q2Failure to Manage Emergent Risk Condition during A1 and A2 RHRSW InoperabilityThe team identified a self-revealing, Green non-cited violation (NCV) of 10 CFR 50.65 (a)(4), Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants, due to BFNs failure to adequately manage the impact of an emergent risk condition related to the A1 residual heat removal service water (RHRSW) quarterly surveillance test. BFN recognized the online maintenance risk condition however, failed to implement appropriate risk management actions (RMAs) in accordance with Procedure BFN-ODM-4.18, Protected Equipment. The A and B emergency diesel generators were required to be protected. BFN entered this issue into their corrective action program (CAP) as SR 730356. Specifically, on May 6, 2013, with the A2 RHRSW pump inoperable for planned maintenance, the A1 RHRSW pump was declared inoperable during the A1 RHRSW pump quarterly test due to a tagging error that resulted in Assistant Unit Operators closing and danger tagging the A1 pump manual discharge valve instead of the required A2 pump discharge valve. Upon starting the A1 RHRSW pump, control room alarms provided the operators indication of a system problem, and in the course of responding to the alarm, the operators noted the danger tag. The tags were removed and the pump was declared inoperable to fill and vent the system prior to returning it to an operable status. This issue was entered in to the corrective action program as PER 722859 and 731570. The team determined that BFNs failure to adequately manage the impact of an emergent risk condition related to the A1 residual heat removal service water (RHRSW) quarterly surveillance test was a performance deficiency that was reasonably within BFNs ability to foresee and correct. The performance deficiency was determined to be more than minor and a Finding because, if the deficiency was left uncorrected, it had the potential to lead to a more significant safety concern. Specifically, the failure to take adequate RMAs could have led to unplanned inoperability of redundant TS or risk significant mitigating systems being relied upon to respond to initiating events to prevent undesirable consequences. The performance deficiency was also determined to be more than minor since it is similar to more than minor Example 7.e of Inspection Manual Chapter (IMC) 0612, Appendix E Examples of Minor Issues. The Finding was evaluated in accordance with Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, of IMC 0609, Significance Determination Process, and was determined to be of very low safety significance (Green). This Finding has a cross-cutting aspect in the area of Human Performance, Work Control, because BFN failed to implement immediate RMAs and communicate to the station personnel the change in plant risk condition and protected equipment requirements that may affect work activities.
05000259/FIN-2013011-14Browns Ferry2013Q2Failure to Implement an Adequate Test Program for RHRSWS and EECSThe team identified a non-cited violation of 10CFR50, Appendix B, Criterion XI, Test Control, because the licensee did not establish a test program for Residual Heat Removal Service Water (RHRSW) and Emergency Equipment Cooling Water (EECW) pumps such that the test adequately demonstrated the pumps would perform satisfactorily in service. Specifically, BFN did not perform RHRSW/EECW pump performance testing such that it adequately accounted for river water temperature impact on the pump lift, which affected pump flow and vibration performance. The test program did not account for changes to pump lift caused by river water temperature changes; as a result the test program did not adequately monitor pump and system performance and degradation. The licensee completed a prompt operability determination verifying that the pumps remained operable and documented the issue in PERs 730497 and 741036. The Finding was more than minor because at affected the Mitigating System Cornerstone and if left uncorrected, could become a more significant safety concern. The team determined the Finding was of very low safety significance because it was not a design or qualification deficiency, and it did not result in an actual loss of one or more trains of the RHRSW or EECW systems and/or their function. The Finding had a crosscutting aspect in the area of Problem Identification and Resolution, Corrective Action Program, because the licensee did not to thoroughly evaluate the changes in RHRSW and EECW pump performance such that the resolution addressed the causes and extent-of-condition.
