IR 05000263/2008008

IR 05000263-08-08, on 10/20/2008 -11/07/2008, Monticello, Biennial Baseline Inspection of the Identification and Resolution of Problems

ML083330412
Person / Time
Site:	Monticello
Issue date:	11/28/2008
From:	Kenneth Riemer NRC/RGN-III
To:	O'Connor T Northern States Power Co
References
IR-08-008
Download: ML083330412 (35)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION REGION III 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352 November 28, 2008

Mr. Timothy Site Vice President Monticello Nuclear Generating Plant Northern States Power Company, Minnesota 2807 West County Road 75 Monticello, MN 55362-9637

SUBJECT: MONTICELLO NUCLEAR GENERATING PLANT PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000263/2008008

Dear Mr. O'Connor:

On November 7, 2008, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution (PI&R) inspection at your Monticello Nuclear Generating Plant.

The enclosed report documents the inspection results, which were discussed on November 7, 2008, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission's rules and regulations and with the conditions of your license. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel. The inspection concluded that your staff was effective at identifying problems and incorporating them into the corrective action program. In general, issues were appropriately prioritized, evaluated, and corrected, audits and self-assessments were thorough and probing, and operating experience was appropriately screened and disseminated. Your staff was aware of the importance of having a strong safety-conscious work environment and expressed a willingness to raise safety issues.

However, your staff not always effective in ensuring that issues, once identified, were properly resolved. The inspectors identified an apparent lack of sensitivity to internal corrective action program performance indicators, examples of inadequate documentation of issues, and inadequate oversight of the Differing Professional Opinions program to ensure that Issues were appropriately addressed and tracked. These were recurring problems, as they had been previously identified during the 2006 PI&R inspection. The inspectors also observed that despite having had several opportunities, your staff had not taken appropriate actions to correct an adverse trend in Human Performance, which had begun in late 2006. Based on the results of this inspection, two NRC-identified findings of very low safety significance were identified. The findings involved violations of NRC requirements. However, because of their very low safety significance, and because the issues were entered into your corrective action program, the NRC is treating the issues as Non-Cited Violations (NCVs) in accordance with Section VI.A.1 of the NRC Enforcement Policy. If you contest the subject or severity of a 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 a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission - Region III, 2443 Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector Office at the Monticello Station. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA by N. Shah, Acting For /

Kenneth Riemer, Chief Branch 2 Division of Reactor Projects

Docket No. 50-263 License No. DPR-22 Enclosure: Inspection Report 05000263/2008008 w/Attachment: Supplemental Information DISTRIBUTION

See next page Letter to

SUMMARY OF FINDINGS

IR 05000263/208008; (October 20, 2008 - November 7, 2008), Monticello Nuclear Generating Station; Biennial Baseline Inspection of the Identification and Resolution of Problems.

This team inspection was performed by three regional inspectors and the senior resident inspector. Two findings of very low safety significance (Green) were identified during this inspection. Each of the findings was classified as a NCV. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using NRC Inspection Manual Chapter (IMC) 0609, ASignificance Determination Process

@ (SDP). The NRC

=s program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, AReactor Oversight Process,@ Revision 4, dated December 2006.

Identification and Resolution of Problems The licensee was effective at identifying problems and incorporating them into the corrective action program (CAP). In general, issues were appropriately prioritized, evaluated, and corrected. Licensee audits and self-assessments were generally thorough, probing, and made good use of outside resources to maintain independence. Operating Experience (OE) was appropriately screened and disseminated and was considered as a potential precursor during cause evaluations. Plant staff was aware of the importance of having a strong safety-conscious work environment (SCWE) and expressed a willingness to raise safety issues. No one interviewed had experienced retaliation for safety issues raised, or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP and the employee concerns program (ECP).

However, the inspectors identified several concerns that were similar to those noted during prior PI&R inspections. The licensee had a continued lack of sensitivity to internal CAP performance indicators, in that some of these indicators, which showed potential deficiencies in the program, had not been evaluated. There were also continued concerns with the proper documentation of issues. Specifically, the inspectors found several examples where the documentation of an issue was insufficient to verify whether it had been appropriately evaluated or resolved. There were also continued problems with the handling of issues identified through the licensee's Differing Professional Opinion (DPO) process. The inspectors also observed that the station had not taken appropriate corrective action to address an adverse trend in Human Performance.

