ML062980103
| ML062980103 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 10/23/2006 |
| From: | Bezilla M FirstEnergy Nuclear Operating Co |
| To: | Caldwell J Region 3 Administrator |
| References | |
| 1-1474, FOIA/PA-2010-0209 | |
| Download: ML062980103 (90) | |
Text
FENOC -
FirstEnergy Nuclear Operating Cmpany 550 I Ncrlh Stare Route 2 Oak Hxbor Ohio 43449 Mark B. Bezilla Vrce Presfdent Nuciear 4 19-32 1 - 7676 fay 419-327-7582 Docket Number 50-346 License Number NPF-3 Serial Number 1-1474 October 23,2006 Mr. James L. Caldwell, Administrator United States Nuclear Regulatory Commission, Region 111 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352
Subject:
Submittal of Independent Assessment Report of Corrective Action Program Implementation and Action Plan for the Davis-Besse Nuclear Power Station, Year 2006
Dear Mr. Caldwell:
The purpose of this letter is to submit the 2006 Corrective Action Program (CAP)
Implementation Independent Assessment Report and action plan for the Davis-Besse Nuclear Power Station (DBNPS). This submittal is in accordance with the Nuclear Regulatory Commission (NRC) letter, dated March 8, 2004, Approval to Restart the Davis-Besse Nuclear Power Station, Closure of Confirmatory Action Letter, and Issuance of Confirmatory Order.
The Assessment was conducted from August 14,2006 to August 25, 2006, in accordance with the CAP Implementation Assessment Plan submitted via DBNPS letter Serial Number 1-1462, dated May 15,2006. The final debrief marking the end of the assessment was conducted on September 11,2006. This submittal contains the results of the Independent Assessment and the action plan to address the Area For Improvement identified by the Assessment.
If you have any questions or require further information, please contact Mr. Clark A.
Price, Manager - Regulatory Compliance, at (419) 321-8585.
Sincerely yours,
- l Mark B. Bezilla JCS RECEIVED OCT 2 42006
Docket Number 50-346 License Number NPF-3 Serial Number 1-1 474 Page 2 of 2
Enclosures:
- 1) Commitment List
- 2) Independent Assessment of the Corrective Action Program Implementation at Davis-
- 3) Action Plan to Address Area For Improvement from the Independent Assessment of Besse Nuclear Power Station the Corrective Action Program Implementation at Davis-Besse Nuclear Power Station cc:
USNRC Document Control Desk DB-1 NRC/NRR Project Manager DB-1 NRC Senior Resident Inspector Utility Radiological Safety Board
Docket Number 50-346 License Number NPF-3 Serial Number 1-1474 Page 1 of 1 COMMITMENT LIST The following list identifies those actions committed to by FirstEnergy Nuclear Operating Companys (FENOC) Davis-Besse Nuclear Power Station (DBNPS) in this document. Any other actions discussed in the submittal represent intended or planned actions by the DBNPS. They are described only for information and are not regulatory commitments. Please notify the Manager - Regulatory Compliance at (419) 32 1-8585 with any questions regarding this document or associated regulatory commitments.
COMMITMENTS DUE DATE
- 1) Assign appropriate maintenance strategy template numbers February 28, 2007 to the population of functional locations (FLOC) currently covered by Preventive Maintenance (PM) tasks.
Implement Business Practice NOBP-ER-39 1 6, Component Health and Trending Reports. This business practice will prescribe:
a) The use of the Component Health and Trending (CHT) Module 16 of the Equipment Reliability (ER)
Workbench for the quarterly equipment trending Component Health and Trend (CHT) process; and b) Outline the process requirement to perform a review to identify changes to the component template if a negative trend is identified in the quarterly CHT.
February 28,2007
Docket Number 50-346 License Number NPF-3 Serial Number 1 - 1474 INDEPENDENT ASSESSMENT OF THE CORRECTIVE ACTION PROGRAM IMPLEMENTATION AT DAVIS-BESSE NUCLEAR POWER STATION (72 pages to follow)
COW-CAP-2006 Team Members:
TABLE OF CONTENTS -~
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..... 111 ACRONYMS......................................
EXECUTIVE
SUMMARY
v 1.O INTRODUCTION......................................................................................................
............ 1 2.0 SCOPE OF ASSESSMENT.............................................................................................................
1 2.1 2.2 2.3 2.4 2.5 2.6 Status of corrective Actions from the 2005 and 2004 Independent Assessments 2.1.1 2.1.2 of the Davis-Besse Corrective Action Program..................................................................
I Condition Reports from 2005 Independent Assessment.............................
. I Observations on Condition Reports from the 2004 Independent Assessment......................................................................................................
2.1.3 Summary.....................................................................................
Quality..................
Identification, Classification, and Categorization of Conditions Adverse to 2.2.1 Evaluation of Identification, Classification, and Categorization of 2.2.2 Interviews with Selected Davis-Besse Personnel.............................
14 8
Condition Reports Categorized as Conditions Adverse to Quality.......................
8 2.2.3 Evaluation of Operational Experience Feedback..
14 2.2.4 2.2.5 Summary....................................................
Evaluation and Resolution of Problems I6 2.3.1 Root Cause Evaluations............................................................
16 2.3.2 Apparent Cause Evaluations......
20 2.3.3 Review for Proper Identification.........................................................................
24 2.3.4 Summary......................................................................
...... 24 Corrective Action Implementation & Effectiveness..........................................................
25 2.4.1 Timeliness of Corrective Actions........................................................................
25 2.4.2 Review of Repeat Condition Reports.............................................................
2.4.3 Review of the activities of the Corrective Action Review Board 2.4.4 Summary.................................................................
Effectiveness of Program Trending.................................
2.5.1 Deficiencies Tracked in the Corrective Ac Evaluation of Implementation Problems and Prog (CARB)............................................................................................................... 30 33 2.5.2 Effectiveness of Corrective Action Trending Program.....
34 Effect of Program Backlogs.....................................
2.5.3 Summary 2.6.1 2.6.2 2.6.3 Summary 42 38 Program Backlog and Backlog Trend.......
Evaluation of the Impact of the Backlog and Backlog Trend Davis-Besse Nuclear Power Station Independent CAP Assessment Page COIA-CAP-2006, August 14 to August 25,2006 I
2.7 Effectiveness of Internal Assessment Activities....._.......
43 2.7.1 Evaluation of Davis-Besse OversightlAudit of the CAP....................................
43 2.7.2 Evaluation of the Davis-Besse Self-Assessment of the CAP..............................
44 2.7.3 Review of Safety Review Committee Activities..............._...
2.7.4 Summary........................................
Evaluation of Open Actions Taken in Response to NRC Special Team Inspection
- Corrective Action Program Implementation - Report 05000346/2003010..........,........ 50 2.8.1 Background.........................................................................................................
50 2.8.2 50
............ 52 2.8.3 Summary....................................................................................
2.8 Open Items....,............................
3.0 METHODOLOGY......................................
54 3.1 Assessment Methodology.........................................................................
3.2 Assessment Categories...............................................................
4.0 REFERENCES
............................................................. 56 4.1 Persons Interviewed during this Assessment.....................................................................
56 4.2 Condition Reports..............................................................................................................
58 4.3 Procedures.........................................................................................................................
62 4.4 Assessments...................................................................................................
.... 62 Davis-Besse Nuclear Power Station Independent CAP Assessment I Page ii COIA-CAP-2006, August 14 to August 25,2006
ACRONYMS ACE AF I AFW ANA BACC CA CAP CARB CAT1 cc CCA CF CNRB COIA CR CREST DBBP DH ECR EDG EOC EPRI EPZ ER FENOC HRA IN INPO 1P IPA LACE LCO MAOM MRFF MSSV M&TE CAQ Apparent Cause Evaluation Area for Improvement Auxiliary Feed Water Area in Need of Attention Boric acid corrosion control Corrective Action Corrective Action Program Condition Adverse to Quality Corrective Action Review Board Corrective Action Program Team Inspection Condition Adverse to Quality - Closed Common Cause Analysis Condition Adverse to Quality - Fix Company Nuclear Review Board Confirmatory Order Independent Assessment Condition Report Condition Report Evaluation and Status Tracking Davis-Besse Business Procedure Decay Heat Engineering Change Request Emergency Diesel Generator Extent of conditiodcause Electric Power Research Institute Emergency Preparedness Zone Effectiveness Review First Energy Nuclear Operating Company High-radiation area Information Notice Institute for Nuclear Power Operations Inspection Procedure (NRC)
Integrated Performance Assessment Limited Apparent Cause Evaluation Limiting Condition for Operation Management Alignment and Ownership Meeting Maintenance Rule Functional Failure Main Steam Safety Valve Maintenance and Test Equipment Davis-Besse Nuclear Power Station Independent CAP Assessment I iii COIA-CAP-2006, August 14 to August 25, 2006
NC NCAQ NF NOBP NOP NRC OE PCR PHC PI PM PR QA RA RCE RCP RCS RP RWP SAP SBODG SCAQ SER SLT SR TM TPCW TR TS USAR Not a Condition Adverse to Quality - Closed Not a Condition Adverse to Quality Not a Condition Adverse to Quality - Fix Nuclear Operations Business Practice Nuclear Operating Procedure U.S. Nuclear Regulatory Commission Operating Experience Procedure Change Request Plant Health Committee Performance Indicator/Performance Improvement Preventive Maintenance Preventive Action Quality Assurance Remedial Action Root Cause Evaluation Reactor Coolant Pump Reactor Coolant System Radiation Protection Radiation Work Permit Activity Tracking Database Station black-out diesel generator Significant Condition Adverse to Quality Significant Event Report Senior Leadership Team Significant Condition Adverse to Quality - Root Cause Temporary modification Turbine Plant Cooling Water (pump)
Technical Report Technical Specification Updated Safety Analysis Report Davis-Besse Nuclear Power Station Independent CAP Assessment I Page iv COIA-CAP-2006, August 14 to August 25, 2006
EXECUTIVE
SUMMARY
This is a report of the Independent Assessment of the Corrective Action Program (CAP) at the Davis-Besse Nuclear Power Station.
The assessment was conducted on-site during a two-week period in August 2006 by a team of three consultants and three peer evaluators.
Based on the definitions in Davis-Besse Business Plan procedure DBBP-VP-0009, Management Plan for Confirmatory Order Independent Assessments, the Team assigned Davis-Besses implementation of the CAP an overall rating of EFFECTIVE. This rating is based on interviews, document reviews, and observations.
The following summarizes the rating of each assessment area. Additional details arc found in the body of this report.
1 7
8 Review of Corrective Actions from 2004 and 2005 Independent Assessment of the Davis-Besse Corrective Action Program Identification, Classification, and Categorization of Condition Adverse to Quality Evaluation and Resolution of Problems Corrective Action Implementation and Effectiveness Effectiveness of Program Trending Effect of Program Backlogs Effectiveness of Internal Assessment Activities Evaluate any open CAS taken in response to the U.S. Nuclear Regulatory Commission (NRC) Special Team Inspection - Corrective Action Program Implementation Team Inspection - Report Number 0500034612003010
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Effective Highly Effective Effect i vc Effective E ffec ti vc Effecti vc E ffec ti ve Effective The Review of CAS From the 2004 and 2005 Assessments was rated as EFFECTIVE bccause thc Team determined that Davis-Besse made substantial progress on closing out most of these open issues which allows the 2006 Team to close most of the concerns. Remaining areas of concern include:
e A lack of attention to the completion of the backlog of old SCAQ corrective actions (CAS),
Implementation of a tracking and trending system for repeat events, Implementation of an equipment trending program, and CR evaluation quality and thoroughness (e.g. CR 05-00288 reactivity summary statement accuracy).
These areas of concern have been identified as Areas in Need of Attention in other sections of this report and remain open items in this section.
The only Area In Need of Attention identified for this section is the Teams determination that the evaluation for Condition Report CR 05-00288 was incomplete.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25,2006
The Identification. Classification, and Categorization of Conditions Adverse To Oualitv Was rated as HIGHLY EFFECTIVE because the Team found a commitment by all organizations to use the condition report (CR) process and an understanding by the supervisor level and above on how to properly categorize CRs. The use of a committee of four individuals to review all separate notification system (SAP) submittals demonstrates the stations strong commitment to accuracy in categorizing CAS and SAP Notifications. The Team saw no evidence where organizations were not initiating CRs. In interviews with Davis-Besse and First Energy Nuclear Operating Company (FENOC) personnel, this was not cited as a current issue. Additionally, the Team noted a strong commitment to submitting Operating Experience (OE) items to the Institute for Nuclear Power Operations (INPO) in a timely fashion. However, the Team did identify some delays in the internal review of incoming OEs by the Davis-Besse staff as an Area in Need of Attention.
The Evaluation and Resolution of Problems was rated as EFFECTIVE because the Team found the Davis-Besse organization demonstrated a good understanding of the CAP and willingness to accept, investigate, and resolve CAQs. The Team identified an Area in Need of Attention in CR evaluation quality, thoroughness, and documentation with the following examples identified:
The Team determined that the documentation for CR 06-00 154 - Loose Parts in Diesel Generator -
could be enhanced by including all of the investigation performed by the Davis-Besse staff.
rn For CR 05-05559, the Team determined that the deferral of extent of conditiodcause (EOC) review to a CA after Corrective Action Review Board (CARB) approval of the Root Cause Evaluation (RCE) without requiring this CA to return to CARB for closure was a missed opportunity for CAKB to verify completion of the RCE of this event.
The Team concluded that the investigation analysis for CR 06-00583 could have been enhanced. The one-time training used for the CA was classified as preventive yet there was no indication that the training would be institutionalized for the future.
For CR 06-01503, the Team determined that the investigation analysis was weak. The investigation of an adverse trend stopped short in looking for common areas that can be improved and instead provided justification of why there is no problem.
The Corrective Action Implementation and Effectiveness was rated as EFFECTIVE because the Team determined that the Management Alignment and Ownership Meeting (MAOM), CR review meeting, and CARB meeting provided an effective review of new key issues and provided confirmation of priority and responsibility for follow-up. The Team also noted some Areas in Need of Attention.
These areas arc the following:
The list of Significant Condition Adverse to Quality (SCAQ) items open over 135 days was an Area in Need of Attention in order to assure that corrective actions (especially preventive and remedial) are receiving the proper priority and attention by the plant staff and managers.
The Team determined that the identification of repeat occurrence was dependent on the memories of individuals involved in the CR process, rather than being retrievable from the CR database. The lack of a clear definition of what was a repeat occurrence and the reliance on staff recollection for repeat issues may limit the ability to establish the effectiveness of the CAP over an extended time period.
The 2006 Team noted this is an Area in Need of Attention.
Condition Report CR 06-02558 had no root cause identified, no extent of condition or extent of cause pursuit; CR 05-05559 on the Boric Acid Pumps was approved without adequate extent of condition Davis-Besse Nuclear Power Station Independent CAP Assessment Page vi COIA-CAP-2006, August 14 to August 25,2006 I
review. These CRs are additional examples of the Area in Need of Attention in CR evaluation quality, thoroughness, and documentation, including CARB review.
The closure of CR 05-05395 with only two thirds of the required training of the designated audience was an Area in Need of Attention.
0 The Team determined that the timeliness of completion for CR 05-00738 (reactor trip breaker fuses) did not preclude additional CRs (06-00928, and 06-01 590).
The Effectiveness of Program Tending was rated as EFFECTIVE because. with the exception of equipment trending, the overall trending program has undergone significant programmatic improvements since the last evaluation. These improvements were based on industry benchmarking and a cultural shift towards line ownership of the Trending program. Many of these improvements had a short track record and as such, need time to evaluate their effectiveness. Additionally, there are further changes currently underway (e.g. converting the CAP database from Condition Report Evaluation and Status Tracking (CREST) to SAP) that may enhance these improvements, or could detract from the progress made. The much improved IPA process was considered an Area of Strength.
During interviews with Davis-Besse personnel the staff was unable to provide information on how the implementation of these labor-intensive trending programs had benefited the station. The Team suggests that Davis-Besse do more to demonstrate the success of the trending program. This will enhancc individual commitment and line ownership of the trending programs.
Open SAP issues contain actions requiring station resources and therefore the inclusion of these items in the IPA is an Area in Need of Attention.
The lack of cognitive binning by many departments during the refueling outage may be indicativc of a lack of focus on trending and its ability to identify long term problems. This is an Area in Need of Attention.
The trending of equipment problems across systems continues to be an Area For Improvement. This is a continuation of the same issue identified during the 2004 and 2005 Assessments. FENOC has developed a draft procedure NOBP-ER-3916 Component Health Trending Reports which, when implemented. may assist FENOC with the identification of common component problems for all four nuclear plants in the FENOC system. The Team determined that this proposed new trending program has the potential to be an excellent tool but this issue remains an unresolved item for this report.
The Effect of Program Backlops was rated as EFFECTIVE because the backlog of open items at Davis-Besse was larger than industrial norms however it received a high level of management attention and was being monitored for its impact on plant safety and operability. While the quantity of open items was going down, the average age was increasing. Few resources were planned to be directed toward backlog reduction until all work packages for 1 5Ih refueling outage were completed. Progress in reduction of the backlog still needs aggressive attention to continue to improve, especially for calculations, procedures, and drawings. This remains an Area in Need of Attention.
The Effectiveness of Internal Assessment Activities was rated as EFFECTIVE because thc Team determined the management support of, and involvement in, the self-assessment process was a positil-c reinforcement of the performance improvement culture. While some internal assessments were not considered to be self critical enough, the overall site evaluations demonstrate Davis-Besses willingness to improve upon past performance. The Team identified additional examples of the Areas in Need of Attention in CR evaluation quality, thoroughness, and documentation.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page vii COIA-CAP-2006, August 14 to August 25,2006 I
The Radiation Protection (RP) group was not self-critical enough in response to two oversight observations of adverse trends in personnel contaminations (CR 06-01503) and incorrect HRA entry (CR 06-01697).
Documentation of CAP follow-up to CNRB findings regarding copper oxide in containment did not include all documentation from the multiple Problem Solving and lndependent Problem teams, which would have improved the CR documentation.
Documentation of CAP follow-up to a clogged radiation detector (CR 05-04988) did not support an independent review reaching the conclusion that the CAP resolution of the issues was satisfactory. No discussion of extent of condition or counseling of maintenance staff in using unauthorized materials was included in the CA.
The Evaluation of Open Corrective Actions from CAT1 Report was rated as EFFECTIVE because the Team evaluated that Davis-Besse had taken action in response to the 2005 Area in Need of Attention.
Although the licensee had indicated in 2005 that, for the most part, it was likely that no further action would be taken on many items since they were considered enhancements and not necessarily required actions, a re-review indicated that certain actions were deemed appropriate since they were associated with U.S. Nuclear Regulatory Commission (NRC) non-cited violations. Davis-Besse conducted a review of the Corrective Action Program Team Inspection (CAT1)-related open corrective action items and their regulatory significance as well as to assure that resources were assigned and due dates established to be completed by the end of 2006.
The 2006 Team determined that, in some cases, it may have been more efficient to revise the procedure vs. creating all the analysis and tracking records in the SAP.
It appears that the conversion of many actions from the CREST data base into the SAP Activity tracking system is an Area in Need of Attention. This was not solely for CATI items but was reinforced by CATI corrective action follow-up. The Team did not conclude this due to any specific immediate safety condition but due to several factors:
The licensee staff was already adding increased attention by providing several resources each day to reviewing the transition of actions from CREST to SAP, The Confirmatory Order Independent Assessment (COIA) Team had difficulty in implementing the COlA Plan when evaluating whether proper actions had been implemented and finding that the CR had been closed with no actual action other than to fill out additional documents to track the actions in another system, and Several licensee staff stated during interviews that the SAP system was not user friendly and that they had difficulty using the system.
OVERALL CONCLUSION The Team assigned Davis-Besse an Overall Rating of EFFECTIVE.
Davis-Besse Nuclear Power Station lndependent CAP Assessment Page viii COIA-CAP-2006, August 14 to August 25, 2006 I
I
.O INTRODUCTION This Independent Assessment of the Davis-Besse Corrective Action Program (CAP) (COIA-CAP-2006) was conducted at the request of the Vice President, Fleet Oversight. The Team used the general guidance of NOBP-LP-200 1, FENOC Focused Self-Assessment/Benchmarking; NRC Inspection Procedure IP 7 1 152, Identification Resolution of Problems, NRC IP 40500, Effectiveness of Licensee Process to Identify, Resolve, and Prevent Problems; Nuclear Operating Procedure NOP-LP-2001, Corrective Action Program, and DBBP-LP-0009, Management Plan for Confirmatory Order Independent Assessment, to evaluate the effectiveness of the implementation of the CAP.
2.0 SCOPE OF ASSESSMENT The Team evaluated the following areas associated with the Corrective Action Program (CAP) implementation:
1.
- 2.
- 3.
- 4.
5.
- 6.
- 7.
- 8.
Review of Corrective Actions (CAS) from the 2004 and 2005 Independent Assessments of the Davis-Besse CAP.
Identification, Classification, and Categorization of Condition Adverse to Quality (CAQ).
Evaluation and Resolution of Problems.
Corrective Action Implementation and Effectiveness.
Effectiveness of Program Trending.
Effect of Program Backlogs.
Effectiveness of Internal Assessment Activities.
Evaluate open CAS taken in response to the U.S. Nuclear Regulatory Commission (NRC) Special Team Inspection - Corrective Action Program Implementation Team Inspection (CATI) - Report Number 05000346/20030 10.
2.1 Status of Corrective Actions from the 2005 and 2004 Independent Assessments of the Davis-Besse Corrective Action Program The Team reviewed the CAS proposed and taken in response to Areas in Need of Attention (ANAs) and Areas For Improvement (AFIs) identified during either the 2004 or 2005 Independent Assessment of thc Davis-Besse CAP. The Team evaluated the CAS for strengths, weaknesses, or slow responses. The following are the observations of the Team for each CR developed in response to the 2004 and 2005 Assessment.
2.1.I Condition Reports from 2005 Independent Assessment The Team evaluated the actions taken to address the observations made in the 2005 assessment. Thc following are the Teams comments Davis-Besse Nuclear Power Station Independent CAP Assessment 1 Page,
COIA-CAP-2006, August 14 to August 25,2006
CR 05-03842 COIA-CAP-2005: CR 04-06498 SCAQ Preventive Action Verification This CR was written to follow-up on a condition where a significant preventive corrective action had been completed and verified by the same individual, a condition which was prohibited by the proccdurc.
The Team determined that the site follow-up was appropriate, especially since this was not detcrmincd to be a frequent occurrence, (Le., it was an isolated case).
CR 05-03845 The 2005 Team identified that CR 05-00239, Corrective Action #1, requested that the event be evaluated for potential Maintenance Rule Functional Failure (MRFF) and if found to be a Functional Failure, then upgrade the CR to at least an Apparent Cause. The corrective action response identified the event as a Functional Failure but the CR was not upgraded and was evaluated as a Fix.
COIA-CAP-2005: CR Determined to be a MRFF Not Upgraded to Apparent Cause Davis-Besse staff reopened the CR, determined it to be a MRFF, and performed an Apparent Cause Evaluation (ACE). Additionally, an extent of condition review was performed which concluded that this was an isolated instance in the previous 2 years.
The 2006 Team found this resolution satisfactory.
CR 05-03961 COIA-CAP-2005: CR 04-06498 Root Cause Evaluation Observations CK 04-06498 involved a boric acid heat trace Technical Specification surveillance commission. The 7005 Tcam identified that the evaluation for this CR had several weaknesses that were not addresscd by the evaluator, the reviewer. or the Corrective Action Review Board (CARB). The Team requested that Davis-Bcsse re-review this event and consider appropriate lessons-lcarned. Davis-Besse re-evaluated the CR deficiencies, appended the original CR with their review, and provided lessons-learned training to the CR analyst, approver, and CARB. The original evaluator was no longer with the company. The 2006 Team found this disposition to be acceptable.
CR 05-04407 COIA-CAP-2005: CR Evaluation and Corrective Action Completion Timeliness; CR 05-04409 COIA-CAP-2005: Age of SCAQ/CAQ Preventive 8 Remedial Actions The 2005 Team assigned an AFI regarding the timeliness of root and ACEs, and the overall timclincss of completing CAS. Davis-Besse initially implemented an integrated backlog reduction plan and after reducing the backlog to some extent, the concentration has shifted to a weekly monitoringifocus at the Management Alignment and Ownership Meeting (MAOM). As of the week of 14 August 2006, the report indicated the following:
0 0
1 open Root Cause Evaluation - 45 days old under re-write for oversight/QA comments.