05000259/FIN-2013002-01Browns Ferry2013Q1Failure to Implement Preventive Maintenance ProgramA self-revealing Apparent Violation (AV) of 10 CFR 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified for the licensees failure to establish an adequate preventive maintenance program as required by procedure NPG-SPP-06.2, Preventive Maintenance. Specifically, the Residual Heat Removal Service Water Pump D1 Cross-Tie to Emergency Equipment Cooling Water Valve (0-FCV-067-0048), was not maintained in a manner that ensured it would perform its design function. The failed valve was replaced on January 16, 2013, with a new valve with a stainless steel disk. Further corrective actions were planned to develop adequate preventive maintenance activities for this valve. The licensee entered this issue into their corrective action program as PER 671314. This finding was determined to be more than minor because it was associated with the Protection Against External Events (fires) attribute of the Mitigating Systems cornerstone objective and adversely affected the cornerstone objective to ensure availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences (i.e. core damage). Specifically, the 0-FCV-067-0048 valve failed and could not perform its isolation function credited in the safe shutdown analysis. Because the finding could not be screened as very low safety significance (Green), nor its safety significance determined prior to issuing the inspection report, it is being characterized as To Be Determined (TBD). The cause of this finding was directly related to the cross-cutting aspect of Appropriately Coordinating Work Activities in the Work Control component of the Human Performance area, because maintenance activities for 0-FCV-067-0048 were more reactive than preventive.
05000254/FIN-2012010-02Quad Cities2012Q4Questions Regarding Aging Management Inspections on the 16\\\' Diameter Discharge PipesAs part of the review of licensee Commitment Item 31, the inspectors identified an unresolved item (URI) related to a 16 foot diameter discharge piping. Specifically, the licensee does not physically inspect the piping for aging effects so that the intended functions of this component will be maintained during the period of extended operation. As part of the review of Commitment Item 31 associated with the Water Control Structures inspection program, the inspectors reviewed the components that are within the scope of this program and how effects of aging are managed. NUREG 1796; Safety Evaluation Report Related to the License Renewal of the Dresden Nuclear Power Station, Units 2 and 3 and Quad Cities Nuclear Power Station, Units 1 and 2; dated 2004, Section 3.5.2.3.4 RG 1.127, Inspection of Water-Control Structures Associated with Nuclear Power Plants described the scope of the program and how the effects of aging are managed. Page 3-426 of NUREG 1796 identified the 16 foot diameter discharge piping as an in-scope component. The 16 foot diameter discharge piping provides an Ultimate Heat Sink (UHS) function in that during a Lock and Dam No. 14 failure the discharge piping provides suction source for portable pumps to provide cooling water flow to the Residual Heat Removal Service Water (RHRSW) pumps and Diesel Generator Cooling Water (DGCW) Pumps. The licensee, however, does not physically inspect the discharge piping. The licensee provided aging management of the discharge piping by crediting the performance of a one-time inspection of a 96 inch diameter ice melt line. The ice melt line prevents freezing of the river water entering the plant intake and also performs a support function for the UHS. During this inspection, the licensee was unable to locate where the Office of Nuclear Reactor Regulation (NRR) had reviewed and approved this method of aging management of the discharge piping. In response to this concern, the licensee initiated Condition Report 01434957, (LR) Scoping Review Required for UHS Discharge Piping, dated November 2, 2012. Therefore, this issue is considered unresolved pending additional review of the information provided by the licensee and consultation with NRR to determine the appropriate aging management of the 16 foot diameter discharge piping.
05000321/FIN-2012008-03Hatch2012Q3Failure to Ensure Adequacy of Intake Structure Ventilation DesignThe team identified a non-cited violation of 10 CFR 50, Appendix B, Criterion III, Design Control, in that the licensee failed to verify or check the adequacy of the design of the intake structure ventilation support function for the plant service water and residual heat removal service water systems. Following the teams discovery, the licensee performed a bounding analysis and verified that the safety related components in the intake structure would not fail under the worst case high temperature conditions. The licensee entered the issue into their corrective action program as condition report 477809 to address the issue. The failure to verify the adequacy of intake structure ventilation design through calculational methods or through a suitable test program as required by 10 CFR 50, Appendix B, Criterion III, was a performance deficiency. The performance deficiency was more than minor because it affected the Mitigating Systems Cornerstone attribute of design control and adversely affected the cornerstone objective of ensuring the reliability, availability and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the licensee did not have adequate measures in place to ensure negative effects due to heat loading did not affect the reliability, availability, and capability of intake structure equipment. The inspectors used Inspection Manual Chapter 0609, Att. 4, Initial Characterization of Findings, for mitigating systems and Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, and determined the finding to be of very low safety significance (Green) because the finding was a design control deficiency issue that did not result in a loss of operability or functionality of the plant service water and residual heat removal service water systems. During the inspection, it was determined that there was adequate margin to preclude component failures when conservative heat loading and single failure criteria were assumed. No cross-cutting aspect was assigned to this finding because the failure to provide an adequate calculation or test is not indicative of current licensee performance due to the age of the heat load analysis.
