IR 05000498/2017004

NRC Integrated Inspection Report 05000498/2017004 and 05000499/2017004

ML18032A519
Person / Time
Site:	South Texas
Issue date:	02/05/2018
From:	Nick Taylor NRC/RGN-IV/DRP/RPB-B
To:	Gerry Powell South Texas
Taylor N
References
IR 2017004
Preceding documents:	ML17249A952 (6 September 2017)
Download: ML18032A519 (34)

Text

UNITED STATES ary 5, 2018

SUBJECT:

SOUTH TEXAS PROJECT ELECTRIC GENERATING STATION - NRC INTEGRATED INSPECTION REPORT 05000498/2017004 AND 05000499/2017004

Dear Mr. Powell:

On December 31, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your South Texas Project Electric Generating Station, Units 1 and 2, facility. On January 18, 2018, the NRC inspectors discussed the results of this inspection with you and other members of your staff. The results of this inspection are documented in the enclosed report.

NRC inspectors documented one finding of very low safety significance (Green) in this report.

This finding involved a violation of NRC requirements. The NRC is treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2.a of the Enforcement Policy.

If you contest the violation or significance of the NCV, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the South Texas Project Electric Generating Station, Units 1 and 2, facility.

If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the South Texas Project Electric Generating Station, Units 1 and 2, facility. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA/

Nicholas H. Taylor, Branch Chief Project Branch B Division of Reactor Projects Docket Nos.: 50-498 and 50-499 License Nos.: NPF-76 and NPF-80 Enclosure:

Inspection Report 05000498/2017004 and 05000499/2017004 w/Attachments:

1. Supplemental Information 2. Initial Request for Information

U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket: 05000498; 05000499 License: NPF-76; NPF-80 Report: 05000498/2017004; 05000499/2017004 Licensee: STP Nuclear Operating Company Facility: South Texas Project Electric Generating Station, Units 1 and 2 Location: FM 521 - 8 miles west of Wadsworth Wadsworth, Texas 77483 Dates: October 1, 2017, through December 31, 2017 Inspectors: A. Sanchez, Senior Resident Inspector N. Hernandez, Resident Inspector J. Melfi, Project Engineer J. Kirkland, Senior Operations Engineer D. Proulx, Senior Project Engineer C. Steely, Operations Engineer Approved By: Nicholas H. Taylor Chief, Project Branch B Division of Reactor Projects 1 Enclosure

SUMMARY

IR 05000498/2017004, 05000499/2017004; 10/01/2017 - 12/31/2017; South Texas Project

Electric Generating Station, Units 1 and 2; Problem Identification and Resolution The inspection activities described in this report were performed between October 1 and December 31, 2017, by the resident inspectors at the South Texas Project and inspectors from the NRCs Region IV office. One finding of very low safety significance (Green) is documented in this report. This finding involved a violation of NRC requirements. The significance of inspection findings is indicated by their color (i.e., Green, greater than Green, White, Yellow, or Red), determined using Inspection Manual Chapter 0609, Significance Determination Process, dated April 29, 2015. Their cross-cutting aspects are determined using Inspection Manual Chapter 0310, Aspects within the Cross-Cutting Areas, dated December 4, 2014. Violations of NRC requirements are dispositioned in accordance with the NRC Enforcement Policy. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, dated July 2016.

Cornerstone: Initiating Events

Green.

A self-revealed, Green, non-cited violation of Technical Specification 6.8.1.a,

Procedures, was documented for the licensees failure to follow a procedure for equipment configuration control, which resulted in a plant transient. Specifically, from July 16 to September 17, 2015, the licensee failed to control the configuration of the plant by not including the motor-operated shut-off valves on an equipment clearance order following troubleshooting of the moisture separator reheater output control circuitry, which resulted in an unplanned transient and the unit exceeding 100 percent rated thermal power. Corrective actions to restore compliance included a revision to an equipment clearance order, training for operations department personnel, and a revised maintenance procedure to provide additional instructions to workers on how to document system configuration recommendations. The licensee entered the issue into the corrective action program as Condition Report 2018-1002.

The failure to control equipment configuration was a performance deficiency. This performance deficiency was more than minor, and therefore a finding, because it is associated with the configuration control attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations.