3 root or apparent cause evaluations being re-written to address CARB comments.
No open ACE reports overdue.
2 1 ACEs in progress meeting expectations.
2 CF reviews exceeding 45 day guideline.
23 open Significant Condition Adverse to Quality (SCAQ) CAS.
o C) 21 of which were greater than 135 day guideline (oldest was 1,3 15 days old).
2 actions with due dates assigned that were greater than 135 days.
The station revised the CAP performance indicators by removing the aging of-issues as an indicator. Thc station took the action to monitor and discuss the individual items not meeting expectations via an aggregate aging indicator. The peer perspective was that assessing aging performance over time (as was the past practice) can add additional performance improvement recognition (either improving or Davis-Besse Nuclear Power Station Independent CAP Assessment 1 Page COIA-CAP-2006, August 14 to August 25,2006
declining). This type of trending was no longer being performed by the site. The 2006 Team recognized the significant improvement in the timeliness of CR evaluations. That aspect of this concern was closed.
The progress made in reducing the numerical backlog of CAS was noted, but as discussed in Section 2.6 of this report, the continued presence of many backlogged and aging CAS creates the appearance of ineffectiveness and may be causing inefficiencies sourced in managing and prioritizing this backlog. The Team determined that more progress in completing the backlog of old SCAQ CAS is needed to close this concern. The 2006 Team has identified this as an Area in Need of Attention in Section 2.6.
CR 05-04408 The 2005 Team concluded that the site was frequently achieving the basic intent of determining the root causes of events and conditions but a significant number of condition report (CR) cause evaluations were too narrow or otherwise inadequate. In general, adequate tools were being used but the narrowness led to certain condition reports with limited CAS.
COIA-CAP-2005: CR Root Cause & Apparent Cause Evaluations Inadequate Davis-Besse initiated a team chaired by the fleet cause analysis specialist to rcvicw the 2005 COlA report as well as all the deficient root causes and apparent causes noted. Davis-Besse addressed the 2005 Team comments for each of the CRs identified and presented the result to CARB for approval.
The Davis-Besse Team also benchmarked 12 procedures from other facilities to evaluate the adequacy of their own procedures. Results of this review concluded that the Davis-Besse procedure was consistent with the industry. A FLEET self-assessment (FL-SA-05-14) was conducted to review 29 RCEs for all three First Energy Nuclear Operating Company (FENOC) sites. The evaluations were graded from 35-99 with a mean grade of 69 on a scale of 100.
As a result of these efforts, Davis-Besse determined that lessons-learned training was needed on better formation of problem statements, the use of the why staircase, and extent of conditiodcausc evaluations. Training was proposed for root cause evaluators, apparent cause evaluators, CR analysts, and CARB members. The CA for the training associated with this CR was closed in December 2005 after performing two training sessions which resulted in approximately 67% attendance. The implementation documentation states that an e-mail with training materials attached was sent to those staff members not in attendance.
The 2006 Team reviewed Davis-Besses disposition of the 2005 COlA and identified evaluation problems. Those dispositions were generally acceptable in view of the generic weaknesses and corrective actions taken by Davis-Besse in this area. During the review of follow-up actions to CR 05-00288, Decrease in T-AVG Below Technical Specification (TS) Limit, the Team noted that Davis-Bcssc added a formal statement addressing the criticality condition of the reactor on 1/17/05. I t was not clear to thc Team that this reactivity summary statement had correctly evaluated the core criticality conditions during the withdrawal of control rods as discussed during the 2005 COlA assessment report. It appeared that thc Davis-Besse review was still focusing on the power level at which criticality was normally dcterrnined on a startup, versus whether or not the reactor was critical or subcritical (ix., negative startup rate in the intermediate range) during the control rod withdrawals.
The Team determined that Davis Besse had adequately responded to the overall concern with the depth and uniformity of cause evaluations. The accuracy of the reactivity summary statement in CR 05-00288 should be addressed and is an additional example of the Area in Need of Attention in CR evaluation quality, thoroughness, and documentation described in Section 2.3 of this report..
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25.2006
CR 05-0441 1 COIA-CAP-2005: Equipment Trending Below Industry Standards This CR was written to address the equipment trending issue identified as an AFJ in Section 2.5 of the 2005 CAP Independent Assessment. The 2005 Team identified the lack of a program for trending component failures to aid in the identification of common component failures. The CR resulted in the generation of six CAS. As of August 25,2006, only two have been closed. The CR investigation recommended that Davis-Besse perfonn benchmarking at other nuclear sites that have been identified as industry leaders. Information from the benchmarking could be used to revise Davis-Besse procedures and practices as appropriate.
The 2006 Team determined that equipment performance trending has made some progress since the last assessment but still lags the industry standards. FENOC is in the process of developing a computerized system to trend component health but, as the system is not yet operational, its performance cannot be evaluated as part of this Assessment.
The 2006 Team reviewed the Plant Health Reports for both the first and second quarters of2006. The Team found that the Plant Health Report monitors CAS in each system but does not monitor or trcnd CRs.
Thc CAS identify what work is required while the CRs provide the "WHY" behind the required work.
Other nuclear facilities have determined that trending the CRs provides a better assessment of thc plant health. While Davis-Besse continues to move toward implementing an effective equipment trending program, they have not made sufficient progress in this area for the Team to close this concern. This item remains open for this section and is considered an Area For Improvement in Section 2.5 of this report.
CR 05-04769 The 2005 Team recommended that the following CRs be reassessed for the following reasons:
COIA-CAP-2005: CR CategorizationlEvaluation Weaknesses rn rn rn CR 05-00239 - The Team determined an Apparent Cause should have been completed.
CR 05-00260 - The Team determined an Apparent Cause should have been completed.
CR 05-00288 - The Team determined a Root Cause should have been completed.
CR 04-07601 - The Team determined an Apparent Cause should have been completed.
CR 05-00016 - The Team determined that the CR was closed before the action was completed.
CR 05-00583 - The Team determined that the problem description was incomplete.
Davis-Besse staff reviewed the identified CRs and determined the following:
CR 05-00239 - Davis-Besse determined that the CR was a Maintenance Rule Functional Failure and, as such, required an Apparent Cause. An Apparent Cause was completed.
CR 05-00260 - No change necessary CR 05-00288 - No change necessary.
CR 04-07601 - No change necessary.
CR 05-0001 6 - Revised CR implementation to indicate that individual was referred to management for appropriate action.
CR 05-00583 - No change necessary.
The staff review and CR was evaluated by the CARB and accepted on November 2,2005.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page COIA-CAP-2006, August 14 to August 25,2006 I
The 2006 Assessment Team considers this action closed (with the exception of CR 05-04408 and CR 05-00288 above).
CR 05-04770 The 2005 Team determined that the identification of repeat problems was dependent on the collective memory of individuals involved in the CAP. There was no direct method to trend repeat events in the Condition Report Evaluation and Status Tracking (CREST) database. Because of the pending transfer of CREST to the separate notification system (SAP), FENOC is not making enhancements to CREST. A SAP notification was issued to track the need for the new SAP-based CAP database to address this issue. This SAP item has a 2008 implementation date. The 2006 Team reviewed the repeat events since the last assessment as discussed in Section 2.4 of this report. Based on the limited site trending information and low priority of the FENOC response to this issue, the Team determined that this area should be revisited in subsequent assessments. The identification and tracking of repeat conccrns is considered an Area in Need of Attention in Section 2.4 of this report.
COIA-CAP-2005: Repeat Event Guidance Weakness CR 05-04771 COIA-CAP-2005: CR-CA Backlog Potential Effect on Effectiveness The 2005 COIA Team concluded that the CR backlog remained at a significant level presenting a continuing challenge to site personnel. In addition, the open NRC CAT1 inspection items had a very low priority and had not been considered as needing corrective action by many station staff since they were considered enhancements. The 2005 Team was concerned that the open CAT1 items should bc rc-reviewed by the licensee and action taken to either schedule them for completion or provide a basis for no action.
Ilavis-Besse implemented a review of SCAQ and CAQ root and apparent cause CAS with the intcnt to disposition the proper action type and completion priority. Additionally thc Design Engineering and Regulatory Compliance groups were designated to make a concerted re-review of NRC CAT1 itcms for completion.
The 2006 Team determined that Davis-Besse had conducted a re-review of the NRC report for non-cited and cited violations and provided a report with the status of each open item as of the end of 7005. The Engineering Director had reviewed this corrective action status and, in interviews, indicated the station goal remained to complete resolution by December, 2006. For the details of this 2006 Team rcvicw ofthc open CAT1 items, see report in section 2.8 of this report.
The Team noted that Davis-Besse has established two key methods to focus on backlog: (1) adding a list to the Monday Management Alignment and Ownership Meeting (MAOM) of all SCAQ items open over 135 days and a numerical listing and bar chart in the Friday meeting package of the open site backlog documents (actions requiring work). The Team attended the morning management meeting on August 2 1, 2006 and determined that the station review of the Open SCAQ Corrective Actions Over 135 Days of Projected Over 135 Days was not effective since several CAS were several years old and there was essentially no discussion of them during the meeting (see also the discussion in Section 2.4 of this report).
The Team concluded that the review and elimination of these old SCAQ action items remains an opcn item in this section of the report and has been identified as an Area in Need of Attention in Section 2.6.
CR 05-04773 The 2005 Team identified that the CA for implementation of the Integrated Backlog Reduction Program did not have clearly defined metrics from which to determine when this CA has been completcd. Davis-Besse revised this CA to state that the item can be completed when the normalized ongoing backlog is bctwccn 4,500 and 6,500 items. This metric was achieved and the CA was closed on 313 1/06.
COIA-CAP-2005: Lack of Smarter Corrective Action Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25,2006
As discussed in Section 2.6 of this report, more stringent goals have been set and are being monitored by management. The 2006 Team found this disposition acceptable. However, the 2006 Team learned that the station has placed top priority on preparing for the 15Ih refueling outage and some Sections have very few to no plans for allocating resources to backlog reduction until all outage preparation activities are completed. The Team can understand the logic of Davis-Besse placing high priority on outage related preparations; however, the lack of any significant effort to reduce long-term backlog can have adverse impact on future operations.
The Team concluded that the lack of a continuous focus on the reduction of station backlog remains an open item in this section and has been identified as an Area in Need of Attention in Scction 2.6 of this report.
CR 05-04774 The 2005 Team concluded that the site was frequently achieving the basic intent of determining the root causes of events and conditions; however, since the majority of cause evaluations reviewed had deficiencies, it appeared that continued management attention was warranted to continue improL ing performance. Most of the individual CR re-evaluation and programmatic aspects of this concern are discussed under CR 05-04408 above. This condition was classified as CF and focuses narrowly on the generic implications for apparent cause evaluators who would not receive training under CR 05-04408.
The one CA associated with this CR involved lessons-learned training for apparent cause evaluators. This CA was closed on 12/12/05 after performing two training sessions which resulted in approximately 67%
attendance. The closure documentation states that an e-mail with training materials attached was sent to the individuals that did not attend. The 2006 Team found the overall response to this CR acceptable. One concern regarding the effectiveness of closure based on partial completion of training and an email of materials to the remainder is discussed in Section 2.4 of this report (CR 05-05395).
COIA-CAP-2005: CR Evaluation Weaknesses 2.1.2 Observations on Condition Reports from the 2004 Independent Assessment The 2006 Team evaluated the responses to CRs generated in response to the 2004 lndepcndcnt Assessmcnt Team that arc still open or were closed after July 3 1, 2005. Below. arc the CRs reviewed by the 2006 Team.
CR 04-05920 COIA-OPS: Cause Determination This CR identified a deficiency in the review and cause determination for Opcrations CR evaluations.
This CR recommended that the cause determination evaluation should include the five WHYS. The investigation stated that the Apparent Cause evaluators are trained in the why staircase and did not recommend training revisions. One CA directed the CARB to review thc samc Operations CRs evaluated by the 2004 Assessment Team and address unresolved comments. This CA was closed on October 29.
2004. Another CA directed the CARB to review ACEs from operations for a period of one year. This CA was completed on 10/17/05.
The Team determined that the CARB has demonstrated good attention to detail during its review of the Operations ACEs.
CR 04-0601 I COIA-CAP-2004: Corrective Action Timeliness Questioned (AFI)
This CR was initiated to resolve a 2004 Team AFI on the negative impact of large CAP backlogs. This CR was reviewed by the 2005 Team, resulting in a repeat MI. CRs 05-04407,04409,0477 1, and 04773 above also address this issue. Davis-Besse developed an integrated backlog reduction program, set and Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25,2006
achieved goals for backlog reduction, and transitioned to a normal management focus for continuing the reduction effort to aggressive corporate-wide goals. This CR was closed on 4/12/06.
The 2006 Team determined that the CR closure was acceptable. The original backlog goals were achieved and continued backlog reduction has occurred despite an increase in the quantity of CAQ CRs initiated in 2006 as compared to 2005. This demonstrates a station commitment to backlog reduction. Team concern over the closure of the oldest open CAS is tracked by CR 05-0477 1. This item is closed.
CR 04-0601 7 COIA-CAP-2004: Unsatisfactory Corrective Action Program Trending This CR was written to address the deficiencies in trending identified by the initial CAP Assessment. This CR had three CAS associated with it, and all three have been closed. This CR was closed 1 i3 1 :05.
The 2006 Assessment Team noted that the site continues to have challenges in tracking and trcnding equipment problems via the CAP, however, the Integrated Pcrformance Assessments (IPAs) prepared by each section, and rolled up to site and fleet reviews has matured. The IPAs appear to be a valuable tool for monitoring section overall performance. The reports identify section issues and CRs are initiated to resolve the issues. The CRs then contain evaluations for the adverse issues and the actions to address same are tracked via the condition reporting process. The lPAs also discuss the results of actions pcrformcd in the previous IPA. Though this process is relatively new (only three semi-annual IPA reports 10 date), each sequential assessment has, for most departments, been a step improvement in value addcd.
The Team is tracking equipment trending issues under CR 05-0441 1 and considers this item closed.
CR 04-06023 This CR was generated after the 2004 Team found that the definition of Repeat Events used in Davis-Besses CAP Performance Indicators (Pls) is too limited. Both the 2004 and 2005 Teams proposed the development of performance indicators to trend a broader definition of repeat events.
COIA-CAP-2004: CAP Performance Indicators Improvements Although this CR was closed October 12,2005 (based on new metrics created in August 2005),
interviews with Davis-Besse staff indicated that the site has decided that repeat occurrences would not be trended as a primary indicator. Instead, a roll-up of the cognitive binning performed as part of the IPAs would provide analysis of common causes.
Thc 2006 Team reviewed a draft of a recent common cause roll-up report for root cause. The draft was dated July 2006 but has not yet been issued for in-house revicw. Davis-Besse intends to gcneratc multiple CRs for new issues identified in this common cause review report. The Team observed that the value of trending can be diminished when the response actions are delayed.
The 2006 Team concluded that trending repeat events (particularly those that exceed the frequency of IPA binning cycles) is an industry standard indicator of CAP effectiveness that deserves consideration by Davis-Besse. Follow-up of repeat events during this assessment period is discussed in Section 2.5 bclow.
Thc Team is tracking trending of repeat issues under CR 05-04770 and considers this item closed.
2.1.3 Summary The Assessment Team reviewed the CAS proposed and taken in response to the ANAs and AFls identified during both the 2004 and 2005 Independent Assessments of the Davis-Bessc CAP. Davis-Bcssc made substantial progress on these open issues allowing the Team to close most of the concerns.
Remaining areas of concern include:
A lack of attention to the completion of the backlog of old SCAQ CAS, Implementation of a tracking and trending system for repeat events, and Davis-Besse Nuclear Power Station Independent CAP Assessment Page COIA-CAP-2006, August 14 to August 25,2006 I
e Implementation of an equipment trending program, and CR evaluation quality, and thoroughness (CR 05-00288 for example).
These areas of concern have been identified as ANAs in other sections of this report and remain opcn items in this section.
Areas of Strength None.
Areas in Need of Attention Records of reactivity conditions during the January 2005 plant shutdown event addressed in CR 05-00288 continue to appear inaccurate. CR re-evaluation did not detect and correct records of sub-critical conditions during control rod withdrawals.
Areas for Improvement None.
Conclusion The Team rated the status of CAs from the 2004 and 2005 Assessments as EFFECTIVE.
2.2 The 2006 Assessment Team performed a review of activities to assess the effectiveness of thc identification, classification, and categorization of CAQs such as:
Identification, Classification, and Categorization of Conditions Adverse to Quality Evaluate the actual identification, classification, and categorization of at least 25 selected CRs categorized as CAQs.
Through interviews with a selected sample of at least ten individuals from various parts of the Davis-Besse Nuclear Power Stations staff, ascertain the Davis-Besse Nuclear Power Station staffs and managements commitment to the CAP, the extent of their understanding of the Davis-Besse Nuclear Power Stations problem identification process, and their willingness to report problems.
Evaluate the adequacy of the Davis-Besse Nuclear Power Stations identification, classification, and categorization of a minimum of 20 CAQs CAS for operational experience feedback.
Evaluate the Davis-Besse Nuclear Power Stations CAP for broad implementation problems or program deficiencies if the above review indicates the potential for such problems.
2.2.1 Evaluation of Identification, Classification, and Categorization of Condition Reports Categorized as Conditions Adverse to Quality In general, the Team found problem identification to be clear and well written and the classification and categorization appropriate. For this specific task the Team reviewed a sample of over 3 1 CRs to determine whether (1) the description statement was clear, (2) the categorizatiordclassification was appropriate, and (3) the evaluation method(s) was appropriate. The Team used the terms classification and categorization interchangeably. These CRs were chosen to cover the period sincc the 2005 Assessment site visit concluded in July 2005.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006. August 14 to August 25, 2006
Each CR was reviewed against the category descriptions and the evaluation methods described in Nuclear Operating Procedure NOP-LP-2001, Condition Report Process. The following is a discussion of the Teams review of the selected CRs:
CR 05-04220 Feed Water Heater 1-4 Normal Drain Line Pipe Hanger Spring Cam is Uncoupled This CR documents the discovery of an uncoupled pipe hanger on the normal drain line for thc 1-4 High Pressure Feed Water heater which allows the drain piping to rub against the building support structure.
The CA included reattaching the pipe hanger under Order 200166646.
The Team found no discussion of any investigation or attempt to identify why the hanger was uncoupled.
Other than that, the description was clear, the CAS appropriate, and the categorization correct.
CR 05-04487 This CR was categorized Not a Condition Adverse to Quality - Fix (NF) as it identified a human performance enhancement. The originator requested unique labels be added to all inverters to help prevent erroneous operation of the equipment. The Shift Engineer and Shift Manager reviewed the request and determined that the inverter labeling was correct but could be enhanced. The request was converted to a SAP notification and the CR was closed.
Labeling Enhancement Requested for Inverters The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-04556 This CR was categorized as Not a Condition Adverse to Quality (NCAQ)-FIX to document evaluation of drifted Maintenance and Test Equipment (M&TE). Usage evaluation concluded the mctcr had not been called upon to function in the suspect range since its last calibration. Satisfactory performance had occurred since the Fluke had been placed in stock.
Fluke Model 189 Digital Multimeter The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-04777 This CR was a NCAQ-NC for two deficiencies noted related to Emergency Diesel Generator (EDG) 1 (1) the Fuel Oil Strainer DC Pump lower right mounting stud has a lock-washcr that appears to havc sprcad and (2) the drop-down personnel support gratings are missing several Cotter Pins and washers.
Minor Hardware Deficiencies on EDG 1 The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-05012 This CR was classified NF to track the correction to a chlorination system drawing.
Correction to OS-48A SHl The Team found that the description was clear and the categorization was appropriate.
CR 05-05078 This CR was a NCAQ-NF describing minor corrections to DB-FP-04038 - 10% Pcnctration Scal Visual Inspection.
Correction to DBB-FP-04038 (10% Penetration Seal Visual Inspection)
The Team found that (1) the description was clear, (2) the categorization was appropriate. and (3) thc evaluation method was appropriate.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25, 2006
CR 05-05316, Potential Deficiency/ Enhancement MOV PMs This CR was a CF to track the follow-up of site Preventive Maintenance (PM) procedures in response to earlier operational experience report monitoring potential corrosion of magnesium rotors. The action was to consider enhancement of the PM to include mention of any commitments made to the NRC in response to NRC Information Notice 86-02.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-05524, Findings from FA-SA-05-02 This CR was a CF to initiate and track each FENOC site creating an excellence plan. Thirty-five CAS were written with one open and due I2/2006.
Thc Team found that (1) the description was clear, ( 2 ) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-05622 This CR was a CF to evaluate repeated failures of pressurc gauges on the fire suppression system. Thc gauges had already been replaced when this CR was initiated. Review showed the gauges arc not required. Management review led to the conclusion that this was not a CAQ and closed thc CK to open notification 600263 148.
PPF Main Fire Header Pressure Indication.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 05-05822 This CR describes the discovery of localized corrosion of a duct support from ground water seepage into the service water tunnel.
Corrosion of Q and Seismic I Components in the Service Water Tunnel The Team found that (1) the description clear, (2) the investigation adequate, (3) the immediate CA acceptable, and (4) the as-left inspcction satisfactory. The addition of notification 6002751 79 to initiatc a review and develop actions to address ground water intrusion indicated good forward-thinking by plant personnel.
CR 06-00067, Re-Evaluate the Need to Perform As-Found SW Flow Test This CR was a CF to change the CA implemented in CR 02-06064-01 to pcrform as-found flow balancc testing of the SW system. It was expected that improved system flow monitoring would replacc the nced for as-found flow balance testing, and the change would improve refueling outage efficiency.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) thc cvaluation method was appropriate.
CR 06-00076, Risk Profile for W 6 0 2 Omitted CR2001 Work This CR was classified a CF to document that the planned risk profile for that section of thc work wcck did not include one work item. This was caught before the work was actually performed and was an example of a good review and catch by the Operations night shift staff.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,o COIA-CAP-2006, August 14 to August 25.2006
CR 06-00338, AVI Personnel Minor Injury This CR identifies the failure of a hinge on a freezer door and subsequent minor injury to a contract worker.
The Team determined that this CR was opened on 12/08/05 and action completed 12/08/05, however thc CR was not closed until 03/23/06. This type of delay can have an adverse impact on station backlog trends. Otherwise, the Team found that ( I ) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-00550 The CR identifies the discovery of low oil on the oil sight gauge for the Number 3 Turbine Plant Cooling Water (TPCW) pump. The originator identified no oil in the Number 3 TPCW site glass. Maintenance added 1.5 quarts to the 3 gallon reservoir to return the oil to its normal level.
Turbine Plant Cooling Water Pump #3 The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-00773 This CR identifies a small quantity of dry white residue that was found on the top of the upper stcam generator 1-2 manway joint during a boric acid corrosion control (BACC) walkdown. Notification 600286245 was written to perform a VT-3 examination of the manway bolts during 14RFO. Photos of the crystal deposit were posted on the T drive for examination.
BACC: Steam Generator Upper Manway The Team found that (1) the investigation to be cornprehensivc, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-00923 This CR identifies a battery failure of an emergency siren. The siren maintenance contractor was called and the siren was repaired within 1 week.
EPZ Siren 091 AC Power Failure The Team notes that the condition was reported on 3/13/06, thc siren repaired on 311 7/06 but the CR was not closed until 4/10/06. Other than the potential delay in closeout of the item, the Team found that ( 1 ) the problem description and investigation was comprehensive, (2) the categorization was appropriate, and (3) the evaluation method was adequate.
CR 06-00951, Decay Heat Auxiliary Spray Throttle This CR was a CAQ-CF for the discovery of boric acid residue on the gland bushing of the decay heat auxiliary spray throttle valve.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) thc evaluation method was appropriate.
CR 06-01 131, CRD Service Structure TC Cable Support Degradation This CR was a Condition Adverse to Quality - Closed (CC) to address the discovery during CRD cable replacement that some cable supports were broken or degraded. Since this component was alrcady scheduled for replacement as part of the resolution of CR 02-07964, this CR was trended and closed.
The Team found that ( 1 ) the description was clear, (2) the categorization was appropriate, and (3) thc evaluation method was appropriate.
I Page 11 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25,2006
CR 06-01263 This CR was a CA to analyze the cause and take appropriate actions following the notification by Areva that chemistry data indicated that the core had several fuel element failures and that they were most probably due to grid fretting. The report included reminders that CRs should be issued promptly upon discovery of the problem. Six additional CRs were written.