There were two Green findings identified during this inspection. One finding was for failing to properly identify and evaluate a Maintenance Rule Functional Failure associated with the High Pressure Coolant Injection (HPCI) system. The second finding was for failing to capture a Conditions Adverse to Quality (CAQ) in the CAP, during a licensee review of OE. Both findings also had associated NCVs.

A. NRC-Identified

and Self-Revealed Findings

Cornerstone: Mitigating Systems

• Green: The NRC identified a Green NCV of 10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," for the failure to identify a Condition Adverse to Quality (CAQ). Specifically, the licensee did not identify a maintenance preventable functional failure (MPFF) associated with the HPCI system. The MPFF was associated with the in-service test (IST) failure of the HPCI accumulator check valve (AI-611) during the 2007 refueling outage. The failure was caused by debris that was lodged in the valve seat. Of particular significance, was the fact that the issue was the subject of three licensee-initiated action requests (ARs) between March 2007 to February 2008, regarding the test failure, the failure to evaluate past-operability and the failure to evaluate the maintenance rule aspects, none of which properly evaluated the issue. The licensee identified the MPFF after an NRC inspector questioned the adequacy of the previous evaluations, in particular, why the source of the debris had never been evaluated. This finding also has an associated cross-cutting aspect associated in the area of PI&R, Corrective Action Program for the failure to properly evaluate the HPCI accumulator check valve IST failure. [P.1(C)] The finding is more than minor because it affects the Equipment Performance attribute of the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding is of very low safety significance, because the HPCI system remained operable and available. (Section 4OA2.1(2))

Cornerstone: Initiating Events and Mitigating Systems

• Green: The NRC identified a Green NCV of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," for the failure to identify and correct a Condition Adverse to Quality (CAQ). Specifically, the licensee failed to capture in the CAP a concern with the potential corrosion of magnesium motor rotor fan blades associated with safety-related motor operated valves (MOVs). The MOVs were associated with the reactor recirculation and residual heat removal (specifically the low pressure core injection mode) systems. The concern was identified during an internal licensee review of OE. The failure to capture this item in the CAP resulted in the licensee not being able to utilize the CAP process to ensure that the CAQ had been properly evaluated and corrected. This finding has an associated cross-cutting aspect associated in the area of PI&R, Corrective Action Program for the failure to properly evaluate the potential impact of the CAQ on the affected, safety-related MOVs. [P.1(C)] The finding is more than minor because it directly affected the Human Performance attribute of the Initiating Events Cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions while at power. The finding also directly affected the Equipment Performance attribute of the Mitigating System Cornerstone objective of ensuring the availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The finding is of very low safety significance, because the issue only involved the potential degradation, but not the actual loss of a plant component (i.e., there was no actual initiating event nor loss of a mitigating system). (Section 4OA2.2)

B. Licensee-Identified Violations

No violations of significance were identified.

REPORT DETAILS

4OA2 Problem Identification and Resolution (PI&R)

The activities documented in sections

.1 Assessment of the Corrective Action Program (CAP) Effectiveness

a. Inspection Scope

The inspectors reviewed the licensee's CAP implementing procedures and attended CAP program meetings to assess the implementation of the CAP by site personnel.

The inspectors reviewed risk and safety significant issues in the licensee's CAP since the last NRC PI&R inspection in November 2006. The selection of issues ensured an adequate review of issues across the NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC documented findings as sources to select issues. Additionally, the inspectors reviewed ARs generated as a result of facility personnel's performance in daily plant activities. In addition, the inspectors reviewed ARs and a selection of completed investigations from the licensee's various investigation methods, including root, apparent and common cause evaluations.

The inspectors performed a more extensive review of station efforts to resolve high temperature concerns with the number 12 reactor feedwater pump and for managing aging/obsolete equipment. This review consisted primarily of a five year search of related issues identified in the CAP and discussions with appropriate licensee staff to assess the licensee's efforts in address the above equipment concerns.