Specifically, the licensee failed to control the configuration of the plant when the motor-operated shut-off valves were not included on an equipment clearance order following troubleshooting of the moisture separator reheater output control circuitry, which resulted in an unplanned transient when the known fault in the circuitry erroneously closed the motor-operated shut-off valves. The inspectors screened this finding using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power, dated June 19, 2012. The inspectors determined that the finding had very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition, high energy line-breaks, internal flooding, or fire. The inspectors determined the finding had a cross-cutting aspect of teamwork in the human performance area because individuals and work groups did not communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, operations and maintenance departments did not demonstrate a strong sense of collaboration and cooperation in connection with projects and operational activities [H.4]. (Section 4OA2)

PLANT STATUS

Unit 1 and Unit 2 began the inspection period at 100 percent power and remained there for the entire inspection period.

REPORT DETAILS

REACTOR SAFETY

Cornerstones: Initiating Events, Mitigating Systems, and Barrier Integrity

1R01 Adverse Weather Protection

Readiness to Cope with External Flooding

a. Inspection Scope

On November 3, 2017, the inspectors completed an inspection of the stations readiness to cope with external flooding. After reviewing the licensees flooding analysis, the inspectors chose four plant areas that were susceptible to flooding:

• Unit 1, essential cooling water intake structure

• Unit 2, essential cooling water intake structure

• Unit 1, mechanical auxiliary building structure

• Unit 2, mechanical auxiliary building structure The inspectors reviewed plant design features and licensee procedures for coping with flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether credited operator actions could be successfully accomplished.

These activities constituted one sample of readiness to cope with external flooding, as defined in Inspection Procedure 71111.01.

b. Findings

No findings were identified.

1R04 Equipment Alignment

Partial Walk-Down

a. Inspection Scope

The inspectors performed partial system walk-downs of the following risk-significant systems:

• October 18, 2017, Unit 1, train C emergency diesel generator while train A emergency diesel generator was out of service for planned maintenance

• November 27, 2017, Unit 2, train B emergency diesel generator while the train C emergency diesel generator was out of service for planned maintenance The inspectors reviewed the licensees procedures and system design information to determine the correct lineup for the systems. They visually verified that critical portions of the systems and trains were correctly aligned for the existing plant configuration.

These activities constituted two partial system walk-down samples, as defined in Inspection Procedure 71111.04.

b. Findings

No findings were identified.

1R05 Fire Protection

Quarterly Inspection

a. Inspection Scope

The inspectors evaluated the licensees fire protection program for operational status and material condition. The inspectors focused their inspection on six plant areas important to safety:

• October 3, 2017, Unit 1, emergency diesel generator, train B, Fire Areas 37, 40, 43 and 46, Fire Zones Z501, 504, 507 and 510

• October 3, 2017, Unit 2, emergency diesel generator, train B, Fire Areas 37, 40, 43 and 46, Fire Zones Z501, 504, 507 and 510

• October 10, 2017, Unit 1, control room heating, ventilation, and air conditioning equipment room, train A, Fire Area 02, Fire Zone Z005

• October 11, 2017, Unit 2, FLEX diesel generator enclosure area, Fire Area 79, Fire Zone Z0162

• October 18, 2017, Unit 1, emergency diesel generator, train C, Fire Area 38, Fire Zone Z514

• October 19, 2017, Unit 2, auxiliary feedwater pump room, train D, Fire Area 51, Fire Zone Z403 For each area, the inspectors evaluated the fire plan against defined hazards and defense-in-depth features in the licensees fire protection program. The inspectors evaluated control of transient combustibles and ignition sources, fire detection and suppression systems, manual firefighting equipment and capability, passive fire protection features, and compensatory measures for degraded conditions.

These activities constituted six quarterly inspection samples, as defined in Inspection Procedure 71111.05.

b. Findings

No findings were identified.

1R06 Flood Protection Measures

a. Inspection Scope

On November 30, 2017, the inspectors completed an inspection of the stations ability to mitigate flooding due to internal causes. After reviewing the licensees flooding analysis, the inspectors chose two plant areas containing risk-significant structures, systems, and components that were susceptible to flooding:

• Unit 1, train C emergency diesel generator

• Unit 2, train B emergency diesel generator The inspectors reviewed plant design features and licensee procedures for coping with internal flooding. The inspectors walked down the selected areas to inspect the design features, including the material condition of seals, drains, and flood barriers. The inspectors evaluated whether operator actions credited for flood mitigation could be successfully accomplished.

These activities constituted completion of one flood protection measures sample, as defined in Inspection Procedure 71111.06.

b. Findings

No findings were identified.