Condition Reports not Generated for Sipping and Spacer Grid Damage The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-01313, Two Personnel Contaminations Events Resulting in Minor Intakes This CR was a CA for an event whose consequences fall into the Marginal category. The probability, based on inappropriate radiological worker practices demonstrated by experienced personnel and a similar event which occurred in the mid-cycle outage in 2005 (CR 05-01 177), would fall into the Probable category. In accordance with the risk table in Attachment 2, this CR would then be evaluated utilizing an apparent cause.
The Team found that (1) the description was clear, (2) the categorization was appropriate. and (3) the evaluation method was appropriate.
CR 06-01382 This CR documents two issues: (1) The breaker covered by this procedure was to be replaced every 20 years. No breaker was available when PM was performed and delivery of a new breaker required 14 weeks. (2) The preventive maintenance procedure (PM 5309) was performed after its allowable late date.
The PM was scheduled for every 8 years and was last performed 12/20/1995. An error in calculating its next performance called for completion of the PM by 3/27/2006 rather than the actual due date of 12/18/2003. The breaker tested satisfactory on 3/27/2006 and was re-installed while awaiting a ncw breaker.
BF 1260 PM Performed Past Late Date The Team found (1) the problem description was clear, (2) the evaluation of the event was comprehensive, and (3) the categorization and CAS appropriate, CR 06-01440, DH12 Testing Delayed by Clearance Issues This CR was a CC to document, for trending, the incomplete clearance closure records that delayed valve testing while the staff resolved thc clearance issues.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) thc evaluation method was appropriate.
CR 06-01 503, Personnel Contamination Events in Non-Posted Areas This CR was a CA due to an adverse trend (four in less than 1 month) in personnel contamination events in non-posted areas.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-01661 This CR describes a perceived procedure non-compliance. The original problem description stated that an engine driven fork truck was used on the dry fuel storage pad without a fire extinguisher. Latcr investigation revealed that the vehicle was equipped with a fire extinguisher but thc originator was unawarc of its location.
Engine Driven Vehicle on Dry Fuel Pad without Required Fire Extinguisher Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,*
COIA-CAP-2006, August 14 to August 25,2006
The Team determined that (1) the problem description was clear, (2) the categorization appropriate, and (3) the evaluation method was acceptable. The only concern the Team had was timeliness for closing thc CR. The CR was opened on 4/6/2006; the investigation completed on 4/9/2006; however, the CR was not closed until 6/14/2006.
CR 06-02192 This CR reports the high oil level alarm for the Reactor Coolant Pump Motor lower bearing. The investigation identified that motor oil level switches were refurbished during 14RFO. Additionally, the bearing temperature has not increased.
RCP 2-1 Lower Bearing Oil Level High The Team found the problem description very brief but the investigation provided excellent background and justification for continued operability of the motor.
CR 06-02441, COIA-ENG-2005 - ANA - Transmittal of Engineering Requirements This CR was a CF to track the actions committed to address an Area Needing Attention from the 2005 independent assessment of the engineering programs. The ANA discusses weaknesses in engineering documents to convey critical parameter values to the departments that control those parameters.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-02481, Radiation Protection Integrated Performance Assessment This CR was a CF analyzing four instances during 14 RFO where workers entered a HRA on an inappropriate radiation work permit, resulting in a non-cited violation of Technical Specification 6.1.12.b.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and ( 3 ) the evaluation method was appropriate.
CR 06-02488 This CR identifies a small accumulation of boric acid on valve stem and packing follower of valve DH64.
DH64 Boric Acid Leak The Team determined that (1) the description and investigation were clear and comprehcnsivc, (2) thc categorization was appropriate, and (3) the CAS were comprehensive.
CR 06-02542, EAB Grades TM 06-0014 as a Failed Product This CR was a CC to track the rejection of a temporary modification (TM) package that did not meet Engineering Assessment Board quality standards. The deficiencies in the TM for installation of a temporary pressure gauge were resolved prior to approval of the TM package and the CR was writtcn for trending purposes.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
CR 06-02612, CW Pump 3 Auto Started When Stopped Due to Erroneous Low Flow This CR was a CC to address a pump automatic start on a low flow signal during performance of valvc testing. The issue was still awaiting completion of CA under open CR 05-05366. This CR was closed to the existing CR.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and ( 3 ) thc evaluation method was appropriate.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,
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CR 06-02663, Coordination of VP Approval and SLT Review This CR was a CF to track the actions performed to improve the coordination of senior management review of completed RCEs to assure timely accomplishment of these requirements.
The Team found that (1) the description was clear, (2) the categorization was appropriate, and (3) the evaluation method was appropriate.
2.2.2 Interviews with Selected Davis-Besse Personnel Interviews were conducted with a cross section of the staff from Davis-Besse and FENOC. Among the topics discussed was their commitment to CAP, the extent of their understanding of the sites problem identification process, and their willingness to report problems. The Team determined that the Davis-Besse staff was knowledgeable and committed to the CAP. Individuals indicated a willingness to report problems using the condition reporting process in the CREST database and, for the most part, an awareness of problem resolutions that have occurred in response to CRs.
The Team interviewed over 35 members of the Davis-Besse staff and management organization during the course of this assessment. Section 5 of this report lists the names of individuals intervicwcd to deteiminc their commitment to, and involvement in, the CA process. Based on thcsc interviews and observations of meetings, the Team concluded that the Davis-Besse staff displayed a commitment to thc CAP. They had an understanding of the problem identification process, and they displayed a willingness to report problems as well as encourage others to report problems.
The Team also attended several morning MAOMs, two CARB meetings, one Senior Leadership Team (SLT) meeting, and other CR and CA review meetings. The members at all of the meetings dcmonstratcd an understanding of the subject under review and a questioning attitude toward problem resolution.
Responsible individuals accepted ownership of items and appeared willing to cooperate in resolving discrepancies. In general, Davis-Besse personnel demonstrated good interdepartmental coopcration and a willingness to commit resources when and where necessary. All of the meetings were well managed, thc reviews of CRs and CAS were crisp, and there was good interaction between managers and CR owners. In all cases, the CR owners were prepared to discuss their packages.
Several license staff stated during interview that the SAP system was not user friendly and that they had difficulty using the system to track items.
2.2.3 Evaluation of Operational Experience Feedback Nuclear Operating Experience Business Practice NOBP-LP-2 100, FENOC Operating Experience Reference Guide, contains guidance on the review, evaluation, and use of Operational Experience (OE) feedback. The Team reviewed CRs developed in response to OEs and spoke to Davis-Besse staff and management on their use of OE notices from FENOC and other nuclear sites. In general, the Team found that Davis-Besse reviews OE notifications when received and prepares CRs and CAS as appropriatc. lhe Team determined that Davis-Besse used a very detailed approached that was worthy of a strength. l h e approach led to Davis-Besse sharing events with the industry that were meaningful and significant. This was verified by a cross-check of Institute for Nuclear Power Operations (INPOs) classification of the reports submitted by the utility over the past year. INPO rated 94.6% of the reports submitted by Davis Besse as noteworthy or significant when reviewed against the defined industry standard for reponing.
The team reviewed the INPO and NRC networks to identify items that would meet the Davis-Bessc procedure for evaluation of industry data. The items selected were NRC-Information Notices (INS) 2006/03,2006/09,2006/14,2005/21,2005/25,2005/30 and from INPO Significant Event Report SER 3-I Page 14 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25, 2006
06, 1-06,4-05; SEN 260 and TR 653. Several of the items were initially entered into the CR process and later transferred to the SAP notification process; however, most were in the SAP process. Some of the evaluation SAP items had not been completed within the Davis-Besse expectations of 60 days. Davis-Besse had self-identified the challenge to meet the 60-day expectation and had irnplementcd a weekly discussion at the MAOM to review the status of the Industry Operating Expericnce reviews. Based on thc Teams attendance of the 8/21/06 MAOM, it did not appear that this action was particularly effective at emphasizing the need to meet this expectation. The OE reviews completed generally addressed the issuc reviewed. A sample of items reviewed is contained in Section 2.2.2 of this report. The Teams review of CRs developed in response to OE feedback is detailed in Section 2.4.1. The reviews completed generally addressed the issue reviewed.
The Team considered Davis-Besses submittal of OEs to industry to be An Area of Strength. The Team determined that increased attention needs to be directed to completing reviews of incoming 013 within the 60-day time limit established by NOBP-LP-2100. The Team considered this to be an Area in Need of Attention.
2.2.4 Evaluation of Implementation Problems and Program Deficiencies Part of the CRs reviewed during this assessment documented the use of the corrective action process to address broad generic problems or programmatic deficiencies. Interviews showed that site personnel arc finding the cognitive binning process and the IPA process useful in identifying these higher level type issues.
In addition, the transfer of CAQ items to the new SAP process was reviewed to provide an assessment of performance expectations being met. The July 2006 new SAP items list was reviewed to detciinine itcms to be reviewed by the Team. Only those items on the list which identified a CR were sampled to be reviewed. There were 22 items and 13 were reviewed; however, one reviewed item was initially a NCAQ, therefore not included in the sample results. The Team reviewed I2 CRs which had actions transferred to the new SAP Notification Process in July 2006. All the process expectations for these actions (enhancement justification) were either captured in the CA, which was closed to the SAP notification or were documented as an enhancement in the original report capturing the review of the event when it occurred.
The Team noted no overarching or broad implementation problems in the review of the CRs or in the application of NOP-LP-2001, Condition Report Process. The team noted marked improvemcnt in the timeliness in the completion of root and apparent causes, as well as a marked reduction in the numbcr of open SCAQs.
2.2.5 Summary The Team identified Davis-Besses reporting and reviewing of operating experiences to be an Area of Strength because the Team found a commitment by all organizations to use the CR process and an understanding by the supervisor level and above on how to properly categorize CRs. The Team saw no evidence where organizations were not initiating CRs. In interviews with Davis-Bessc and FENOC personnel, this was not cited as a current issue. Additionally, the Team noted a strong commitment to the use of the Operating Experience process and involvement with other utilities.
The use of a committee of four individuals to review all SAP submittals demonstrates the stations strong commitment to accuracy in categorizing CAS and SAP Notifications.
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Areas of Strength Categorizing CRs and CAS was effective.
Reporting of Operating Experience to industry was very good.
Areas in Need of Attention The timeliness of reviewing incoming OEs frequently does not always meet the program expectations.
Areas For Improvement None.
Conclusion The Team rated the Identification, Classification, and Categorization of CAQ as HIGHLY EFFECTIVE.
2.3 Evaluation and Resolution of Problems The Assessment Team performed an analysis of at least five selected issues or problems that have gone through the entire applicable CAP process, to identify strengths and weaknesses in their evalualion and resolution. The analysis included:
An analysis of the ACE or RCE of at least five selected CRs.
An analysis of selected issues, which should have been identified as CAQ on CA documcnts but wcrc not or were only partially identified.
An analysis of the problems selected above. An evaluation of the Davis-Besse Nuclear Power Stations effectiveness in implementing the CAP.
An identification and discussion of any strengths and/or weaknesses or slow response identified during the detailed analysis above.
To address thcsc issues, the Team reviewed approximately 126 CRs, including a minimum of 12 RCEs, 24 ACES, 5 Limited Apparent Cause Evaluations (LACES), and 44 CRs categorized as Fix. The Tcam rcviewed these documents to determine whether (1) the investigation tools used (event and causal factor flow chart, failure mode analysis, change analysis, barricr analysis, task analysis, ctc.) wcrc appropriate.
(2) the stand-alone document was clear and follows the procedure. and (3) whether the depth ofthc investigation was appropriate.
The Team also reviewed a sample of the oldest open CAS for their safety significance. The Tcam reviewed CRs in the following areas:
2.3.1 Root Cause Evaluations CR 05-05349 The initial RCE associated with this SCAQ-SR Condition Report was returned with comments from the C A M. Revision 1 of the root cause report was reviewed by the Team and fond to be in accordance with industry expectations. The CR was opened 10/13/05 and the last CA was closed 3/21/06. As of the date of this review, the CR is in the review status. This exceeds the industry standards for timeliness of completion.
Check Valve Found in Outlet of Moisture Trap (MT9) in C3801 for AE5027 Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,6 COIA-CAP-2006. August 14 to August 25, 2006
CR 05-05559 This CR was an SR addressing additional non-conservative assumptions in the calculation supporting minimum technical specification boric acid flow. CRs 05-03327 and 05-05 184 had previously identified incorrect assumptions in this calculation that resulted in new guidance to opcrators nccded to assure continued operability of the boric acid pumps. With the new errors identified in this CR, the past-operability review determined that both boric acid pumps had been inoperable under certain conditions during the past operating cycle. The RCE concluded that this was an original construction dcsign error and that inadequate engineering department rigor in the development, review and approval of a subsequent (2005) revision to this calculation did not identify all of the calculation errors. This delayed the ultimate identification of boric acid pump inoperability without compensatory measures to avoid conditions that adversely affect boric acid flow rate. The CAS credited latent issue and engineering rigor actions taken during the 2002-3 extended outage. Retraining of engineering personnel on the lessons-learned from this event, and referral to the engineering training curriculum for inclusion in continuing training was also included as a CA. The extent of conditiodcause (EOC) review focused on the latent issues portion of the eventkause, but did specify a verification of calculations for othcr Technical Spccification required pumps. The calculations for those pumps were verified with the cxccptlon of the service water pumps, which were exempted based on calculation revisions completed in 2003.
Boric Acid Pumps Operability Standing Order OS-013 Thc Team dctermined that thc RCE was thorough and the CAS were appropriate and timcly. The document for of the justification for exempting service watcr pumps from the EOC CA did not address why thc same organization that failed to exercise appropriate rigor in the 2005 boric acid pump calculation did not apply to the 2003 service water calculation. Also, the Team determined that the dcferral of EOC review to a CA after CARB approval of the RCE without requiring this CA to return to CARB for closure was a missed opportunity for CARB to verify completion of the RCE of this cvcnt. The Team considers this to be an Area in Need of Attention.
The Team also noted that although the evaluation of this CK was CARB approved on OliO62006. thc required Senior Leadership Team (SLT) review of this CR did not occur until 8/14/2006. Thc Tcam performed a review of other SCAQ items since the 2005 Assessment revealed that five of scvcn evaluations had similarly late reviews. The Team was conecrned that a 7-month delay betwecn CARB approval and SLT review could result in a decline in CARB performance. The delayed review of RCEs had been identified by Davis-Besse (CR 06-02663) and CAS for this CR were driving down the backlog.
The Team observed SLT review of three old root cause packages during the assessment. The review was pertinent and probing and no significant discrepancies were noted. The senior managers interviewed could not recall an instance when additional actions were created after SLT review. The Team peer perspective was that senior management review of all RCEs is not standard in the industry. Howcver, to achieve the highest value added for this effort, a timelier implementation is appropriate.
CR OS-05650 This CR was designated a SCAQ-SR that would require a root cause analysis for follow-up to thc finding of the service water outlet valve for the standby component cooling water heat cxchangcr, which was found in the closed position as opposed to the required open position.
SW38 Found Out Of Position Closed The Team determined that (1) the problem statement was clear, (2) the categorization of the cvent was corrcct, and ( 3 ) the CR evaluation was thorough. The initial safety systems affcctcd by this condition were promptly assessed and the valve position was corrected. Appropriate consideration was given for a potential maintenance rule functional failure, potential issuance of Operating Experience information, prcventative actions for reviewing procedures requiring independent valve positions. and discussions with on shift personnel.
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The root causes were determined to include the original operator not properly verifying the valve position.
a less than adequate pre-job briefing, and not independently verifying required system lineups. CAS, in addition to the above, included issuance of a Standing Order for independent verification of certain site procedures.
The Team determined that the identification of this deficiency was a good finding by the plant operator.
The root cause analysis included a note that the original shift, on which the error had occurred, included 26 activities scheduled. Although the cause analysis did not discuss further details of the potential for this shift to have an overly excessive burden and any more detailed human factor deficiencies or fitness for duty issues, the Team determined that the cause analysis was comprehensive.
The Team observed a SLT meeting in which this RCE was reviewed. No changes to the Evaliiation were made by the SLT. It was confirmed that the sites Standing Order for independent verification of safety system lineups was still in effect.
CR 06-00154 The Team determined that the investigation for 06-001 54 was thorough in evaluating the organizational and programmatic elements that led to the event (Le., procedural inadequacies in not requiring concurrent verification of steps critical to the proper performance of safety related equipment). Additionally, the corrective action to shift the responsibility/accountability for documenting the completion of steps performed from the lead mechanic to the actual personnel performing the step was appropriate.
- 2 EDG Broken Parts in Rocker Arm Area It was also noted that the investigation focused on the organizational and programmatic causes of the event and CAS were appropriately taken for the same. However, corrective actions to repair the damaged components on EDG 2 were not included in the investigation documentation. Although the investigation report states that all of the lash adjustment screw lock nuts were not torqued on EDG 2, no corrective action was included in the investigation to verify the proper torque of the remaining cylinders.
Additionally, the extent of condition section of the RCE states that there are two additional diesels of the same manufacture and design at Davis-Besse and the same 6-year preventive maintenance was performed using the same process which was determined to be flawed in this investigation. No corrective action was identified to verify torque of the lash adjustment screw lock nuts on those generators. The reason for not verifying torque on the other diesel-generators was: EDG I and the Station Blackout Diesel Generator have not experienced the same symptoms identified in EDG 2.
The extent of cause (associated with level of verification of torquing critical to proper performance of Tech. Spec. equipment) was well-addressed during the investigation. A sample of mechanical maintenance procedures was reviewed and found the level of verification for torquing operations was higher than within the diesel engine maintenance procedure. This was used to bound the extent of cause to the diesel maintenance procedure.
The Team concluded that the investigation analysis was particularly strong in reviewing organizational and programmatic elements associated with maintenance performance and verification of the activity. The extent of cause was also well addressed. However, the investigation did not document corrective actions taken to correct the condition, nor did it adequately document actions to address the extent of condition on the three diesel generators on which similar maintenance had been performed. The Team considers this lack of documentation to be an Area In Need of Attention.
CR 06-00207 The Team determined that Davis-Besse demonstrated good problem recognition in identifying and researching the problem. The expanded evaluation determined that the condition was bounded which Wrong Load Value Used in Calculation Addendum Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,8 COIA-CAP-2006, August 14 to August 25, 2006
allowed the CR to be downgraded to CAQ. The root cause technique analysis was completed and the institutionalization of the lessons-learned in the training program was viewed as a strength. The action to review and ascertain the effectiveness of the CAS remained open.
CR 06-00583 The Team determined that Davis-Besse demonstrated good recognition that the problem associated with operational decision-making in declaring the EDG 2 operable (despite an abnormal noise emanating from the engine) was a separate problem from that investigated under 06-00154, and it was a good decision to split it out in a separate investigation.
Further Evaluation Actions Regarding EDG #2 Tapping Noise on 1/13/06 However, the Team also noted that the CR for this issue was not initiated until identified in the CARB review of 06-00154 on March 2, 2006, 41 days after the event. The CARB meeting minutes indicate that the investigation adequately addressed the problem statemcnt but that the problem statement did not adequately address the condition. This calls into question the process by which the problem statement was initially developed and approved. It is worthy of note that previous CRs 05-4774 & 05-04408 resultcd in training on, among other things, problem statement creation. This was completed in mid-December of 2005, although the training was only attended by -2/3 of the target audience. The rest received an e-mail with the training material. A review of the attendance sheets indicates that one presentation was made on December 12, 2005. To achieve more participation, more than one presentation could havc been implemented. In addition, the CARB review of CR 06-001 54 investigation indicates that this training may not havc been effective in that the problem statement and investigation scope was determined to not address the entire problem, and that an additional root cause investigation would be required to addrcss the rest of the issue.
The investigation report states that implementation of the problem-solving and decision-making process (which was proceduralized in NOP-ER-3001, Rev. 1) requires both implementation of the procedure and a change in individual behaviors and in organizational culture. It is not enough to simply invoke a procedure that describes the process. The process must become ingrained in the habits of the individuals in the organization.
Corrective Action #3 for this CR states to Coordinate design, development, and presentation of training activities to address the root cause of this event and improve worker understanding/perforinancc in this area. Activities should address the specifics of this event (EDG-2 Tapping noise). A case study that includes a discussion of the event and the actions taken versus the desired behavior is suggested. The training activities should address a problem-solving technique based on NOP-ER-3001. lntcrnal and external OE examples should also be included. The recommended target audience for these training activities are engineering personnel, maintenance and operations supervisors, and above. This training should also address the missed opportunities (by the on-shift SRO and the notification screening team) to recognize that the maintenance notification should have been upgraded to CR status. Training audiencc, design, development, and delivery should be coordinated through the appropriate training review committees. Although this action was classified as preventive, there was no indication that this training would be institutionalized for the future.
The Team concluded that the investigation analysis could have been of greater potential value. This was due in part to the late start in investigating this aspect of the earlier event documented in CR 06-00 I54 and the associated loss of time-dependent evidence. This, in turn, is a result of the narrow scope and problem statement of the previous investigation. In addition, the corrective action to preclude recurrence associated with training on problem solving and decision making was not institutionalized in the training process. Therefore the stated desire to change individual behaviors and organizational culture appears to Davis-Besse Nuclear Power Station Independent CAP Assessment I Page,9 COIA-CAP-2006, August 14 to August 25, 2006
remain a challenge. This is an example of the Area In Need of Attention in CR evaluation quality, thoroughness, and documentation.
CR 06-01091 This CR was written to report a weld flaw indication found in a butt weld between dissimilar metals (alloy 600/82/182) on the Reactor Coolant Pump (RCP) cold leg drain line nozzle-to-elbow weld. The probable cause was identified as less than adequate welding during construction. A structural weld overlay was performed and an acceptable ultrasonic examination was completed. The Effectiveness Review (ER) determined that no additional action was needed because:
Axial Indication in RCP 1-1 Drain Line Davis-Besse personnel do not perform dissimilar metal butt welds; The weld flaw was, most probably, a legacy issue from construction; and Any future dissimilar metal butt welds will be performed by outside contractors using their Quality Assurance (QA) program.
The Team dctermincd that the corrective action investigation provided a comprehensive problem statement, event narrative, data analysis, probable cause, CAS, and commitments. The investigation appcars thorough with extensive identification of similar occurrenccs at other nuclear facilitics. an analysis of other locations within Davis-Besse that have dissimilar welds, and a comprehensive list of CAS and notifications.
2.3.2 Apparent Cause Evaluations CR 05-05184 The Team determined that evaluating this CR concurrent with CR 05-05559 was correct since they were both worked concurrently. The cause code of F07, Self Checking to Ensure Correct Component. should be reconsidered. The Team determined that a cause code of F08, Workmanship, might be more suitable.
Boron Injection Flowrate Calc. 034.009 Non-Conservative Assumptions CR 05-05278, Fuel Integrity Monitoring Did Not Identify Cycle 14 Fuel Defects This CR was designated CA and was written following the report from Framatome that there were from one to four fuel element defects in the core. This CR required an ACE to determine the cause of the site not identifying the fuel defects through programmatic monitoring processes. The analysis included the condition that the site was not using the Xenon isotopic ratio of Xe-133 to Xe-135 as an indication of fuel defects.
The CAS included the issuance of an operating experience report, the review of practices by Peny, Bcavcr Valley, and the industry, and review of Electric Power Research Institute (EPRI) and INPO reference material.
The CARR rejccted the cause analysis because it did not answer why the site procedure was inadequatc.
The cause analysis stopped short and did not go far enough. The subsequent licensee review dctermincd that the skill level was less than expected by and the opportunity was missed when EPRI had earlier revised their guidance. CAS included the support to place a staff person on the EPRI working group to keep up-to-date on this type of issue.
CR 05-05334, WW0541 Inadvertent Risk Entry This CR was designated CA and required an Apparent Cause analysis to follow-up a condition involving inadvertent entry in to an Orange risk work condition.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 2o COIA-CAP-2006. August 14 to August 25,2006
The cause analysis was accepted by CARB with comments. The cause analysis used the why staircase at least two times as required. The planned work was scheduled and assessed for risk acceptably, but one test continued into the next period where it had not originally been scheduled and created the unplanned Orange condition. The analyst determined that the site process was not followed, which requircd that if work was extended that it be treated like a change in schedule.
CR 05-05427 This CR consolidated 39 earlier CRs that were evaluated and categorized as NF, CF and, in a few instances, CAS. All of the earlier CRs addressed various problems with doors throughout the station. This consolidated CR was used to elevate the level of concern and focus station management and employee attention on a potential generic problem with station doors.