During the reviews, the inspectors evaluated whether the licensee staff's actions were in compliance with the facility's CAP and 10 CFR Part 50, Appendix B requirements. Specifically, the inspectors evaluated if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the station's CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also evaluated whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and NRC findings, including NCVs.

b. Assessment

(1) Effectiveness of Problem Identification In general, the inspectors considered the licensee's identification of equipment deficiencies to be good. Workers were encouraged to identify issues and were familiar with the various avenues available (NRC, CAP, etc). This was evident by the large number of ARs generated annually, which were reasonably distributed across the 4 Enclosure various departments. A shared computerized database was used for creating individual reports and for subsequent management of the processes of issue evaluation and response. This included determining the issue's significance, addressing such matters as regulatory compliance and reporting, and assigning any actions deemed necessary or appropriate.

However, the inspectors identified a continued lack of sensitivity with the licensee's evaluation of some of the internal performance indicators monitoring the CAP. A similar issue had been identified during the 2003 and 2006 PI&R inspections and was documented in AR 01064612. One notable example was the licensee's indicator for CAP action items that were open greater than 90, 120 or 180 days. Normally the licensee expects CAP actions to be completed within 90 days, however, the indicator showed that about 40 percent of the open items had exceeded this goal as of August 2008. The inspectors noted that there was no explanation or evaluation of why this had occurred or whether this result was acceptable. The inspectors also identified other indicators having similar issues. The licensee documented this issue in AR 1158446.

The licensee was generally effective at identifying and resolving trends. This was apparent by the large number of trend ARs generated either through "binning" of issues or through evaluation via the quarterly department roll-up meeting (DRUM) reports. However, the inspectors noted that the licensee's trending program was somewhat limited in that it did not always identify trends involving issues affecting the same functional area, but having dissimilar aspects. The inspectors noted that the licensee had reached a similar conclusion in a recent self-assessment and had generated AR 1129683 to address this concern.

For example, the inspectors noted that the licensee had been slow to identify an adverse trend in human performance. Since late 2006, the plant has experienced numerous issues in this area. These issues were primarily of low significance and did not result in NRC findings. These issues continued through 2007 and 2008, with the significance of the findings increasing, until a sufficient number of NRC findings had accrued (around mid-2008) that an adverse trend in human performance had become evident.

The inspectors noted that the licensee's trending program had identified trends having multiple issues in the same human performance aspect (such as procedural adherence), but was less effective at identifying trends having multiple issues crossing over several aspects (such as procedural adherence, work coordination, training, etc). This limitation resulted in the licensee believing that the human performance issues were limited to specific behaviors or work groups, instead of recognizing that it was a more widespread concern involving fundamental human behaviors.

During the NRC PI&R inspection, the licensee was in the process of completing a self-assessment of human performance. Although the results had not yet been entered into the CAP, they were discussed with the inspectors and during a Management Review Committee meeting held on October 22, 2008. The licensee identified that the CAP trending program had been ineffective at identifying the human performance trend and that the issues were principally due to a lack of resources and an inappropriate tolerance for risk among workers. The inspectors concluded that while the licensee had achieved a better understanding of the human performance issue, more effort was needed to understand the reasons behind the underlying causes.

5 Enclosure Findings No findings of significance were identified.

(2) Effectiveness of Prioritization and Evaluation of Issues The inspectors attended several daily CAP screening meetings and observed that issues were being appropriately screened and challenged. The majority of issues were of low level and were either closed to trend or at a level appropriate for a condition evaluation.

Many of these issues were closed to a work request or to another AR, but the inspectors noted that both the parent and daughter documents had the necessary verbiage to document the interrelationship. Although fewer in number, the inspectors did not have any concerns with those issues assigned an apparent cause evaluation (ACE) or root cause evaluation. There were no items in the operations, engineering, or maintenance backlogs that were risk significant, individually or collectively. There were no classifications or immediate operability determinations with which the inspectors disagreed.

The inspectors noted that while root cause evaluations were generally of good quality, there continued to be problems with the quality of documentation of ACEs. Similar issues were noted during the 2006 PI&R inspection. For example, ACEs were required to be reviewed and approved by a licensee ACE screening inspector prior to issuance. The screening inspectors comprised management representatives from each of the major plant departments (operations, maintenance, etc). The inspectors identified several examples where the screening inspectors had identified issues with the evaluation quality, but had nevertheless assigned the evaluation a passing grade. While this was acceptable under the licensee's procedures, there was no requirement to ensure that the screening team observations were addressed. This meant that potential, recurring issues with ACE documentation went uncorrected, and that licensee standards for ACE quality were not reinforced. The inspectors noted that similar issues had been identified in recent station audits as documented in AR 1144130.