05000259/FIN-2012003-01Browns Ferry2012Q2Failure to Maintain Flood Barrier Results in Inoperable Safety Related PumpsAn NRC-identified non-cited violation (NCV) of the Technical Specifications 5.4.1.a was identified for the licensees failure to maintain an Emergency Equipment Cooling Water (EECW) pump flood barrier in accordance with written procedures which resulted in the inoperability of two other safety related pumps. The licensee immediately restored the flood protection configuration of the C Residual Heat Removal Service Water (RHRSW) pump room by properly re-installing the flood protection cover and permanently stenciled the aluminum plate with the required procedure for installation. The licensee entered this issue into their corrective action program as PER 532050. The finding was more than minor because it was associated with the Mitigating Systems cornerstone attribute of Protection Against External Events, and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of RHRSW pumps to perform their intended safety function during a design basis flooding event. Specifically, the improper re-installation of an external flood protection cover resulted in the inoperability of two Residual Heat Removal Service Water (RHRSW) pumps. The significance of this finding was evaluated in accordance with the IMC 0609 Attachment 4, Phase 1- Initial Screening and Characterization of Findings, which required a Phase 3 analysis because the finding involved the degradation of equipment designed to mitigate a flooding event and it was risk significant due to external initiating event core damage sequences. The finding was determined to be Green because of the short exposure time, and the low likelihood of the flood. The cause of this finding was directly related to the cross cutting aspect of Supervisory Oversight in the Work Practices component of the Human Performance area, because of the foremans assumption that workers knew to restore the flood protection cover to meet procedural requirements without a formal pre-job brief (H.4(c)).
05000331/FIN-2012003-01Duane Arnold2012Q2Lack of Procedures for Monitoring the Performance of RHRSW Pump Motor Cooling CoilsThe inspectors identified a finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure to prescribe a procedure for activities affecting quality. Specifically, the licensee did not develop procedures for monitoring the thermal performance of the residual heat removal service water pump motor upper thrust bearing oil cooling coils. This finding was entered into the licensees corrective action program (CAP) to generate procedures to collect monitoring data and to correlate to design conditions. The performance deficiency was determined to be more than minor because it was associated with the procedure quality and 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. The finding screened as of very low safety significance (Green) because the finding was a qualification deficiency confirmed not to result in loss of operability or functionality. Specifically, the licensee performed a functionality evaluation and determined the most limiting cooler had sufficient margin. The inspectors determined that this finding had a cross-cutting aspect in the area of human performance because the licensee did not ensure supervisory and management oversight of work activities associated with the performance of residual heat removal service water pump motor cooler functional testing. Specifically, management did not ensure personnel developed procedures conforming to their Quality Assurance Program to be used when performing activities affecting quality.
05000324/FIN-2011005-01Brunswick2011Q4Failure to Verify Bearing Oil Level Resulted in Residual Heat Removal Service Water Pump FailureA self-revealing Green non-cited violation of TS 5.4.1, Procedures, was identified for failure to implement procedural requirements for verifying lubrication levels on the 2B RHRSW Booster pump. This finding resulted in failure of the 2B RHRSW Booster pump. The condition was entered into the licensee s corrective action program as AR #489386 and the licensee investigated the failure and repaired the pump. The failure to follow procedural requirements for verifying lubrication levels was a performance deficiency. The performance deficiency was more than minor because it was associated with the Mitigating Systems cornerstone attribute of Equipment Performance Availability, 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 failure of the 2B RHRSW booster pump which is credited for decay heat removal and service water injection. Using Inspection Manual Chapter 0609, Significance Determination Process, Attachment 0609.04, Phase 1 Screening Worksheet, the finding screened as potentially greater than green because it represented an actual loss of a single train of equipment for more than its Technical Specifications (TS) allowed outage time. Therefore, a phase 2 significance determination evaluation was required. Inspectors with assistance from a regional Senior Reactor Analyst (SRA) determined the significance of this finding to be very low safety significance (Green) using Phase 2 pre-solved tables. The cause of the finding was directly related to the training cross-cutting aspect in the Resources component of the Human Performance area because the licensee failed to ensure that workers had adequate knowledge of the RHRSW pump oilers to execute procedures for verifying lubrication levels which caused a failure of a safety-related pump.