1R11 Licensed Operator Requalification Program and Licensed Operator Performance

.1 Review of Licensed Operator Requalification

a. Inspection Scope

On December 11, 2017, the inspectors observed simulator training for an operating crew. The inspectors assessed the performance of the operators and the evaluators critique of their performance. The inspectors also assessed the modeling and performance of the simulator during the requalification activities.

These activities constituted completion of one quarterly licensed operator requalification program sample, as defined in Inspection Procedure 71111.11.

b. Findings

No findings were identified.

.2 Review of Licensed Operator Performance

a. Inspection Scope

On November 1 and 2, 2017, the inspectors observed the performance of on-shift licensed operators in the Unit 2 main control room. At the time of the observations, Unit 2 was in a period of heightened risk due to steam generator feedwater pump manipulations to perform a mitigative maintenance activity that could have tripped one or more steam generator feedwater pumps.

In addition, the inspectors assessed the operators adherence to plant procedures, including conduct of operations procedure and other operations department policies.

These activities constituted completion of one quarterly licensed operator performance sample, as defined in Inspection Procedure 71111.11.

b. Findings

No findings were identified.

.3 Annual Review

a. Inspection Scope

The inspectors conducted an in-office review of the annual requalification training program to determine if pass/fail results exceeded the thresholds established by Inspection Procedure 71111.11, Licensed Operator Requalification Program and Licensed Operator Performance, and Inspection Manual Chapter 0609, Significance Determination Process.

On December 19, 2017, the licensee informed the inspector of the following South Texas Project Electric Generating Station operating and written test results:

• 14 of 14 crews passed the simulator portion of the operating test

• 72 of 72 licensed operators passed the simulator portion of the operating test

• 68 of 72 licensed operators passed the job performance measure portion of the operating test

• 66 of 70 licensed operators passed the written examination portion of the biennial exam The four individuals that failed the job performance measure portion of the operating test were remediated, retested, and passed their retake examinations. The four individuals that failed the written exam were remediated, retested, and passed their retake examination.

The difference in numbers between operators that took the operating test and written examination is due to one individual leaving the company since completing the operating test and one individual who did not take the written exam after completing the operating test since he is due to retire in January 2018. This individual had his qualifications removed.

b. Findings

No findings were identified.

.4 Biennial Review

During the week of October 16, 2017, the inspectors reviewed both the written examination and operating test quality and, observed licensee administration of an annual requalification test while onsite. The operating test observation included six job performance measures and two scenarios that were used in the current biennial requalification cycle. These observations allowed the inspectors to assess the licensee's effectiveness in conducting the operating test and to determine if feedback of operator performance was being accomplished.

The inspectors observed examination security measures in place during administration of the exams, reviewed medical records of licensed operators for conformance with operator license conditions, and reviewed simulator performance for fidelity with the actual plant and the overall simulator program of maintenance, testing, and discrepancy correction. As necessary, the inspectors reviewed remedial training and re-examinations for licensed operators who did not pass an NRC required requalification examination.

The inspectors completed one inspection sample of the biennial licensed operator requalification program.

b. Findings

No findings were identified.

1R12 Maintenance Effectiveness

.1 Routine Maintenance Effectiveness

a. Inspection Scope

The inspectors reviewed two instances of degraded performance or condition of safety-significant structures, systems, and components (SSCs):

• December 20, 2017, Unit 1, emergency diesel generator system for high number of unavailability hours

• December 26, 2017, Unit 2, emergency diesel generator system for high number of unavailability hours The inspectors reviewed the extent of condition of possible common cause SSC failures and evaluated the adequacy of the licensees corrective actions. The inspectors reviewed the licensees work practices to evaluate whether these may have played a role in the degradation of the SSCs. The inspectors assessed the licensees characterization of the degradation in accordance with 10 CFR 50.65 (the Maintenance Rule), and verified that the licensee was appropriately tracking degraded performance and conditions in accordance with the Maintenance Rule.

These activities constituted completion of two maintenance effectiveness samples, as defined in Inspection Procedure 71111.12.

b. Findings

No findings were identified.

.2 Quality Control

a. Inspection Scope

On December 22, 2017, the inspectors reviewed the licensees quality control activities through a review of parts that were purchased as commercial-grade parts and were dedicated prior to installation in a quality-grade application.

These activities constituted completion of one quality control sample, as defined in Inspection Procedure 71111.12.

b. Findings

No findings were identified.