The inspectors identified that the licensee had failed to identify a Maintenance Preventable Functional Failure (MPFF) of the HPCI system, due to an improper evaluation following an in-service test failure of the HPCI accumulator check valve. Because the HPCI is a safety-related system, the MPFF was considered a SCAQ.

The test failure occurred during the 2007 refueling outage and was the subject of three ARs, written between March 2007 and February 2008. These ARs collectively concluded that the issue did not affect the HPCI system. In August 2008, the licensee initiated AR 1148193, after an NRC inspector questioned the adequacy of the licensee's review. The licensee subsequently concluded that the HPCI system availability had been affected and that the test failure should have been identified as an MPFF. This was considered a Finding (Green) and NCV.

Findings Failure to Identify a CAQ and to Take Corrective Actions to Prevent Recurrence

Introduction:

A finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," was identified by the inspectors for the failure to identify a CAQ. Specifically, the licensee did not properly 6 Enclosure evaluate the failure of the HPCI accumulator check valve (AI-611) after it failed its in-service test. This resulted in the licensee not identifying a MPFF of the safety-related HPCI system.

Description:

On March 31, 2007, the licensee identified that the AI-611 valve had failed its in-service test due to a piece of debris lodged in the valve seat preventing it from closing. The valve was subsequently repaired and successfully retested. The test failure was documented in AR 1086927, but was closed with no evaluation. On August 29, 2007, the licensee initiated AR 1109246, after identifying that the effect of the test failure on the past operability of the HPCI system had not been evaluated.

The AR identified that the debris on the valve seat was not caused by any past events and that therefore, there were no past operability concerns. On February 23, 2008, the licensee initiated AR 1128442 after identifying that the leak test failure had not been evaluated against the maintenance rule program. The AR concluded that since the test failure had not resulted from any past activity, it was not a MPFF. On August 21, 2008, the licensee initiated AR 1148193, after an NRC inspector found that the licensee had failed to identify the source of the valve debris and that, therefore, the conclusions regarding the affect of the test failure were potentially inaccurate. The licensee subsequently identified that the valve debris was brazing material likely originating from work on instrument air valve AI-221, located directly upstream of the AI-611 valve. This work occurred from June 10-14, 2005. Since the debris had resulted from a planned maintenance activity, the licensee subsequently concluded that the test failure should be reevaluated as a potential MPFF. The AI-611 valve had last been successfully tested during the March/April 2005 refueling outage.

The AI-611 is a safety-related valve that has a safety function to close. It allowed instrument air (which is a non-safety related system) to supply a safety-related accumulator that, in turn, supplied air to the HPCI minimum flow valve (CV-2065). The CV-2065 valve is safety-related and has safety functions to both open and close. If the AI-611 valve fails to close, then upon a loss of the instrument air system, air would bleed out of the accumulator resulting in the CV-2065 valve failing open. If this occurred, then part of the HPCI flow would be diverted to the torus instead of the reactor vessel. Because this is an unevaluated condition, it is possible that there would be insufficient flow to the reactor vessel to meet the design basis. The CV-2065 valve is required to remain operable during a station blackout (where instrument air would be lost) and a small break loss of coolant accident coincident with a loss of instrument air. Both of these are design basis accidents.

The licensee subsequently reclassified the in-service test failure as a MPFF that had affected the availability of the HPCI system. The licensee also identified that other in-service test failures occurring during the 2007 refueling outage also needed to be reevaluated. These actions were being tracked under AR 1148193.

Analysis The failure to properly evaluate the in-service test failure was considered a performance deficiency. Specifically, by not considering the source of the debris in the AI-611 valve seat, the licensee failed to identify a MPFF affecting the safety-related HPCI system. This prevented the licensee from properly evaluating the affect of the MPFF on the HPCI system and implementing any corrective actions to prevent recurrence.