05000331/FIN-2011004-01Duane Arnold2011Q3Degraded or Non-Conforming Conditions not Properly EvaluatedA finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified by the inspectors for the licensees failure on two occasions to follow procedure EN-AA-203-1001, Operability Determinations/Functionality Assessments, when degraded or non-conforming conditions were identified. Specifically, in one case, the duty Shift Manager incorrectly concluded that an immediate determination of operability for the Ultimate Heat Sink (UHS) was not applicable when a degraded wing dam condition was identified upstream of the intake structure. In another case, the duty Shift Manager incorrectly concluded that immediate determinations of operability for Residual Heat Removal (RHR) and Residual Heat Removal Service Water (RHRSW) thermal relief valves were not applicable when it was identified that several valves had not been tested in accordance with American Society of Mechanical Engineers (ASME) Code requirements. For each issue, the conclusions were contrary to the requirements of procedure EN-AA-203-1001 which requires all degraded or non-conforming conditions be evaluated under an immediate operability determination and prompt operability determination (POD) if warranted. The licensee entered the inspectors concerns into the Corrective Action Program (CAP) as Condition Report (CR) 01679373 and 01684521, for the UHS and RWS system, and RHR and RHRSW systems, respectively. The licensee performed PODs that determined the affected structures, systems, and components (SSCs) were operable but degraded or non-conforming pending restoration of the SSCs to full design and licensing basis qualification. The inspectors determined that the issues of concern represented a performance deficiency because they were the result of the licensees failure to meet a procedural requirement, and the cause was reasonably within the licensees ability to foresee and correct and should have been prevented. The performance deficiency was determined to be more than minor and a finding because, if left uncorrected, failing to properly assess the operability of degraded or non-conforming conditions would have the potential to lead to a more significant safety concern. The inspectors applied IMC 0609, Attachment 4, Phase 1 Initial Screening and Characterization of Findings, to this finding. Because the finding was a qualification deficiency confirmed not to result in loss of operability (Question 1 under the Mitigating Systems Cornerstone column of Table 4a), the finding screened as very low safety significance (Green). The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting aspect of Human Performance, having Decision-Making components, and involving the licensee making safety-significant decisions using a systematic process. Specifically, by deciding that systematic evaluations of operability were not required to assess the impact of the conditions on the design and licensing bases of the SSCs, the licensee did not ensure that the impact was clearly understood and whether compensatory measures were necessary.
05000298/FIN-2011004-07Cooper2011Q3Inadequate Procedure Results in Inoperable Essential PumpThe inspectors identified a noncited violation of 10 CFR Part 50, Appendix B, Criterion VII, Control of Purchased Material, Equipment, and Services, associated with the licensees failure to have adequate receipt inspection procedures to establish measures to assure that purchased material, equipment, and services conform to the procurement documents. Specifically, using the station procedure for the receipt inspection of the essential motor for the residual heat removal service water booster pump, the licensee failed to identify loose bearing cap bolting. The motor was subsequently installed in the plant for ten months before the degraded condition was identified. The licensee entered this issue into their corrective action program with CR CNS 2011-04643. Corrective actions resulted in revised receipt inspection requirements. The failure to have adequate receipt inspection procedures to establish measures to assure that purchased material, equipment, and services conform to procurement documents is a performance deficiency. The performance deficiency was more than minor because it adversely impacts 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 (i.e., core damage). Using Manual Chapter 0609, Attachment 4, Phase 1 - Initial Screening and Characterization of Findings, the finding screened as potentially risk significant since the finding represents an actual loss of safety function of a single train for greater than its Technical Specification allowed outage time. When evaluated per Manual Chapter 0609, Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations, and the Cooper Phase 2 pre-solved table item, One RHRSWBP, the inspectors determined this finding to be potentially risk significant. The finding was forwarded to a senior reactor analyst for review. The senior reactor analyst performed the Phase 3 analysis and determined that the finding was of very low safety significance. This finding did not have a cross-cutting aspect since the receipt inspection took place greater than three years ago and, therefore, the finding is not reflective of current performance.