1R13 Maintenance Risk Assessments and Emergent Work Control

a. Inspection Scope

The inspectors reviewed two risk assessments performed by the licensee prior to changes in plant configuration and the risk management actions taken by the licensee in response to elevated risk:

• October 5, 2017, Unit 2, train C reactor containment fan cooler corrective maintenance to replace backdraft damper closing spring

• October 31 through November 2, 2017, Unit 2, emergent maintenance to lift the steam generator feedwater pump turbine vibration monitoring leads due to a suspected card malfunction The inspectors verified that these risk assessments were performed timely and in accordance with the requirements of 10 CFR 50.65 (the Maintenance Rule) and plant procedures. The inspectors reviewed the accuracy and completeness of the licensees risk assessments and verified that the licensee implemented appropriate risk management actions based on the result of the assessments.

Additionally, the inspectors observed two emergent work activities that had the potential to cause an initiating event, to affect the functional capability of mitigating systems, or to impact barrier integrity:

• October 19, 2017, Unit 1, train B extended diesel generator 12 work window due to a human performance error during maintenance restoration

• October 31, 2017, Unit 2, extended maintenance on train B essential cooling water and train B essential chilled water that resulted in exceeding the allowed outage time and entry into the Configuration Risk Management Program The inspectors verified that the licensee appropriately developed and followed a work plan for these activities. The inspectors verified that the licensee took precautions to minimize the impact of the work activities on unaffected SSCs.

The inspectors also reviewed the licensees action for entering the Configuration Risk Management Program for determining and implementing the risk-informed allowed outage time for the planned piping replacement activities on the Unit 2, train B essential cooling water system, on October 31, 2017.

These activities constituted completion of four maintenance risk assessments and emergent work control inspection samples, as defined in Inspection Procedure 71111.13.

b. Findings

No findings were identified.

1R15 Operability Determinations and Functionality Assessments

a. Inspection Scope

The inspectors reviewed four operability determinations and functionality assessments that the licensee performed for degraded or nonconforming SSCs:

• October 4, 2017, functionality assessment of the Unit 1, technical support center diesel generator due to indicator issues

• November 20, 2017, operability determination of the Unit 1, train C essential cooling water and emergency diesel generator due to 1-ECW-0250 erosion present on valve disk and valve body

• December 28, 2017, operability determination of the Unit 2, train C steam generator power-operated relief valve due to water intrusion in the hydraulic oil

• December 28, 2017, operability determination of the Unit 2, train A essential cooling water pump due to bolt degradation The inspectors reviewed the timeliness and technical adequacy of the licensees evaluations. Where the licensee determined the degraded SSC to be operable, the inspectors verified that the licensees compensatory measures were appropriate to provide reasonable assurance of operability. The inspectors verified that the licensee had considered the effect of other degraded conditions on the operability of the degraded SSC.

These activities constituted completion of four operability and functionality review samples, as defined in Inspection Procedure 71111.15.

b. Findings

No findings were identified.

1R18 Plant Modifications

.1 Permanent Modifications

a. Inspection Scope

The inspectors reviewed three permanent plant modifications that affected risk-significant SSCs:

• December 22, 2017, Unit 1, control room door, 1-EAB-DOOR-206, complete replacement

• December 27, 2017, Unit 1 and Unit 2, cask connecting channel water level indication installation

• December 28, 2017, Unit 1, pressurizer manway cover replacement The inspectors reviewed the design and implementation of the modifications. The inspectors verified that work activities involved in implementing the modifications did not adversely impact operator actions that may be required in response to an emergency or other unplanned event. The inspectors verified that post-modification testing was adequate to establish the operability of the SSCs as modified.

These activities constituted completion of three samples of permanent modifications, as defined in Inspection Procedure 71111.18.

b. Findings

No findings were identified.

1R19 Post-Maintenance Testing

a. Inspection Scope

The inspectors reviewed three post-maintenance testing activities that affected risk-significant SSCs:

• October 4, 2017, Unit 1, technical support center diesel generator test following maintenance

• October 30, 2017, Unit 1, train B essential cooling water system test following aluminum bronze piping replacement

• November 4, 2017, Unit 2, train B emergency diesel generator test following the five-year preventative maintenance The inspectors reviewed licensing- and design-basis documents for the SSCs and the maintenance and post-maintenance test procedures. The inspectors observed the performance of the post-maintenance tests to verify that the licensee performed the tests in accordance with approved procedures, satisfied the established acceptance criteria, and restored the operability of the affected SSCs.

These activities constituted completion of three post-maintenance testing inspection samples, as defined in Inspection Procedure 71111.19.

b. Findings

No findings were identified.