7 Enclosure The finding is more than minor because it directly affected the Equipment Performance attribute of the Mitigating Systems Cornerstone objective of ensuring the availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the failure to identify the MPFF prevented the licensee from evaluating the affect on the HPCI system and implementing any corrective actions to prevent recurrence.

The inspectors conducted a Phase I characterization and screening of the finding in accordance with IMC 0609, Appendix A, "Determining the Significance of Reactor Inspection Findings for At-Power Situations." Because there had been no loss of the instrument air system during the period that the AI-611 valve may have been unable to close, the HPCI system remained operable, therefore, the finding screened out as having very low safety significance (Green).

The performance deficiency has a cross-cutting aspect in the area of PI&R, Corrective Action Program, because the licensee did not evaluate the source of the debris in the AI-611 valve and therefore, did not identify a MPFF of the HPCI system. P.1(c)

Enforcement:

10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances are promptly identified and corrected. Licensee procedure FP-PA-ARP-01, "CAP Action Request Process," revision 20, defines a CAQ (step 4.23), in part, as "Failures, malfunctions, deficiencies, deviations, defective material and equipment and non-conformances that have the potential to affect operability or functionality of safety-related systems, structures or components." This same step required that CAQs be captured in the CAP.

Contrary to the above, on March 31, 2007, the licensee failed to identify that the in-service test failure of the AI-611 valve was due to prior maintenance and was therefore a MPFF. Because this MPFF potentially prevented the safety-related HPCI system from performing its design function, this met the licensee's definition of a CAQ that should have been captured in the CAP. Because this violation was of very low safety significance and it was entered into the licensee's corrective action program as AR 1148193, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000263/2008008-01 - Failure to Identify a Condition Adverse to Quality and Implement Corrective Actions to Prevent Recurrence).

(3) Effectiveness of Corrective Actions The inspectors concluded that over the two year period encompassed by the inspection, the licensee implemented effective corrective actions. Corrective actions were generally well implemented, effective in addressing the parent issues, and timely. The inspectors identified no significant examples where problems recurred.

Findings No findings of significance were identified.

8 Enclosure

.2 Assessment of the Use of Operating Experience (OE)

a. Inspection Scope

The inspectors reviewed the licensee's implementation of the facility's OE program. Specifically, the inspectors reviewed implementing OE program procedures, attended CAP meetings to observe the use of OE information, completed evaluations of OE issues and events, and selected monthly assessments of the OE composite performance indicators. The inspectors' review was to determine whether the licensee was effectively integrating OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensee's program was sufficient to prevent future occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and effectively and timely implemented.

b. Assessment In general, OE was effectively used at the station. The inspectors observed that OE was discussed as part of the daily station planning meetings, at shift turnover meetings, and at maintenance pre-briefings. Also, the inspectors determined that OE was appropriately reviewed during causal evaluations. During interviews, several licensee personnel commented favorably on the use of OE in their daily activities.

The inspectors noted that OE was not always effectively utilized by the licensee. For example, the ineffective use of OE was a precursor to the vessel overfilling event and the underground cabling issues that were reviewed during an NRC Special Inspection conducted in September 2008 (Inspection Report 05000263/2008009). The inspectors also identified two examples where OE evaluations were poorly documented, in part due to a lack of sufficient oversight regarding the quality of OE evaluations. These examples were associated with the licensee's review of NRC Information Notices (IN) 2006-26, "Failure of Magnesium Rotors in Motor-Operated Valve Actuators," and 2006-29, "Potential Common Cause Failure of Motor-Operated Valves as a Result of Stem Nut Wear." The inspectors further noted that the licensee had identified a potential CAQ in one of these evaluations, but had failed to enter it in the CAP. This was considered a finding and NCV.

The licensee issued AR 1158444 to address the failure to properly document and make CAP entries for the above two INs.

Findings Failure to Capture a CAQ In the CAP

Introduction:

A finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," was identified by the inspectors, for the failure to identify and correct a CAQ. Specifically, during a review of OE, the licensee identified a concern with the potential corrosion of magnesium motor rotor fan blades and shorting rings associated with some 9 Enclosure safety-related motor operated valves (MOVs). The licensee did not enter this concern into the CAP, resulting in a CAQ not being identified or corrected.