Adverse Trend Related to Recent Door Issues Davis-Besse staff tried to downgrade the CR from a Category CA to a Category CC because the problems with doors were adequately addressed in earlier investigations and sufficient CAS. The downgrade request was denied by Davis-Besse management and an ACE was performed.
The completed Apparent Cause identified 27 equipment failures; the rest were human performance issues.
Past CAS consisted of equipment repair, coaching, sign postings, and modifications to the training program. The first Corrective Action (CA-1) for this CR requires Plant Engineering to complete field observations of high-traffic areas and provide coaching and complementing to workers. These observations were done and the CA was closed on 5/9/06. The ER requested by the CARB as CA-2 has a due date of 1 O/ 15/06.
The Team determined that the evaluation was extensive and identified multiple similar problems at other nuclear sites. The CAS were appropriate to the severity of the problem.
CR 05-05689 This CR contains the results of an audit of the Activity Tracking Screening Committee by Nuclear Oversight staff during the 4th quarter of 2005. Nuclear Oversight observed the Activity Tracking Screening Committees review and transfer of 99 NCAQ CRs from the CREST system to thc SAP Activity Tracking system.
Assessment of SAP Activity Tracking Generation Process The Nuclear Oversight group identified multiple problems with the transfer process. These problems included:
0 0
Notifications had typographical errors.
Notifications entered into the S A P without due dates.
Notifications entered into the S A P with due dates different from the original CA.
Notifications referenced the wrong CA or did not identify which CA it closed.
Notifications were written that should have been CRs.
The 2006 Team determined that the deficiencies identified during the licensee audit occurred early in the review and transfer process. The CAS were completed and spot check follow-ups of the infonnation being transferred from CREST to S A P have not identified new issues. The Team determined that this CR.
ACE, and CAS were performed adequately.
CR 05-05990 This CR reports that the source range indication on Channel 1 was pegged low with Channel 2 already inoperable. while wide range indication at 0.01 YO power. The Team determincd that the report description Channel 1 Gammametrics Has Failed I
page21 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25,2006
was very good. The description of the system function was written to help readers who may be unfamiliar with the topic to understand the issue.
The analysis of the cause of Channel 2 being inoperable was identified as a pre-existing test circuit problem that had not been fixed at the time of Channel 1 failure. Work on the Channel 2 problem was assigned a low priority and subsequently exceeded the Technical Specification surveillance frequency, which required that the channel be declared inoperable. CAS were not assigned due to this being previously evaluated and the double failure attributed to occurrence of an assumed risk. This appears to contradict a later section of the investigation report that attributes the cause of Channel 2 being inoperable to insufficiently strict policies & controls, and the work prioritization procedurc attachment being confusing or incomplete.
The analysis of the cause of Channel 1 being inoperable identified that the power supply had failed and that the age of the power supply was 4 years beyond the vendor recommended replacement frequency with no PM in place for periodic replacement. CAS were established to change out both channcl power supplies and to establish PMs to perform this periodically in the future.
The Team determined that the extent of condition appropriately bounded problems to similar power supplies.
An OE scarch was limited to failures of this power supply type. No OE search was pcrformcd to idcntify other cases where. vendor recommendations for PM were not followed. This may have provided insights into a PM program weakness (extent of cause).
The C A M review concluded that a CA was needed to address the apparent cause of Channel 2 repair not being properly prioritized. The CARE3 directed initiation of a CR to identify the improvement needed to prioritize redundant technical specification equipment notifications/orders. CR 06-009 16 was initiated on 3-1 5-06 and was subsequently closed as being redundant to existing CR 06-00428. CR 06-00428 determined that the prioritization process was adequate, but that it was inadequately applied in the Operations SRO and Screening Committee review. The following CA was issued:
CA # I - Review this CR with Operations SROs and Screening Committee members and placc emphasis on the operability review determining impact of the deficiency; this should also include a review of the impact on future operability (docs the deficiency prevent testing?); include in this rcvicw a discussion of the Ranking Index of Orders system per CR initiator request. This action was opcn, and due 9i23106.
The Team concluded that, although there were weaknesses, the investigation analysis was adequate for an apparent cause. Important omissions were identified by CARB and corrected.
CR 06-00624 The Team determined the evaluation was satisfactory for replacing the foreign material exclusion boundary but the cause assessment did not document the cause or source of the water and concluded that the source could not be located.
Water Spray on Motor Control Centers E l l B and E I I C This CR was opened 03/07/06 and all actions closed as of 3/30/06; however, CR is still opcn in the review status. The Team believes that this type of delay in closing CRs can have an adverse impact on the perception of the Davis-Besse backlog.
Davis-Besse Nuclear Power Station Independent CAP Assessment 1 Page 22 COIA-CAP-2006. August 14 to August 25, 2006
CR 06-00857 Violation of NOP-LP-3005 (FENOC Confined Space Entry Program)
This CR was a CAQ-CA that resolved the March 12,2006 entry into a condenser water box without the required safety and asbestos protection measures in place. A barrier analysis dctermined that the work plan documents were inadequate and the self-checking efforts by individuals were inadcquate.
The Team determined that (1) the problem statement was clear, (2) the categorization of the event was correct, (3) the CR evaluation was thorough, and (4) the CAS were appropriate in scope and schedule.
CR 06-01313 Two Personnel Contaminations Events Resulting in Minor Intakes The Team determined that the analysis of the event was-well written and accurately documented the underlying organizational & programmatic elements that led to the event. The analysis also demonstrated in-depth evaluation through its recognition that a similar event in 2005 indicated the need for more robust barriers to limit the potential for future occurrences of this type.
The activity being performed was cleaning a gasket surface, presumably to minimize the potential for leaks following reassembly. The investigation and subsequent CAS were aimcd at impro\\.ing barriers associated with decontamination activities. It is not clear that an activity, such as was performcd to clean a gasket sealing surface, would be considered a decontamination activity in thc future and thcrcforc, use improved procedural controls.
The Team determined that the investigation analysis was adequate. The work activity in question should be classified as a decontamination activity at Davis-Besse in the future to realize the benefits of thc procedural improvements made in the CAS.
CR 06-01 503 Personnel Contamination Events in Non-Posted Areas The Team determined that the investigation included an analysis of five additional personnel contamination events in non-posted areas that have occurred since the initiation of the CR. However, the investigation concluded that no adverse trend existed due to: (1) the low numbcr of occurrenccs and (2) all occurrences were at EPRI Level 1. Therefore, these events were not indicators of any weakncss in contamination control practices. EPRI Action Level 1 (100 to 5,000 ccpm) recommendations include decontamination of the individual, logging of the occurrence, and periodic trending. Therefore, the conclusion that no trend existed due to all nine events being within the bounds of EPRI Level 1 appears to be circular logic.
The investigation focused on the validation that postings and surveys were in accordance with cstablishcd procedures and processes, rather than identifying commonalities that could be used to focus corrective action to reverse the trend. Although the condition was classified as a CAQ, no CAS were taken. It was noted in this review that six of the nine events occurred in Mechanical Penetration Rooms. It would haw been prudent to look at activities performed in these areas to determine the source of thc contamination, and/or to perform focused decontamination activities in those areas to reduce the number of n'cnts.
The Radiation Protection (RP) Department Integrated Performance Assessment covering 1 1 / I 105 to 4/30/06 (IPA 2006-00025) noted that 35 CRs were the result of personnel contamination on skin, clothing or shoes. The assessment states that a potential cause of the outage contamination events was that on at least two occasions there was ventilation flow from Containment to the Auxiliary Building. The assessment also states that an evaluation (600287901) has been accepted by Engineering to consider methods or processes to be used during future outages to reduce the potential for flow of air from Containment into the Auxiliary Building. This information was not included in the investigation of CK 06-0 1 503.
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The Team determined that the investigation analysis could be enhanced. The investigation of an adverse trend stopped short in looking for common areas that can be improved and instead provided justification of why there is no problem. This is an additional example of the Area in Need of Attention in CR evaluation quality, thoroughness, and documentation.
2.3.3 Review for Proper Identification The 2006 Team performed an analysis of CRs and SAP notifications to determine if conditions which should have been identified as CAQ on CA documents were misidentified or only partially identified.
The transfer of CAQ items to the new SAP process was reviewed to provide an assessment of performance expectations being met. The July 2006 new SAP items list was reviewed to determine items to be reviewed by the Team. Only those items on the list which identified a CR were sampled to be reviewed. There were 22 items and 13 were reviewed which had actions "transferred" to the new SAP Notification Process in July 2006. All the process expectations for these actions (enhancement justification) were either captured in the CA which was closed to the enhancement OR were documented as an enhancement in the original report capturing the review of the event when it occurred.
The Team was unable to identify any improperly classified CRs or SAP notifications. The Team determined that the classification and categorization of issues is well-controlled at Davis-Besse.
2.3.4 Summary The Team rated the Evaluation and Resolution of Problems as EFFECTIVE because the organization demonstrated a good understanding of the CAP and willingness to accept, investigate, and resolve CAQs.
Areas of Strength None.
Areas in Need of Attention The Team identified an Area in Need of Attention in CR evaluation quality, thoroughness, and documentation with the following examples:
The Team determined that the documentation for CR 06-00154 - Loose Parts in Diesel Generator -
could be enhanced by including all of the investigation performed by the Davis-Besse staff.
0 For CR 05-05559, the Team determined that the deferral of EOC review to a CA after CARB approval of the RCE without requiring this CA to return to CARB for closure was a missed opportunity for CARB to verify completion of the RCE of this event.
The Team concluded that the investigation analysis for CR 06-00583 could be enhanced. The one-time training CA was classified as preventive, yet there was no indication that the training would be institutionalized for the future.
For CR 06-01503, the Team determined that the investigation analysis could be enhanced. The investigation of an adverse trend stopped short in looking for common areas that can be improved and instead provided justification of why there is no problem.
Areas for improvement None.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 24 COIA-CAP-2006. August 14 to August 25,2006
Conclusion The Team rated the Evaluation and Resolution of Problems as EFFECTIVE.
2.4 The Team performed an analysis of CAQ CA implementation and effectiveness. The analysis consisted O f Corrective Action Implementation & Effectiveness An evaluation of the timeliness of CAS for at least 20 CRs.
A review of the number of repeat CRs and CAS and evaluation of the effectiveness of CAS.
An evaluation of the adequacy of the Davis-Besse Nuclear Power Station's implementation of CAs for operational experience feedback.
A review of the activities of the CARR and evaluation of the effectiveness of the CARB.
2.4.1 Timeliness of Corrective Actions During the course of the Assessment, the Team reviewed several dozen CRs and their associated CAS.
The Team determined that Davis-Besse is generally effective in completing the required CAS however thc Team noted a delay in closing of CRs after all CAS had been completed. This delay can have an advcrse impact on the station backlog. The CRs evaluated by the 2006 Team for this section of the report are discussed below.
CR 05-03779 Oversight identified that a single INPO OE report may not have been sent to all appropriate departments for their information. Based on technical review, CR 05-04287 was initiated which became GAT 06626.
No ER was required but referred to snapshot self-assessments for OEs are performed and the 2006 Team rated this as satisfactory.
INPO OE Report Not Fully Distributed CR 05-03965 The Team determined that the evaluation was timely and adequately addresses the vendor recommendations.
OE - Beaver Valley MOV Failure Due to Damaged Gear Teeth CR 05-03974 This was an NF classified report issued to track and implement an evaluation of a significant industry summary report.
SER 2003-05 Weakness in Operator Fundamentals The Team concluded that the evaluation was completed and that thc CR had been closcd in March, 2006.
The CA had been "closed to a SAP notification."
CR 05-04026 This CR was an NF to track the confirmatory screening of a North Anna 2 event where loose trunnion screws caused a steam-driven auxiliary feedwater pump triphhrottle valve failure. The CR evaluation found the subject component is applicable to Davis Besse, but there was no evidence of loose screws.
Loose Trunnion Screws at North Anna 2 The Team found the review of operating experience to be timely and effective, the proposed maintenance procedure enhancement appropriate.
I page25 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006. August 14 to August 25.2006
CR 05-04110 INPO Technical Report on Circuit Boards originally extended evaluation in 2005. This CR was closed to SAP notification 60025 17 10.
INPO Technical Report on Circuit Boards CR 05-04414 PY CR 2005-6616 Confirmatory Screening CR Misclassification CR generated based on Perry misclassification of CR relating to deficiencies in effectiveness. MAOM originally classified this as NCAQ for Davis-Besse but it was upgraded to CAQ as part of the conversion of NCAQ to SAP.
The Team determined that Davis-Besse performed a satisfactory review of extent of condition with identified potential deficiencies resulting in the generation of new CRs.
CR 05-04563 Condition Within 6 Hours as Required by TS LCO due to a Maintenance Procedure Error Which Left Switches on a Circuit Card in the Ow Position The Team determined that the evaluation appears to adequately address the station processes and practices that serve as barriers to this type of event.
OE - Beaver Valley NCV for not Placing an Inoperable OTDT Channel in the Tripped CR 05-04672 NRC IN 2005-24: Nonconservatism in Leakage Detection Sensitivity This was an NF to track the cvaluation of NRC Information Notice 2005 Nonconscrvatism in Leak Detection Sensitivity. Since the origination of this CR, the Operating Expcrience Program tracking has been shifted from CREST to the companys SAP computer tracking system. Therefore, this action was transferred to SAP notificatiodorder 6002403021200175093. In this transfer, the evaluation duc date was extended 10 months past the target 60-day evaluation expectation.
The Team determined that the OE evaluation a year after receipt was not considered timely.
CR 05-04845 This was an NC classification report to document receipt of an Information Notice from the NRC regarding industry operating experience of a reactor trip caused by defective circuit cards. This CR was closed with the annotation that the IN would be evaluated by CR 05-041 10 which was initiated following receipt of an associated OE from industry (INPO), Technical Report 5-47, a review of circuit board failures. This was an NF CR and was closed to a notification.
IN 2005-25 Inadvertent Trip due to Tin Whisker The Team noted that the licensee performance improvement staff provided a status of Open OE Evaluations, Confirmatory Screenings, and Follow-up Actions in the Monday MOAM packagc for station management to review in addition to other priority items in the morning management mceting.
Items which are overdue or coming due are included along with the original due date (if cxtendcd) and the responsible person for the action. The Team determined that this was a good practice to review these especially since the station had recently changed its practice to use a data base system called SAP as opposed to the CR system called CREST. However, based on the Teams attendance of the 812 I io6 MAOM, it did not appear that this action was particularly effective at emphasizing the need to meet this expectation.
The Team verified that the OE for review of TR 5-47, Review of Circuit CardIBoard Issues was included in the listing reviewed in the MOAM on Monday August 14, 2006. Three separate actions were being tracked and were due (and overdue) 711 812006, 811 912006, and 913012006 respectively.
The Team subsequently discussed the status of this item with the engineering staff. Due to the complcxity and sensitivity of this operating experience item, the Instrument and Control (I&C) engineer indicatcd Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 26 COIA-CAP-2006, August 14 to August 25,2006
that they had put together a draft plan to include training for awareness but were cautious when identifying any specific actions so as to not cause any other problems with circuit cards by inspecting or analyzing their equipment. Due to the complexity of this, the engineer had rcqucstcd an cxtcnsion until the end of September to complete the plan.
CR 05-04854 This CR was a NF to track the future changes needed to the control room annunciator procedure associated with a change to the Reactor Protective System variable low pressure trip scheduled for cycle
- 15. The CR was closed because the record was converted to the SAP database.
PCR-Tracking OPS Procedure Revision for ECR 05-0089 The Team verified that notification number 600261087 was opened to track completion this action.
CR 05-05395 CAQ-CF-2005 INPO AFI P1.2-I CAQ-CF-2005 INPO AFI PI.2-1 : Some evaluations of significant and repetitive problems for extent of condition, extent of cause, and effectiveness of previous operating experience reviews were narrow in scope and added little value. As a result, CAS have not always been comprehensive enough to rcducc the occurrence of events having similar organizational causes.
The Team determined that CAS included providing a hands-on lessons-learned session on the extent of condition, extent of cause, and previous OE reviews from assessments conducted at Davis-Bcssc in 2005 to applicable trained or qualified individuals. However, the hands-on lessons-learned session was not attended by 45 individuals (-1/3 of the target audience), who were subsequently sent the Power Point presentation via e-mail. Missing attcndccs included Directors with root cause approval authority, CARH members, root cause evaluators, apparent cause evaluators, and CR Analysts. It was unclear from review of the training material what portion of the session was hands-on, but if that was the intcnt it would not have been pcrformed by the 45 members of the target audicncc that received the material via e-mail. This is considered to be an Area In Need of Attention. Additionally, the presentation states undcr the Extent of Condition requirements that it constitutes an evaluation of the characteristics of a condition to determine if there are other identical or similar applications in which the condition or its causes could or do exist. Including or its causes in this description could be confusing since that was the function of thc Extent of Cause review. The Team considers the CAS for CR 05-05395 to be partially completed. In a positive light, the Team identified a good presentation of thc nccd to perform OE reviews at two timcs for two separate reasons (to help in identification of causes, then to help in identification of CAS).
CR 05-05396 INPO 2005 EVALUATION - AFI P1.2-2 (TIMELINESS/AGING)
The Team determined that the CR resolution was satisfactory. The Station developed an integrated indicator capturing all backlog activities and setting goals for backlog.
CR 05-05397 INPO 2005 EVALUATION - AFI P1.3-1 (USE OF OE)
INPO determined that Davis-Besses evaluation of incoming Operating Events (OEs) for extent of condition, extent of cause, and effectiveness of previous operating experience reviews was sometimes too narrow in scope and add little value. As a result, corrective actions have not been comprehensive enough to reduce the occurrence of events having similar organizational cause.
Thc Team reviewed Davis-Besses response and corrective actions which included enhanced training materials (on-the-job training, task performance, and leadership) and determined that the CA was appropriate.
I page27 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25,2006
CR 05-05444 The Teams limited investigation of the SAP and CREST database systems determined that this condition has been satisfactorily resolved.
Oversight Concerns Related to SAP Notifications Not Identified in CR Program CR 05-05894 NOP The Team determined that this condition was resolved satisfactorily. The response noted that actions werc performed to address the individual performance shortfalls; the items identified as not meeting expectations were corrected; and action was assigned to revise CREST softwarc to provide better processing of the computer system such that performance expectations would bc ingrained into the systcm to reduce potential for non-compliance with the expectations.
DB-SS-05-20 Corrective Actions Due Date and Action Type Assignment not per CR 05-05895 The Team determined this CR was resolved in a timely and satisfactory manner.
OB-SS-05-20 Condition Reports Not Written for Maintenance Notifications CR 06-02580 This CR addresses an evaluation of a sample of 20 Limited Apparent Cause Evaluations (LACES) showcd scven instances where the individuals had not completed the required self study training and had bcen cntered as qualified. The Team evaluated the extent of condition review and determined it was cffcctive and comprehensive. The Team recommends the cause code be revised from I02 (no training available) to H03 (change management) since training was available on-line.
DE-SS-06-04: Individuals Performing LACE without Completing Training CR 06-02663 This CR was a CF to track the actions performed to improve the coordination of senior managcmcnt review of completed RCEs to assure timely accomplishment of these requirements.
Coordination of VP Approval and ELT Review of Root Cause Evaluations The team verified that the completed CAS for this CR were effectively implemented, and the backlog of incomplete reviews is declining.
2.4.2 Review of Repeat Condition Reports The Team determined that Davis-Besse only uses the CREST tracking code for repeat occuncncc for those repeat events where preventive actions have been previously taken. Becausc the numbcr of these occurrences is very limited, Davis-Bcsse had tcrminated trending of this codc duc to its limited ~alue.
The Team peer perspective was that a broader definition of repeat events and subsequent trending of this category would provide a valuable measure of the overall effectiveness of the CAP.
Davis-Besse relies on the collective memory of their staff involved in the CAP to identify thesc lesser recurrent events and take additional actions when appropriate. Unless a generic implications review is required, the CAP does not provide specific guidance for elevated action in response to repeat cvcnts.
Davis-Besse does trend CR events and causes in the Integrated Performance Assessment (IPA) Proccss.
However, the typical focus period is limited to 6 months, thereby eliminating the identification of cvcnts with a longer repeat cycle.
The Team performed a word search of the CREST system for the words repeat, repeatable, and duplicate. The identified CRs were manually sorted for clearly identified repeat events. The Team identified 1 1 CRs that were determined to be repeating events. Most of the repeat events werc immediately closed citing coverage by the CR for the prior event. In many cases, the corrective actions to be taken for the prior event, while prioritized within the site work processes, could be viewed as untimely with respect to the reoccurrence of the event. One example of the recurrent events is discussed below.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 28 COIA-CAP-2006, August 14 to August 25,2006
CR 06-01 590 CR 06-00928 CR 05-00738 CRs 06-0 1590 and 06-00928 identify discrepancies between certain plant drawings regarding the proper size for reactor trip breaker fuses. For one discrepancy, two drawings specify a 20 Amp slow blow fuse and one (the controlling drawing) reflects the 30 Amp fast blow field installation. These CRs were dispositioned as CC because the same discrepancy was identified in CR 05-00738 more than a year earlier. The latter CR was a CF which concluded that the proper fuses are the 20 Amp fuses as specified in the vendor design drawings, but that the 30 Amp fuse provides equivalent protection. Thus, replacing the 30 Amp fuses was not required and a CA was created to change the controlling drawing. The drawing change CA was subsequently closed to an SAP notification because it was considered an administrative change. To date, the drawing error had not been corrected.
Vendor Prints Do Not Match Field for Cabinet C4606 Configuration Control Discrepancy-Cabinet C4603 Fuse FB5 Fuse Size Discrepancy in C4603 Cabinet for Fuse Block FB5 Davis-Besse attempted to replace the installed fuses with 20 Amp fuses during a Spring 2006 outage preventive maintenance activity. The fact that the drawing error had not been corrected complicated the pie-job planning because the drawing discrepancy had to be resolved again. Further, thcrc was a fuse holder compatibility issue with the 20 Amp fuses that required reinstallation of the 30 Amp fuscs. Other discrepancies between field and vendor drawings were noted but not Corrected.
The Team had several concerns with the implementation of these CRs The end state of CR 05-00738 appeared to be a use-as-is justification for an existing non-conforming condition in the field (30 Amp field installation with a 20 Amp drawing requirement). The CR hardware disposition block was not checked so the non-conforming condition could not be tracked. Typically, field discrepancies are labeled in some manner so that subsequent observers will know the condition has bccn identified and evaluated, thus reducing workarounds and repeat CRs. No field labeling was applicd to this condition.
The drawing change for an inaccurate controlling drawing did not get high priority such that the condition still existed over a year later.
The CR 05-00738 CA closure to an SAP notification, where it is not tracked as a CAP open item, seemed inappropriate.
The immediate closure of the two repeat CRs missed the opportunity to address all of the identified discrepancies (e.g. cabinet C4606 in addition to C4603, 0.5 Amp vs 5 Amp in one application) and revisit whether the CA priority is appropriate given the amount of effort the discrepancies arc continuing to cause.
The Team recommended that Davis-Besse review the processing of these CRs with regard to thc conformance of the hardware disposition with the QA Program, and the timeliness of corrccting plant controlling drawings. The Team determined that this was an example of how a focus on repeat cbents can be helpful in measuring the effectiveness of the CAP. The Team considers that the original CA (change the drawing) was not completed in a timely fashion which resulted in recurrence of the issue. This is considered to be an Area in Need of Attention.
I page29 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006. August 14 to August 25, 2006
2.4.3 Review of the activities of the Corrective Action Review Board (CARB)
Review of CARB Meeting Minutes for August 8, 2005 The Team reviewed the minutes of the CARB meeting on August 8, 2005. The CARB approved CR 04-07693 (Evaluation of INPO SOER 99-1 Addendum) with comments to rectify two corrective action discrepancies and createhalidate an additional enhancement action. CARB did not comment on the failure to meet the 150-day INPO expectation for evaluation of this issue.
The Team determined that the CARB exercised its responsibility for technical reviewioversite of CR 04-07693, but missed the opportunity to reinforce the Operating Experience Program goals.
Review of CARB Meeting Minutes from February 13, 2006 The Team reviewed the CARB Meeting Minutes from 2-13-06 (Agenda included review of six ER evaluations, five ACES, and three other CR evaluations)
The Team determined that ERs are performed in accordance with site document NOBP-LP-2007. Section 4.1.3 states that the ER date is established by the CR owner and validated by CARB, when applicable, with the intent being to evaluate effectiveness at the earliest expected opportunity. Contrary to this direction, the CARB minutes reflect that the ERs reviewed were scheduled late for CARE3 review due to an oversight, and as such, CARB members noted that they were reviewing ER evaluations for adequacy many months after the ERs were actually performed.