05000271/FIN-2011002-01Vermont Yankee2011Q1Failure to Follow Foreign Material Exclusion ProcedureA self-revealing, non-cited violation (NCV) of very low safety significance (Green) of Technical Specifications 6.4, Procedures, was identified for inadequate implementation of Entergy procedure EN-MA-118, Foreign Material Exclusion, Revision 6, which resulted in foreign material intrusion into the Residual Heat Removal Service Water (RHRSW) system. Specifically, Entergy did not establish a Foreign Material Exclusion (FME) Zone 1 around the open RHRSW system between completing the closeout inspection and system closure following pump replacement. Entergy\'s immediate corrective actions included conducting a stand down, reinforcing the standards and requirements for FME controls and general procedural compliance, as well as reinforcing expectations for the attention to detail of work practices. Entergy entered the issue into their corrective action program to evaluate for additional corrective measures. The inspectors determined that the finding was more than minor because it was associated with the Equipment Performance attribute of the Mitigating Systems cornerstone, and affected the cornerstone objective to ensure the availability of systems that respond to initiating events to prevent undesirable consequences, (ie., core damage). Specifically, foreign material made its way into the \'A\' Residual Heat Removal Heat Exchanger (RHR HX) and rendered the \'A\' RHRSW train inoperable for several days. A review of NRC Inspection Manual Chapter (IMC) 0612, Appendix E, Minor Examples, revealed that no minor examples were applicable to this finding. The inspectors used IMC 0609.04, Phase 1 - Initial Screening and Characterization of Findings, and determined that the finding required a Phase 2 review because the \'A\' RHRSW train had an actual loss of safety function for greater than its allowed outage time (7 days). This finding was assessed using IMC 0609 and was determined to be of very low safety significance (Green) based on a Phase 2 analysis. The finding had a cross-cutting aspect in the Human Performance crosscutting area, Work Practices component, because Entergy personnel did not follow EN-MA- 118. Specifically, they did not establish a FME Zone 1 after the system closeout inspection. (H.4(b)
05000387/FIN-2010005-01Susquehanna2010Q4Failure to Adequately Evaluate Periods of Elevated Risk for Necessary Risk Management ActionsAn NRC-identified NCV of 10 CFR 50.65(a)(4) occurred when PPL failed to conduct an adequate risk assessment of online maintenance activities during the week of October 24, 2010. In one period of elevated risk on October 27, 2010, the entire duration in which valve functionality was affected was not appropriately accounted for in the risk assessment for work on the Residual Heat Removal Service Water (RHRSW) system. Though the maintenance window was calculated as Yellow risk, when the entire period of functionality was considered the duration of Yellow risk was extended from 9.5 to 12.5 hours. Additionally, on October 26, 2010, online risk was calculated as Yellow for a period of 13.5 hours due to work on the Residual Heat Removal (RHR) system. In neither of these cases was the protected equipment program implemented as a risk management action as required by station procedures. PPL entered these issues into their CAP as condition reports (CRs) 1318550 and 1318602. This finding affected the Human Performance attribute of the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The finding is more than minor because it is similar to example 7.e. in IMC 0612 Appendix E, Examples of Minor Issues, in that failure to perform an adequate risk assessment when required by 10 CFR 50.65 (a)(4) is not minor if the overall elevated plant risk would put the plant into a higher licensee established risk category or would require, under plant procedures, risk management actions (RMAs) or additional RMAs. In one case, plant risk was reclassified from Green to Yellow when the maintenance was properly modeled and in both cases the maintenance duration was in excess of the PPL established threshold requiring protected equipment as an RMA; therefore, the violation is more than minor. The inspectors evaluated the finding using IMC 0612, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process. Since the incremental core damage probability deficit was less than 1 E-6 and the incremental large early release probability deficit was less than 1 E-7, this finding is determined to be of very low safety significance (Green). This finding was determined to have a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program. Specifically, though PPL had recognized a negative trend, as well as the underlying weaknesses in the assessment of on-line risk; prior to this violation occurring they failed to take appropriate corrective actions to address the adverse trend in a timely manner, commensurate with the safety significance and complexity.