Description:

On December 11, 2006, the licensee initiated AR 1066797 to review NRC IN 2006-26, "Failure of Magnesium Rotors in Motor-Operated Valve Actuators." The IN described recent failures of MOV actuators due to oxidation and corrosion of the magnesium motor rotor fan blades and shorting ring resulting from exposure to high humidity and temperatures. The licensee's evaluation concluded that a similar concern existed at Monticello and identified five safety-related MOVs that were "at risk" due to the operating environment (i.e., temperature and humidity) and duty cycle. These MOVs included:

• Division 1 Residual Heat Removal (Low Pressure Core Injection) Outboard MOV;

• Division 2 Residual Heat Removal (Low Pressure Core Injection) Outboard MOV;

• Division 1 Residual Heat Removal (Low Pressure Core Injection) Inboard MOV;

• #11 reactor recirculation pump discharge MOV; and

• #12 reactor recirculation pump discharge MOV.

This review had been performed by a licensee engineer who was no longer working at the station. The engineer had not documented this review or entered it into the CAP. Instead, the engineer had initiated a General Action Request (GAR) to track industry resolution of the concern and initiated work requests to examine the MOVs during a subsequent outage.

Issues potentially affecting safety-related components were required to be identified in the CAP as CAQs, in accordance with station procedure FP-PA-OE-01, "Operating Experience Program," revision 9. As stated in station procedure FP-AR-ARP-03, "Non-CAP Action Request Process," revision 2, a GAR is not considered part of the CAP. A GAR is typically used to track low level items that don't meet the threshold of the CAP. Unlike CAP items, they are not screened or otherwise evaluated for operability, reportability or otherwise required to have corrective actions.

The lack of a CAP entry meant that this issue was not identified a CAQ and that, therefore, there was no independent review of the engineer's conclusions or recommended corrective actions. This also meant that the work requests could be cancelled without justification as there was no indicator that they were necessary to address a CAQ.

Analysis The failure to follow the procedural requirement to identify this issue as a CAQ in the CAP is a performance deficiency. This deficiency resulted in the licensee failing to ensure that a CAQ had been properly identified and corrected.

The finding is more than minor because it directly affected the Human Performance attribute of the Initiating Events Cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions while at power. The finding also directly affected the Equipment Performance attribute of the Mitigating System cornerstone objective of ensuring the availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, by not identifying this issue as a CAQ in the CAP, the 10 Enclosure licensee was unable to ensure that the affect on the above safety-related MOVs were properly evaluated and that the appropriate corrective actions were implemented.

The inspectors conducted a Phase I characterization and screening of the finding in accordance with IMC 0609, Appendix A, "Determining the Significance of Reactor Inspection Findings for At-Power Situations." Because the issue only involved the potential degradation, but not the actual loss of plant components, there was no actual initiating event or loss of a mitigating system function; therefore, this finding screened out as having very low safety significance (Green).

The performance deficiency has a cross-cutting aspect in the area of PI&R, Corrective Action Program, because the licensee did not enter the item into the CAP preventing it from being properly evaluated. P.1(c)

Enforcement:

10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Licensee procedure FP-PA-ARP-01, defines a CAQ (step 4.10), in part, as "failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances that have the potential to affect nuclear safety, operability or functionality of safety-related systems." Station procedure FP-PA-OE-01 required that CAQs identified through OE review be entered into the CAP.

Contrary to the above, on December 11, 2006, the licensee failed to identify a potential concern associated with some safety-related MOVs as a CAQ in the CAP. Specifically, the licensee identified that some MOVs may have experienced corrosion of the magnesium motor rotor fan blades and shorting ring based on their operating history. Because these MOVs were safety-related, this issue would be considered a CAQ that is required to be identified in the CAP. Because this violation was of very low safety significance and it was entered into the licensee's corrective action program as AR 1158444, this violation is being treated as an NCV, consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000263/2008008-02 - Failure to Identify a Condition Adverse to Quality).

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors assessed the licensee staff's ability to identify and enter issues into the CAP program, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits.

b. Assessment The inspectors considered the quality of the nuclear oversight (NOS) audits to be thorough and critical. The self-assessments were acceptable but, as expected, they were not at the same level of quality as the audits. The inspectors observed that ARs had been initiated for issues identified through the NOS audits and self-assessments.