Additionally, the Teams review of the CARB Minutes indicated that CARB review of ACES were critical and directed evaluation changes as appropriate.
Review of CARB Meeting Minutes from May 22, 2006 The Team reviewed the minutes of the CARE3 meeting on May 22,2006. The CARB approved evaluations for CRs 06-0053 I, 06-00564,06-00101, and 06-00432 with comments. CR 06-00624 was accepted as written. CR 06-001 0 1 addressed a discrepancy in a contractors background history not identified prior to him receiving unescorted access to the site. The CARB discussed that thcrc had been a procedure requirement to use Team Badging and how to prevent a procedure requirement from being undone in the future as documented in this case. The CARB added a CA to add a statement to the contract purchase order to require using Team Badging or to notify the site if they change the procedural requirement. CR 06-00289 (discussed difficulty implementing changes to improve Fleet performance) was tabled because of no representation present.
The Team determined that the CARB exercised its responsibility for technical reviewioversight of CR evaluations. CR Corrective Action item 2 was completed in May, 2006 and included the requirement for Team Badging in the contractors own background screening procedure.
Attendance at CARB Meeting of August 14,2006 Members of the 2006 Assessment Team attended the CARB meeting on August 14,2006 and observed the Boards review of significant CR 06-02558 (B Turbine Trip Solenoid failed to indicatc valve tripped during periodic test).
The Team determined that the presentation discussion was well done. The presenter was challenged by CARB members and was able to explain why certain actions were performed. The Team noted that the investigation pursued two separate problems (only one was significant) and made it unclear which problem the CAS addressed. This confusion was demonstrated by several questions from CARE3 members as to which problem (failure to trip or slow to reset) the CAS addressed.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 3o COIA-CAP-2006. August 14 to August 25, 2006
The C A M, after much discussion on whether to close the investigation when no root cause had been found, elected to declare the investigation complete. In fact, the CARE3 approved waiving of the ER action, since no cause had been found. There was no discussion on the acceptability of recurrence of the event, which, without corrective action to preclude recurrence, was more likely to occur. There was no discussion on the basis for classification of the CR as significant or on the option of downgrading the CR.
There was a distinct command and control flavor exhibited by the CARB Chair (Director of Site Performance and Improvement), yet there was an equally distinct willingness of other CARB mcmbcrs to carry on a collegial discussion and at times disagree with the comments of the Chair. There was no indication that participants were in any way unwilling to express opinions and/or concerns.
The Team concluded that the investigation analysis was weak. Although appropriate investigative techniques were used, the use of those techniques did not result in identification of a root cause.
Therefore, no extent of condition or extent of cause was pursued. Based on not identifying a root cause, not providing CAS to preclude recurrence, and not pursuing extent of condition or extent of cause, the likclihood of event recurrence was high. This is an additional example of the Area in Need of Attention in CR evaluation quality, thoroughness, and documentation including CARR rcview.
Attendance at CARB Meeting of August 21,2006 During the CARB meeting on August 2 1, 2006, following discussions concerning the previous outage performance (and Limited Cause evaluation 06-01 179) regarding main fuel handling problems, a CARB member asked whether the fuel handling mast guide bars were going to be replaced as had been requested. The limited cause evaluation included review of CR 06-00897, Guide Bars for ERC 05-0304, had less clearance than the original bars.
In addition, during the CAlU3 meeting, a 2-month assessment of chemistry issues was discussed. This was considered to be a useful look at emerging issues. It was noted that the second tier chemistry analysis (e.g. amines and sulfates) were unable to be measured due to equipment deficiencies.
The meeting also reviewed three LACEs and an ER in accordance with NOBP-LP-2008, FENOC Corrective Action Review Board. The following items were reviewed:
CR06-01183 NRC ISI: Reportability of CR 02-08782 CR06-01313 Two Personnel Contamination Events Resulting in Minor Intakes CR06-01179 Main Fuel Handling Bridge Problems During 14RFO rn ER 04-01996-2 Effectiveness of Actions to Prevent Valve Stem Ejection The results of recent cognitive binning efforts by the Chemistry and RP sections were also presented at this meeting. The Team found these presentations to be insightful, and CARE3 members probed thc bascs for the conclusion reached by the Sections. The Team noted that part of the Chemistry Dcpartmcnts presentation included information that the second tier chemistry analysis (e.g. amines and sulfates) wcre unable to be measured due to equipment deficiencies.
The LACE presentations summarized the problem, cause analysis, and CAS recommended for each event.
Board members were critical and thorough in each review, raising appropriate questions for the cvaluator to address prior to closure of the CR. CARB uses a grading process to determine whether evaluations arc approved, approved with comments (to address before closure), or reject a CR analysis. The Team noted that the grading sheet for LACEs has three assessment topics that are applicable to ACES but not suitable for a LACE. The use of this grading sheet artificially inflates the CARB grade by 12 points and can mislead evaluator and condition owner as to the acceptability of the work product. During the discussion Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 3, COIA-CAP-2006. August 14 to August 25, 2006
of CR 06-01 183, CARB had many comments and questions that the Team perceived would result in at best a marginally-acceptable rating. The actual grade of 96 out of 100 appeared to send the owners an incorrect assessment of the quality of the CR product as presented. During interviews with the Perfonnance Improvement Section, the Team learned that the FLEET CAP coordinator had already accepted an action tracking item to address this issue.
Finally, the CARB was scheduled to review SCAQ Items Open more than 135 Days, but the Team noted that an earlier Condition Report, CR 02-06178, included a CA, coded Preventive Action (PR) to prevent a repeat condition, to replace the guide bars with ones which have gradual sweep on each end.
Although it appears that the motive of this later CR was to improve the outage schedule due to unreliable refueling equipment and there were no underlying safety issues, it appears that the types of issues being raised with the refueling equipment had been raised several years ago and that the problems had not been fully resolved.
The Team also noted that, during the morning management meeting on August 21, 2006, the list of Open Significant Corrective Actions Open Over 135 days was not discussed in detail. The abovc CR 02- 06 I78 was included in this list and was not projected to be completed until mid-2008.
The Team determined that the list of significant SCAQ items open over 135 days was an Area in Need of Attention in order to assure that CAS (especially preventive and remedial) are receiving the propcr priority and attention by the plant staff and managers.
2.4.4 Summary The Team determined that Davis-Besse has a narrow definition of repeat events and therc is no clear method for sorting repeat events from the CREST database. The sites dependence on individual memories for identification of repeat events may limit the ability to identify similar occurrcnccs. NOP-LP-2001, Condition Report Process, requires an SCAQ categorization for multiple types of repeat events. Correct identification of repeat occurrences is presently dependent on the memory of Davis-Bcssc staff and management.
The MAOM, CR review meeting, and CARB meeting provided an effective review of new key issues and provided confirmation of priority and responsibility for follow-up in the continuity of corporate experience and memory.
Areas of Strength None.
Areas in Need of Attention The Team determined that the list of significant SCAQ items open over 135 days was an Area in Need of Attention in order to assure that CAS (especially preventive and remedial) are receiving the proper priority and attention by the plant staff and managers.
The Team determined that the identification of repeat occurrence was dependant on the memorics of individuals involved in the CR process, rather than being retrievable from the CR database. The lack of a clear definition of what was a repeat occurrence and the reliance on staff recollection for repeat issues may limit the ability to establish the effectiveness of the CAP over an extended time pcriod.
The 2006 Team noted this is an Area in Need of Attention.
. CR 06-02558 had no root cause identified, no extent of condition or extent of cause pursuit; CR 05-05559 on the Boric Acid Pumps was approved without adequate extent of condition review. These Davis-Besse Nuclear Power Station Independent CAP Assessment COJA-CAP-2006, August 14 to August 25,2006
CRs are additional examples of the Area in Need of Attention in CR evaluation quality, thoroughness, and documentation, including CARB review.
The closure of CR 05-05395 with only two-thirds of the required training of the designated audiencc was an Area in Need of Attention.
The Team determined that CR 05-00738, corrective active implementation was untimely to prevent additional CRs (06-00928,06-01590).
Areas for Improvement None.
Conclusion The Team determined that implementation and effectiveness of the CAP was EFFECTIVE at identifying and correcting problems. The problems were properly captured and characterized by the CAP. The implementation of the SAP Notification Action process has reduced the CR and CA backlog and fostered increased focus on the adverse conditions.
2.5 Effectiveness of Program Trending The Assessment Team performed an analysis of the effectiveness of the trending of CAS. The analysis included:
A review of the deficiencies tracked in the CAP.
An evaluation of the effectiveness of the Corrective Action Trending Program.
2.5.1 Deficiencies Tracked in the Corrective Action Program (CAP)
This section discusses the deficiencies tracked in the CAP. The condition reporting process has been reviscd since the last Assessment. In September 2005, the site revised the CREST database to eliminate all work items classified as NCAQ. All open CAS were evaluated and those determined to be NCAQ issues were closed and an SAP Activity lnitiation Form was generated to replace it. New CRs were generated for open CAS if it was determined that they should be converted a CAQ and remain in thc CREST database. The transfer of NCAQ issues from the CREST database to the SAP database increased the visibility of the SCAQ and CAQ items remaining in the CREST system. This helped Davis-Besse Management focus on the work items with the largest probability of adversely impacting plant operation.
The purpose of the CAP was to identify and document adverse conditions, their cause, and to take actions to correct and prevent recurrence. Individuals reported SCAQ or CAQ deficiencies by completing a CR in the CREST database. Conditions considered to be NCAQ were entered into the SAP database system.
The Team reviewed multiple CRs and their associated CAS as part of the 2006 Assessment. The Teams evaluation determined that Davis-Besse does an effective job of tracking CAQ and SCAQ deficiencies in the CREST database system. The Team also performed a limited review of the enhancement actions tracked SAP database in an effort to identify CAQ or SCAQ deficiencies that may have been incorrectly categorized.
The Team determined that deficiencies tracked in the CREST database are appropriately categorized and receive management attention commensurate with their importance to the site. During its Iimitcd rcvIcw of the items in the SAP database, the Team did not identify any CAQ or SCAQ deficiencies that had been entered into SAP in error.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 33 COIA-CAP-2006, August 14 to August 25,2006
2.5.2 Effectiveness of Corrective Action Trending Program This section evaluates the effectiveness of Davis-Besses trending activities, the CAP for both organizationallprogrammatic issues, and equipment failure issues.
Davis-Besse has visited multiple top-tier nuclear sites to benchmark the trending methods and trending reports. This information has been used to develop trending programs for the site. These trending programs are described below:
Davis-Besse Trending Programs The Davis-Besse Trending Program comprises five primary programs along with other programs that are unique to each Section:
I
- 2.
- 3.
Plant Health Report
- 4. Snapshot Self-Assessment
- 5. Outage Trend Summary Report Integrated Performance Assessment (IPA) Program Cognitive Binning and Trending Program lhc IPA was the most comprehensive of the trending programs at Davis-Besse. It was based on procedure NOBP-LP-2018 Integrated Performance AssessmentlTrending which was developed to standardize thc CR trending requirements of procedure NOP-LP-200 1, Condition Report Process. Each section is to develop a complete IPA every 6 months (April and November) which become part of the Davis-Besse Site Summary report to FENOC.
Cognitive binning was a part of the IPA program. Each site section manager was required to review and bin all CRs assigned to their section. The CRs were binned to identify repetitive conditions and trends.
Currently, the CARB required each Section to prepare and present a binning process summary report to the CARB every three months.
Plant Health Reports were prepared every quarter by the Plant Health Committee (PHC) with input from the system engineers. Procedure NOBP-ER-3002, Plant Health Committee, identified thc mcmbcrs of the PHC and describes the plant health review process and report format.
Snapshot self-assessments were focused assessments in accordance with NOBP-LP-200 1, FENOC Focused Self-Assessment Process, that covered a short period of time and concentrated on a single issuc.
They were an effective method of performing a short, high-intensity, targeted evaluation of a specific activity within a specific department. The Common Cause Analysis (CCA) was one type of snapshot sclf-assessment. It was done in response to NOP-LP-2001, Corrective Action Program, and NOBP-LP-201 1, FENOC Cause Analysis. The CAP manager used common cause analysis to assist with the identification of long-term recurring failures, degraded equipment, and performance issues. The CCA process required an evaluation of multiple events to determine whether a common or underlying incident contributed to each event or failure.
The Outage Trend Summary was a review that occured after each outage to identify problems and adversc trends and develop implementation programs to minimize the likelihood of recurrence. While the CCA looked at events during plant operation, the Outage Trend Summary Report consolidated recurrent events and performance issues specific to the outage.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 34 COIA-CAP-2006. August 14 to August 25.2006
Evaluation of Trending Programs The Team reviewed trend reports completed since the completion of the 2005 Assessment. A summary of the Teams evaluation of each trending program follows.
Integrated Performance Assessment The Team reviewed the following IPAs:
CCN NO. 05-00200 CNN RAS05-005 10 DSM-06-00053 DBE-06-0099 CNN RAS 06-00212 D S M 000 5 3 KAS-06-00259 Design Engineering - Integrated Performance Assessment - May 1, 2005 through October 3 1,2005 Davis-Besse Regulatory Compliance - Integrated Performance Assessmcnt - May 1, 2005 to October 3 1,2005 Davis-Besse Maintenance - Integrated Performance Assessment - May I, 2005 to October 3 1,2005 Design Engineering - Integrated Performancc Assessincnt - November 1, 2005 through April 30, 2006 Davis-Bessc Regulatory Compliance - Integrated Performance Assessmcnt -
November 1,2005 to April 30,2006.
Davis-Besse Maintenance - Integrated Performance Assessment - November 1, 2005 to April 30,2006 Davis-Besse Site Summary of Integrated Performance Asscssments - November 1, 2005 to April 30, 2006 Thc Team determined that the IPA program was being effectively implemented within each dcpartment at Davis-Besse. Departmental staff was sufficiently self-critical and both positive and negative items were being identified and, when appropriate, SAP notifications or CREST CRs were prepared. The 2006 IPAs identified the lack of CR cognitive binning during the 141h refueling outage and the Station has idcntified this as an Area in Need of Improvement for future outages.
Cognitive Binning Process Each Section used the cognitive binning process to sort CRs and identify potentially adverse trcnds. The binning and trending process was part of the IPA, which was summarized at the end of 6 months. This gave each Section a relatively short history for trending. The Team determined that trending would bc cnhanccd if the binning records were compared over a longer time period.
The Team attended the August 14, 2006 CARB meeting and witnessed the prcsentation of the Cognitive Binning for the Plant Engineering Section. The presenter from Plant Engineering stated that they did not bin CRs during the refueling outage due to a lack of available manpower. The CARE3 challenged this reasoning and stressed the need to complete the process, even if it is after the outage. During its review of the presentation, CARB members found it difficult to obtain meaningful information from trcnd charts and requested the report be re-done and brought back to CARB at a future date. Additionally, the trcnd report presenter was unprepared for questions from the CARB members and frequently referred to being new to the task and only doing what his predecessor had told him to do. At one point, he appcarcd frustrated and informed the CARB that he doesnt relish doing this. The Team determined that this indicated a lack of preparation for the meeting.
Davis-Besse Nuclear Power Station independent CAP Assessment I Page 35 COIA-CAP-2006. August 14 to August 25, 2006
During the Teams review of the information, it was noticed that the 3d level equipment performance binning chart broke the CRs down by types (e.g., doors, MOVs, heat exchangers, etc.). One category stood out prominently - Boric Acid Corrosion Control, yet this was explained by the presenter as consistent with what has been seen in the past. The CARB accepted this without challenge. This may indicate that the CARB was willing to accept the excuse this is the way it has always been for a potentially adverse trend.
The Plant Engineering Sections trend report included charts associated with operational and procedural issues as well as equipment problems. The CARB Chairman questioned whether the equipment should be trended separately. One CARB member asked if the report included all equipment related CRs. The presenter stated that the report only covered equipment assigned to his organization. The CARM directed the report be combined with trend reports from other organizations to trend all equipment related CRs.
The Team determined that the CARB was sufficiently cognizant of the purpose of binning and enforced a sufficiently focused review of trend information presented to them.
Plant Health Report The Team reviewed the Plant Health Reports for the first and second quarters of 2006. The review noted improved documentation of system performance and analyses of problem areas and recovery plans for each system. The use of the past eight quarters for system health trending demonstrates Davis-Besses goal for improved trend analysis.
Snapshot Self-Assessment The Team reviewed DB-SS-06 Snapshot assessment of the Davis-Besse 14th refueling outagc issues compared to FENOC as a whole and to evaluate whether trends of CRs are identified for rcsolution of program or process weaknesses.
The fact that Davis Besse was performing a post-refueling outage self-assessment to compare performance against other FENOC plants in the area of identification of program and/or process weakness was considered useful. In the review of CR 06-01503 (Nuclear Oversight identified an adverse trend in the area of workers contaminated in non-posted areas), the Section reported that the associated cause evaluation concluded that there was no adverse trend and no corrective actions were pursucd. This CR is an additional example of the Area in Need of Attention in CR evaluation quality, thoroughncss, and documentation discussed in Section 2.3 of this report.
Although the assessment report states that a Nuclear Oversight identified weakness (CR 06-0 1697, written on 4/7/06) associated with workers entering HRAs under the wrong Radiation Work Permit (RWP) was evaluated as not representing an adverse trend (and therefore no associated CAS), there was a subsequent CR written by the RP organization on this same topic (CR 06-0248 1, written on 6-6-06) in which the trend was analyzed and corrective action assigned. It is not clear what prompted this change.
The assessment identified that CRs for four conditions discovered during BACC inspections had two-part CAS that were only partially implemented with the associated CRs ready for closure. The assessment resulted in initiation of a new CR (06-02684) to resolve the CAP issue related to inadequate corrective implementation which the Team determined to be appropriate.
The Team determined that open items from the SAP database were incorporated in only one IPA. The SAP items should be included in the IPA evaluation for each department or Section. The Team considered this to be an Area In Need of Attention.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 36 COIA-CAP-2006, August 14 to August 25, 2006
The Team also reviewed DB-SS-06-26, Condition Report Common Cause Review (draft), and found it to be a good review; but the evaluation period ended in June 2006, the report is dated July 2006 and it is still in review. Based on interviews, the evaluators intended to initiate two CRs for common issues. The Team believed that timeliness was important for the effectiveness of resolving problems.
Outage Trend Summary Report The Team reviewed the CR Trend Summary for Unit Outages dated February 2006.
This assessment report summarized certain trends from CRs that have occurred during outagc pcriods at Davis Besse, Perry, or at Beaver Valley for the last several outages. The report identified global issues and site specific issues depending on the frequency and significance.
Issues identified included the following:
Housekeeping.
Personnel contamination.
Dose alarms.
Working hour guidelines exceeded.
Industrial safety.
Borated water leakage, fuel damage, and main steam safety valve set points.
Although the trend report was considered useful in preparation of the outage, the licensee expericnccd many difficulties during the outage as discussed in many post outage critiques, discussions with site personnel, and CNRB meeting minutes.
The licensee generated a CR 06-02686, Abandonment of Site Organization Cognizant Trending During Outages, in response to departments failing to perform monitoring and a low self identification rate during the refueling outage.
2.5.3 Summary With the exception of equipment trending, the overall trending program has undergone significant programmatic improvements since the last evaluation. These improvements were bascd on industry benchmarking and a cultural shift towards line ownership of the Trending program. Many of thcse improvements had a short track record and as such, need additional time to evaluate their effectivcncss.
Additionally, there are further changes currently planned (e.g. converting the CAP database from CREST to SAP) that may enhance these improvements or could detract from the progress made.
During interviews with Davis-Besse personnel, the staff was unable to providc information on how thc implementation of these labor-intensive trending programs had benefited the station. The Team suggcsts that Davis-Besse do more to demonstrate the success of the trending program. This will enhancc individual commitment and line ownership of the trending programs.
Areas of Strength The IPA process was much improved.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 37 COIA-CAP-2006, August 14 to August 25,2006
Areas in Need of Attention Open SAP issues were part of the IPA and Trend Process for only one department. Since the SAP database contains action items that require station resources, it seems appropriate that these items bc included in the IPA.
The lack of cognitive binning by many departments during the refueling outage may be indicative of a lack of focus on trending and its ability to identify long term problems.
Areas For Improvement The trending of equipment problems across systems continues to be an Area For Improvement. This is a continuation of the same issue identified during the 2004 and 2005 Assessments. FENOC has developed a draft procedure NOBP-ER-3916, Component Health Trending Reports, which, when implemented, may assist FENOC with the identification of common component problems for all four nuclear plants in the FENOC system. The Team determined that this proposed new trending program has the potential to be an excellent tool but this issue remains an unresolved item for this report.
Conclusion The Team rated the effectiveness of Program Tending as EFFECTIVE.
2.6 Effect of Program Backlogs The Assessment Team performed an analysis of the effect of program backlogs on organizational and operational effectiveness. The Teams assessment consisted of:
A review of program backlogs and the trend of the backlogs.
An evaluation of the impact of the backlog and backlog trend on organizational and operational effectiveness.
The Team reviewed the status of the backlog of open and unresolved work items at Davis-Bessc. This was conducted through a series of interviews with plant staff and a review of the Davis-Bessc databases, reports, Integrated Performance Assessments, and numeric summaries.
2.6.1 Program Backlog and Backlog Trend Davis-Besse continued to reduce the backlog of open CRs and CAS. The implementation of the SAP database to track enhancement activities has proved enhancement activities are identified and transferred to the SAP database in accordance with NOBP-LP-20 19, Rev. 2, Corrective Action Program Supplemental Expectations and Guidance.
The 2006 Monthly Performance Report process has established a target for Davis-Besses short-term CAS of 680 open CAS by December 3 1, 2006. The follow-on target is to reduce open short-term CAS to no more than 500 by December 3 1,2007. These will probably require extensive support from staff and management to meet.
Review of Oldest Open SCAQ CRs The August 2 1,2006 MAOM was scheduled to review SCAQ Items Open more than 135 Days but the Team noted that, during the morning management meeting on August 2 1, 2006, thc list of Opcn Significant Corrective Actions Open Over 135 days was not discussed in detail. One of the oldcr items is part of CR 02-06 178, which included a CA, coded PR to prcvent a repeat condition, to replace thc guide bars with ones which have gradual sweep on each end. The work is not projected to bc completed until I
Page38 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25,2006
mid-2008. This action appears to be aimed at improving outage schedule by correcting unreliable refueling equipment and it also appears that there were no underlying safety issucs. The Team dctcrmincd that the types of issues being raised with the refueling equipment had been raised several ycars ago and that the problems had not been fully resolved.
The Team noted that the licensee had established two key methods to focus on backlog: adding a list to the Monday MAOM of all SCAQ items open over 135 days and a numerical listing and bar chart in thc Friday meeting package of the open site backlog documents (actions requiring work ). The Team attended the morning management meeting on August 2 1, 2006 and determined that the station review of thc Open SCAQ Corrective Actions Over 135 Days of Projected Over 135 Days was not effective sincc several CR CAS were several years old and there was essentially no discussion of them during the meeting.
The Team reviewed the average age of the oldest open CRs identified in the meeting minutes for the Monday MAOM. As demonstrated in the following table, the average age of the 10 oldest CRs continucs to increase. As identified in Section 2.4 of this report, the Team concluded that the revicw of thcsc old SACQ action items continued to be an Area in Need of Attention.
Age of Oldest Condition Reports Average Age of 10 Oldest CRs 382 days 540 days 830 days Oldest Preventive Actions (PAS) 889 days 1,219 days (outage) 1,610 days (outage)
Oldest Remedial Actions (RAs) 691 days 862 days 1,224 days Review of Old Condition Reports The Team evaluated the following CRs.
CR 01-00430 RCS Boron Increase When Deborating Demin #I Placed in Service This CR was an SR event addressing a reactivity excursion when a deborating demineralizer was placcd in scrvicc. The only action that was open in this CR was an ER with a due date of 513 1/04. Thc CA was extended to 5/3 1/06 because the plant conditions to support the ER would not exist until carly 2006. In mid-2004, the CR owner decided to close the ER now based on an altematc vcrification mcthod (procedure rcvision verification) because the required plant conditions were so far in the futurc. Aftcr some iterations with C A M on the documentation of the closure justification, the CA was closcd on 8/24/05, CARB-approved on 1011 1/05 and the CR was closed on 1 1/17/05.
The Team found the use of alternate closure methodology for this action to be acceptable and contributing to backlog reduction.