05000333/FIN-2010006-03FitzPatrick2010Q3Inadequate Corrective Action on RHRSW Strainer Housing Wall DegradationThe team identified a finding involving a non-cited violation of 10 CFR 50, Appendix 8, Criterion XVI, \"Corrective Actions,\" for failure to identify and correct a condition adverse to quality. Specifically, Entergy did not take corrective actions to evaluate the rate of identified degradation on the 1OS-581 residual heat removal service water (RHRSW) strainer casing. This resulted in a through wall leak in the strainer which was identified by the team. The team\'s review found that in 2006 Entergy had conducted ultrasonic test (UT) measurements of the strainer and determined that degradation was occurring. Corrective actions for the deficiency required that aUT examination be performed to monitor for further degradation but it was not performed. In response, Entergy entered the issue into the corrective action program, and conducted an UT examination at the leak location to determine the size and extent of the defect which determined that strainer\'s structural integrity was maintained. The finding is more than minor because it is associated with the equipment performance attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The team determined the finding was of very low safety significance (Green) because the finding was determined to be a qualification deficiency confirmed not to result in loss of operability. This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Corrective Action Program Component, because Entergy did not take appropriate corrective actions to address safety issues in a timely manner. Specifically, Entergy did not take action to determine the degradation rate of the 10S581 RHRSW strainer which resulted in a through wall leak.
05000324/FIN-2008005-02Brunswick2008Q4Failure to Take Prompt Corrective Actions for Low Oil Level in the 2B RHRSW Booster PumpThe inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action for failure to assure that a condition adverse to quality was promptly corrected, which resulted in the licensee declaring the 2B residual heat removal service water (RHRSW) booster pump inoperable while responding to the Unit 2 reactor scram on November 9, 2008. The licensee added oil to the bearing, restored the RHRSW to operable and entered the issue into the Corrective Action Program (CAP). The deficiency associated with this event is not promptly investigating and correcting the low oil level in the 2B RHRSW booster pump bearing. The finding is more than minor because it affects the Mitigating Systems Cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e. core damage). It is also associated with the cornerstone attribute of equipment availability and reliability. Since the finding affects both core damage frequency (CDF) and suppression pool cooling, an evaluation using NRC Inspection Manual Chapter (IMC) 0609, Appendix H, Containment Integrity Significance Determination Process was performed. Appendix H table 4.1 lists suppression pool cooling as a contributor to late containment failure, but not large, early release frequency (LERF). Therefore the change in CDF associated with the finding was used to characterize its significance. Using the NRC, pre-solved phase two significance determination process worksheets, the change in core damage frequency was found to be less than 1E-6, therefore this finding is of very low safety significance (Green). The cause of the finding is related to the cross-cutting aspect of thoroughly evaluating problems as described in the Corrective Action Program component of the Problem Identification and Correction cross-cutting area, since the low oil level was identified, but a thorough investigation of the problem was not promptly performed. (P.1(c)) (Section 4OA3
05000254/FIN-2008004-01Quad Cities2008Q32D Vault Door Work Order Instructions Not FollowedA self-revealing finding of very low safety significance and associated NCV of TS 5.4.1 was identified for failure to follow written work instructions resulting in a nonfunctional main control room alarm and degraded flood protection measures. Specifically, a contract electrician did not perform work instructions as written and lifted energized leads for the 2D residual heat removal service water (RHRSW) vault door limit switch without the appropriate work package documents as required by station procedures. This action resulted in an inoperable control room alarm that was not corrected for approximately three months. Further investigation revealed the licensee was performing a surveillance to verify the RHRSW vault doors closed once per day, contrary to the surveillance periodicity of once per shift credited in the licensees flood protection analysis. The failure to follow the credited once-per-shift surveillance in combination with the non-functional supplemental control room alarm resulted in degraded flood protection measures associated with the 2D RHRSW vault. This finding has a cross-cutting aspect in the area of Human Performance, Resources Component, Documentation Aspect because the licensee failed to provide enough detail in the work package to ensure that the control room alarm was verified as functional during the postmaintenance testing following completion of the work activity (H.2(c)). Corrective actions included repair of the limit switch and correction of the operator rounds to verify the vault doors closed each shift. The finding is determined to be more than minor because it is was associated with the Mitigating Systems Cornerstone attribute of external factors, flood hazard, and affects the cornerstone objective of ensuring the availability and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of findings, Table 4a for the Mitigating Systems cornerstone because the finding is associated with the operability and availability of the 2D train of the RHRSW mitigating system. The finding is of very low safety significance, Green, because the degraded flood protection measures did not result in the loss of operability or functionality of the 2D RHRSW system. (Section 1R06)