1R22 Surveillance Testing

a. Inspection Scope

The inspectors observed three risk-significant surveillance tests and reviewed test results to verify that these tests adequately demonstrated that the SSCs were capable of performing their safety functions:

In-service tests:

• December 27, 2017, Unit 2, train A low head safety injection pump and high head safety injection pump inservice tests Other surveillance tests:

• October 8, 2017, Unit 2, train S reactor trip breaker surveillance testing

• November 21, 2017, Unit 2, train B emergency diesel generator surveillance test The inspectors verified that these tests met technical specification requirements, that the licensee performed the tests in accordance with their procedures, and that the results of the test satisfied appropriate acceptance criteria. The inspectors verified that the licensee restored the operability of the affected SSCs following testing.

These activities constituted completion of three surveillance testing inspection samples, as defined in Inspection Procedure 71111.22.

b. Findings

No findings were identified.

1EP6 Drill Evaluation

Emergency Preparedness Drill Observation

a. Inspection Scope

The inspectors observed an emergency preparedness drill on October 25, 2017, to verify the adequacy and capability of the licensees assessment of drill performance. The inspectors reviewed the drill scenario, observed the drill from the simulator, and attended the post-drill critique. The inspectors verified that the licensees emergency classifications, off-site notifications, and protective action recommendations were appropriate and timely. The inspectors verified that any emergency preparedness weaknesses were appropriately identified by the licensee in the post-drill critique and entered into the corrective action program for resolution.

The inspectors observed an emergency preparedness drill on November 8, 2017, to verify the adequacy and capability of the licensees assessment of drill performance.

The inspectors reviewed the drill scenario, observed the drill from the simulator, and attended the post-drill critique. The inspectors verified that the licensees emergency classifications, off-site notifications, and protective action recommendations were appropriate and timely. The inspectors verified that any emergency preparedness weaknesses were appropriately identified by the licensee in the post-drill critique and entered into the corrective action program for resolution.

These activities constituted completion of two emergency preparedness drill observation samples, as defined in Inspection Procedure 71114.06.

b. Findings

No findings were identified.

OTHER ACTIVITIES

Cornerstones: Initiating Events, Mitigating Systems, Barrier Integrity, Emergency Preparedness, Public Radiation Safety, Occupational Radiation Safety, and Security

4OA1 Performance Indicator Verification

.1 Mitigating Systems Performance Index: Emergency AC Power Systems (MS06)

a. Inspection Scope

The inspectors reviewed the licensees mitigating system performance index data for the period of July 2016 through June 2017 to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.

These activities constituted verification of the mitigating system performance index for emergency AC power systems for Units 1 and 2, as defined in Inspection Procedure 71151.

b. Findings

No findings were identified.

.2 Mitigating Systems Performance Index: Heat Removal Systems (MS08)

a. Inspection Scope

The inspectors reviewed the licensees mitigating system performance index data for the period of July 2016 through June 2017 to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.

These activities constituted verification of the mitigating system performance index for heat removal systems for Unit 1 only, as defined in Inspection Procedure 71151.

b. Findings

No findings were identified.

.3 Mitigating Systems Performance Index: Residual Heat Removal Systems (MS09)

a. Inspection Scope

The inspectors reviewed the licensees mitigating system performance index data for the period of October 2016 through September 2017 to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.

These activities constituted verification of the mitigating system performance index for residual heat removal systems for Units 1 and 2, as defined in Inspection Procedure 71151.

b. Findings

No findings were identified.

.4 Mitigating Systems Performance Index: Cooling Water Support Systems (MS10)

a. Inspection Scope

The inspectors reviewed the licensees mitigating system performance index data for the period of October 2016 through September 2017 to verify the accuracy and completeness of the reported data. The inspectors used definitions and guidance contained in Nuclear Energy Institute Document 99-02, Regulatory Assessment Performance Indicator Guideline, Revision 7, to determine the accuracy of the reported data.

These activities constituted verification of the mitigating system performance index for cooling water support systems for Units 1 and 2, as defined in Inspection Procedure 71151.

b. Findings

No findings were identified.

4OA2 Problem Identification and Resolution

.1 Routine Review

a. Inspection Scope

Throughout the inspection period, the inspectors performed daily reviews of items entered into the licensees corrective action program and periodically attended the licensees condition report screening meetings. The inspectors verified that licensee personnel were identifying problems at an appropriate threshold and entering these problems into the corrective action program for resolution. The inspectors verified that the licensee developed and implemented corrective actions commensurate with the significance of the problems identified. The inspectors also reviewed the licensees problem identification and resolution activities during the performance of the other inspection activities documented in this report.

b. Findings

No findings were identified.