CR 01 -01 508 This CR was an SR CR written to evaluate the cause and establish CAS for an event resulting in thc risk values remaining green when it should have resulted in a move to the yellow condition. Thc removal of a CCW heat exchanger from service was not correctly entered into the Safety Monitor risk asscssinent program.
Equipment Lineups Affected Maintenance Risk Assessment Intcrim actions were taken when this was identified in 2001, including a Standing Order to haw thc Probabilistic Risk Assessment engineer validate the risk assessment prior to release of work by operations. Most CAS were completed in 2001 and 2002. The CR had been held open to conduct an ER.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 39 COIA-CAP-2006, August 14 to August 25,2006
This was granted an extension and the first ER was completed and accepted by CARB on 8/12/04, and the second ER was accepted by CARB on 1 1/21/05.
Subsequently, the station conducted a comprehensive Self-Assessment of the Risk Management process at the station during October, 2004. Several CRs were written to initiate suggestions for revising processes and procedures. The subsequent ER was completed in August, 2005 and concluded that there were no further similar issues with the risk management program or its implementation.
The Team found that although the CR was kept open until 2005, the October 2004 audit was comprehensive and effective.
CR 02-00502 This was an SR CR written due to the as-found setting found out of Technical Specification limits. The cause was attributed to bonding of the disc and seat over time due to similar materials. The corrective action was to replace the discs with pre-oxidized Inconel discs.
Main Steam Safety Valve As-Found Teat Results The Team concluded that this CR was still open because thc licensees plan to replace the discs on all twelve Safety Valves had not been completed yet. The licensee still has one more disc to rcplacc in thc next refueling outage.
CR 02-00784 The Teams review determined that Davis-Bcsse has completed new fuel design with an improved spacer in the latest outage. The only remaining action is an ER.
CR 02-02419 The Team determined that this CR was opened June 2002. The last action was taken April 2005 but the CR was not closed until June 2006. The Team determined that this was untimely closeout.
Collective Review of the Nuclear Fuel Related CRs for Common Cause Untimely Corrective Actions to Address Corrective Action Program W LP2 CR 02-02494 RCP Seal Injection AOVs Are Installed Contrary to Design Assumptions Made During Startup and Pre-Operational Testing The Team determined that the ER was completed 3/29/05, which concluded CAS were satisfactorily implemented and that they were effective in preventing recurrence.
CR 02-02575 This CR was an SR event addressing a marginal area for fire brigade training in a QA audit. The only action that was open was to resolve CARB rejection comments for the ER of CAS. There were three CARB rejections of the ER based on incomplete documentation of the ER process expectations.
Audit AR-02-FIRE P-01 Marginal Rating The Team found the final closure acceptable and noted that CARB scrutiny was not affected by backlog reduction emphasis.
CR 02-02606 The ER was completed 5/27/04, which concluded CAS were satisfactorily implemented and that they were effective in preventing recurrence.
Implementation and quality of the Radiation Protection (RP) corrective action program is considered unacceptable CR 02-02846 This CR was an SR event addressing containment sump deficiencies identified in 2002. The only CA open was the ER. The ER took credit for other ERs for CRs more focused on the root cause (lack of Containment Emergency Sump Issues Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 4o COIA-CAP-2006, August 14 to August 25,2006
managerial methods) of this CR. That root cause had already been addressed by several other similar events identified during the extended outage. The CARB approved the ER on 1/9/06, The Team determined that ER closure was appropriate.
CR 02-02943 This item was closed in an untimely manner. The root cause was identified and actions were assigned to address the root cause. The CR open 07/02/02, ER completed 06/22/05, last CA (#71) transferred to SAP system on 04/22/06; however, the CR was not closed until 0711 3/06.
Containment Air Cooler Boric Acid Corrosion CR 02-04674 AFW Strainers This CR identified that the Auxiliary Feed Water (AFW) strainers to protect the pump and turbine bearing coolers and the turbine governor coolers are designed to catch particles smaller (0.0470 inches) than those screened by the Service Water strainers (0.0625 inches), which introduced the potential for a common mode failure of both trains of AFW pumps andor turbines by first clogging the strainers, then overheating the bearing coolers or governor coolers.
The Teams evaluation determined that CA-14 remains open to add AFW Pump high bcaring tcmperaturc as an input to AFW Pump Trouble alarm (due 10/19/06). CA-15, to revise alarm procedures commensurate with CA-14, is open and due 6/30/08. This date does not appear timely in light of the duc-date associated with CA-14.
CR 02-04914 This CR was closed in an untimely manner. The CR was opened 08/28/02 and the last action was closed 12/20/2004; however, the CR was not closed until 07/07/2006.
Apparent Violation of 10 CFR 50.9, Completeness and Accuracy of Information CR 02-05548 This CR was an SR CR written on 9/5/02 due to an adverse trend on observations of the Bcchtel cadweld quality control inspections, qualifications, and supervisory oversight.
Breakdown of Bechtel QA Program CAS included issuing a Stop Work Order pending CAS; and a back to work plan was put in place by Bechtel. The station QA organization provided follow-up and the CAS were all closed out by 2003.
However, the CR was not closed until July 2006.
A related CR, 02-05591, was also closed out at the same time in July 2006 regarding an adverse trend in human performance with contractors in general.
The Team found the final closure was not completed until July 2006 and questioned why it appcarcd that this CR was kept open for 3 years with no apparent action.
CR 02-06019 The Team determined that the cause codes in CR did not completely match those in the root causc report and the NRC violation response.
Inspection Procedure EN-DP-01508 Findings for Inspection Area 603-4 CR 02-07409 This CR was an SR event addressing service water pump room flooding issues identified in 2002. Thc only CAs open were the ER and implementation of an Engineering Change Request (ECR) to affcct drawing changes. The ER took credit for other ERs for CRs more focused on the root causc (latent design issues) of this CR. That root cause had already been addressed by several other similar cvcnts identified during the extended outage. The CARB approved the ER on 1/9/06. The documentation for Potential Loss of Service Water Due to Flooding Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 4, COIA-CAP-2006, August 14 to August 25, 2006
closure of the CA that tracked issue and implementation of an ECR indicated that the CA was closed before full implementation (based on ECR issue) of this remedial action. Subsequent follow-up determined that the ECR had been fully implemented.
The Team found the closure of this backlog CR satisfactory, noting the weakness of the ECR CA implementation as a stand alone document. The CA verifier and approver could do a better job assuring that the CREST documentation completely addresses the CARB approved action.
CR 02-07596 LIR-EDG-High Temperature Overall CR CR, open 10/07/02, ER (last action) completed 06/29/02; however, the CR remains open pending Senior supervisory review of the report and final review of the CR pending closure.
CR 02-08530 This CR was held open to complete both an ER and a snap shot self-assessment. Both completed and appear satisfactory. Closed in July 2006.
PWAOTC: Potential Programmatic Breakdown of the AOTC Program CR 03-00363 CCW Pump 2 Tripped on Instantaneous Over Current and Instantaneous Ground This CR was a carry-over from the old CR database - 1999-1648 - CCW Pump 2 tripped on instantaneous over current and instantaneous ground. Entered Tech Spec 3.8.1.1, 3.7.3.1, and 3.5.2 due to #2 EDG, #2 CCW Train, and #2 ECCS Train Components inoperable.
The Team determined that the ER was performed 1/18/06 according to revision 3 of NOBP-LP-2007, which concluded that the CAS were not effective. Condition Report CR 06-00069 was written as a rcsult.
CR 03-04773 RCPlRTD Installation Not in Accordance With Vendor Manual The Team determined that the last two CAS were completed in February 2005. The CR was not closed until July 2006 with no evidence of any other work on it documented. The Team believes that this demonstrates untimely closure.
2.6.2 Evaluation of the Impact of the Backlog and Backlog Trend The numerical backlog of work items was declining and Davis-Besse had a program in place to monitor the continued reduction in backlog. While this was appropriate, the average age of the oldest open CRs continues to increase and interviews with Davis-Besse personnel identified that several Sections were dedicating their full resources to preparing for the lSh refueling outage. Few resources were planned to be directed toward backlog reduction until all work packages for 15RFO are completed. The continued progress in reducing the backlog is an Area in Need of Attention.
2.6.3 Summary Several of the CRs reviewed stayed open for extended periods of time, some awaiting an action scheduled far in the future, others with no open activities. The Team noted that many of the long term CRs remained open simply because the staff did not focus on completing the items.
Areas of Strength None.
Areas in Need of Attention Progress in reducing the backlog still needs aggressive attention to continue to improve, especially for calculations, procedures, and drawings used for design, operations, and maintenance activities.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page 42 COIA-CAP-2006, August 14 to August 25,2006 I
Areas For Improvement None.
Conclusion Overall, the Team rated the effectiveness of the backlog program as EFFECTIVE. The backlog of open items at Davis-Besse was larger than industrial norms; however, it received a high level of management attention and was being monitored for its impact on plant safety and operability. While the quantity of open items was slowly going down, the average age was increasing.
2.7 The Assessment Team evaluated the effectiveness of the Davis-Besse Nuclear Power Stations internal assessment activities associated with the implementation of the CAP. This assessmcnt included:
Effectiveness of Internal Assessment Activities A review of the results of Davis-Besse auditsheviews conducted since the 2005 Independent Assessment of the CAP that evaluated the effectiveness of the implementation of the CAP.
Interviews with individuals involved with the oversighuaudit function to detcrmine thc effectiveness of these efforts and the responsiveness of Davis-Bessc management and staff to the issues raiscd.
An evaluation of the effectiveness of Davis-Besses sclf-assessment capability with regard to the CAP, and the aggressiveness of the Davis-Besse management and staff in responding to sclf-assessment findings.
A review of other internal assessment activities that focused on CAP performance.
An evaluation of the effectiveness of the Davis-Besse safety review committees oversight of the implementation of the CAP.
2.7.1 Evaluation of Davis-Besse OversighWAudit of the CAP To evaluate the effectiveness of the Davis-Besse oversight of the CAP, the Team rcvicwcd the results of oversight auditsireviews conducted since the 2005 Independent Assessment that evaluated the effcctivencss of the implementation of the CAP. This review was completed to determine if the audits!rcviews were comprehensive and whether effective actions were taken to correct problems or weaknesses identified. The Team also interviewed at least four individuals involved with the Oversight/audit function, as well as the audited organization, to gain their insight on the effectiveness of oversight efforts and the responsiveness of Davis-Besse management and staff to the issues raiscd.
The Team reviewed three quarterly Oversight audit reports completed since the last Independent Assessment. Focusing on the oversight of CAP implementation, the Team found that the audits covered a broad spectrum of CAP activities, and the audit process included a 2-year reconciliation to assure that all CAP performance areas were audited. These reports contained well-supported findings for individual areas audited and also provided an assessment of cross-cutting areas such as procedure adherence. The Oversight audit findings were consistent with the Teams findings in the areas that were audited and CRs are tracking Davis-Besse response to the findings, most notably, the need for more progress in the trending program (see Section 2.5 of this report).
The Team also interviewed numerous individuals involved in the audit process to ascertain their insights on the value-added by the Oversight processes and the responsiveness of Davis-Besse staff to oversight findings. These individuals covered a spectrum of line and Oversight managers, auditors, and CAP Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 43 COIA-CAP-2006, August 14 to August 25, 2006
administrators. For a list of individuals interviewed, see Section 5 of this report. In general, the staff was receptive to Oversight findings and perceived that the quality of the observations has been improved by the collation of similar findings and documentation of the irnportancc of each finding. The Oversight staff believed the line staff was responsive to audit findings within the context of the current workload, but believe some actions could be more timely as the burden of the current backlog diminishes. Resolution of trending program deficiencies was cited as an example.
The Team validated these insights through review of Oversight generated CRs and confirmation of FENOC findings during Team assessment of CAP performance areas. Two instances were identified where the RP groups response to oversight CRs was not sufficiently self-critical. In one case (CR 06-0 1 503), several personnel contaminations occurred in non-posted radiological areas. An adverse trend was rejected and no action was taken. The Team noted that focused decontamination was a typical industry response to contamination events even in non-posted areas. In the second case (CR 06-0 1697),
RP initially rejected an adverse trend associated with workers entering HRAs undcr the wrong RWP. A proper response to this issue was eventually taken in response to a later CR 06-0248 1. The Team also noted that these deficiencies were highlighted by a Davis-Bessc snapshot self-asscssmcnt (DB-SS I 1 )
of the 14RFO outage issues. The CR 06-01503 analysis is an additional cxamplc of thc Area in Need of Attention in CR evaluation quality, thoroughness, and documentation dcscribcd in Section 2.3.
2.7.2 Evaluation of the Davis-Besse Self-Assessment of the CAP To evaluate the effectiveness of the Davis-Besse self-assessment of the CAP, the Team assessed the depth and quality of self-assessments and the scope and timeliness of corrective actions taken for identi ticd findings. The Team reviewed five self-assessment reports completed since the 2005 Indcpendcnt Assessment to determine the depth of review, the level of criticality, and the significance of the findings.
During this assessment, several othcr self-assessment evaluations applicablc the CAP were idcntificd and those findings were also evaluated by the Team.
The Team evaluated the aggressiveness of the Davis-Besse staff in correcting self-assessment findings on the implementation of the CAP. This included determining whether the CAS for the reviewed sclf-assessments were adequate, timely, and properly prioritized; and whether ERs were ensuring thc desircd results.
Davis-Besse performed planned (focused) and reactive (snapshot) self-assessments. The focused self-assessment schedule was derived annually, based on managements collective judgment of priority needs.
Senior site and corporate management participation in this process reinforced management support of the self-assessment program. Snapshots were performed as effectiveness verifications, prior to significant outside inspections, or when a manager perceived the need for performance adjustment. While the number of focused assessments has remained about the same, the Team noted that the number of snapshots has increased in 2006. This reflected an emphasis on self-criticality and management support of, and involvement in, the self-assessment process. The Team found the currently selectcd sclf-assessment topics appropriate, but noted that there was no master topic list from which to judge the comprchcnsiveness of self-assessment coverage over the long term. In addition, an industry bcst practicc is to perform a periodic effectiveness evaluation of the self-assessment program. The Team did not find such an ER conducted during the past 2 years.
The Team reviewed the following self-assessment reports:
DB-SS-05-07 The self-assessment reviewed 255 CRs assigned to the Regulatory Compliancc Section over the past 2 years. These CRs were filtered for those with procedure compliance implications and sorted by Snapshot Self-Assessment of Regulatory Compliance Procedure Compliance 1
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occurrence date procedure violated. The assessment found that the errors were primarily with in-house procedures and that the number of events had declined in the last year. Actions taken previously by Regulatory Compliance Supervisors were deemed appropriate and observed to be taking effect.
The Team noted that the self-assessment was comprehensive and reinforced the remedial actions being taken by Section Supervisors.
DB-SS-05-20 The Self-Assessment reviewed the assignment of CA duc dates, maintenance notifications requiring CR initiation, and the appropriate use of ES CAS during the 4'h quarter of 2005. The assessment identified an AFI in each area reviewed; indicating that staff implementation of CAP requirements was not at the expected level. CRs 05-05299,05894, and 05895 were generated to address the AFIs.
Snapshot Self-Assessment of Corrective Action Program Implementation - qth Quarter, 2005 The Team noted that the self-assessment was a critical review of a number of plant CAP activities and focused management attention on the need for greater attention to detail in CAP implementation within Davis-Besse staff.
DB-SS-06-02 Snapshot Self-Assessment of Corrective Action Program Implementation - 1
Quarter, 2006 The Self-Assessment reviewed a sample of closed CAS, Maintenance Notifications, Operations logs, CAQ CRs categorized as CF, and the CA backlog during the 1 quarter of 2006. The assessment identified only one Area For Improvement for a CA that was not implemented as written and not approved by a Director as required by procedure. CR 06-02303 was generated to track thc Area For lmprovement.
The Team noted that the self-assessment completed a comprehensive review of a broad area of plant activities and only identified a single implementation error. This indicated a heightened attention to detail within Davis-Besse staff.
DB-SS-06-04 The Self-Assessment reviewed a sample of closed root cause CAS, CRs categorized as closed hardware repair and use-as-is dispositions, the completion of COIA and INPO AFI CAS, and the implcmcntation of LACE evaluations during the 2"* quarter of 2006. The assessment identified three AFIs regarding the implementation of the newly created LACE. CRs 06-02528,02580, and 02583 were generated to address incomplete evaluator training/certification, missing extent of condition documentation and missing CR analyst reviews.
Snapshot Self-Assessment of Corrective Action Program Implementation - 2"d Quarter, 2006 The Team noted that the self-assessment completed a comprehensive review of several CAP activities and only found problems symptomatic of a newly implemented change in the CAP process. This indicated that CAP implementation was generally good but heightened oversight of the LACE process was appropriate.
DB-SS-06-11 Snapshot Assessment of D-6 14RFO Outage Issues Compared to FENOC as a Whole and to Evaluate Whether Trends of CRs are Identified for Resolution of ProgramlProcess Weaknesses Davis-Besse's performed a post-refueling outage self-assessment to compare Davis-Bessc performance against other FENOC plant outages to identify program and/or process weaknesses. Their review of CK 06-01 503 (Nuclear Oversight identified adverse trend in area of workers contaminated in non-posted Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 45 COIA-CAP-2006. August 14 to August 25, 2006
areas) accepted that the associated cause evaluation concluded that there was no adverse trend and no CAS were pursued. Similarly, the assessment report states that a Nuclear Oversight identified weakness (CR 06-0 1697, written on 4-7-06) associated with workers entering high-radiation areas (HRAs) under the wrong RWP was evaluated as not representing an adverse trend (and therefore, no associated CAS). In this case, there was a subsequent CR written by the RP organization regarding HRA entries (CR 06-02481, written on 6-6-06) in which the trend was analyzed and CA assigned. It is not clear what prompted this change.
The assessment identified that CRs for four conditions discovered during BACC inspections had two-part CAS that were only partially implemented with the associated CRs ready for closure. The self-assessment resulted in initiation of a new CR (06-02684) to resolve the CAP issue related to inadequate corrcctivc action implementation.
The Team determined that this self-assessment was a commendable effort to improve fleet-wide outage performance. The Team noted the missed opportunity to resolve why the RP Section was not more responsive to thc Oversight findings on personnel contaminations and HRA entries.
DB-SS-06-13 Davis-Besse performed a self-assessment to detect trends bascd on human performance cross-cutting events to assure that appropriate CAS were implemented such that additional outside focus on this area was not justified.
Snapshot assessment of human performance cross-cutting issues The assessment report provided great detail on each individual issue and what actions have been taken, and appropriately concluded the need to take specific action to target improvement in the area of attention to detail. The report cited actions currently being taken, including creation and staffing of a new position titled Fleet Human Performance Manager, who is on loan from INPO and is tasked with developing human performance initiatives to improve overall human performance within the FENOC fleet.
The Team determined that this was a thorough and valuable self-assessment effort.
DB-SS-06-26 The self-assessment performed the first common cause roll-up for the IPA cycle ending 6!30106. Two trends of causes were identified, but the report was still in draft form late in August.
Davis-Besse Condition Report Common Cause Review The Team determined that the compilation of individual IPA findings was a good practice that revealcd significant site-wide findings. However, the delay in publishing these findings, and therefore any remedial actions required, reduces the effectiveness of this self-assessment effort.
Overall, the Team concluded that these self-assessment reports were comprehensive, with findings well-justified. CAS for self-assessments were administered by writing CRs for the findings, thus required actions are prioritized consistent with other adverse conditions, and tracked to closure either in CREST or SAP. With the exception of the spccific weaknesses detailed above, the Team found Davis-Rcsscs sclf-assessment performance to be improved.
2.7.3 Review of Safety Review Committee Activities To evaluate the effectiveness of the safety review committees oversight of the implementation of the CAP, the Team reviewed committee minutes, audits/reviews, or other actions initiated by the committees as they relate to risk significance or major corrective action successes or failures.
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From the minutes of the last three Company Nuclear Review Board (CNRB) meetings, the Tcam selected issues raised by the CNRB to identify, assess, and correct areas of weakness. The Tcam performed an independent review of these issues to evaluate the effectiveness of the Davis-Besse response. Thc Tcam also reviewed auditsheviews of the CAP conducted within the last 12 months under the cognizance CNRB to determine if the auditheview findings were consistent with such external assessments as INPO, NRC, and consultants. The results of this review are detailed in Section 2.7.1, above. The Team reviewed the CRs and CAS for several CNRB/audit initiated findings to determine the effectiveness of the CAP in resolving these issues. These issues are discussed below.
Based on this review, the Team concluded that the CNRB was being critical and was highlighting potential safety issues for site and corporate management attention. The station staff through the CAP and other activities had effectively responded to the issues raised. The Team found that the entire record of actions taken in response to CNRB issues had not been integrated with the CAP such that an independent CR review could reach the same conclusion.
Review of CNRB Meeting Minutes for November 11, 2005 This meeting concluded that the top two issues included intcgration of Operations configuration and tagging controls and the preparations for the upcoming refueling outage. The CNRB noted a decrease in the backlog of site work and an incrcase in the quality of RCEs and ACES.
Review of CNRB Meeting Minutes for February 10,2006 The minutes of this meeting focused on three events or conditions that had not bcen pursued as thoroughly as they should have: (1) turbine building crane near miss event, (2) thc root causc for SW 38 out of position not including contributing causes, and (3) CR 06-00019, over prcssurization of thc moisture separator demineralizer. The CNRB concluded that the management team was not in thc right place yet and was not exhibiting a self-critical behavior.
The 2006 Team reviewed a July IO, 2006, memorandum from the site VP to the CNRB chairman which described several actions the site leadership team was taking to determine gaps to excellence, assess obstacles, and clarify roles and responsibilities. Examples were given of self-critical actions including a recently completed integrated performance assessment resulting in approximately 38 CRs identifying areas for improvement and those in need of attention.
Attendance and Review of CNRB Meeting of July 14,2005 This CNRB meeting concluded that discussion of several emergent containment issucs lacked dcpth and perspective:
Copper oxide inside containmcnt.
Small reactor coolant leak.
Containment accessibility, low oxygen levels.
This meeting also highlighted several other issues including operations shift schedules, outage preparations, and uniodmanagement issues in the Security Section. The CNRB rccommcndcd that site management fully understand the situation and adjust actions promptly.
The Team followcd up on several of these issues to verify that corrective actions were taken. Davis-Bessc staff indicated that the low oxygen levels were caused by a nitrogen system valve leak and that once fixed, the atmosphere returned to normal. A routine containment entry was planncd for thc second wcck of this assessment.
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The Team conducted extensive follow-up of the Green Dust issue inside containment because of the level of concern expressed by the CNRB. CNRB members stated that...the plant needs to get hold qf this issue... We cannot afford to let this go on like the Boric Acid issue. The Team conductcd a key word search of the CREST system to generate all CRs related to this issue. The following CRs were subsequently reviewed:
CR 03-07160 Control of dust /dirt in Containment, (Categorized as NF)
CR05-00293 COIA-ENG-2005 Green Dust on 565 During Initial CTMT BLDG Initial Entry, (Categorized as CF)
CR05-03334 RE4597AA Flow Indicator Getting Cloudy, (Categorized as NF)
CR05-04988 Analysis of Material collected from RE4597AA, (Categorized as CF)
CR06-02422 2005 Engineering Assessment Copper Dust ANA, (categorized as CF)
The Team concluded that the station eventually performed a thorough evaluation of the identification of the green dust (determined to be a copper salt formed from corrosion of the Containment air coolcrs) that it did not appear to be an immediate safety issue and that monitoring was taking place to assurc that it did not become a significant issue. The Team reviewed records of scanning electron microscopy and energy dispersive spectroscopy from BWXT laboratories, acceptable Reactor Coolant System (RCS) coppcr concentration limits from Areva, and independent review of actions taken.
The Team, howcver, noted several comments regarding the sitcs actions:
The CR records have conflicting statements regarding Lvhether or not the origin of the green dust was from thc corrosion of the old and new containment atmosphere coolers along with wet boric acid environment i.e. an acidic containment or the passivation of the new rcplaccment coolcrs.
The CRs frequently make reference to a Problem Solving Team which was tasked with taking actions to evaluate the causes and assign CAS. Following discussions with sitc engincers, the Team determined that there was more than one licensee Problem Solving Team. As a direction from sitc management, an additional independent review team was also created to assurc adequate actions wcrc being taken and the results were briefed to site management. In addition, it was not clear whcrc thc Problem Solving Teams reports were located or filed. When the 2006 Assessment Team rcqucsted a briefing, the site engineers produced a Green Dust in CTMT folder with several additional records of investigation summaries, etc. that provided additional explanation of the extent of FENOC and independent industry follow-up, as well as records of briefings to the site management team. The licensee provided the Team with an additional CR,05-043 13, Documentation of Operational Decision-Making Team Report, which provided the documentation of the Team initiated on 7-28-05.