05000259/FIN-2008003-03Browns Ferry2008Q2Failure to Identify and Correct Deficiencies in Degraded Flood Protection DoorsThe NRC identified a Green non-cited violation of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to identify and correct deficiencies in watertight doors that protect the safety-related Residual Heat Removal Service Water pumps and Emergency Equipment Cooling Water pumps from external flooding. The licensee issued work orders to correct the conditions and entered the issue into their corrective action program as Problem Evaluation Reports 133891 and 134346. This finding was more than minor because it affects the External Factors (Flood Hazard) attribute of the Mitigating Systems Cornerstone. It impacted the cornerstone objective of ensuring the availability, reliability, and operability of safety-related pumps to perform their intended safety function during a design basis flooding event. A Significance Determination Process Phase 3 analysis determined that the finding was of very low safety significance because of the low likelihood of the design basis flood. The finding was directly related to the cross-cutting aspect of procedural compliance of the work control component of the cross-cutting area of Human Performance. Mechanics were not complying with quarterly work orders and maintenance procedure to assure functionally of the watertight doors (H.4(b))
05000321/FIN-2008002-01Hatch2008Q1Residual Heat Removal Service Water Hanger FailuresDuring a walkdown of the Unit 1 torus room, the licensee found two broken RHRSW supports (1E11-RHR-H98 and 1E11-RHR-H291). These discoveries were documented in CR2008101477 and CR2008101507, respectively. Additionally, Unit 1 Torus Room Penetration No. 25, RHRSW, was identified with linear indications in the weld area where each lug (four total) was welded to the wall sleeve facing, and documented in CR2008101702. CR2008101568 was created to provide an overall evaluation and apparent cause determination for all three previously mentioned condition reports. Both RHRSW flow control valves (one for each loop of RHRSW) were designed to control flow through the RHRSW system while minimizing downstream cavitation via a series of orifices. Design Change 93-019 modified the RHRSW flow control valves and was intended to insert a number of larger diameter orifices in the upper 1.0 of the orifices corresponding to 87% of valve stroke. The intent of the modification was to minimize the possibility of control valve clogging in the event that significant debris accumulated in the system (e.g. failed strainer). The actual modification drilled holes in the upper 1.5 of the orifices which corresponded to 81% of valve stroke. One consequence of the modification appears to have been a significant increase in cavitation downstream of the flow control valves when operated past the first 81% of their stroke with two RHRSW pumps operating. No changes in the RHRSW operating procedures were incorporated to minimize time spent in that portion of the operating envelope (two pump operation with valve stroke beyond 81%) that produced increased cavitation. This increased cavitation appears to have been a direct contributor to the failure of the RHRSW piping hangers (H98 and H291). Following discovery of the Unit 1 hanger failures, the licensee performed a VT-3 examination of all A and B loop RHRSW piping supports downstream of the RHR heat exchanger (which included the flow control valve). These exams revealed there were no additional failed supports. The licensee performed an operability determination and determined there were no past operability concerns. The licensee has instrumented the piping of concern and was operating within the bounds of ANSI/ASME OM3-1982, Requirements for Preoperational and Initial Start-up Vibration Testing of Nuclear Power Plant Piping Systems. Due to similar concerns for the Unit 2 RHRSW piping supports, the licensee issued CR2008102081 to perform a root cause evaluation. This issue is unresolved pending completion of the NRC review of the licensees Root Cause Evaluation, and the Hanger H98 and H291 Failure Analysis Report and is identified as URI 05000321/2008002-01, RHRSW Hanger Failures
05000321/FIN-2008002-03Hatch2008Q1Residual Heat Removal Service Water Vent Valve Weld FailureThe root cause for the 2E11FV001 Vent Valve weld failure was pending licensee approval. This URI is being opened to review the completed root cause
05000259/FIN-2007007-03Browns Ferry2007Q4Degraded Flood Protection Doors for the Intake Cooling StructureDuring system walkdown, the team observed degraded watertight doors at the intake cooling structure which houses the residual heat removal service water (RHRSW) and emergency equipment cooling water (EECW) pumps. Subsequent licensee evaluation of the four watertight doors determined that three of the four were degraded. With the doors closed, gaps up to 12 inch existed between the door seal and door frame. The licensee initiated work orders to repair the doors and initiated PER 133899. The UFSAR (Section 12.2.7.1.2) states in part that the doors provide flood protection against the probable maximum flood (PMF) of 572.5 feet. For the PMF, the licensee located a TVA corporate calculation (GEN-CEB-CDQ-0999-98-00-01) which states the PMF is 569.2 feet, not 572.5 feet. This item is unresolved pending the following: 1. The licensees acceptance of the 1998 calculation as their design basis for the PMF. 2. The inspectors review of the new design basis for the PMF. 3. Using the revised PMF, the inspectors review and inspection of the licensees evaluation of the potential impact of the degraded doors. This item is identified as URI 05000259/2007007-03, 05000260/2007007-03 and 05000296/2007007-03, Degraded Flood Protection Doors for the Intake Cooling Structure.