.2 Semiannual Trend Review

a. Inspection Scope

The inspectors reviewed the licensees corrective action program, performance indicators, system health reports, and other documentation to identify trends that might indicate the existence of a more significant safety issue. The inspectors verified that the licensee was taking corrective actions to address identified adverse trends. The following trends were reviewed:

• Inspectors reviewed a negative trend in supplemental worker performance

• Inspectors identified a negative trend in maintenance workmanship and supervisory oversight issues

• Inspectors reviewed a negative trend in station breaker performance These activities constituted completion of one semiannual trend review sample, as defined in Inspection Procedure 71152.

b. Observations and Assessments Supplemental Worker Performance The inspectors reviewed a negative trend in supplemental worker performance. The licensee independently noted the adverse trend in a mid-cycle self-assessment and initiated Condition Report 2017-17876 to perform a common cause evaluation. The common cause considered a number of performance errors. Some of the more notable performance errors were: 1) blind flange inadvertently installed on the Unit 1 reactor vessel head vent, which resulted in loss of reactor coolant system inventory while at lowered inventory; 2) damaged fuel bundles during Unit 1 core offload; and 3) dropped 55 gallon oil drum onto Unit 1 reactor coolant pump 1C, which resulted in a large amount of fibrous insulation replacement, clean-up of reactor coolant system piping and challenged reactor cooling pump functionality.

The common cause determined that although the overall number of events attributed to supplemental workers has decreased, the significance had increased. The common cause identified that the station has failed to adequately train the supplemental workers and ensure that supplemental workers consistently apply the station standards and expectations for safety and human performance. The licensee has established and scheduled to establish corrective actions to: 1) re-tool the training given to the supplemental work force, especially just prior to refueling outages; 2) re-tool the training program for supervisors and a new oral board with higher expectations; 3) provide a dedicated and qualified craft supervisor for all lifting and rigging inside the reactor containment building; and 4) modify several pertinent procedures for lifting and rigging, containment management, and the fuel handling program. The inspectors determined that the licensees common cause evaluation and corrective actions, taken and proposed, appear to be adequate to address supplemental worker performance. The licensee will also perform an effectiveness review after Refueling Outage 2RE19, scheduled for spring 2018.

Maintenance Workmanship and Supervisory Oversight Issues The inspectors identified an on-going negative trend in maintenance workmanship and supervisory oversight. The inspectors noted the following examples: 1) material conditions following work on Unit 2 train A electrical auxiliary building heating ventilation and air conditioning motor replacement such as motor grounding wire not reconnected, lack of adequate thread engagement on ductwork bolting, a loose bolt on the support structure, and housekeeping issues; 2) damaged door seal and broken screws in door jamb following the Unit 1 control room door replacement; 3) Unit 1 train A sequencer test module unnecessarily replaced because of a test key issue; 4) Unit 1, train B, 4160 under voltage relay was retested until the relay became in tolerance; and 5) Unit 2, train C auxiliary feedwater pump relay replacement where maintenance lack of engagement resulted in being in the technical specification action statement for approximately an extra four hours. After a couple of meetings with the maintenance manager, Condition Report 2017-18609 was written to perform a common cause evaluation of recent human performance issues. The common cause reviewed 25 relevant events.

The common cause identified a gap regarding maintenance workers failing to follow and properly implement station procedures (16 of 25 issues). Corrective actions included:

1) issuing a maintenance communication bulletin that briefly covered three of the more pertinent issues and emphasized the need to adhere to station procedures; 2) requirement for supervisors to perform field observations of all the workers, document and discuss with maintenance management; 3) modify conduct of maintenance to outline action to take for a human performance event or repetitive events; and 4) small group briefs on the common cause evaluation. The inspectors determined that the licensees common cause evaluation and corrective actions, taken and proposed, appear to be adequate to address the maintenance workmanship and supervisory oversight issues. The licensee will perform an effectiveness review in February 2018.

Breaker Performance The inspectors reviewed an apparent trend in breaker issues at the station. Since the beginning of 2017, the station had experienced several breaker issues. Although the breakers had different failure mechanisms, spanned various breaker types, sizes, and manufacturers, station management commissioned a deep dive into the breaker issues to identify, improve, and correct any common deficiencies. Condition Report 2017-20177 was initiated to keep track of the assessment and any corrective actions or recommended enhancements. The deep dive team considered issues with breaker operation, racking practices, maintenance practices, training practices, preventative maintenance strategies and breaker procedures since January 1, 2016.