The report was dated August 5,2005 and provided a detailed summary of five issues in Containment including the green dust, RCS leakage, oxygen levels, fire detectors, and sump pump out rate. This is an additional example of the Area in Need of Attention in CR evaluation quality, thoroughness. and documentation described in Section 2.3.
The 2006 Team noted that CR 05-043 13 states that this was the final report of the Operational Decision - Making Team; however, another site team was being formed on 8-8-05 to further addrcss the copper dust phenomenon. The 2006 Team concluded that the site should assurc that all reports and other documents associated with the CAP be included with the CRs or at least refcrcnced to where they were filed elsewhere and could be found.
Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 48 COIA-CAP-2006, August 14 to August 25, 2006
It was not clear in the CR 05-04988 record documentation whether there was an appropriate preventive action taken when the most likely cause of fogging of the radiation flow element RE4597 AA from a sticky silicon compound was the inappropriate use of Dow compound DC 55 grease on the sample pump skid during past maintenance. Following questions by the Team, the system engineer stated that he would add CAS to the CR data base which would document the instructions given to the three technicians who were qualified to perform maintenance on that equipment. These instructions were presumably that they should not use any materials not approved for that special equipment. This is an additional examplc of the Area In Need of Attention in CR evaluation quality, thoroughness, and documentation described in Section 2.3.
It was not clear whether earlier follow-up to CR 03-07160, initiated by a RP technician duc to an accumulation of dust and dirt in the containment, would have provided the station managcmcnt with more prompt assessment of the copper corrosion issue with the containment air coolers, etc. and prevented the CNRB, as well as the COIA of Engineering Programs, from determining that additional management attention was warranted. By the time that the close-out CAS were documentcd, the green dust issue had been acted upon.
Conclusion The Team concluded that the CNRB was being critical, was highlighting potential safety issues for site and corporate management attention, and was effectively being responded to by thc station staff based on the sample of resulting actions and efforts.
Summary The Assessment Team reviewed the effectiveness of Davis-Besses internal assessment of the CAP including oversight audits, self-assessments, and CNRB meetings. Davis-Besse is identifying and correcting most of its CAP weaknesses internally. Some minor discrepancies were identified.
Areas of Strength The team considered the management support of and involvement in the self-asscssmcnt process to bc a positive reinforcement of the performance improvement culture.
Areas in Need of Attention The three ANAs below are also summarized as Areas in Need of Attention in Section 2.3.
Documentation of CAP follow-up to CNRB findings regarding copper oxide in containment did not include all documentation from the multiple Problem Solving and Independent Problem teams, which would have improved the CR documentation.
The RP group was not self-critical enough in response to two oversight observations of adverse trends in personnel contaminations and incorrect HRA entry.
Document of CAP follow-up to a clogged radiation detector (CR 05-04988) did not support an independent review reaching the conclusion that the CAP resolution of the issue was satisfactory. No discussion of extent of condition or counseling of maintenance staff in using unauthorized materials was included in the CA.
Areas For Improvement None.
Davis-Besse Nuclear Power Station Independent CAP Assessment Revised 9-1 8-2006 COIA-CAP-2006. August 14 to August 25, 2006
Conclusion The Team rated the Effectiveness of Internal Assessment Activities at Davis-Bessc CAP as EFFECTIVE.
2.8 Evaluation of Open Actions Taken in Response to NRC Special Team Inspection - Corrective Action Program Implementation - Report 05000346/2003010 The Team reviewed the status of the open CATI CAS as of July, 2006. According to the list provided by the site in preparation for the assessment visit, there were six open CAS associated with three CRs. These were associated with the following issues: lack of vendor data for switchgear at high temperatures, calculation quality, and fuse sizing for motor operated valves. The following provides the current status of the licensee response to the 2005 Independent Assessment Report and those original NRC CAT1 inspection items.
2.8.1 Background Thc 2005 Team had been concerned that very little action had been takcn on the rcmaining itcms as of July 2005 and that CAP effectivcncss would be adversely affected by continuing to utilize rcsources to track and report the backlog if no further actions were planncd.
Response
The licensee had initiated CR 05-04771 on August 12,2005, to document the 2005 Area in Nced of Attention and to assess the remaining open items for regulatory significance, as well as for whcrc enhanced completion priority was warranted. The affected site managers acknowledged that it'thcy wcrc not going to implement actions related to a non-cited violation, then they would be obligated to rcspond back to the NRC with the basis for the disagreement. As of December, 2005, there were eight opcn itcms tracking eight non-cited violations. The licensee had established due dates ranging from January to December 2006 to complete these actions and had verified that resources were available to accomplish them. The Engineering Director indicated that the site had plans to complete all actions regarding these items.
2.8.2 Open Items CR 03-06944 This action was assigned to assure proper protection for the AFW System by initiating Enginccring Change Request 03-0474 to changc thc power and control fuses to the proper sizcs. Licensec opcrability evaluations indicated no operability concerns for either circuit.
CATI: Fuse sizing for MOV 0106 and MOV 38700 Two CAS were opened: one to track initiation of the ECR and one for implcmentation.
As of July 2006, this ECR was open and was assigned to an engineer to work on with a duc datc of August 30, 2006.
(The Team noted that an associated action had been completed in July 2006 (CA02-00412) to updatc a calculation for voltage drops C-EE-002.01-010 rev 30. This concluded that the voltage drop was small and the action was closed.)
CR 03-02730 The CA was initiated to review the Davis-Besse design specification related to ambient tcmpcraturcs.
Consideration was also given to updating the Updated Safety Analysis Report (USAR) with dcsign input CATI: Lack of Vendor Data for High Voltage Switchgear at High Temperature Davis-Besse Nuclear Power Station Independent CAP Assessment I Page COIA-CAP-2006, August 14 to August 25,2006
information wherever applicable. The licensee also planned to revise the procurement specifications as a remedial action but recognized that procurement procedures refer to the USAR, which was updated.
The Corrective Action Number 2 remains open to update the USAR with a due date of March 2007 CR 03-06907 This CA was generated to identify what the NRC saw as a lack of stand-alone engineering calculations to support engineering products. This was considered a lack of attention and a lack of engineering rigor. The CR resulted in 16 CAS of which three remain open: (1) calculations C-EE-0 15.03-007, ( 2 ) C-EE-002.0 1 -
014, and (3) C-NSA-052.01-017.
CATI: Calculation Quality Collective Significance Review The Team noted that the licensee intended to update these calculations and had scheduled them for completion between August 30, and October 30, 2006.
OPEN Non-Cited Violations (NCVs)
CAT1 NCV 03-010-08 A new spare pump has been approved and the licensee has scheduled this item for completion by December 2006.
Failure to Demonstrate HPI Pump Minimum Recirculation Time CAT1 NCV 03-010-17 Lack of Design Basis Calculation to Support Service Water Single Failure Assumption The set point basis for the two pressure switches has been incorporated into calculation C-NSA-0 I 1.O I -
016. ROO.
CAT1 NCV 03-010-20 Borated Water Storage Tank Leakage Calculation Affects Dose Calculation The licensee agrees that this calculation needs to be revised and has scheduled the action with a due date of December 2006.
CLOSED CRs; Actions Not Necessarily Completed CR 03-02651, CATl Framatome AFW Calculation Issues with MSSV This action was completed. FENOC accepted an updated calculation from Framatome, incorporated the calculation into a Davis-Besse calculation, and approved it for inclusion into the USAR.
CR 03-02654, CATl Cable Ampacity on Containment Spray Pump Motor This CR was closed. The remedial action included a revision to the USAR as well as the Design Criteria Manual to address when it was acceptable to use 125 % of full load current. The CR was closed with the USAR updates made; however, the update to the Design Criteria Manual had not been completed and was being tracked to a notification.
The Team determined that the action to update the Design Criteria Manual should have been completed before the CR was closed out. The process of closing out CRs for CAQs to a notification appears to be an Area in Need of Attention.
CR 03-03572, CATI: Lack of Coordination on Bus E l and F l This CR was closed. Action 12 was to replace the overload heaters in the circuit breakers for approximately 20 Motor Control Center loads. The site re-classified this as an enhancement action since they determined that the overload heaters would not cause any failures. This corrective action was not completed but was transferred to the Notification tracking system.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page 5, COIA-CAP-2006, August 14 to August 25, 2006 I
CR 03-05715, CAT1 SBODG Does not Have a Load Table This CR was closed. The described corrective action to create a station black-out diesel generator (SBODG) load calculation table was determined not to be needed; the operation is controlled manually by procedure and is limited to 2865 kW. The loads are listed in a table which is attached to an engineering calculation. The licensee determined that this original action was not needed.
CR 03-05739, CAT1 Deficiencies in Component Evaluation for EDG Room High Temperature This CR was closed. However, the CA was not completed.
Another CR was written, CR 06-00327, with CA #2 classified as a remedial action RA, because cable ampacity evaluations for higher room temperatures were not performed. Thc purpose of this CA is to ensure that the cables in the EDG rooms are addressed in the new calculation addressing the concern in CA 03-05739.
The Team noted that this action, CA 06-00327-02, was scheduled to be completed in November, 2006.
CR 03-06475, CAT1 Evaluation of Overloads on MOVs This CR is closed. ECR 03-0472 implementation was complete in RFO 14 as of 4-16-2006. The original scope included three valves but was reduced to only one since the temperaturc used for two cables was not indicative of actual conditions. Implementation of ECR 03-0472 was reclassified as an enhancement vs. a remedial action and was implemented by changing the breaker to a more suitable size for protection against postulated overloads.
CR 03-06497, CATl: The NRC Inspector Disagrees with CR 03-03891 Resolution This CR is closed but the action was not completed.
This action was opened to implement the recommendations of the evaluation performed in CA 03-06497-01, namely to revise the alarm procedure for providing additional heaters for the EDG rooms. Activity tracking item 00421 37 has been initiated to track completion of the procedure.
2.8.3 Summary The Team evaluated that the licensee had taken action in response to the 2005 Area in Need of Attention.
Although the licensee had indicated in 2005 that, for the most part, it was likely that no further action would be taken on many items since they were considered enhancements and not necessarily required actions, a re-review indicated that certain actions were deemed appropriate since they were associated with NRC non-cited violations. The liccnsee conducted a review of the CATI-related opcn corrective action items and their regulatory significance as well as to assure that resources were assigned and due dates established to be completed by the end of 2006.
The 2006 Team determined that, in some cases, it may have been more efficient to revise the procedure vs. creating all the analysis and tracking records in the SAP.
Areas of Strength None.
Areas in Need of Attention It appears that the conversion of many actions from the CREST data base into the SAP Activity tracking system is an Area in Need of Attention. This was not solely for CATl items but was reinforced by CATl Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 52 COIA-CAP-2006, August 14 to August 25,2006
corrective action follow-up. The Team did not conclude this due to any specific immediate safety condition but due to several factors:
The licensee staff was already adding increased attention by providing several resources each day to reviewing the transition of actions from CREST to SAP, rn The COIA Team had difficulty in implementing the COIA Plan when evaluating whether proper actions had been implemented and finding that the CR had been closed with no actual action other then to fill out additional documents to track the items in another system, and Several licensee staff stated during interviews that the SAP system was not user friendly and they had difficulty using the system.
Areas for Improvement None.
Conclusion The Tcam rated the Evaluation of Open Actions Taken in Response to NRC Special Tcam Inspcction, Corrective Action Program Implcrnentation - Report 05000346 1 2003010, as EFFECTIVE.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page 53 COIA-CAP-2006, August 14 to August 25,2006 I
3.0 METHODOLOGY 3.1 Assessment Methodology The assessment methodology included the following:
Observing activities.
Interviewing personnel.
a Reviewing documentation.
Evaluating trend analysis.
a Reviewing procedures, instructions, and programs.
Comparing actual performance levels with pre-established PIS.
The Team gathered data on the implementation of the Corrective Action Program (CAP) through document reviews, observations, and interviews. The Team observed several Management Alignment and Ownership Meetings (MAOMs), two Corrective Action Review Board (CARB) meetings, and Senior Leadership Team (SLT) Meetings. The Team also observed on-going 2-day CAP training for supervisors.
The Team reviewed Condition Report (CRs), Apparent Cause Evaluations (ACES), Root Causc Analyscs (RCEs), Trend Reports, Self-Assessment, and other assessment reports. The Team also intcrvicwcd CR initiators, evaluators, and management personnel. The data obtained was evaluated in order to idcntify Areas of Strength, Areas in Need of Attention (ANAs), and Areas for Improvement (AFls).
The following general standards of acceptable Corrective Actions (CAS) were applied to the Asscssmcnt of the Davis-Besse CAP implementation:
The problem is identified in a timely manner Commensurate with its significance and ease of discovery.
Identification of the problem is accurate and complete and includes consideration of the gcncric implications and possible previous occurrences.
The problem is properly prioritized for resolution commensurate with its safety signiticancc.
The root causes of the problem are identified and CAS are appropriately focused to address the causes and to prevent recurrence of the problem.
0 CAS are completed in a timely manner.
Areas of Strength, ANAs, and AFIs were based on the definitions in DBBP-VP-0009, Management Plan for Confirmatory Order Independent Assessments, using the following terminology:
Area of Strength This term is used to characterize demonstrated performance in a program or process element within an area being assessed that is exceptionally effective in achieving its desired rcsults, demonstrates a high degree of attention to detail and is significant in obtaining desired rcsults. An Area of Strength is a program, process, or activity of such a high quality that it could serve as an example for other similar elements.
I Page54 Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25, 2006
Area in Need of Attention This term is used to identify a performance, program, or process element that is sufficient to meet its basic intent. However, management attention is required to achieve full effectiveness and consistency. ANAs are not normally identified or addressed in action plans submitted to the U.S. Nuclear Regulatory Commission (NRC), but are brought to management attention for consideration and possible entry into the Davis-Besse CAP.
Area For Improvement This term is used to characterize an identified performance, program, or process clement that rcquircs improvement to obtain the desired results in a consistent and effective manner. All AFIs identified in the Assessmcnt Report will be addressed by the Action Plan submitted to the NRC.
3.2 Assessment Categories Based on the Teams overall assessment, each area evaluated was given a rating of the areas overall effectiveness. The categories used to identify the overall effectiveness are dcfincd in DBBP-VP-0009 and below.
Highly Effective Assessment results identified no AFls and no or few ANAs. Performance, programs, and processes are morc than sufficient to obtain the desired results with consistency and effectiveness.
Effective Assessment results identified one or several AFIs and no or a few ANAs. Performance, programs, and processes are sufficient to obtain the desired results with consistency and effectiveness.
Marginally Effective Assessment results identified more than several AFIs and several or more ANAs. The basic intent of the program or process is achieved; however, the performance, program, or process is challenged to obtain the desired results with consistency and effectiveness. Prompt management action is required.
Not Effective Assessment results identified significant shortcomings such that the basic intent of the program or proccss in not being achieved. AFls identified as Not Effective require immediate management action.
Davis-Besse Nuclear Power Station Independent CAP Assessment Page 55 COIA-CAP-2006, August 14 to August 25,2006 I
4.0 REFERENCES
4.1 The following is the list of individuals interviewed during the 2006 Zndependent Assessment of the Corrective Action Plan (CAP) Implementation at Davis-Besse Nuclear Power Station between August 14 and August 25,2006.
Persons Interviewed during this Assessment
, SUPERVISION, OVERSIGHT, AND TRAINING Regina M. Amidon Mark B. Bezilla Edward Chimahusky Clarence Dctray Raymond A. Hruby Rick Jarosi Employee Concerns Program David R. Kline Steve Loehlcin Tom Simonetti
'Training Supervisor Paul Southerland Henry Stevens Dave R. Wahlers Dale R. Wuokko B. Zibung SITE PERFORMANCE IMPROVEMENT Brian T. Hennessy Robert W. Schraudcr Mark A. Trump Tom Victch ENGINEERING John J. Grabnar John Hook Scott Plymale Jane Mallernee L
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Supervisor - Nuclear Employee Concerns 1 Vice President - Davis-Besse Nuclear Power Station Supervisor - Performance Assessment l Nuclear Oversight Assessor Manager - Fleet Oversight Manager - Site Protection FENOC Director, Corrective Action Programs & Assessments 1
FENOC Preventive/Predictive Maintenance Engineer IFleet Corrective Action Program Manager Supervisor - Compliance Audit
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Jsupervisor
- Nuclear Compliance
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'Nuclear Oversight Staff Supervisor - Nuclear Performance Improvement Director - Performance lmprovemcnt Manager - Site Training Acting Manager - Site Regulatory Compliancc Director - Site Engineering Manager - Design Engineering (Acting)
Manager - Plant Engineering (Acting)
Adv Nuclear Specialist, Engineering Configuration Control Group
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Davis-Besse Nuclear Power Station lndependent CAP Assessment I Page 56 COIA-CAP-2006, August 14 to August 25,2006
Allen McAllister Gary Melssen Jon Otermat Dennis Schreiner MAINTENANCE Brian D. Boles
, Dave Dallas John C. Dominy Gary H. Kendrick I --
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Lucas Ring Henry Stevens Doug Whalen OPERATIONS Barry S. Allen Nick Buehler Bob Lakis Pat J. McCIoskey Doug Nobel Randy L. Patrick
'Bill Raybum Dave Witt CONTRACTORS Independent Team Leader i Staff Nuclear Engineer - Maintenance Rule Coordinator System Engineer (CAC)
Sr. Consultant - Technical Services Engineering 1
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Director - Site Maintenance Lead Mechanical Maintenance Planner Supt of Planning and Support Manager - Site Maintenance Maintenance Engineer Manager of Corrective Actions Supervisor, Cycle Management 1 -.
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Director - Site Operations Non-Licensed Operator (NLO)
Senior Reactor Operator (SRO)
Manager - Site Chemistry Radiation Protection Supervisor - Operations Services Chemistry Reactor Operator (RO)
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Contract Electrician Contract Electrician I Mike Wood
' Keith Bogan ROOT CAUSE EVALUATORS Kevin Browning
'Senior Nuclear Specialist Ken Filan Aaron Quadeven I - -
Staff Nuclear Specialist Root Cause Evaluator
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Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 57 COIA-CAP-2006, August 14 to August 25, 2006
4.2 Condition Reports The following is a list of the CRs reviewed during the 2005 Independent Assessment of the Corrective Action Plan (CAP) Implementation at Davis-Besse Nuclear Power Station.
0 1-00430 01-01508 01-01687 02-00502 02-00784 02-0 1438 02-024 19 02-02494 02-02575 02-02606 02-02846 02-02943 I 02-04674 02-049 14 02-05548 02-060 19 02-07409 02-07596 02-07808 02-08530 02-1 0 14 1 03-00363 03-0265 1 03-02654 03 -02 730 03 -03 5 72 03-04773 Probability Safety Assessment Improvement Equipment Lineups Affected Maintenance Risk Assessment AFW Status Changing to Category (A)( I ) Pcr Maintenance Rule Main Steam Safety Valve As-Found Test Results Collective Review of The Nuclear Fuel Related CRs for Common Cause Potential Release of Hot Particles to Other Sites Untimely Corrective Actions to Address Corrective Action Program W LP2 RCP Seal Injection AOVs Are Installed Contraiy to Dcsign Assumptions Made During Startup and Pre-Operational Testing Audit AR-02-FIRE P-0 1 Marginal Rating Implementation And Quality Of The Radiation Protection (RP) Corrective Action Program is Considered Unacceptable Containment Emergency Sump Issues, LER 2002-005 Containment Air Cooler Boric Acid Corrosion AF W Strainers Apparent Violation Of I O CFR 50.9, Completeness and Accuracy of Information Breakdown of Bechtel QA Program Inspection Procedure En-Dp-01508 Findings For Inspection Area 603-3 LIR-SW: Potential Loss Of All Service Water Due To Flooding In The SW Pump Room LIR-EDG-High Temperature Overall CR LIR-RCS-Appendix R-RCS Makeup PrlAOTC: Potential Programmatic Breakdown Of The AOTC Program Snubber Program Focused Self Assessment 2002-0083 Findings CCW Pump 2 Tripped On Instantaneous Over Current And Instantaneous Ground CATI: Framatome AFW Calculation Issues With MSSV CATI: Cable Ampacity On Containment Spray Pump Motor CATI: Lack Of Vendor Data For High Voltage Switchgear At High Temperature CATI: Lack Of Coordination On Bus El And F 1 RCPRTD Installation Not In Accordance With Vendor Manual
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Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 58 COIA-CAP-2006. August 14 to August 25, 2006
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CATI: Security Building D/G Does Not Have A Load Table CATI: Deficiencies In Component Evaluation For Edg Room High Temperature CATI: Evaluation Of Overloads On Motor Operated Valves CATI: The NRC Inspector Disagrees With CR 03-03891 Resolution CATI: Calculation Quality Collective Significance Review
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03-057 15 03 -05 7 3 9 I 03-06475 03-06497 03-06907 1
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CATI: Fuse Sizing for MOV 0106 and MOV 38700 Disc Pins May Have Entered The RCS COIA - OPS: Cause Determination 03-06944 03-07049 04-05920 04-0601 1 04-060 17 COIA - CAP - 2004: Corrective Action Timcl~ness Questioned (AFI)
COlA - CAP - 2004, Unsatisfactory Concctive Action Program Trending COIA - CAP - 2004: Cap Performance Indicators Improvements INPO OE: Report Not Fully Distributed COIA - CAP - 2005 CR 04-06498 SCAQ Preventive Action Verification COlA - CAP - 2005. CR Determined to be a MRFF Not Upgraded to Apparent Causc COlA - CAP - 2005: CR 04-06498 Root Cause Evaluation Obscrvations OE - Beaver Valley MOV Failure Due To Damaged Gear Teeth 04-06023 05-03779
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05-03842 I 05 -03 845 I
05-0396 1 05-03965 SER 2003-05 Weakness In Operator Fundamentals INPO Technical Report On Circuit Boards Feed Water Heater 1-4 Normal Drain Line Pipe Hanger Spring Cam Is Uncoupled COIA - CAP - 2005: CR Evaluation And Corrective Action Completion Timeliness COlA - CAP - 2005: CRRoot Cause & Apparent Cause Evaluations Inadequate
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05-03974 05-041 I O 105-04220 0 5 -04407 05-04408 05-04409 COIA - CAP - 2005: CR Age Of SCAQKAQ Preventive & Remedial Actions COlA - CAP - 2005: Equipment Trending Below Industry Standards PY CR 2005-661 6 Confirmatory Screening CR Misclassification Labeling Enhancement Requested For Inverters Fluke Model 189 Digital Multimeter OE - Beaver Valley NCV For Not Placing An Inoperable OTDT Channel In The 05-0441 1 05-044 14 05-04487 05-04556 05-04563
' Tripped Condition Within 6 Hours Required By TS LCO Due To A Maintenance Procedure Error Which Left Switches On A Circuit Card In The "Off" Position NRC IN 2005-24: Nonconservatism In Leakage Detection Security 05-04672 05-04769 05-04770 05-0477 1 COlA - CAP - 2005: CR CategorizatiodEvaluation Weaknesses COIA - CAP - 2005: Repeat Event Guidance Weakness COIA - CAP - 2005: CR-CA Backlog Potential Effect On Effectiveness Davis-Besse Nuclear Power Station Independent CAP Assessment I 59 COIA-CAP-2006, August 14 to August 25,2006
COIA - CAP - 2005: Lack Of Smarter Corrective Actions COlA - CAP - 2005: CR Evaluation Weaknesses Minor Hardware Deficiencies On EDG 1 In 2005-25 Inadvertent Trip Due To Tin Whisker PCR-Tracking Ops Procedure Revision For ECR 05-0089 05-04773 05-04774 05 -0477 7 0 5 -04 84 5 05-04854 05-05012 Correction To OS-481 Shl Correction to DBB-FP-04038 ( I 0% Penetration Seal Visual Inspection)
I 4
05-05078 Boron Injection Flowrate Calc. 034.009 Non-Conservative Assumptions Fuel Integrity Monitoring Did Not Identify Cycle 14 Fuel Defects Potential Deficiency/Enhancement Opportunity In Mov Pm's WW 0541 Inadvertent Risk Entry Check Valve Found In Outlet Of Moisture Trap (MT 9) In C3801 For AE 5027 INPO 2005 Evaluation - AFI PI.2-1 (Cause Analysis)
INPO 2005 Evaluation - AFI P1.2-2 (Timeliness/Aging)
INPO 2005 Evaluation - AFI PI.3-1 (Use Of OE)
Adverse Trend Related To Recent Door Issues Oversight Concerns Related To SAP Notifications Not Identified In CR Program Findings From FA-SA-05-02 Conduct Of Operations/Reactivity Management Fleet SA Boric Acid Pumps Operability Standing Order 05-01 3 Fire Suppression System Pressure Gauges Are Regularly Out Of Tolerancc SW 38 Found Out Of Position Closed Assessment Of SAP Activity Tracking Generation Process Corrosion Of Q And Seismic I Components In The Service Water Tunnel DB-SS-05-20 Corrective Actions Due Date And Action Type Assignment Not Per NOP DB-SS-05-20 Condition Reports Not Written For Maintenance Notifications Ch 1 Gammametrics Has Failed.