05000254/FIN-2007003-06Quad Cities2007Q2Review of Unit 1 4 kV Breaker FailuresOn May 7, 2007, the 1D residual heat removal pump breaker, a 4 kV Merlin Gerin AMHG model breaker, tripped open while operations personnel attempted to place the pump in service using QCOP 1000-10, Torus Water Transfer to the Main Condenser Via the Condensate Demineralizers. The licensee developed and implemented a detailed troubleshooting plan and was able to identify that the breaker cubicle mechanism operated cell switch linkage assembly cam follower rod length was slightly out of tolerance. This caused the attached cam follower to come in contact and apply a load to the breakers spring discharge roller. Strike marks (minor wear marks) were made on the cam follower due to contact with the breakers spring discharge roller. The spring discharge roller then applied a pre-load to the breakers trip paddle which made the breaker very susceptible to tripping during breaker movement. The licensees extent of condition review for Unit 1 included an inspection of all 48 4 kV Merlin Gerin AMHG model breaker cubicles before completion of the 2007 refueling outage. In addition, the licensee was in the process of implementing an inspection schedule for Unit 2 and had inspected 10 of the 47 4 kV breaker cubicles that contained the 4 kV Merlin Gerin AMHG model breakers by the conclusion of the inspection period. The inspectors noted that the licensee found strike marks on the 4 kV breaker cubicles cam followers for the Unit 12 emergency diesel generator feed to Bus 13-1, the 1A core spray pump, the 1B residual heat removal pump, the 1D residual heat removal service water, and the 1C condensate booster pump. Once identified, the licensee implemented a design change to remove a small portion (approximately 1/4 inch) of the cam follower in the location where strike marks were being found. This was implemented for cam followers in all breaker cubicles that had been inspected and for those that were to be inspected. The removal of the material will allow a larger gap between the cam follower and breakers spring discharge roller to add margin and prevent the breaker from tripping due to the physical contact between components. The inspectors consider the licensees corrective actions appropriate to prevent recurrence regarding this failure mode. At the conclusion of the inspection period, the inspectors had several unanswered questions regarding the causes of and contributors to the 4 kV Merlin Gerin breakers failure to remain in the closed condition. Based on the unanswered questions, the inspectors determined that this item should be unresolved pending review of the licensees final apparent cause evaluation report (URI 05000254/2007003-06; 05000265/2007003-06).
05000333/FIN-2000011-02FitzPatrick2000Q3Failure to Identify Conditions Adverse to QualityA Severity Level IV, Non-Cited Violation of 10CFR50, Appendix B, Criterion XVI, was identified associated with three examples of failure to promptly identify problems. Specifically, two opportunities were missed to identify a degraded condition with the safety related flow indication for the residual heat removal service water system (RHRSW); NYPA failed to identify conflicts between operating and surveillance test procedures for flow rate limitations; and NYPA failed to identify an adverse trend with the performance of core spray automatic start timers. These examples of promptly failing to identify conditions adverse to quality were determined to be more than minor because they indicated an adverse performance trend. The failure to promptly identify deficiencies was not subjected to a cornerstone significant determination process, and is, therefore, a no color finding in accordance with NRC Manual Chapter 0610*, Appendix E.
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