The deep dive team met every week for ten weeks and produced an evaluation and numerous recommendations.

Some of the more significant recommendations included: 1) handswitch replacement efforts in the control room; 2) improving maintenance procedures for breaker teardowns; 3) improve breaker training for both maintenance and operations by having more hands on training, which would require purchasing breaker mockups for common types of breakers used in the plant; 4) just-in-time breaker training prior to infrequent or new breaker installation in the field; and 5) enhance troubleshooting guidance for operations to preserve as-found conditions when a failure occurs.

The inspectors attended the initial meeting of the deep dive team and spoke with several members throughout the review. The inspectors concluded that the team composition was appropriate, diverse, and members were subject matter experts from their respective departments. The inspectors were given a copy of the evaluation and the recommended improvement items. The inspectors also met with the deep dive management sponsors and discussed the results. The inspectors concluded that the effort was well supported, and team members were dedicated to the effort. Furthermore, the inspectors determined that the deep dive effort was effective and if fully supported and implemented by station management, should improve the breaker program and reduce the overall number of issues at the station.

c. Findings

No findings were identified.

.3 Annual Follow-up of Selected Issues

a. Inspection Scope

The inspectors selected one issue for an in-depth follow-up on September 17, 2015, an inadequate equipment clearance order failed to control plant configuration allowing the Unit 2 moisture separator reheater motor-operated shut-off valves to go closed and caused the plant to exceed 100 percent rated thermal power.

The inspectors assessed the licensees problem identification threshold, cause analyses, extent of condition reviews and compensatory actions. The inspectors verified that the licensee appropriately prioritized the corrective actions and that these actions were adequate to correct the condition.

This activity constituted completion of one annual follow-up sample, as defined in Inspection Procedure 71152.

b. Findings

Introduction.

A self-revealed, Green, non-cited violation of Technical Specification 6.8.1.a, Procedures, was documented for the licensees failure to follow a procedure for equipment configuration control, which resulted in a plant transient.

Specifically, from July 16 to September 17, 2015, the licensee failed to control the configuration of the plant by not including the motor-operated shut-off valves on an equipment clearance order following troubleshooting of the moisture separator reheater output control circuitry, which resulted in an unplanned transient and the unit exceeding 100 percent rated thermal power.

Description.

On July 16, 2015, Unit 2 moisture separator reheater temperature control valves and the motor-operated shut-off valves closed due to an unknown malfunction in the moisture separator reheater output control circuitry. The closure of these valves caused a down power to 93.5 percent rated thermal power. To support continued plant operation an equipment clearance order was used to control equipment configuration.

This clearance order directed operators to take the temperature control valves and the motor-operated shut-off valves out of auto and place the components in the open position with caution tags hanging on them (manually opened). For determining the cause of the malfunction, the equipment clearance order for plant operation was removed and another equipment clearance order for troubleshooting and maintenance was hung. This new clearance order required the temperature control valves to remain in the open position with caution tags hanging on them, but the motor-operated shut-off valves were returned to the automatic or auto position.

Troubleshooting failed to determine the cause of the malfunction and the decision was made to recommence troubleshooting in the upcoming refueling outage, 2RE18, scheduled to begin on October 27, 2015. At the conclusion of troubleshooting, maintenance and engineering personnel communicated with the control room that the moisture separator reheater was to be left in manual. Maintenance and engineering departments understood this to mean that the motor-operated shut-off valves would be returned to the manual and open position with caution tags hanging on them.

However, operations department personnel assumed that leaving the moisture separator reheater controller in manual was the desired equipment configuration. The equipment clearance order in effect was once again removed and another equipment clearance order for continued operation was hung, which did not require that the motor-operated shut-off valves be placed in manual and open.

Plant Procedure 0PGP03-ZO-0051, Operational Configuration Control for Online Maintenance Program, Revision 0, step 6.2.2, directs the licensee to, Verify affected equipment is secured or the restoration of equipment will not affect plant operations.

Adherence to this step would have required that the motor-operated shut-off valves be placed in manual and in the open position to prevent the error in the control circuitry from affecting plant operation. On September 17, 2015, the motor-operated shut-off valves spuriously closed and caused reactor power to lower from 100 percent to 98.9 percent then rise to 100.5 percent before steadying at 99.9 percent rated thermal power. During the next maintenance outage, the licensee discovered that the extended memory card in the control circuitry was not operating properly and replaced that card.

Analysis.

The failure to control equipment configuration was a performance deficiency.