Re-Evaluate The Need To Perform As-Found Service Water Flow Balance Test Risk Profile For Work Week 602 Omitted CV 2001 Work
- 2 EDG Broken Parts In Rocker Arm Area Wrong Load Valve Used In Calculation Addendum AVI Personnel Minor lnjury I 05-05 184 I
05-05278 05-053 16 05-05334 I
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05-05349 05 -053 95 05-05396 05-05397 05-05427 05-05444 05-05524 05-05 559 05-05622 05-05650 I 05-05689 05-05822 1 05-05894
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Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 6o COIA-CAP-2006, August 14 to August 25, 2006
Turbine Plant Cooling Water Pump 3 06-00550 06-00583 I 06-00624 06-00730 06-00773 06-00857 06-00923 06-0095 1 06-0 1 09 I 06-01 13 1 06-0 1263 06-01313 06-0 1382 Further Evaluation Actions Regarding EDG #2 Tapping Noise On 1/13/06 Water Spray On Motor Control Centers El 1B And El 1C Violation Of ISDP-085 12 BACC: Steam Generator 1-2 Upper Manway Violation Of NOP-LP-3005 (FENOC Confined Space Entry Program)
Emergency Preparedness Zone (EPZ) Siren 09 1 AC Power Failure 14 RFO BACC Inspection Of DH 2736 Axial Indication In RCP 1-1 Cold Leg Drain Line CRD Service Structure TC Cable Support Degradation Condition Reports Not Generated To Document Fuel Assembly Integrity Conditions Two Personnel Contamination Events Resulting In Minor Intakes BF 1260 PM Performed Past Late Date 1
I I DH 12 Testing Delayed By Clearance h u e s With 2001 17362.
06-0 1440 06-01456 06-01 466 06-0 1 503 I
1 Corrective Action Program Timeliness Issues Common Cause For Overtime Deviations During 14RFO Personnel Contamination Events In Non-Posted Areas Engine Driven Vehicle On Dry Fuel Pad Without Required Fire Extinguisher Decline In Site Radiation Protection Performance During I4RFO Potential Trend Of Unqualified Outage Personnel Performing Work RCP 2-1 Lower Bearing Oil Level High DB-SS-6-02: Incorrect Approval Authority For Corrective Action 02-04764-4 Change In Approach To Performance Of Statistical CR Trending C01A-ENG-2005 - ANA-Transmittal Of Engr. Requirements For Ops And Maint Radiation Protection Integrated Performance Assessment 06-0 166 I 06-0 1697 06-02 108 06-02 192 06-02303 06-02433 06-0244 1 06-0248 1 06-02488 DH 64 Boric Acid Leak EAB Grades TM 06-0014 As A Failed Product Weekly ERO Pager Test Results June 12 DB-SS-06-04: Individuals Performing LACE Without Completing Training CCW Pump 3 Auto Started When Stopped Due To Erroneous Low Flow Coordination Of VP Approval And SLT Review Of Root Cause Evaluations Abandonment Of Site Organization Cognizant Trending During Outages
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06-02542 1 06-02544 06-02580 06-026 12 1-06-02663 06-02686 I
Davis-Besse Nuclear Power Station Independent CAP Assessment COIA-CAP-2006, August 14 to August 25, 2006 Page 61
4.3 Procedures The following is a list of the Procedures reviewed and used during the 2005 Independent Assessment of the Corrective Action Plan (CAP) Implementation at Davis-Besse Nuclear Power Station.
Management Plan for Confirmatory Order Independent Assessments Materials Readiness and Housekeeping Inspection Program DBBP-VP-0009 I
1 NG-DB-002 1 5
' Fleet Value Rating (FVR) Methodology
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NPBP-ER-1004 FENOC Focused Self Assessment Process
' NOBP-LP-200 1 NOBP-LP-2007 NOBP-LP-2008 NOBP-LP-20 I O NOBP-LP-2011 NOBP-LP-2018 NOBP-LP-2019 I
NOBP-LP-2 100
, NOBP-LP-2501 Condition Report Process Effectiveness Preview FENOC Corrective Action Revicw Board, Rev. 5, 02-10-2006 CREST Trending Codes, Rev. 4, 6-29-06 FENOC Cause Analysis, Rev. 5, 2-10-06 Integrated Performance AssessmentlTrending, Rev. 1, 10-25-05 Corrective Action Program Supplemental Expectations and Guidance, Rev. 2.
21 10106 FENOC Operating Experience Reference Guide DRAFT - Safety Culture Assessment - Draft #8 Corrective Action Program, Rev. 0, 10110105 Condition Report Process, Rev. 13,2-10-06 Analytical Methods Guidebook, Rev. 00, 9-26-05 Internal Assessment Process
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NOPL-LP-2007 NOP-LP-200 1 NORM-LP-2003 NOP-LP-2004
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4.4 Assessments The following audits, self-assessments, and reports were reviewed by the Team during the completion of this report.
NIA NIA NIA NIA NIA NIA Cognitive Binning Process Summary - Davis-Besse Site Chcmistry. May 2006 through July 2006 Radiation Protection Cognitive Trending Jun-Jul, 2006 June 2006 - Davis-Besse Nuclear Power Station, Monthly Performance Report July 2006 - Davis-Besse Nuclear Power Station, Monthly Performancc Report.
Davis-Besse Nuclear Power Station - Condition Report Trend Summary, Unit Outages, 21 10106 Davis-Besse Plant Health Report, 2nd Quarter 2006 Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 62 COIA-CAP-2006, August 14 to August 25,2006
CCN No: 05-00200 Design Engineering - Integrated Performance Assessment May 1, 2005 through October 3 I, 2005, Rev. 1, 12-22-05 Davis-Besse Regulatory Compliance - Integrated Performance Assessment, May 1, 2005 - October 3 1,2005, dated I 1/8/05 Davis-Besse Regulatory Compliance - Integrated Performance Assessment (November I, 2005 to April 30,2006), Rev. 1,611 6/06 Davis-Besse Condition Report, Common Cause Review, June 2005, 7-7-2005 Snapshot Self-Assessment - Corrective Action Program Implementation, 4th Quarter, 2005 (CA 05-03226-01)
Snapshot Self Assessment - Corrective Action Program Implementation, 1 st Quarter 2006 (CA 05-03226-02)
Davis-Besse 14th Refueling Outage Condition Report Trend Summary, 6-29-06 Integrated Performance Assessment - November I, 2005 through April 30, 2006, Rev. 1,6-9-06 Davis Besse Maintenance - Integrated Performance Assessment, May 1 2005 -
October 3 1, 2005, dated 12/14/05 Davis-Besse Maintenance - Integrated Performance Assessment Novembcr I,
2005 - April 30,2006, Rev. 1 Section Level Corrective Action Program Trending, 10/24/05 to I 1/14/05.
Davis-Besse Site Summary of Integrated Performance Assessments, Novembcr 1, 2005 - April 30, 2006, dated 819106
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CCN RAS05-005 10 I CCN RAS06-002 12
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1
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DB-SS-05-0 I DB-SS-05-20
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4 DB-SS-06-02
_ _ _ ~ I _
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- -~ _.
I-_____I DB-SS-06-11
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I DBE-06-0099
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- _-_-___I-DSM-05-00090 DSM 005 3 FL-SA-05-05 RAS-06-00259 Davis-Besse Nuclear Power Station Independent CAP Assessment I Page 63 COIA-CAP-2006, August 14 to August 25,2006
Docket Number 50-346 License Number NPF-3 Serial Number 1-1 474 ACTION PLAN TO ADDRESS THE AREA FOR IMPROVEMENT FROM THE INDEPENDENT ASSESSMENT OF THE CORRECTIVE ACTION PROGRAM IMPLEMENTATION AT DAVIS-BESSE NUCLEAR POWER STATION (3 pages to follow)
ACTION PLAN TO ADDRESS AREA FOR IMPROVEMENT (AFI)
FROM THE INDEPENDENT ASSESSMENT OF THE CORRECTIVE ACTION PROGRAM IMPLEMENTATION AT DAVIS-BESSE NUCLEAR POWER STATION COIA-CAP-2006 Action Plan Reviewed and Approved by:
The Area for Improvement (AFI) Action Plan contained in this enclosure was developed by the Davis-Besse Nuclear Power Station (DBNPS) in response to the AFI identified by the Independent Assessment Team.
The Confirmatory Order assessment provided an independent and comprehensive review of Corrective Action Program (CAP) Implementation at the Davis-Besse Nuclear Power Station. The assessment team identified one (1) Area for Improvement (AFI), which has been entered into the DBNPS Corrective Action Program. The AFI and the associated Action Plan are presented in this enclosure.
Davis-Besse Action Plan to address the Corrective Action Program Implementation Independent Assessment Area for Improvement:
AFI COIA-CAP-2006-01 AFI (DBNPS CR 06-6723)
The trending of equipment problems across systems continues to be an Area For Improvement. This is a continuation of the same issue identified during the 2004 and 2005 (CAP) Assessments. FENOC has developed a draft procedure NOBP-ER-3916, Component Health Trending Reports I which, when implemented, may assist FENOC with the identification of common component problems.
Action Plan for AFI COIA-CAP-2006-01 This CAP Assessment 2006-01 AFI Action Plan supersedes the CAP Assessment 2005-03 AFI Action Plan in its entirety. The CAP Assessment 2005-03 AFI Action Plan was submitted via DBNPS letter Serial Number 1-1439, dated September 19,2005.
Business Practice NOBP-ER-3902, Component Template Development ER Workbench Module 2, establishes a review to be conducted approximately every two years of the component maintenance strategy templates. This review analyzes Maintenance Order and Condition Report data to see if new predictive maintenance technologies may apply to improve reliability. This Business Practice requirement is designed to periodically review equipment performance or failure trends to gage the effectiveness of the prescribed maintenance strategy activities provided through the component templates. This review is led by a Fleet Component Engineer and includes a peer review team.
A computer application has been developed to provide for quarterly binning and analysis of Maintenance Orders by component type. This computer application resides in the FENOC Equipment Reliability (ER) Workbench and systematically collects appropriate Maintenance Orders of components that are assigned to the template for common failure trend identification.
This binning software tool known as Component Health and Trending (CHT), Module 16 of the Equipment Reliability (ER) Workbench, will provide a quarterly Component Health and Trend (CHT) process to help facilitate early identification of potential or emerging adverse trends of equipment failures and/or degraded as-found conditions. Business Practice NOBP-ER-39 16, Component Health and Trending Reports, is currently being developed and will govern this Page 1 of2
quarterly CHT process. Should a negative trend be identified in the quarterly CHT process, a review to identify changes to the applicable component template(s) to facilitate performance improvement will also be prescribed in NOBP-ER-3916. Development of NOBP-ER-3916 is described in item 2 below.
Actions to be completed:
I. Assign appropriate maintenance strategy template numbers to the population of functional locations (FLOC) currently covered by Preventive Maintenance (PM) tasks. Use of Maintenance Order data for trending relies on proper assignment of FLOC numbers to appropriate maintenance strategy templates. This will enable the CHT Module 16 of the ER Workbench software to more accurately perform trending. These assignments will be complete by February 28,2007.
- 2. Business Practice NOBP-ER-39 16, Component Health and Trending Reports, will prescribe the use of the CHT Module 16 of the ER Workbench for the quarterly equipment trending CHT process. This business practice will also outline the process requirement to perform a review to identify changes to the component template if a negative trend is identified in the quarterly CHT. NOBP-ER-3916 will be implemented by February 28,2007.
Page 2 of 2
FENOC FirstEnergy Nuclear Operating Ccfnpany 5501 North Slate Route 2 Oak Harbor. Ohio 43449 Mark 8. Bezilla Vice President - Nuclear 4 19-321-7676 Fax: 419-321-7582 Docket Number 50-346 License Number NPF-3 Serial Number 3291 October 22, 2006 United States Nuclear Regulatory Commission Document Control Desk Washington, D. C. 20555-0001
Subject:
Supplemental Information Regarding the 2005 Steam Generator Tube Inspections (TAC No. MD0528)
Ladies and Gentlemen:
By letters dated February 17,2005 (Serial Number 3 125), April 29,2005 (Serial Number 3 147), and February 16, 2006 (Serial Number 321 8) the FirstEnergy Nuclear Operating Company (FENOC) reported the results of the Davis-Besse Nuclear Power Station (DBNPS) steam generator tube inspections performed during the Cycle 14 Mid-Cycle Outage (1 4MCO). On August 4,2006, by facsimile the Nuclear Regulatory Commission provided FENOC with additional questions regarding the DBNPS 2005 steam generator inspections. The responses to these questions are provided in Attachment 1 to this letter. identifies that there are no commitments contained in this submittal.
Should you have any questions or require additional information, please contact Mr. Gregory A. Dunn, Manager - FENOC Fleet Licensing, at (330) 3 15-7243.
Very truly yours, Mark /B454&/
B. Bezilla, Vice Presfient - Nuclear TSC Attachments
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 2 cc:
Regional Administrator, NRC Region I11 NRCNRR Project Manager NRC Senior Resident Inspector Utility Radiological Safety Board
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 1 of 7 RESPONSE TO REQUEST FOR ADDITIONAL INFORMATION DAVIS-BESSE NUCLEAR POWER STATION 14h CYCLE MID-CYCLE OUTAGE (14 MCO) STEAM GENERATOR INSPECTION
/TAC NO. MD0528)
Question #I Discuss whether any indications were identified as dents or dings. If so, identify the tube and provide the size and orientation of the flaw along with the size of the dentlding.
DBNPS Response:
The designation for tubing deformation as a ding is not used at DBNPS; only dents are designated as tubing deformation.
Four hundred and fifty eight dented locations were inspected with the plus point and pancake eddy current examination technique (253 locations in Once Through Steam Generator 2-A and 205 locations in OTSG I-B). This inspection scope included 434 locations of previously reported dents and new dents using a 2.5 volt bobbin threshold and 24 locations of greater than 0.5 volts between the 15s and UTS in the periphery region. No indications in dents were identified in either OTSG for this examination scope. One tube with one dent was removed from service for reasons unrelated to the dent.
Question #2:
Discuss the number and size of any flaws within the sleeved portions of tubes or within 6-inches of the bottom of the sleeves.
DBNPS Response:
During 14MCO a total of 126 sleeves were inspected with a sleeve bobbin probe (42 sleeves in OTSG 2-A and 84 sleeves in OTSG 1-6). Eighty seven sleeves (both upper and lower rolls) were inspected with the plus point eddy current examination technique (42 tubes in OTSG 2-A and 45 tubes in OTSG 1-B). The lower roll plus point eddy current examination inspected both lower rolls down to at least six inches past the sleeve. The three hundred and twenty four remaining sleeves (lower sleeve roll to six inches past the sleeve in the parent tube) were inspected with the plus point eddy current examination technique (157 tubes in OTSG 2-A and 167 tubes in OTSG I-B).
Within the scope of these examinations a 100% plus point eddy current examination was completed for the region six inches below the sleeves. No indications were reported in either OTSG for this examination scope.
1
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 2 of 7 Question #3:
Identify any tubes in which groove intergranular attacklstress corrosion cracking was observed during your 2005 inspections. Discuss the severity of the flaws detected.
DBNPS Response:
The groove intergranular attackktress cracking corrosion indications observed during 14MCO are listed below:
These indications were plotted and compared to the pre-established performance criteria for this damage mechanism which related the plus point voltage value and crack length to the structural limit of three times normal operating differential pressure. All the identified indications were below the Condition Monitoring acceptance curves. This demonstrated that the degraded tube burst pressures were above the three times normal operating differential pressure requirement of 4050 psi with a greater than 0.95 probability at 50% confidence.
OTSG Axial ODSCCnGA CM Limit Curves 0.95 Probability, 50% Confidence 0.90 Probability 50% Confidence SG 2A 0
I 0.0 !
I I
I I
0 0.5 1
1.5 2
2.5 3
Plus Point Crack Length, inches 2
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 3 of 7 Question M:
Discuss the cause of the volumetric indications (other than wear) detected during the outage. For example, the volumetric indications identified in SG 1B in tubes 10-47, 78-67 and 81-73, and in SG 2A in tube 146-50.
DBNPS Response:
Volumetric indications other than wear observed during 14MCO are listed below:
17.4 520PP 36 Internal AFW 1
I I Oe3' I 0.25 I Alianment Pin
-1.49 1.63 0.73 E 520PP Y
ID IGA in Roll Transition 0.21 ID IGA in SRR ID IGA in Roll I "' I Heel ID IGA in Roll 0.94 520PP 27 0.2 0.19 Transition There was one small volumetric wear indication in SG 2A tube 146-50. This was as a result of tube contact with the abandoned internal AFW header dowel pin support stay which required plugging. The eddy current inspection demonstrated that the AFW header was not moving and was greater than 0.25 inches away from all in service tubes.
The OTSG eddy current inspection for movement of the internal AFW header analysis is performed on 100% of the in-service periphery tubes using a site-specific qualified bobbin coil technique.
It appears that flow conditions in SG 2A during this time period were suitable to support some tubing movement sufficient to cause contact with the support stay and initiate wear. With benefit of looking back there was some evidence of the indication in the bobbin data from 12RF0, but this was not apparent in the 13RFO data due to the bobbin coil probability of detection. The flaw in SG 2A tube 146-50 was not large enough to be a challenge to tube integrity. A 100% bobbin exam of the AFW header region was performed so no inspection escalation was necessary. There has been no other similar indication observed in the history of the Davis-Besse OTSGs.
There were also four volumetric indications located in roll transitions. This mechanism is believed to be the result of IGA that was forming in the roll transitions similar to that observed in a tube pull performed in 1996 (2A-58-119), where a small amount of grain drop out was observed to form a band of patch intergranular attack in the roll transition region of this tube. The grain drop out in these four tubes had grown to be more severe than that observed in the tube pull. These flaws were not large enough to be a challenge 3
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 4 of 7 to tube integrity. This region of grain drop out is believed to provide the initiation sites for the roll transition stress corrosion cracking that is beginning to be observed.
Question #5:
Discuss the nature, cause, and severity of the obstruction identified in SG 2A in tube 61-109. Discuss the largest size probe to ever pass through this tube and the probe sizes used on this tube during your 2005 inspections.
DBNPS Response:
Tube 61-109 of SG 2A was removed from service during 14MCO due to an obstruction.
This tube contains a large dent that has provided a challenge to inspect over the entire history of this OTSG. Historically the maximum size 0.480 inch bobbin coil was able to pass with difficulty through this dent; therefore, this tube was plugged to prevent this tube from being a challenge in future inspections.
Question #6:
Following the identification in the shop rerolls in 2005; you indicated that you were planning to investigate construction records for other unusual design characteristics.
Discuss whether you have identified any other unique conditions which could affect a tubes susceptibility to degradation. In addition, discuss any other corrective actions taken as a result of the discovery of the shop rerolls (other than the performance of the tu be inspections).
DBNPS Response:
As a result of identifying double rolls in the lower tubesheet of OTSG 1-B, a review of the manufacturing records for the Davis-Besse OTSGs for the identification of any unknown design changes or construction features that could potentially impact the OTSG tubing integrity was performed. This review did not identify any remaining unknown design or fabrication features that could affect OTSG integrity, therefore no additional corrective act ions were required.
Question #7:
Confirm that no cracks were observed at wear scars.
DBNPS Response:
During 14MCO all reported wear indications (wear scars) received a plus point exam and no crack like indications were observed in this inspection.
4
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 5 of 7 Question #8:
Confirm that no indications were identified during your rotating probe examinations in the sludge pile region that were not also identified with a bobbin probe.
DBNPS Response:
No confirmed sludge pile region indications were observed during 14MCO and the supplemental sludge pile region rotating probe exams in this region did not identify any indications.
Question #9:
You identified an indication in SG 2A which was attributed to an alignment pin (dowel pin) associated with an internal auxiliary feedwater header. You also indicated that the indication increased in size when compared to the prior outage. Discuss the dates and results of your visual inspections of the secured internal auxiliary feedwater header, header to shroud attachment welds, and the external header thermal sleeves. Discuss whether the header will remain stable during all postulated accident conditions such that tube integrity will not be affected. Discuss the eddy current criteria you use to ensure the header is not moving (or approaching the tubes) for the time period between the visual inspections of the header. Summarize the basis for this criteria.
DBNPS Response:
In 1981, a tube leak was experienced by the SG 2A at Davis-Besse Nuclear Power Station. Eddy current testing and visual examinations revealed that the internal AFW headers and the brackets that attached them to the upper steam wrapper were damaged. This degradation resulted in damage to some of the peripheral once-through steam generator (OTSG) tubes due to movement of the internal header during plant operation. The AFW internal headers were subsequently stabilized and functionally replaced by external headers.
The repairs were qualified for postulated accident conditions to preserve the integrity of the OTSGs.
The internal AFW header and supporting welds are visually inspected each 10-year inservice inspection (ISI) interval per Technical Specification 4.4.5.8. Inspections in 1990 and 1998 showed no evidence of movement or degradation of the AFW header or degradation of the AFW supply nozzles and thermal sleeves, therefore these welds are still considered qualified for postulated accident conditions to preserve the integrity of the OTSGs. One AFW nozzle was found stuck in 1998 during visual inspection and the header at this nozzle location was inspected in 2000 with no evidence of movement or change in the header. The next 10-year IS1 interval begins in 2012; therefore the next visual inspection is scheduled for 16RFO.
During each OJSG eddy current inspection, an AFW header analysis is performed on 5
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 6 of 7 100% of the in-service periphery tubes using a site-specific qualified bobbin coil technique. The analysis is performed by a specially trained analyst(s) using the bobbin probe data and a special calibration method. The data is reviewed for the presence of a header signal and the gap is estimated for each indication detected. When the gap is greater than 0.250", it is beyond the ability of the technique to accurately measure and no measurement is made. In this case, a signal may be present, but the amplitude is too small and is outside the bounds of the established calibration curve. The 14MCO ANV header analysis confirmed that no AFW header movement had occurred.
Question #I 0:
Summarize the number of tubes with rerolls in each SG.
DBNPS Response:
At the completion of 14MCO there were a total of 104 inservice repair rolls in OTSG 2-A and 8 inservice repair rolls in OTSG 1-6. These repair rolls were installed using the repair roll process that was tracked for leakage under FTI Topical Report No BAW2303, Revision 04, "OTSG Repair Roll Qualification Report".
Question #I 1 :
Confirm that all tubes in which degradation was identified had adequate tube integrity at the time of the inspection.
DBNPS Response:
The observed degradation at the 14MCO outage was evaluated in a manner consistent with NE1 97-06. The observed degradation did not challenge the structural margin requirements at the 14MCO inspection or challenge required leakage integrity limits under postulated accident conditions.
6
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 7 of 7 Len CM DNT Deg.
The following abbreviations were used in above Attachment 1.
Ax Len
[ Axial Length Circ 1 Circumferential Length Condition Monitoring Dent Degradation Mode Mode IGA Intergranular Attack riw ID LTE I LTS 1 Lower iuoe meet I
Indications Inside Diameter Lower Tube End MCO MVI OTSG 7
Mid-Cycle Outage Multiple Volumetric Indications Once Throueh Steam Generator
Docket Number 50-346 License Number NPF-3 Serial Number 3291 Page 1 of 1 COMMITMENT LIST The following list identifies those actions committed to by the Davis-Besse Nuclear Power Station (DBNPS) in this document. Any other actions discussed in the submittal represent intended or planned actions by the DBNPS. They are described only for information and are not regulatory commitments. Please contact Mr. Gregory A. Dunn, Manager - FENOC Fleet Licensing, at (330) 3 15-7243 of any questions regarding this document or any associated regulatory commitments.
COMMITMENT DUE DATE None N /A