11 Enclosure The inspectors attended a meeting of the Performance Assessment Review Board on November 5, and reviewed board meeting minutes from January to June 2007 and from April to October 2008. The Board provided oversight for the CAP including the self-assessment program. The inspectors identified no issues with the Board's performance during the inspection.

Findings No findings of significance were identified.

.4 Assessment of Safety-Conscious Work Environment (SCWE)

a. Inspection Scope

The inspectors assessed the licensee's safety-conscious work environment through the reviews of the facility's ECP implementing procedures, discussions with ECP coordinators, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results of licensee safety culture surveys.

b. Assessment The inspectors determined that the plant staff were aware of the importance of having a strong SCWE and expressed a willingness to raise safety issues. No one interviewed had experienced retaliation for safety issues raised, or knew of anyone who had failed to raise issues. All persons interviewed had an adequate knowledge of the CAP and ECP.

Based on these limited interviews, the inspectors concluded that there was no evidence of an unacceptable SCWE.

The inspectors observed that there continued to be a concern with the level of rigor over the DPO process. A similar issue had been identified during the 2006 PI&R inspection and documented in ARs 01062966 and 01063040. Specifically, in 2006, the inspectors had identified that there was no designated site individual to assist program users and that typically those wanting to use the programs had to assume the burden in ensuring that the issues were properly resolved. In addition, there was no clear interface between the DPO and the CAP, in that DPO issues were not captured in the CAP nor were related CAP issues generally linked to DPO items. The inspectors were concerned that the overall lack of rigor over the DPO process may result in some workers feeling reluctant to raise concerns and/or some issues not being properly evaluated or documented.

During a self-assessment of the CAP done in preparation for the 2008 NRC PI&R inspection, the licensee identified that DPO initiators continued to bear the burden for issue resolution. In addition, the NRC inspectors noted that while DPOs were now entered into the CAP, there was no specific designator or identifier such that the DPOs were easily tracked or retrievable. In fact, the inspectors identified one example of a DPO that, while it was in the CAP, had not been identified by the licensee during a review of the CAP entries in preparation for the NRC inspection. The licensee documented both of these issues in ARs 1147604 and 1158451, respectively.

12 Enclosure Findings No findings of significance were identified.

4OA6 Management Meetings

.1 Exit Meeting Summary

On November 7, 2008, the inspectors presented the inspection results to Mr. O'Connor and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

T. Blake, Regulatory Affairs Manager

A. Brown, Performance Assessment Coordinator

M. Fish, CAP Coordinator

W. Flaga, Maintenance Manager

J. Grubb, Engineering Director

D. Horgan, Performance Assessment Supervisor

K. Jepson, Business Support Manager

T. O'Connor, Site Vice-President

S. Radebaugh, Acting Plant Manager

L. Taufen, Self-Assessment Coordinator

E. Weinkam, Nuclear Licensing and Emergency Preparedness Director Nuclear Regulatory Commission

K. Riemer, Chief, Branch 2, Division of Reactor Projects

Other

J. Ruff, Institute of Nuclear Power Operations

LIST OF ITEMS

OPENED, CLOSED AND DISCUSSED

Opened

05000263/2008008-01 NCV Failure to Adequately Identify a Condition Adverse to Quality and Identify Corrective Actions to Prevent Recurrence (4OA2.1(2))

05000263/2008008-02 NCV Failure to Identify a Condition Adverse to Quality (Section 4OA2.2)

Closed

05000263/2008008-01 NCV Failure to Adequately Identify a Condition Adverse to Quality and Identify Corrective Actions to Prevent Recurrence (4OA2.1(2))

05000263/2008008-02 NCV Failure to Identify a Condition Adverse to Quality (Section 4OA2.2)

Attachment

LIST OF DOCUMENTS REVIEWED

The following is a list of documents reviewed during the inspection.

Inclusion on this list does not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that selected sections of portions of the documents were evaluated as part of the overall inspection effort.

Inclusion of a document on this list does not imply NRC acceptance of the document or any part of it, unless this is stated in the body of the inspection report.