This performance deficiency was more than minor, and therefore a finding, because it is associated with the configuration control attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the licensee failed to control the configuration of the plant, per Procedure 0PGP03-ZO-0051, Operational Configuration Control for Online Maintenance Program, Revision 0, when the motor-operated shut-off valves were not included on an equipment clearance order following troubleshooting of the moisture separator reheater output control circuitry, which resulted in an unplanned transient when the known fault in the circuitry erroneously closed the motor-operated shut-off valves. The inspectors screened this finding using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) For Findings At-Power, dated June 19, 2012. The inspectors determined that the finding had very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition, high energy line-breaks, internal flooding, or fire. The inspectors determined the finding had a cross-cutting aspect of teamwork in the human performance area because individuals and work groups did not communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, operations and maintenance departments did not demonstrate a strong sense of collaboration and cooperation in connection with projects and operational activities [H.4].

Enforcement.

Technical Specification 6.8.1.a. requires in part that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2. Section 1.c of Appendix A to Regulatory Guide 1.33, Revision 2, requires procedures for the control of equipment, including lockouts and tagouts. The licensee established Procedure 0PGP03-ZO-0051, Operational Configuration Control for Online Maintenance Program, Revision 0, to meet the Regulatory Guide 1.33 requirement.

Step 6.2.2 of Procedure 0PGP03-ZO-0051 directs the licensee to verify that affected equipment is secured or that the restoration of equipment will not affect plant operations.

Contrary to the above, from July 16 to September 17, 2015, the licensee failed to verify that affected equipment was secured or that the restoration of equipment did not affect plant operations. Specifically, the licensee failed to implement the operational configuration control procedure when the moisture separator reheater motor-operated shut-off valves were not appropriately caution tagged open and placed in manual to mitigate a malfunction in the control system, which caused a plant transient and exceeding of the licensed thermal power limit of the plant. The licensee restored compliance when the crew revised the equipment clearance order and placed the motor-operated shut-off valves in the open position with caution tags hung on them.

Additional corrective actions taken included 100 percent operations department personnel training on the lessons learned from this event, and the maintenance department revised Work Control Guideline 008, Preventing Recurring Equipment Problems, Revision 7, to include instructions on how to document system configuration recommendations. The issue was entered into the licensees corrective action program as Condition Report 2018-1002. This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2.a of the NRC Enforcement Policy.

NCV 05000499/2017004-01, Failure to Control Equipment Configuration in Accordance with Procedures.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On December 20, 2017, the licensed operator requalification program inspectors briefed Mr. J. Connolly, Site Vice President and Chief Nuclear Officer, and other members of the licensee's staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

On January 18, 2018, the resident inspectors presented the inspection results to Mr. G. Powell, Interim President, Chief Executive Officer, and Chief Nuclear Officer, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

R. Aguilera, Manager, Plant Protection/Emergency Response

J. Atkins, Manager Performance Improvement

L. Blaylock, Owner Representative, CPS Energy

J. Bodnar, Manager, Security

W. Brost, Engineer, Senior Licensing

A. Capristo, Executive Vice President and Chief Administrative Officer

J. Connolly, Site Vice President and Chief Nuclear Officer

R. Dunn Jr., Manager, Nuclear Fuel and Analysis

R. Jackson, Manager, Employee Concerns Program

R. Gibbs, Manager, Operations Division, Unit Operations

M. Glover, Manager Projects

R. Gonzales, Senior Licensing Engineer

G. Hildebrandt, Manager, Training

T. Hurley, Supervisor, Simulator Support and Exam Team

G. Janak, Operations Training Manager

B. Jefferson, Director, Operations

B. Lane, Manager, Operations Division, Unit Operations

J. Lovejoy, Manager, I&C Maintenance

E. Matejceck, Manager, Mechanical Maintenance

R. McNeil, Manager, Maintenance Engineering

M. Murray, Manager, Regulatory Affairs

M. Ortiz, Manager, Instrumentation and Controls Maintenance

M. Page, General Manager, Engineering

G. Powell, Executive Vice President and Chief Nuclear Officer

D. Rencurrel, Senior Vice President, Operations

R. Savage, Engineer, Licensing Consult Specialist

R. Stastny, Maintenance Manager

L. Sterling, Supervisor, Licensing

C. Stone, Manager, Health Physics

M. Uribe, Manager, Operations, Production Support & Programs

Attachment 1

LIST OF ITEMS

OPENED AND CLOSED

Opened and Closed

05000499-2017-01 NCV Failure to Control Equipment Configuration in Accordance with Procedures (Section 4OA2.3)